经桡动脉及股动脉介入治疗冠脉分叉病变的临床研究

目的评价经桡动脉与经股动脉处理冠状动脉分叉病变的治疗效果。方法选取2008年5月至2010年4月行支架治疗的共278例分叉病变患者,224例病变采用单支架,54例采用双支架植入。其中经桡动脉途径160例,经股动脉118例。对比两种途径手术操作时间、X线投照时间、造影剂用量及最终球囊对吻成功率。结果桡动脉途径的手术操作时间、X线投照时间、造影剂用量及最终球囊对吻成功率与股动脉途径差异均无统计学意义。结论经桡动脉途径处理,冠状动脉分叉病变治疗效果与股动脉途径相似。     

冠状动脉分叉临界病变边支行血流储备分数测定的临床意义

目的:分析血流储备分数(fractional flow reserve,FFR)指导的冠状动脉分叉临界病变边支介入治疗的临床效果。方法:回顾性分析冠状动脉主支支架植入后行边支治疗的冠状动脉分叉临界病变患者80例,分为FFR指导边支介入组(FFR组)和常规介入组,每组40例。其中FFR组对FFR测值<0.75的边支血管行介入治疗,包括双球囊对吻及必要时的支架植入。比较两组患者的临床资料、冠状动脉介入治疗结果以及术后随访的心血管不良事件(MACE)。结果:两组在边支支架的植入、双球囊对吻、术后边支残余狭窄>50%中差异有统计学意义(P分别为0.026,0.021,0.043)。两组随访6个月,18个月时MACE发生率差异无统计学意义(P>0.05);在3年MACE中FFR组的发生率比常规介入组低(P<0.05)。结论:FFR指导分叉病变边支治疗会更少地使用球囊与支架,3年的随访中FFR指导组MACE发生率比常规冠状动脉造影组要低。     

DK Crush技术治疗真性冠状动脉分叉病变(附2例分析)

目的:观察DK Crush技术治疗真性冠状动脉分叉病变的价值。方法:回顾性分析2例运用DK Crush技术治疗真性冠状动脉分叉病变的临床资料并结合国内外文献复习。1例患者冠脉CTA示:LAD近端局限性严重狭窄(腔内软斑块形成),LCX近端局限性显著狭窄。LM-LAD、LCX三叉病变80%狭窄LAD近段90%狭窄,D1未受累。1例患者冠脉CTA示:RCA"几"字扭曲病变,RCA远端于后三叉前95%狭窄,LAD、LCX双开口于左窦D1 50%～60%狭窄,LCX于OM处90%狭窄。结果:2例患者分叉病变处均运用DK Crush技术治疗,成功对吻扩张。结论:DK Crush技术治疗真性冠状动脉分叉病变具有较好的临床效果。     

Mini-culotte stenting for bifurcation coronary disease

Coronary bifurcation lesions remain a challenging subset of lesions for percutaneous coronary intervention （PCI） with use of drug-eluting stents.Side branch （SB）is the most problematic lesion with higher rates of instent restenosis leading to the need for revascularization.1The current consensus based on clinical studies have reported that two-stent strategies are required in only a small number of patients.Of currently used complex stenting techniques,culotte stenting is comparable with the others.2-4 Unfortunately,the culotte technique has some limitations,of which double layers of metal struts is reported to be related to the occurrence of stent thrombosis （ST）.Stenting sequences of culotte stenting shares features with provisional T stenting,indicated by a jailed wire in a SB at risk of SB loss after stenting the main vessel （MV）.Accordingly we reported our modified mini-culotte stenting technique in 2008,5 but we found that mini-culotte is not always correctly used in China.As a result,it is crucial to systematically describe the tips and pitfalls of mini-culotte techniques in details.     

冠状动脉分叉病变介入治疗时小分支保护对患者预后的影响

目的 探讨冠状动脉分叉病变在主支血管置入支架时,小分支应用导丝进行保护对患者预后的影响.方法 回顾性分析2008年9月～2010年11月在中南大学湘雅医院因冠状动脉分叉病变(BCL)行冠状动脉介入治疗(PCI)且BCL的分支血管(SB)管径为2.0～2.5 mm的100例患者.按是否在分支内放置保护导丝将患者分为分支保护组(n=36)和分支非保护组(n=64).通过分析手术光盘、手术记录、住院病历资料及9个月随访,比较两组介入治疗手术即刻成功率、住院期间及术后9个月内主要心脏事件发生情况.结果 ①SB保护组患者在手术时间、对比剂用量上均较SB未保护组增加,且差异具有统计学意义(P＜0.05);②两组患者PCI术后分支血管狭窄程度均较术前有所增加,但差异无统计学意义(P＞0.05);③两组术后均无院内MACEs发生;(出院后9个月随访,保护组MACEs发生率5.6％,未保护组MACE发生率7.8％,两组结果差异无统计学意义(P＞0.05).结论 冠状动脉分叉病变行PCI时,对小分支(管径为2.0～2.5 mm)血管实施导丝保护并未能进一步改善患者近期临床效果及远期预后,反而较对照组延长操作及曝光时间,增加治疗费用.     

