严重钙化病变的pci治疗ppt课件

《严重钙化病变的pci治疗ppt课件》由会员分享，可在线阅读，更多相关《严重钙化病变的pci治疗ppt课件（46页珍藏版）》请在装配图网上搜索。

1、12022-8-91Xijing Hospital Application of Percutaneous Coronary Intervention for Severe Calcification Lesions 严重钙化病变的严重钙化病变的PCI治疗治疗王海昌王海昌第四军医大学西京医院心脏内科第四军医大学西京医院心脏内科 陕西西安陕西西安22022-8-92Xijing Hospital 32022-8-93Xijing Hospital Culprit and Healed Plaques in a Coronary BifurcationCoronary artery disease

2、:Diffuse disease with a variable mix of stable,vunerable and culprit plaques Fuster V,etal.JACC,2005:46:937-95442022-8-94Xijing Hospital Epidemiology o由动脉粥样硬化导致，非退行性变o检出率存在显著的性别差别 女：男=1：2o冠状动脉钙化计分随年龄添加呈添加趋势 o冠心病危险要素与冠状动脉钙化亲密相关 oBakdash 等报告非脂质性冠状动脉危险要素的数目与冠状动脉钙化堆积有关 52022-8-95Xijing Hospital 29%of me

3、n and 15%of women who had no cardiovascular symptoms and exhibited no other common risk factors,had extensive coronary artery calcification.European Heart Journal 25:4855,2004 62022-8-96Xijing Hospital q Angiogram cannot detect calcifications(CAG)q Ultrafast computed tomography(CT scanning)q can mea

4、sure arterial calcification(noninvasive)q Intravascular Ultrasound IVUSq Optical Coherence Tomography(OCT)Diagnosis Methods 72022-8-97Xijing Hospital 82022-8-98Xijing Hospital 92022-8-99Xijing Hospital Calcified coronary plaques imaged in vivo by optical coherence tomography(OCT)and intravascular ul

5、trasound(IVUS)OCTOCTIVUSIVUS102022-8-910Xijing Hospital Non-invasive Quantification for Calcified Lesions by CT Scan112022-8-911Xijing Hospital 122022-8-912Xijing Hospital 132022-8-913Xijing Hospital“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要素 1988年ACC/AHA心血管诊治技术评价的报告142022-8-914Xijing Hospital 钙化病变

6、介入治疗q 单纯球囊扩张PTCAq 胜利率低74，夹层率高，急性血管闭塞率高q 球囊扩张支架术q 可改善球囊扩张后的效果，提高胜利率q 严重钙化病变，单凭高压力植入支架，并发症高、q 再狭窄率高152022-8-915Xijing Hospital 钙化病变单纯PTCA的局限性q 即刻效果即刻效果q 病变不能扩展和发生弹性回缩病变不能扩展和发生弹性回缩q 再狭窄再狭窄q 多数研讨没有显示钙化病变和多数研讨没有显示钙化病变和PTCAPTCA后再狭窄之间的后再狭窄之间的q 关系关系162022-8-916Xijing Hospital Case 1(Balloon+DES)CAG172022-8-

7、917Xijing Hospital Case 1(Balloon+DES)COSTLY!p 3.5 hrs Operation time p Long X-Ray Exposure p 6 Balloons p 3 Guide Wire p 3 Drug Elution Stents182022-8-918Xijing Hospital Case 1(Balloon+DES)Pre-O Final CAG192022-8-919Xijing Hospital 球囊成形术PTCAq 冠脉夹层q发生率高，程度重。q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q发生率

8、从旋磨后的22添加到辅以球囊扩张后的77，夹层分别的部位也从钙化斑块的内旋磨后移至钙化斑块的外PTCA后q高压扩张，添加了球囊破裂和夹层分别的危险。202022-8-920Xijing Hospital Initial Reaction:Fear 212022-8-921Xijing Hospital Atherectomy remove the plaque itself,cutting the soft plaque from the obstruction site depositing it in a capsule which is then withdrawn.Atherocath

9、Atherocathcourtesy courtesy GuidantGuidant222022-8-922Xijing Hospital LaserSome catheters have also been fitted with special lasers which can photo-dissolve the tissue obstructing the arteries.Laser Laser cathetercatheter准分子激光冠脉成形术ELCA有报道称手术胜利率较高。使钙化破裂而不是去除，对一些不能扩张的病变是有效的。术后再狭窄率较高为4050。曾经被旋磨取代232022

10、-8-923Xijing Hospital Rotablator:rotational atherectomy catheterRotablatorRotablatorolive-shaped diamond burrrotates at extremely high speed242022-8-924Xijing Hospital Rotablator Syetem 驱动杆驱动杆导丝导丝钻石涂层磨头钻石涂层磨头1.25 mm-2.5 mm(0.25 mm increments)鞘管鞘管 4.3 french O.D.252022-8-925Xijing Hospital Rotablatio

