严重钙化病变的pci治疗-王海昌

11XijingHospitalApplicationofPercutaneousCoronaryInterventionforSevereCalcificationLesions严重钙化病变的PCI治疗王海昌第四军医大学西京医院心脏内科陕西西安22XijingHospital33XijingHospitalCulpritandHealedPlaquesinaCoronaryBifurcationCoronaryarterydisease:Diffusediseasewithavariablemixofstable,vunerableandculpritplaquesFusterV,etal.JACC,2005:46:937-95444XijingHospitalEpidemiology由动脉粥样硬化导致，非退行性变检出率存在显著的性别差异（女：男=1：2）冠状动脉钙化计分随年龄增加呈增加趋势冠心病危险因素与冠状动脉钙化密切相关Bakdash等报告非脂质性冠状动脉危险因素的数目与冠状动脉钙化沉积有关55XijingHospital29%ofmenand15%ofwomenwhohadnocardiovascularsymptomsandexhibitednoothercommonriskfactors,hadextensivecoronaryarterycalcification.[EuropeanHeartJournal25:48–55,2004]66XijingHospitalAngiogramcannotdetectcalcifications(CAG)Ultrafastcomputedtomography(CTscanning)canmeasurearterialcalcification(noninvasive)IntravascularUltrasound（IVUS）OpticalCoherenceTomography(OCT)DiagnosisMethods77XijingHospital88XijingHospital99XijingHospitalCalcifiedcoronaryplaquesimagedinvivobyopticalcoherencetomography(OCT)andintravascularultrasound(IVUS)OCTOCTIVUSIVUS1010XijingHospitalNon-invasiveQuantificationforCalcifiedLesionsbyCTScan1111XijingHospital1212XijingHospital1313XijingHospital“中－重度钙化（B型）病变是导致冠状动脉球囊成形术（PTCA）手术失败和血管急性闭塞的主要危险因素”—1988年ACC/AHA心血管诊治技术评价的报告1414XijingHospital钙化病变介入治疗单纯球囊扩张（PTCA）成功率低（74％），夹层率高，急性血管闭塞率高球囊扩张＋支架术可改善球囊扩张后的效果，提高成功率严重钙化病变，单凭高压力植入支架，并发症高、再狭窄率高1515XijingHospital钙化病变单纯PTCA的局限性即刻效果病变不能扩展和发生弹性回缩再狭窄多数研究没有显示钙化病变和PTCA后再狭窄之间的关系1616XijingHospitalCase1(Balloon+DES)CAG1717XijingHospitalCase1(Balloon+DES)COSTLY!3.5hrsOperationtimeLongX-RayExposure6Balloons3GuideWire3DrugElutionStents1818XijingHospitalCase1(Balloon+DES)Pre-OFinalCAG1919XijingHospital球囊成形术（PTCA）冠脉夹层1.发生率高，程度重。2.部位在钙化与非钙化斑块的移行处，与球囊扩张过程中所产生的不均匀的剪切力有关3.发生率从旋磨后的22％增加到辅以球囊扩张后的77％，夹层分离的部位也从钙化斑块的内（旋磨后）移至钙化斑块的外（PTCA后）4.高压扩张，增加了球囊破裂和夹层分离的危险。2020XijingHospitalInitialReaction:Fear2121XijingHospitalAtherectomy•removetheplaqueitself,•cuttingthesoftplaquefromtheobstructionsite•depositingitinacapsulewhichisthenwithdrawn.AtherocathcourtesyGuidant2222XijingHospitalLaserSomecathetershavealsobeenfittedwithspeciallaserswhichcanphoto-dissolvethetissueobstructingthearteries.Lasercatheter准分子激光冠脉成形术（ELCA）有报道称手术成功率较高。使钙化破裂而不是清除，对一些不能扩张的病变是有效的。术后再狭窄率较高为4050％。