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1、CTO病变介入治疗技巧,介入心脏医生的最后挑战CTO,The Final Frontiers 分叉病变 小血管病变 多支血管及/或弥漫性病变 慢性闭塞性病变(CTO),Multi-vessel disease with CTO,CTO病变比率,30%,70%,Patients with Total,Occlusions,Patients without,Total Occlusions,Source:Cardiac Data Resources,The BLG Group,30%of patients have one or more total occlusions,CTO病变血管再通的理论
2、价值,延长生命 改善左室功能 增加心肌电活动稳定性，减少心律失常事件增加以后可能出现的冠状动脉闭塞事件耐受性减少CABG提高生活质量,开通CTO的理由 生存率结果,2,007 Consecutive CTO patients June 1980 December 1999 distinct 10-year survival advantage for successful CTO treatment compared to failed CTO treatment.(73.5%vs 65.1%,p=0.001)Suero et.al-JACC August 2001,开通CTO的理由 生存率结
3、果,“At one year follow up,patients with successful PCI of a CTO had a significantly better clinical outcome than those whose PCI was unsuccessfulOlivari,et al.,JACC May 21,2003 At 12 months,patients with a successful CTO procedure experienced:Lower incidence of cardiac deaths or MIs(1.05%vs 7.23%,p=0
4、.005)Reduced need for CABG(2.45%vs 15.7%,p0.0001)Free of angina(88.7%vs 75%,p=.0008),开通CTO的理由 Cardiac Function Outcomes,“Long term patency after recanalization of old,chronic total occlusions in patients with angina pectoris is associated with improvement in global and regional left ventricular func
5、tions”Sirnes,P.A,et al.,European Heart Journal 19(2)273-81,95 patients with recanalized CTO Left ventriculogram at baseline and 6.7 month follow upLVEF increased from.062 to.067(p=.001)Possible recovery of hibernating myocardium,CTO病变介入治疗技巧,非CTO病变的介入治疗成功率:95%CTO病变的介入治疗成功率:大约 60%The major determinant
6、 of success is passage of the guide wire across the lesion！,CTO病变介入治疗技巧,常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理,CTO操作常见的失败原因,导丝不能通过（85%）包括不能穿透闭塞近端/远端纤维帽，进入假腔，或穿孔球囊不能通过（10）不能扩张病变（5）,CTO病变介入治疗技巧,常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理,CTO病变介入治疗成功失败的预测因素,闭塞时间3个月对成功不利闭塞段血管长度15mm
7、对成功不利闭塞近端管状或鼠尾状VS齐头状齐头状使导丝侧滑对成功不利血管闭塞处存在侧支血管对成功不利桥侧支血管的形成对成功不利,利于或不利于成功的CTO病变特征,逆向造影显示闭塞远端显影良好易成功,LAD闭塞处发出对角支不易成功,对角支,LAD,闭塞的右冠发自左冠，侧支循环良好易成功,闭塞段,CTO近端重度扭曲并分叉不易成功,闭塞处分支,严重扭曲,闭塞处,LAD闭塞处发出对角支不易成功,LAD闭塞处发出对角支不易成功,对角支,LAD侧支循环,LAD闭塞处,右冠闭塞处不确切不易成功,分支,主干闭塞处？,LAD闭塞侧支循环良好易成功,前降支侧支循环显影,闭塞段呈鼠尾状易成功,闭塞段长，桥侧支血管形成
8、不易成功,桥侧支血管,功能性闭塞易成功,功能性闭塞段,OM支功能性闭塞易成功,桥侧支血管形成不易成功,桥侧支血管的存在使导丝可能进入多条孔道不易成功,Neo channels can lead through the stenosis or can connect with vasa-vasorum.Connections with vasa-vasorum more likely result in sub-intimal dissection or wire exit,对病变的了解不全面或技术没有完全掌握就可能给患者带来风险,CTO病变介入治疗技巧,常见的失败原因容易成功病变（病例）的选择
