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分叉病变介入治疗天津市第三中心医院心脏中心刘迎午Content◼Definitionofbifurcationlesion◼Classificationofbifurcationlesion◼Strategyofbifurcation---onestentort

wostents◼Specificstentforbifurcation◼Clinicalcasesdefinition◼累及到冠状动脉分叉的病变◼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(pereutaneo

uscoronaryintervention，PCI)的15％~20％◼分叉病变的解剖结构(斑块负荷、斑块位置、血管角度、血管直径、分叉位置)千变万化．而治疗过程中解剖结构也会随时改变(斑块迁移、血管夹层)◼所以无两个完全一致的分叉病变，更无一种

可适用于所有分叉病变的手术方法ClassificationClassificationofbifurcationlesionsaccordingtoplaqueburdenA:DukeB:SanbornC:SafianD:LefevreMedinaA.e

tal.RevEspCardiol.2019;59:183-4ANewClassificationofCoronaryBifurcationLesions-MedinaClassification1,1,11,1,01,0,10,1,11,0,

00,1,00,0,1MBDistalMBProximalSB◼一个好还是两个好？◼如果选２个，应该采取何种策略?◼策略选择的根据◼简单化vs复杂化◼循证结果vs个人选择◼并发症率(especiallyMI/thrombosis)分叉病变介入

治疗-关注热点Stentingforbifurcationlesionsin2019主支放支架，分支临时决定Stentingthemainvesselwithprovisionalstentingofthesidebran

chProvisionalStentingStrategy◼If2ndstentisneededforsidebranchfollowingmainvesselstenting◼ModifiedT-stenting◼Reversecrush

ing◼Culottestenting分支血管的保护与放置支架◼并非所有分支血管同等重要!◼根据以下情况实施分支血管保护和支架植入◼分支血管大小与分布区域◼分支血管开口病变与病变程度◼分支与主支成角程度SidebranchclosureafterPCISide-branchmayb

ecompromisedfollowingmainvesselstentingPre-treatmentAfterstentingPlaqueshifting(“Snow-plow”)OstialspasmorSide-branchcompromisebystent

materialDissectionofplaqueatoriginofside-branchDissectionflapatmainarteryobstructingoriginofside-branchAttimes,thesidebranchcouldbecompromisedby

thrombustooDifferenttechniquesoftwostentsbyintentiontotreatbifurcationlesions◼TheVstentingtechnique◼Thesimultaneouskissin

gstentstechnique◼TheTstentingandmodifiedTstentingtechnique◼Thecrushtechnique(Thereversecrushtechnique/Thestepcrushtechnique/Theinvertedcrusht

echnique)◼Theculottesstentingtechnique◼TheYstentingtechnique◼TheskirttechniqueTheVstentingtechniquThesimult

aneouskissingstentstechniqueTheVstentingandthesimultaneouskissingstentingtechnique◼适合于分叉病变位于接近开口的血管近端，例如位于左主干的分叉病变，并且左主干短或无病变。理想夹角<90°。◼V支架也适合于其他

部位的分叉病变，近段无病变或无须支架。TheVstentingandthesimultaneouskissingstentingtechnique◼优点:➢保证不会丢失分支。➢对吻技术时无须re-crossanyst

ent.TheVstentingandthesimultaneouskissingstentingtechnique◼缺点:➢双支架近端定位较困难；➢不可避免造成其中一个支架偏心，往往引起agap。The

TstentingtechniqueThemodifiedTstentingtechniqueTheTandmodifiedTstentingtechnique◼优点:➢较crush技术容易完成。➢缺点:➢大多数情况下，分支开口不能完全

覆盖。4.8%5.7%14.2%21.8%18.7%28%051015202530Stent+StentStent+BalloonRestenosis(%)MainbranchSidebranchOverallColomboetalCircu

lation2019;109:12441249*Highcross-overratefromStent+BalloontoStent+Stentgroup(22/43,51%)CypherBifurcationStenting(T-stenting)Effe

ctsoftheTstentingtechniqueRESEARCHbifurcationsubgroup16.7%7.1%0%5%10%15%20%Tstentothersothers：Culotte，kissingstentRRofdifferenttechniquesThehighre

stenosisrateofTstentingtechniquemayberelatedtotheincompletecoverageofstentingbeinglocatedattheostiumofS

