严重钙化病变的pci治疗王海昌

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1、ApplicationofPercutaneousCoronaryInterventionforSevereCalcificationLesions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CulpritandHealedPlaquesinaCoronaryBifurcationCoronaryarterydisease:Diffusediseasewithavariablemixofstable,vunerableandculpritplaquesFusterV,etal.JACC,2005:46:937-954Epidemiology由动脉粥样硬

2、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%ofmenand15%ofwomenwhohadnocardiovascularsymptomsandexhibitednoothercommonriskfactors,hadextensivecoronaryarterycalcification.[EuropeanHeartJournal25:48–55,2004]Angiogramcannotdetectcalc

3、ifications(CAG)Ultrafastcomputedtomography(CTscanning)canmeasurearterialcalcification(noninvasive)IntravascularUltrasound（IVUS）OpticalCoherenceTomography(OCT)DiagnosisMethodsCalcifiedcoronaryplaquesimagedinvivobyopticalcoherencetomography(OCT)andintravascularultrasound(IVUS)OCTOCTIVUSIVUSN

4、on-invasiveQuantificationforCalcifiedLesionsbyCTScan“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Case1(Ba

5、lloon+DES)CAGCase1(Balloon+DES)COSTLY!3.5hrsOperationtimeLongX-RayExposure6Balloons3GuideWire3DrugElutionStentsCase1(Balloon+DES)Pre-OFinalCAG球囊成形术（PTCA）冠脉夹层发生率高，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。Initi

6、alReaction:FearAtherectomyremovetheplaqueitself,cuttingthesoftplaquefromtheobstructionsitedepositingitinacapsulewhichisthenwithdrawn.AtherocathcourtesyGuidantLaserSomecathetershavealsobeenfittedwithspeciallaserswhichcanphoto-dissolvethetissueobstructingthearteries.Lasercatheter准分子激光冠脉成形术（E

7、LCA）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Rotablator:rotationalatherectomycatheterRotablatorolive-shapeddiamondburrrotatesatextremelyhighspeedRotablatorSyetem驱动杆导丝钻石涂层磨头1.25mm-2.5mm(0.25mmincrements)鞘管4.3frenchO.D.Rotablationisrecommende