已经被旋磨取代2323XijingHospitalRotablator:rotationalatherectomycatheterRotablatorolive-shapeddiamondburrrotatesatextremelyhighspeed2424XijingHospitalRotablatorSyetem驱动杆导丝钻石涂层磨头1.25mm-2.5mm(0.25mmincrements)鞘管4.3frenchO.D.2525XijingHospitalRotablationisrecommendedforfibroticorheavilycalcifiedlesionsthatcanbewiredbutnotcrossedbyaballoonoradequatelydilatedbeforeplannedstenting.Onemustknowhowtomanagethecomplicationsinherenttorotablation.AHA/ACC/FDAPCIGuideline2626XijingHospital钙化病变的分类内膜面钙化严重者影响球囊、支架的充分扩张，需要旋磨外膜或斑块基底部钙化造影显示明显，对PCI影响不大，不需旋磨2727XijingHospitalDES时代钙化病变治疗的要点钙化病变预扩张支架完全覆盖病变支架释放压16-18ATM后扩张血管内超声2828XijingHospitalSTRTAS(StudyToDetermineRotablatorandTransluminalAngioplastyStrategy)初步结果显示，采用更大的磨头和较长的旋磨时间进行强烈的消蚀与更保守的消蚀方法相比，并没有改善即刻和远期效果。旋磨＋支架（rotastent）能得到最大的管腔和最小的残余狭窄。2929XijingHospital钙化病变介入治疗的难点（I）单纯依靠冠脉造影评价钙化程度欠准确植入支架后的再狭窄率高旋磨术适于内膜弥漫钙化病变，利于支架充分植入，长期疗效更好，“无复流现象”增加斑块切除术（DCA、TEC、ELCA）对钙化病变帮助较小3030XijingHospital钙化病变介入治疗的难点（II）直接支架植入应当慎重支架通过困难，易造成支架脱落率增加如用高压力（16atm）仍未使支架充分扩张者，采用更高压力（20atm），仍可能不会达到满意的支架扩张支架不能充分扩张，亚急性血栓发生率增加内膜夹层、撕裂率增加球囊破裂、血管破裂、心包填塞增加3131XijingHospitalCase2：SevereCalcificationandBalloonSuboptimalDilationleadtoAcuteStentThrombosisMale，57yrsSmoking30yrs，Chestpain3yrs，RestECG：V1-V3leadSTsegmentdepression0.1mvCadiacTriponinT(-)SevereCalcificationBaloondilationStenting3232XijingHospitalCase2：SevereCalcificationandBaloonSuboptimalDilationleadtoAcuteStentThrombosis4dayslater!!!3333XijingHospitalFemale，76yrsExertionalchestpain8yrs,recurrent10daysEF:40%RCA1:50％，RCA3:75％LAD6：75％,7段90withseverecalcification，8:50％，9:50％；LCX13:100％,14:25%,15:50％Case3：RotationalAtherectomyforSevereCalcification3434XijingHospitalCuttingBalloon:2.5*10(16ATM,20)Postdilateballoon:2.5＊13(18ATM,12)Case3：RotationalAtherectomyforSevereCalcification3535XijingHospitalGuiding：6FEBU3.5GuideWire：Stablizer/PT2MSBur:1.5mmRotorrate：160000rpmCase3：RotationalAtherectomyforSevereCalcification3636XijingHospital2.5＊24TAXUS(10ATM,8)2.75＊28TAXUS(12ATM,7)FinalCAGStenting3737XijingHospital钙化病变的器械选择（I）导引导管：强支撑力导引导丝：亲水涂层导丝，支撑力好，采用微导管交换钢丝球囊和支架通过性好3838XijingHospital钙化病变的器械选择（II）支架建议选择设计有桥连接的支架设计良好的管状支架，闭环系统、辐射力好、金属覆盖率好。能够使支架更合理扩张、血栓率低、再狭窄率低旋磨头依据血管直径，从小到大更换，最大旋磨头应选择直径小于血管直径的75％。3939XijingHospital钙化病变的操作要点（I）预扩张：非常重要！支架往往不能直接通过病变；支架直接植入常会导致支架不能充分扩张球囊扩张选择比血管直径小0.5mm以上的半顺应性、耐高压球囊，扩张压在8atm以上，逐渐增加压力，直至球囊切迹消失切割球囊的使用小样本研究显示，明显钙化病变的切割球囊治疗安全有效4040XijingHospital132patients–atleastonemoderate-severelycalcifiedlesiononfluoroscopyRotablation/DESvsDESalonePrimaryendpoint–8monthbinaryangiographicrestenosisSecondaryendpoints–proceduralsuccess/MACE;acute/subacute/latestentthrombosisROCCSTARTrial(RandomisationOfCalcifiedCoronaryStenosestoTAxusstentingwithorwithoutRotationalatherectomy)4141XijingHospitalObservationstodatereimpactofRotablationonproceduraloutcomeincalcifiedlesions1.Inar