9、器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理,Amplatz指引导管增加支撑力，利于球囊通过闭塞段,Amplatz(AL 1.0),JR 4.0指引导管时1.5mm球囊不能通过,闭塞的右冠发自左冠,指引导管的选择6F EBU 3.5导丝的选择亲水涂层的PT2 LS1.5*15mm Over The Wire 球囊,EBU 3.5PT2 LS1.5mm Over The Wire 球囊,前降支开口处闭塞导丝的选择,LAD闭塞处,LCX,导丝的选择：缠绕硬导丝,Hydrophilic(slippery)wire tip has difficulty engaging entry
10、point dimple,Low lubricity(spring coil)wireTip can more easily engage entry point dimple,强支撑力指引导管6F EBU 3.5前降支开口处闭塞导丝的选择：CROSS-IT 200,EBU 3.5CROSS-IT 200,Second and Third Generation Wires,HydrophylicChoice-PT(BSC)PT Series,Stiff SpringMiracle Bros(Abbott)Cross-It(Guidant),Stiff HydrophylicShinobi(Co
11、rdis)PT Interm.(BSC),CTO介入治疗器械决定操作是否成功,CTO病变介入治疗技巧,常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理,对侧造影能够显示导丝是否在血管真腔,当第一根导丝进入夹层时：平行导丝技术,平行导丝技术,导丝在血管腔外,平行导丝技术,第二根导丝进入真腔,2006-08-27 北京首都机场,平行导丝技术要求的技巧,远端管腔显影良好避免两条导丝缠绕建议使用头部性能好的导丝,逆向导丝法,逆向导丝法,逆向导丝法,球囊,PT2-MS导丝（经左冠）,BMW（经右冠）,闭塞的LAD严重成角谁能进入前降支？,对角支,前降
12、支,验证导丝是否在闭塞远端管腔内的方法：造影时回撤球囊可显示闭塞远端血管,闭塞病变时应用OTW球囊进行锚定示意图,闭塞病变扩张边支开口技术,球囊堵塞边支开口,If guide wire consistently goes into the side branch-use a compliant balloon at low pressure to better direct guide wire,导丝通过 CTO病变,CTO病变介入治疗技巧,常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理,坚持、坚持、再坚持！但下列情况时STOP,出现并发
13、症（大或小）造影剂用量过多（5001000CC）曝光时间过长（60min）手术时间过长（2-3小时),CTO病变介入治疗技巧,常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理,WISDOM 注册研究:Objective,To evaluate the 12-month outcome of“real world”interventions using the paclitaxel-eluting TAXUS SR Express stent in high-risk patient and lesion subgroupsDiabetics
14、Patients with acute coronary syndromsTotal occlusionsLonger lesionsSmaller vessels,Aim of the PRISON II Study,To compare the immediate and long-term angiographic and clinical results of BMS(Bx Velocity)implantation with Sirolimus-eluting Stent(CYPHER)implantation for the treatment of CTO,6-month Cli
15、nical Follow-up,Clinical Event(%),20,4,P0.001,24,8,22,8,19,4,3,2,0,P=0.003,P=0.009,P=0.001,P=NS,P=NS,0,P0.0001,P0.0001,41,36,11,7,%,73%,81%,6 Month Angiographic Binary Restenosis Relative Risk Reduction,6-month Angiographic Follow-up Binary Restenosis(50%),Note:*Stented segment including proximal an
16、d distal 5 mm,41,11,36,7,13,4,*,p0.0001,p0.001,p0.04,%,(Stent)Thrombosis in Target Vessel,p=ns,CTO病变介入治疗技巧,常见的失败原因容易成功病变（病例）的选择器械的选择方法的选择何时应该停止手术药物支架的效果并发症的处理,CTO病变介入治疗并发症,导丝穿出血管壁外致手术失败超声观察心包,急性心包填塞的处理：覆膜支架+心包穿刺引流,心包穿刺引流管,有时会产生心脏壁内血肿,CTO病变介入治疗失败的形式,导丝不能通过 不确定导丝在真腔内球囊不能通过出现并发症 无论严重与否,停止操作对患者最安全造影剂和射线达到极限,指引导管支撑力良好微导管或Over The Wire 球囊的应用逐渐增加导丝的硬度多角度投照正确的病例选择耐心和坚持,CTO介入治疗技术（一）,CTO介入治疗技术（二）,双侧同时造影平行导丝及see-saw 技术管腔再进入（STAR)技术逆向技术新器械的尝试一定掌握快速心包穿刺技术,