11、n is recommended for fibrotic or heavily calcified lesions that can be wired but not crossed by a balloon or adequately dilated before planned stenting.One must know how to manage the complications inherent to rotablation.AHA/ACC/FDA PCI Guideline262022-8-926Xijing Hospital 钙化病变的分类q 内膜面钙化q 严重者影响球囊、支

12、架的充分扩张，需求旋磨q 外膜或斑块基底部钙化q 造影显示明显，对PCI影响不大，不需旋磨272022-8-927Xijing Hospital DES时代钙化病变治疗的要点q 钙化病变预扩张q 支架完全覆盖病变q 支架释放压16-18ATMq 后扩张q 血管内超声 282022-8-928Xijing Hospital STRTAS(Study To Determine Rotablator and Transluminal Angioplasty Strategy)初步结果显示，采用更大的磨头和较长的旋磨时间进展剧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rotas

13、tent能得到最大的管腔和最小的剩余狭窄。292022-8-929Xijing Hospital 钙化病变介入治疗的难点Iq 单纯依托冠脉造影评价钙化程度欠准确q 植入支架后的再狭窄率高q 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，“无复流景象添加q 斑块切除术DCA、TEC、ELCA对钙化病变协助较小302022-8-930Xijing Hospital 钙化病变介入治疗的难点IIq 直接支架植入该当慎重q 支架经过困难，易呵斥支架零落率添加q 如用高压力16atm仍未使支架充分扩张者，q 采用更高压力 20atm，仍能够不会到达称心q 的支架扩张q 支架不能充分扩张，亚

14、急性血栓发生率添加q 内膜夹层、撕裂率添加q 球囊破裂、血管破裂、心包填塞添加312022-8-931Xijing Hospital Case2：Severe Calcification and Balloon Suboptimal Dilation lead to Acute Stent ThrombosisMale，57yrsSmoking 30yrs，Chest pain 3yrs，Rest ECG：V1-V3 lead ST segment depression0.1mvCadiac Triponin T(-)Severe Calcification Baloon dilation S

15、tenting 322022-8-932Xijing Hospital Case2：Severe Calcification and Baloon Suboptimal Dilation lead to Acute Stent Thrombosis4 days later!332022-8-933Xijing Hospital Female，76yrsExertional chest pain 8yrs,recurrent 10daysEF:40%RCA1:50，RCA3:75 LAD6：75,7段段90 with severe calcification，8:50，9:50；LCX13:10

16、0,14:25%,15:50Case3：Rotational Atherectomy for Severe Calcification 342022-8-934Xijing Hospital Cutting Balloon:2.5*10 (16ATM,20)Post dilate balloon:2.513 (18ATM,12)Case3：Rotational Atherectomy for Severe Calcification 352022-8-935Xijing Hospital Guiding：6F EBU3.5Guide Wire：Stablizer/PT2MSBur:1.5mmR

17、otor rate：160000 rpmCase3：Rotational Atherectomy for Severe Calcification 362022-8-936Xijing Hospital 2.524 TAXUS(10ATM,8)2.7528 TAXUS(12ATM,7)Final CAG Stenting 372022-8-937Xijing Hospital 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 球囊和支架经过性好 382022-8-938Xijing Hospital 钙化病变的器械选择IIq 支架q建议选择设计有

18、桥衔接的支架q 设计良好的管状支架，闭环系统、辐射力好、金属覆q 盖率好。可以使支架更合理扩张、血栓率低、再狭窄q 率低q旋磨头q 根据血管直径，从小到大改换，最大旋磨头应q 选择直径小于血管直径的75。392022-8-939Xijing Hospital 钙化病变的操作要点I 预扩张：非常重要！支架往往不能直接经过病变；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，逐渐添加压力，直至 球囊切迹消逝切割球囊的运用 小样本研讨显示，明显钙化病变的切割球囊治疗安 全有效402022-8-940Xijing Hosp

19、ital 132 patients at least one moderate-severely calcified lesion on fluoroscopyRotablation/DES vs DES alonePrimary endpoint 8 month binary angiographic restenosisSecondary endpoints procedural success/MACE;acute/subacute/late stent thrombosisROCCSTAR Trial(Randomisation Of Calcified Coronary Stenos

20、es to TAxus stenting with or without Rotational atherectomy)412022-8-941Xijing Hospital Observations to date re impact of Rotablation on procedural outcome in calcified lesionsIn arriving at 56 pts in DES alone limb,of 64 pts intended for this limb,8(12.5%)unable to predilate fully(placed in ROCCSTA

21、R Rotablator registry)Subacute stent thrombosis 2/56(3.6%)in DES alone limb(both in small vessels)vs 0/57 in Roto/DES limb422022-8-942Xijing Hospital 432022-8-943Xijing Hospital 442022-8-944Xijing Hospital 452022-8-945Xijing Hospital oRotational atherectomy expands the potential for safe and effecti

22、ve percutaneous treatment oThe device is indicated particularly in high risk pts turned down for CABG(calcification).oThere may also be longer term benefits in reducing restenosis improved stent deployment,reduced adventitial plaque,reduced plaque shift.462022-8-946Xijing Hospital THANK YOU A healthy smile may promote a healthy heart!