CTO介入治疗策略的选择课件.ppt

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1、CTO介入治疗策略的选择,复旦大学附属中山医院心内科 上海市心血管病研究所葛 雷,Dual Catheter Angiography,Clear proximal capGood Distal Target,3.Length 20mm,Antegrade,Retrograde,yes,no,Wire escalation,Dissection Reentry(crossboss-stingray),Wire escalation,Dissection Reentry(reverse CART),yes,yes,no,no,Brilakis ES et al.JACC Cardiovasc In

2、terv 2012,The Hybrid Algorithm for CTO PCI in USA,CTO介入治疗策略的选择,仅仅评价了CTO正向的解剖结构，对侧枝血管的评估不够正向技术和逆向技术的相互转化条件不够细化忽略了平行导引钢丝技术忽略了IVUS在CTO PCI中的作用过分强调了ADR技术,CTO介入治疗策略的选择,一百个观众心中就有一百个哈姆雷特，与之相似，不同的术者，就有不同的手术策略,尽管手术策略多种多样，但仍然有规律可循！,Careful analysis of coronary angiogram/MSCT,Consider stopping if 3 hr;3.7x eGF

3、R ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Failed,060235,Case 1:Male,47 yrs,Tiny stump,healthy distal vessel,length 20mm,CTO介入治疗策略的选择,Careful analysis of coronary angiogram/MSCT,Features favouring early use ofdis

4、section-reentry:Ambiguous course in CTOLength 20 mmTortuous CTO segmentHeavy calcificationLength 20 mmPrevious failed attempt,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Failed,06

5、0235,Corsair+Fielder XT,CTO介入治疗策略的选择,060235,Gaia First,CTO介入治疗策略的选择,060235,Stenting and Final Result,CTO介入治疗策略的选择,68323,Case 2:Male,69 yrs,CTO介入治疗策略的选择,68323,CTO介入治疗策略的选择,68323,7F EBU 3.5,CTO介入治疗策略的选择,Careful analysis of coronary angiogram/MSCT,Features favouring early use ofdissection-reentry:Ambig

6、uous course in CTOLength 20 mmTortuous CTO segmentHeavy calcificationLength 20 mmPrevious failed attempt,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Failed,68323,KDL(Crusade)+Sion

7、,CTO介入治疗策略的选择,68323,IVUS(iLab),Frame,CTO介入治疗策略的选择,68323,Frame,GAIA Second+130cm FineCross,CTO介入治疗策略的选择,68323,CTO介入治疗策略的选择,68323,Tip Injection+150cm FineCross,CTO介入治疗策略的选择,68323,Sion+150cm FineCross,Tough Situation 1,CTO介入治疗策略的选择,68323,Sion+150cm FineCross,CTO介入治疗策略的选择,68323,GAIA Second+150cm FineCro

8、ss,CTO介入治疗策略的选择,68323,Position of Retrograde Wire,Frame,CTO介入治疗策略的选择,68323,Retro W not into Ante GC,even through Guidezilla used,Tough Situation 2,Guidezilla,CTO介入治疗策略的选择,68323,Home made Snare with 5F child catheter,150cm FineCross,RG3,Big loop of Sion,5F child catheter,CTO介入治疗策略的选择,68323,Home made

9、Snare with 5F child catheter,CTO介入治疗策略的选择,68323,Pre-dilation and IVUS,CTO介入治疗策略的选择,68323,a,b,a,c,d,e,b,c,d,e,True to true lumen tracking,CTO介入治疗策略的选择,68323,Final Results,CTO介入治疗策略的选择,大连医科大学2015,Case 3:Male,55,2015-9-8 failed to attempt recanalization LAD,CTO介入治疗策略的选择,Careful analysis of coronary ang

10、iogram/MSCT,Features favouring early use ofdissection-reentry:Ambiguous course in CTOLength 20 mmTortuous CTO segmentHeavy calcificationLength 20 mmPrevious failed attempt,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Success

11、ful crossing,IF Antegrade approaches Failed,大连医科大学2015,Fielder XT-R,GAIA Second+Corsair,CTO介入治疗策略的选择,大连医科大学2015,Ipislateral CC tracking with 150 Corsair+Sion,CTO介入治疗策略的选择,大连医科大学2015,Pingpang Technique and Reverse CART with 2.5 mm balloon(A:GAIA First;R:GAIA Second),CTO介入治疗策略的选择,大连医科大学2015,Pingpang T

12、echnique and Externalizaition with RG3,CTO介入治疗策略的选择,大连医科大学2015,Final Results,CTO介入治疗策略的选择,56439,Case 4:Male,48 yrs,2015-3-10 D1 stented(misrecognition for LAD),CTO介入治疗策略的选择,Primary Retro:No stump,Stent struts,Promising CC,Careful analysis of coronary angiogram/MSCT,Features favouring early use ofdis

13、section-reentry:Ambiguous course in CTOLength 20 mmTortuous CTO segmentHeavy calcificationLength 20 mmPrevious failed attempt,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Failed,56

14、439,150 Finecross+Sion,CTO介入治疗策略的选择,56439,150 Finecross+Fielder XT,CTO介入治疗策略的选择,56439,Modified Reverse CART+GAIA Second,Sion,CTO介入治疗策略的选择,56439,Modified Reverse CART+Sion,Sion not into Ante GC,CTO介入治疗策略的选择,56439,Guidezilla,CTO介入治疗策略的选择,56439,Finecross changed to Corsair,externalization with RG3,CTO介

