双对吻挤压技术治疗分叉病变

即使在今天药物洗脱支架时代,介入治疗冠状动脉分叉病变依然是极具挑战性的,主要表现为再狭窄率高,随访期内主要心脏不良事件发生率较高.从金属裸支架开始的多项临床就已经证实双支架术式并不比单支架术优异,主要原因在于分支血管开口的再狭窄率没有得到有效的降低.但是,位于特殊部位的分叉病变必须使用双支架术,这就促使开展双支架术的深入研究.在回顾不同双支架术的基础上,详细介绍了改良后的双对吻挤压技术及特殊类型分叉病变专用支架.     

改良mini-Crush技术治疗冠状动脉分叉病变

冠状动脉病变中分叉病变较为常见,约占经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)的15%～20%[1]。由于存在斑块移位、病变弹性回缩及支架内再狭窄,冠状动脉分叉病变的介入治疗存在许多难题[2]。经典挤压(Crush)支架技术支架可完全覆盖分支开口,但是与其他技术相比,Crush支架术支架内血栓发生率似乎有增加的趋势[3]。我们近年来采用改良mini-Crush支架技术(原mini-Crush技术采用两次对吻球囊扩张,而我们的技术只采用一次最终球囊对吻扩张,简化了步骤)治疗真性冠状动脉分叉病变,取得了良好的近期结果。     

改良mini—Crush技术治疗冠状动脉分叉病变

冠状动脉病变中分叉病变较为常见,约占经皮冠状动脉介入治疗（percutaneous coronary intervention,PCI）的15％-20％。由于存在斑块移位、病变弹性回缩及支架内再狭窄,冠状动脉分叉病变的介入治疗存在许多难题。经典挤压（Crush）支架技术支架可完全覆盖分支开口,但是与其他技术相比,Crush支架术支架内血栓发生率似乎有增加的趋势。     

冠状动脉分叉病变单支架治疗分支是否需要对吻后扩张

冠状动脉分叉病变是冠状动脉介入治疗的一个难点。尽管药物洗脱支架的广泛使用提高了介入治疗分叉病变的疗效,但选择双支架还是单支架、单支架分支开口狭窄是否对吻后扩张、单支架分支血管术中及术后闭塞风险和支架内血栓问题仍值得研究。现就单支架治疗冠状动脉分叉病变分支血管是否对吻后扩张做一综述。     

经桡动脉途径行改良球囊挤压支架术治疗冠状动脉分叉病变

目的 分析经桡动脉途径应用改良球囊挤压支架术治疗冠状动脉分叉病变的可行性及成功率。方法 经桡动脉途径造影证实血管病变处有直径>2.5 mm分支,分支起始部有>70%狭窄的患者17例,应用改良球囊挤压支架术治疗分叉病变,观察病变血管狭窄程度、斑块移位及球囊对吻扩张成功率和随访效果。结果 分叉病变中均成功植入雷帕霉素药物洗脱支架,15例患者行同步对吻球囊技术进行后扩张, 术后前向血流均为TIMI Ⅲ级,所有患者未发生边支急性闭塞、支架内血栓、心源性休克、死亡等并发症。结论 冠心病分叉病变介入治疗中,经桡动脉途径通过6F或7F指引管完成改良球囊挤压支架术可获得满意结果,支架间隙小或无,再狭窄率低。     

应用双药物洗脱支架治疗分叉病变的近远期临床疗效

目的探讨应用双药物洗脱支架（DES）治疗分叉病变的临床疗效。方法选择分支开口有严重狭窄且分支口径≥2．50mm的分叉病变患者为本研究的入选对象。2003年10月至2005年6月共入选应用双DES治疗分叉病变的患者112例,113处病变。分叉病变的类型为前降支／对角支62例（54．9％）,左冠状动脉主干分叉病变32例（28．3％）,回旋支／钝缘支18例（15．9％）,右冠状动脉远端分叉病变1例。113处分叉病变中采用Crush技术64处,“T”型支架置入27处;改良“Y”型支架置入11处;对吻支架置入5处;“V”型支架置入和Culotte技术置入各3处。结果入选112例患者113处分叉病变中（226处病变）使用Cypher或Cypher select DES 91个,TAXUS DES 74个,Firebird DES 67个。64处分叉病变采用Crush技术置入双支架后60处（93．7％）完成了最后的对吻球囊扩张技术。手术成功率为100％。住院期间1例发生亚急性血栓致急性心肌梗死（AMI）,再次介入治疗成功。住院期间心脏事件发生率（MACE,包括死亡、AMI、再次血管重建）为0．89％（1／112）。112例均完成了9个月的临床随访,无死亡发生,1例发生AMI由晚期血栓形成所致。48例完成了9个月的冠状动脉造影随访（42．9％）,8例发生了支架内再狭窄,其中1例进行了冠状动脉旁路移植术,5例再次行介入治疗,总再狭窄发生率为16．7％（8／48）。随访期间MACE发生率为8．04％（9／112）。结论本研究结果显示对于分支口径≥2．5mm且口部有严重狭窄性病变的分叉病变,采用双DES治疗是安全的,近、远期临床疗效是满意的。与Cypher DES相比较,TAXUS DES的再狭窄发生率有增加的趋势。     

