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1、Application of Percutaneous Coronary Intervention for Severe Calcification Lesions,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,Culprit and Healed Plaques in a Coronary Bifurcation,Coronary artery disease : Diffuse disease with a variable mix of stable , vunerable and culprit plaques Fuster V, etal. JACC, 2
2、005:46:937-954,Epidemiology,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,29% of men and 15% of women who had no cardiovascular symptoms and exhibited no other common risk factors, had extensive coronary artery calcification. Europ
3、ean Heart Journal 25: 4855, 2004,Angiogram cannot detect calcifications (CAG) Ultrafast computed tomography (CT scanning) can measure arterial calcification (noninvasive) Intravascular Ultrasound （IVUS） Optical Coherence Tomography (OCT),Diagnosis Methods,Calcified coronary plaques imaged in vivo by
4、 optical coherence tomography (OCT) and intravascular ultrasound (IVUS),OCT,OCT,IVUS,IVUS,Non-invasive Quantification for Calcified Lesions by CT Scan,“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,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
5、化病变，单凭高压力植入支架，并发症高、 再狭窄率高,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,Case 1 ( Balloon + DES),CAG,Case 1 ( Balloon + DES),COSTLY!,3.5 hrs Operation time Long X-Ray Exposure 6 Balloons 3 Guide Wire 3 Drug Elution Stents,Case 1 ( Balloon + DES),Pre-O,Final CAG,球囊成形术（PTCA）,冠脉夹层 发生
6、率高，程度重。 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 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） 高压扩张，增加了球囊破裂和夹层分离的危险。,Initial Reaction :Fear,Atherectomy,remove the plaque itself, cutting the soft plaque from the obstruction site depositing it in a capsule which is then withdrawn.,Atherocat
7、h courtesy Guidant,Laser,Some catheters have also been fitted with special lasers which can photo-dissolve the tissue obstructing the arteries.,Laser catheter,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4050。已经被旋磨取代,Rotablator : rotational atherectomy catheter,Rotablator,olive-sh
8、aped diamond burr,rotates at extremely high speed,Rotablator Syetem,Rotablation 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
9、.,AHA/ACC/FDA PCI Guideline,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,DES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,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）
10、能得到最大的管腔和最小的残余狭窄。,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,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,Case2：Severe Calci
11、fication and Balloon Suboptimal Dilation lead to Acute Stent Thrombosis,Male ，57yrs Smoking 30yrs， Chest pain 3yrs， Rest ECG：V1-V3 lead ST segment depression0.1mv Cadiac Triponin T(-),Severe Calcification,Baloon dilation,Stenting,Case2：Severe Calcification and Baloon Suboptimal Dilation lead to Acut
12、e Stent Thrombosis,4 days later!,Female，76yrs Exertional chest pain 8yrs, recurrent 10days EF:40%,RCA1:50，RCA3:75 LAD6：75,7段90 with severe calcification， 8:50，9:50； LCX13:100,14:25%,15: 50,Case3： Rotational Atherectomy for Severe Calcification,Cutting Balloon: 2.5*10 (16ATM, 20“) Post dilate balloon
13、: 2.513 (18ATM, 12“),Case3： Rotational Atherectomy for Severe Calcification,Guiding ： 6F EBU3.5 Guide Wire： Stablizer/ PT2MS Bur: 1.5mm Rotor rate ： 160000 rpm,Case3： Rotational Atherectomy for Severe Calcification,2.524 TAXUS(10ATM, 8“) 2.7528 TAXUS(12ATM, 7“),Final CAG,Stenting,钙化病变的器械选择（I）,导引导管：
14、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,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。,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，
15、明显钙化病变的切割球囊治疗安 全有效,132 patients at least one moderate-severely calcified lesion on fluoroscopy Rotablation/DES vs DES alone Primary endpoint 8 month binary angiographic restenosis Secondary endpoints procedural success/MACE; acute/subacute/late stent thrombosis,ROCCSTAR Trial (Randomisation Of Calci
16、fied Coronary Stenoses to TAxus stenting with or without Rotational atherectomy),Observations to date re impact of Rotablation on procedural outcome in calcified lesions In arriving at 56 pts in DES alone limb, of 64 pts intended for this limb, 8 (12.5%) unable to predilate fully (placed in ROCCSTAR
17、 Rotablator registry) Subacute stent thrombosis 2/56 (3.6%) in DES alone limb (both in small vessels) vs 0/57 in Roto/DES limb,Rotational atherectomy expands the potential for safe and effective percutaneous treatment The device is indicated particularly in high risk pts turned down for CABG( calcification). There may also be longer term benefits in reducing restenosis improved stent deployment, reduced adventitial plaque, reduced plaque shift.,THANK YOU,A healthy smile may promote a healthy heart !,