15、入治疗策略的选择,56439,Final Results,CTO介入治疗策略的选择,广西南宁2015,CASE 5：Male,58 yrs,IDDM,LVEF 60%,First attempt failed,CTO介入治疗策略的选择,广西南宁2015,CTO介入治疗策略的选择,广西南宁2015,R:6F SALL:7F EBU 3.75,CTO介入治疗策略的选择,J-CTO Score 2:Stump,length20 mm,re-try case,Careful analysis of coronary angiogram/MSCT,Features favouring early use

16、 ofdissection-reentry:Ambiguous course in CTOLength 20 mmTortuous CTO segmentHeavy calcificationLength 20 mmPrevious failed attempt,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Fai

17、led,广西南宁2015,130cm FineCross+Fielder XT-R,CTO介入治疗策略的选择,广西南宁2015,150cm FineCross+Sion,AV Groove Channel injured,CTO介入治疗策略的选择,Careful analysis of coronary angiogram/MSCT,Features favouring early use ofdissection-reentry:Ambiguous course in CTOLength 20 mmTortuous CTO segmentHeavy calcificationLength 2

18、0 mmPrevious failed attempt,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Failed,广西南宁2015,Parallel Wiring with GAIA First,CTO介入治疗策略的选择,J-CTO Score 3:Without Stump,length20 mm,re-try

19、 case,广西南宁2015,Sion into RCA-PL,CTO介入治疗策略的选择,广西南宁2015,Final Results,CTO介入治疗策略的选择,广西南宁2015,CASE 6：Male,55 yrs,OMI,R:AL 0.75 SHL:7F EBU 3.5 SH,CTO介入治疗策略的选择,J-CTO Score 1:length20 mm,Careful analysis of coronary angiogram/MSCT,Features favouring early use ofdissection-reentry:Ambiguous course in CTOLen

20、gth 20 mmTortuous CTO segmentHeavy calcificationLength 20 mmPrevious failed attempt,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Failed,广西南宁2015,Balloon anchoring+Parallel wiring(F

21、ielder XT-R,GAIA First),CTO介入治疗策略的选择,J-CTO Score 3:length20 mm,calcification,bending 45 degrees,Careful analysis of coronary angiogram/MSCT,Features favouring early use ofdissection-reentry:Ambiguous course in CTOLength 20 mmTortuous CTO segmentHeavy calcificationLength 20 mmPrevious failed attempt,

22、Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Failed,广西南宁2015,150 Corsair+Sion,CTO介入治疗策略的选择,广西南宁2015,Knuckle wiring(Fielder XT,Conquest Pro),CTO介入治疗策略的选择,广西南宁2015,Preparing for Reve

23、rse CART with GAIA First,CTO介入治疗策略的选择,广西南宁2015,GAIA First into the true lumen,CTO介入治疗策略的选择,广西南宁2015,Final Results,CTO介入治疗策略的选择,61887,Case 7.Male,60 yrs old,CTO介入治疗策略的选择,61887,7F EBU 3.5 SH6F SAL 1.0 SH,CTO介入治疗策略的选择,Careful analysis of coronary angiogram/MSCT,Features favouring early use ofdissection

24、-reentry:Ambiguous course in CTOLength 20 mmTortuous CTO segmentHeavy calcificationLength 20 mmPrevious failed attempt,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,Successful crossing,IF Antegrade approaches Failed,61887,Cro

25、ssBoss,Fielder XT,Ultimatebros 3,CTO介入治疗策略的选择,61887,Final results,CTO介入治疗策略的选择,Careful analysis of coronary angiogram/MSCT,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,AP CTO Club PCI Algorithm,IF Antegrade approaches Failed,Careful analysis of coron

26、ary angiogram/MSCT,Consider stopping if 3 hr;3.7x eGFR ml contrast;Air Kerma 5 Gy unless procedure well advanced.,In-stent restenosis,AP CTO Club PCI Algorithm,IF Antegrade approaches Failed,市东医院,Case 8:Male,75,one month ago attempt recanalization for ISR-CTO,but failed,CTO介入治疗策略的选择,市东医院,7F SAL 1.0

27、SH,135cm Corsair+Fielder XT-R,CTO介入治疗策略的选择,市东医院,Parallel wiring:Ultimate Miracle 3,CTO介入治疗策略的选择,市东医院,150cm Corsair+Sion,CTO介入治疗策略的选择,市东医院,Reverse CART with 2.5mm balloon,CTO介入治疗策略的选择,市东医院,Fielder XT-R into Ante GC,CTO介入治疗策略的选择,市东医院,Externalization with RG3,CTO介入治疗策略的选择,市东医院,KDL(Crusade)+Sion to RCA-PL,CTO介入治疗策略的选择,市东医院,Final Results,CTO介入治疗策略的选择,CTO介入治疗策略的选择,CTO-PCI治疗策略的选择应根据闭塞近端、闭塞远段解剖学特征，有无合适的侧枝血管来进行；进行复杂CTO PCI时，术者不应拘泥于某一种治疗方法，应灵活使用正向介入治疗和逆向介入治疗；当无合适侧枝血管，且无ADR器械时，平行导引钢丝技术不失是一种可行、有效的治疗选择，尤其是远段血管相对健康时。,小 结,