改良T型支架置入术与经典crush技术治疗冠状动脉分叉病变的比较研究

目的评估改良T型支架置入术与经典crush技术治疗真性冠状动脉分叉病变的安全性及有效性。方法自2008年12月至2010年1月共入选62例真性冠状动脉分叉病变患者(分支血管直径≥2.5mm),其中34例患者行经典crush治疗,28例患者行改良T型支架置入术,比较两组患者术后即刻成功率、住院期间及术后30d内的主要不良心脏事件、术后6个月支架再狭窄率。结果与经典crush组相比,改良T型支架治疗组术后分支最小管腔直径大〔(2.72±0.22)mmvs(2.39±0.30)mm,P0.01〕,分支残余狭窄程度小〔(8.3±6.8)%vs(18.6±10.2)%,P0.01〕,最终球囊对吻扩张成功率高(100%vs73.5%,P0.01),支架内再狭窄率较低(5.0%vs32.0%)。两组患者术后即刻成功率无统计学差异(88.24%vs100%,P=0.12)。经典crush组有1例患者因亚急性血栓再次行PCI治疗。结论改良T型支架置入术治疗冠状动脉分叉病变是安全的,其远期有效性优于经典crush技术。     

冠状动脉分叉病变的定义、分类和治疗策略

目前,冠状动脉分叉病变定义、分类和治疗策略,国内尚未见系统报道。研究现状:冠状动脉分叉病变的介入治疗极具挑战性且仍存争议,分叉病变的分类、治疗策略命名繁复,而且缺乏统一描述治疗策略手段。研究用途:现结合欧洲分叉俱乐部五次会议共识,旨在系统报道分叉病变的定义、分类和治疗策略最新进展,以"MADS"四种术式为中心,对每一种术式及其变异进行详细介绍,并不失其可记忆性及临床指导意义,最后提出了逐步描述支架治疗策略互动电子表格。     

冠状动脉分叉病变介入治疗策略及技术

<正>目前,冠心病最有效、最直接的治疗策略是经皮冠脉介入治疗(PCI),而分叉病变约占所有冠脉介入治疗病例的10%~20%〔1〕。分叉病变介入治疗的过程中技术操作难度大,接受放射线量多,手术成功率相对低而再狭窄率高,近期及远期主要心脏不良事件发生率高,因此分叉病变一直是介入医生面临的挑战之一。分叉病变介入治疗过程中发生"铲雪"效应、分支痉挛或血管夹层等均可导致分支狭窄或闭塞,然而每个患者、每     

国产雷帕霉素洗脱支架应用于冠状动脉分叉病变的效果评价

目的 评价冠状动脉分叉病变与非分叉病变支架植入术后预后是否存在差别.方法 回顾性分析1877例冠心病患者,其中568例冠状动脉分叉病变患者,1309例冠状动脉非分又病变患者.植入Excel支架.术后6、12及18个月临床随访两组主要不良心脏事件发生率的情况.结果 术后6、12及18个月两组死亡(心性和非心性)、非致死性心肌梗死及主要不良心脏事件的发生率均无差剐(P＞0.05),6及12个月两组靶病变血运重建的发生率无差别(P＞0.05),18个月两组靶病变血运重建的发生率存在差别(P＜0.05).结论 Excel支架治疗冠状动脉分叉病变具有安全性和可靠性.     