吸烟对不同病变支数冠心病患者下肢动脉硬化闭塞的影响

目的 探讨吸烟对不同病变支数冠心病患者下肢动脉硬化闭塞的影响.方法 选择行冠状动脉造影检查的患者200例,按结果分为无冠心病的对照组和冠心病组,其中冠心病组患者又分为单支病变、两支病变、三支病变,每组各50例.分析患者吸烟与下肢动脉硬化闭塞情况及下肢动脉踝肱动脉压力指数(AAI)的关系.结果 吸烟者中,冠心病患者的下肢动脉闭塞情况较非冠心病者的严重(P<0.05);非吸烟者中,冠心病患者的下肢动脉闭塞情况与非冠心病者无差异(P>0.05);随着冠状动脉病变支数增多,吸烟者AAI的降低幅度要大于未吸烟者(P<0.05).结论 吸烟对不同冠状动脉病变患者下肢动脉硬化闭塞较高,吸烟冠心病患者病变分支越多,其AAI值越低.     

冠状动脉靶病变钙化相关因素分析

目的探讨冠状动脉靶病变钙化与相关凶素的关系。方法50例确诊为冠心病患者,其中男30例,女20例,采用血管内超声虚拟组织学成像（IVUS—VH）测量冠脉靶病变钙化负荷,结合相关因素,采用多元回归分析寻找相关性。结果冠状动脉靶病变钙化与尿酸（P〈0．01）、碱性磷酸酶（P〈0．01）、骨结合蛋白（P=0．027）呈正相关性,与骨保护素（r=-1．1229,P=0．0242）呈负相关。结论尿酸、碱性磷酸酶等因素可能影响冠脉钙化。     

DK crush technique: modified treatment of bifurcation lesions in coronary artery

Bifurcation lesions are still technically challenging even in the era of modern stents.1 High incidence of restenosis both in main vessel and side branch limits the long-term prognosis although several kinds of techniques have been identified to be successful for coronary bifurcations.2-5 Reports have demonstrated the main reason for higher incidence of ostial side branch even though drug-eluting stent used in side vessel lies in that there were gaps in metal coverage and drug application.6-9 Therefore, new technique ensuring complete vessel scaffolding without gaps in drug delivery at the bifurcation is crush technique which is similar to other techniques including T- and Y- stenting still needing postdilatation of kissing balloon angioplasty to expand the stent fully in the ostial side branch and to prevent stent distortion in main vessel.10 As a result, kissing balloon angioplasty is a key step to improve the final result and to reduce the restenosis after stenting bifurcation lesions. However, kissing angioplasty is difficult to be underwent or impossible because operators usually fail to rewire two layers of metal strut, which would result in suboptimal stent deployment, a main reason of high incidence of restenosis, and acute- or-late-thrombosus. The present study reports modified DK crush technique improving success rate of kissing balloon angioplasty under the guidance of intravascular ultrasound (IVUS).     

DK crush technique: modified treatment of bifurcation lesions in coronary artery

Biefvuernca itnio nthe le esrioan osf maroede srtnil lst etnectsh·n1i calHlyig hch ianlcliednegninceg of restenosis both in main vessel and side branch limits the long-term prognosis although several kinds of techniques have been identified to be successful for coronary bifurcations·2-5 Reports have demonstrated the main reason for higher incidence of ostial side branch even though drug-eluting stent used in side vessel lies in that there were gaps in metal coverage and drug application·6-9…     