B.TanabeK,HoyeA,LemosPA,etal.AmJCardiol,2019,91:115-8EffectsoftheTstentingtechniqueVstentingvsTstenting1.5%19.5%2.0%5.2%0%5%10%15%20%25%ST9mo

nsTLRTstentingVstentingP=0.007◼Sharmaetal.◼Vstenting:100◼ProvisionalTstenting:100◼32%subjectsreceivedCypherstentandRVDwas3.32mm。

ProvisionalTstenting◼优点:➢Higherproceduralsuccessrate➢Lowerexpense➢Lowercomplications➢Lowerre-PCI◼7monsTLR<15%。◼Lefevreetal:ProvisionalTstentingist

hegoldenstandardtotreatfalsebifurcationlesion(tpye2,3and4a),mostsubjectsonlyneedonestentimplantation。ProvisionalT

stentingThecrushtechniqueThecrushtechnique◼优点:➢可以保证两条分支的立刻开通,这点对保护功能上重要的分支非常重要。➢可以完全覆盖分支开口。◼缺点:➢由于有多层

支架金属，导丝和球囊再次通过较困难，操作复杂。GeetalJACC2019;46:613Longtermoutcomeof“Crush”Stentingtechnique7.1%12.5%5.5%35.

0%0%10%20%30%40%MBSBFKBnon-FKBP=0.116monsRRColomboetal.ThecrushtechniqueThereversecrushorinternalcrus

htechniqueThereversecrushorinternalcrushtechnique◼主要用于临时分支支架植入provisionalSBstenting.Thereversecrushorinternalcrushtechnique优点:➢可以保证两条分支

的立刻开通，6Fguidingcatheter可以完成操作。缺点:➢由于有多层支架金属，导丝和球囊再次通过较困难，操作复杂。ThestepcrushtechniqueCase:ThestepcrushtechniqueFirstkissing

SecondkissingFinalresultThestepcrushtechnique◼优点:➢6Fguidingcatheter可以完成操作，特别适合于桡动脉经路，第二次导丝和球囊再次通过较容易成功。缺点:➢同thestandardcrushte

chnique.TheinvertedcrushtechniqueTheinvertedcrushtechnique◼适用于分支管径不小于主支的情况。◼分支支架挤压crush主支支架。◼缺点:➢同thestandardcrushtechnique.Restenosi

sinMV=12.2%RestenosisinSB=2%Galassietal.Cath&Cardiovas.Intervn2019;69:976-83TheculottesstentingtechniqueTheculo

ttesstentingtechnique◼优点:➢适合于任何角度的分叉病变，并提供完美的分支开口覆盖。◼缺点:➢分叉病变近段双层支架重叠，金属密度高。NordicBifurcationStudyII-TheNordicSten

tTechniqueStudy:CrushvsCulottestentingNordicBifurcationStudyII-TheNordicStentTechniqueStudy:CrushvsCulottestentingI

ndividualend-pointat6monthsTheYstentingtechniqueTheskirttechniqueTheYstentingtechniqueandTheskirttechnique◼优点:➢这是最后一种治疗分叉病变的方法，适用于非常复杂的分叉病变并要求

保证导丝进入两分支。◼缺点:◼近端支架释放系统需要改良，手工将支架捻在双球囊上。应用DES易破坏polymer。◼近端支架很难完全连接远端双支架。◼采用Y支架技术时，多数术者将分支导丝回撤并放入主支，这时释放近端支架可以更好连接远端支架TheYstentingtechnique◼77

casebeingwithbifurcationlesionsreceivedtheYstentingtherapyand6monsfollow-upresults:RR36%,TLR30%。MaillardL,GuerinL,DrieuL,etal.AmJCard

iol2019;82:7A–50SClassificationofbifurcationlesionsaccordingtoplaqueburdenA:DukeB:SanbornC:SafianD:Lefev

reTheVstentingtechniqueThesimultaneouskissingstentstechniqueTheTstentingandmodifiedTstentingtechniqueThecrushtechnique(Therevers

ecrushtechnique/Thestepcrushtechnique/Theinvertedcrushtechnique)TheculottesstentingtechniqueEachlesionmustbeapproachedtherapeut

icallyinthecontextofitsownanatomy.