Serial intravascular ultrasound analysis comparing double kissing and classical crush stenting for coronary bifurcation lesions

Background : Compared with the classical crush, double kissing (DK) crush improved outcomes in patients with coronary bifurcation lesions. However, there is no serial intravascular ultrasound (IVUS) comparisons between these two techniques. Objectives : This study aimed to analyze the mechanisms of the two crush stenting techniques using serial IVUS imaging. Methods : A total of 54 patients with IVUS images at baseline, post‐stenting and eight‐month follow‐up were classified into classical (n = 16) and DK (n = 38) groups. All patients underwent final kissing balloon inflation (FKBI). Unsatisfactory kissing (KUS) was defined as the presence of wrist or >20% stenosis during FKBI at the side branch (SB) ostium. The vessels at bifurcation lesions were divided into the proximal main vessel (MV) stent, the crushed segment, the distal MV stent, the SB ostium and the SB stent body. Results : KUS and incomplete crushing were commonly observed in the classical group (62.5%, 81.3%), compared with DK group (18.0%, 39.5%, P < 0.001 and P = 0.004). The post‐stenting stent symmetry in the classical group was 71.85 ± 7.69% relative to 85.93 ± 6.09% in DK group (P = 0.022), resulting in significant differences in neointimal hyperplasia (NIH, 1.60 ± 0.21 mm² vs. 0.85 ± 0.23 mm², P = 0.005), late lumen loss (1.31 ± 0.81 mm² vs. 0.55 ± 0.70 mm², P = 0.013), and minimal lumen area (MLA, 3.57 ± 1.52 mm² vs. 4.52 ± 1.40 mm^2, P = 0.042) at the SB ostium between two groups. KUS was positively correlated with the incomplete crush and was the only predictor of in‐stent‐restenosis (ISR) at the SB ostium. Conclusion : DK crush was associated with improved quality of the FKBI and larger MLA. KUS predicted the occurrence of ISR. © 2011 Wiley Periodicals, Inc.     

改良Y支架术与reverse crush支架术治疗冠状动脉分叉病变的疗效比较

目的对比改良Y支架术与reverse crush支架术治疗冠状动脉分叉病变的临床疗效。方法将65例冠状动脉分叉病变患者随机分为两组,分别行改良Y支架术（改良组）和reverse crush支架术（对照组）治疗,观察两组疗效和随访1年主要心脏不良事件发生率。结果改良组手术时间、X线曝光时间短于对照组（P均〈0．01）;造影剂和球囊用量少于对照组（P均〈0．01）,最终球囊对吻成功率更高,但无统计学差异（P〉0．05）;6～9个月造影随访,改良组分支血管再狭窄率低于对照组（P〈0．01）。1年随访结束,对照组心脏不良事件发生率高于改良组,但无统计学差异（P〉0．05）。结论改良Y支架术较teverse crash支架术操作简单、费时少,具有更低的分支再狭窄率,有减少随访1年临床心脏不良事件的趋势,推荐临床优先选用。     

DK Crush技术治疗真性冠状动脉分叉病变:与经典Crush技术的对比

目的 检验作者改良的DK Crush技术能否确保最终对吻扩张的成功.方法 本研究属于连续、非随机和开放式研究,共入选了88例真性分叉病变(分支血管直径＞2.0 mm)的患者.其中2004年10月至2005年1月间入选的44例患者接受经典Crush技术治疗,2005年1月至2005年6月间入选的44例患者接受DK Crush技术治疗.比较两组患者术前、术中和术后30 d内的诸项参数.结果 DK Crush组与经典Crush组比较,患者分支血管病变长度长(13.5±3.4 mm比7.8±3.1 mm,P＜0.05)、经皮冠状动脉介入术需时短(44±12 min 比68±17 min,P＜0.05)、最终对吻扩张成功率高(100%比70%,P＜0.01)、使用球囊数鼍少(1.6±0.4个比2.7±0.7个,P＜0.05)及造影剂使用量小(102±38 mL比176±46 mL,P＜0.05).DK Crush组与经典Crush组患者的主干与分支血管之间的夹角[(57±18).比(47±15).],主干血管病变长度(24.3±8.6 mm比21.1±7.3 mm)差异均无统计学意义(P均＞0.05).经典Crush组有两例(4.3%)最终对吻失败的患者出现亚急性血栓栓塞.DK Crush组术后即刻分支血管开口部位最小血管直径显著大于经典Crush组(3.01±0.13 mm比2,74±0.12 mm,P＜0.01),而残余狭窄却显著小于后者(7.3%±8.6%比17.4%±11.2%,P＜0.05).经典Crush组有5例患者术后即刻分支血管开口残余狭窄＞30%(对吻失败).结论 经典Crush技术存在的技术缺陷是导致预后不良的主要原因.改良的DK Crush技术能显著提高对吻扩张的成功率.进一步的随机研究可以明确后者的有效性.     

Long-term outcomes of bifurcation lesions after implantation of drug-eluting stents with the "mini-crush technique".

OBJECTIVES: To evaluate clinical and angiographic long-term outcome of "the mini-crush" technique for treating bifurcation lesions. BACKGROUND: Despite proven efficacy of drug-eluting stent (DES) within most lesions subsets, bifurcation lesions continue to exhibit high restenosis rate using current DES stenting technique. METHODS: We report a new stenting technique which was employed in 45 consecutive patients (52 lesions) between April 2004 and July 2005 to treat true bifurcation lesions using DES in both branches. RESULTS: Using this technique procedural success was obtained in 100% of cases, without complications and with excellent angiographic result in 96.1% and 98.1% of main vessel and side branch. Preprocedure reference vessel diameter and minimal lumen diameter (MLD) were 2.68 +/- 0.48 and 0.90 +/- 0.55 mm for the main branch, respectively and 2.28 +/- 0.34 and 1.14 +/- 0.47 mm for the side branch, respectively. Postprocedure MLD was 2.56 +/- 0.39 mm for the main branch and 2.16 +/- 0.29 mm for the side branch. There were no in-hospital major adverse cardiac events (MACE). At 72 days after procedure there was one case of side branch stent thrombosis (2.2%), which resulted in non Q-wave MI. Angiographic follow up was obtained in 100% of patients at 7.5 +/- 1.3 months. Target lesion revascularization (TLR) was 12.2%; no death and Q-wave MI were observed; reference vessel diameter and MLD for the main branch were 2.79 +/- 0.51 and 1.99 +/- 0.65 mm respectively and for the side branch 2.28 +/- 0.40 and 1.63 +/- 0.48 mm respectively. Restenosis rate in the main branch was 12.2% while in the side branch was 2.0%. CONCLUSIONS: In-hospital outcome indicates that the mini-crush technique for bifurcation lesions with DES can be easily performed. It provides very low total MACE rate and restenosis at 8-month follow-up. These results confirmed the advantage of this specific technique to give complete coverage of the ostium of the side branch using two stents technique.     

Percutaneous treatment of coronary bifurcation lesions in the era of drug-eluting stents

The current report provides an overview of the evolving techniques for percutaneous treatment of bifurcation lesions, including the approaches most commonly used in the current era of DES, and reviews the angiographic and clinical outcomes from clinical series published to date.     

Modified crush technique with double kissing balloon inflation (sleeve technique): a novel technique for coronary bifurcation lesions.

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3-5 mm of proximal stent segment into the main vessel. At the same time, a size-matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side-branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.     

Outcomes of stenting with overlapping drug-eluting stents versus overlapping drug-eluting and bare-metal stents for the treatment of diffuse coronary lesions

Introduction

We investigated the outcomes of stenting with overlapping drug-eluting stents (DES) versus overlapping stenting with a combination of drug-eluting and bare metal stents (BMS) in very long ≥(≥ 25 mm).

Methods and Results

Fifty-two patients treated with either overlapping DES-DES (n = 22) or DES-BMS (n = 30) were selected from a registry of 588 patients with very long coronary lesions. Patients with acute myocardial infarction (MI) within the preceding 48 hours were excluded. The DES-DES combination was more frequently used for longer lesions compared with the DES-BMS group (47.95 ± 9.25 vs 39.98 ± 9.15 mm, p = 0.003). Left anterior descending artery lesions were also more frequently treated with the DES-DES combination (95.5 vs 66.7%, p = 0.02). In four patients in the DES-BMS group, overlapping stents were used for the coverage of dissections. Peri-procedural non-Q-wave MI occurred in one patient in the DES-BMS group. On follow up, only one case of non-fatal MI occurred in a patient with overlapping DES-DES.

Conclusion

Overlapping a BMS in the proximal part of a long DES instead of exclusive deployment of two or more overlapped DES seems to be a safe and feasible therapeutic strategy in our practice.