拘禁球囊技术与双导丝技术在冠状动脉分叉病变治疗中对分支开口保护的效果比较

目的 观察对比拘禁球囊技术(JBT)与双导丝技术治疗冠状动脉分叉病变对分支开口保护的优劣.方法 选择2010年9月至2016年5月在冀中能源峰峰集团总医院经冠脉造影确诊为冠状动脉分叉病变的81例患者,根据随机数字表法将所有患者分为两组:双导丝技术组(40例),采用双导丝技术治疗,根据单支架释放后边支血流情况,决定是否Rewire导丝;拘禁球囊技术组(41例),采用小内径球囊保护分支开口,主支单支架释放,同时边支球囊压力扩张保护,支架植入后,观察分支血流情况.对比两组患者在实施经皮冠状动脉介入治疗(PCI)时间、边支闭塞、曝光时间、对比剂用量、手术费用、术后主要不良心血管事件(MACE)、冠脉造影定量分析(QCA)等方面的差异.结果 双导丝技术组有10例发生边支闭塞,拘禁球囊技术组有2例发生边支闭塞,差异有统计学意义(P<0.05);与双导丝技术组比较,拘禁球囊技术组PCI实施时间及曝光时间更短、对比剂用量更少、手术费用更低,差异有统计学意义(P<0.05);术后1年随访,MACE发生率及QCA差异无统计学意义(P>0.05).绪论拘禁球囊技术治疗冠状动脉分叉病变可有效保护分支开口,降低边支闭塞率及手术费用,值得推广.     

无保护左主干病变不同治疗策略远期临床效果

目的观察无保护左主干(ULM)冠状动脉病变不同治疗策略远期临床效果。方法比较211例冠状动脉内药物洗脱支架置入术(DES)(DES组)和176例冠状动脉搭桥术(CABG)(CABG组)治疗ULM病变后远期主要心脑血管事件(MACCE)发生率。结果 DES组远期再次血运重建率明显高于CABG组,心源性病死率明显低于CABG组(P<0.05)。采用倾向性得分法分析,血运重建方式与远期MACCE、总病死、心源性病死、心肌梗死和脑卒中发生率未见明显相关(P>0.05);DES与远期再次血运重建率明显相关,风险比为3.050,95%可信区间(1.289,7.217),P<0.05。结论与DES比较,CABG治疗的ULM病变患者临床状态更复杂,冠状动脉病变更严重。DES是接受血运重建的ULM病变患者远期再次血运重建的独立预测因子。     

动态心电图对病变冠脉及狭窄程度的预测

目的　评价 12导动态心电图 (12导Holter)对冠心病 (CHD)患者病变冠脉及狭窄程度的诊断价值。方法　选择 87例拟诊为冠心病的住院患者 ,同期内 (间隔 <1周 )分别接受冠状动脉造影 (CAG)和 12导Holter检查 ,以CAG作为对照 ,对 12导HolterST段结果进行分析。结果　①单支组ST段压低幅度、持续时间在冠脉狭窄≥ 75 %组较冠脉狭窄 5 0 %～ 74 %组增大 ,两组间比较有统计学意义。②单支组LAD病变 16例 ,ST段压低表现在V4～V65例 ,ⅡⅢavFV5V611例 ;RCA病变 8例 ,ST段压低表现在ⅡⅢavF 1例 ,ⅡⅢavFV5V67例 ;LCX病变 1例 ,ST段压低表现在V5V6。结论　根据ST段压低出现导联、压低幅度和持续时间 ,可以对病变冠脉及病变冠脉狭窄程度进行初步的预测和评估     

冠状动脉病变支数及介入治疗对冠心病心功能的影响

目的:观察冠状动脉病变支数及介入治疗对冠心病病人心功能的影响。方法:对60例成功进行经皮冠状动脉成型和支架术的冠心病患者,术前和术后3月通过二维超声心动图观察冠状动脉病变不同支数组的左心室收缩功能的变化及对心功能的影响。结果:冠状动脉的病变支数与LVEF、FS值呈明显负相关;即冠状动脉病变累及越多,左室EF、FS值越低。术后各组左室射血分数及心功能分级均有不同程度改善。结论:冠状动脉的病变支数越多,左室收缩功能受损越明显。PC I能有效改善冠心病患者心脏收缩功能,减轻临床症状。     

心脏不停跳下双桥技术治疗冠状动脉前降支弥漫性病变

目的：评价心脏不停跳冠脉搭桥“双桥”技术在冠状动脉前降支弥漫性病变治疗中的安全性和有效性。方法2008年10月-2012年12月,我院对36例前降支弥漫性病变患者在心脏不停跳下采用“双桥”技术治疗,其中男26例,女10例;年龄46~78（63.8±7.3）岁;双支病变3例,三支病变33例,其中合并左主干病变8例;术前欧洲心血管手术危险因素评分系统（European system for cardiac operative risk evaluation,EuroSCORE）评分为2~7（5.2±1.4）分;左心室射血分数为32.8%~65.0%（49.4±12.2）%。结果所有患者手术均成功,无住院死亡。其中左乳内动脉与前降支狭窄近端搭桥26例,桡动脉和大隐静脉与前降支狭窄近端搭桥分别为3例和7例;大隐静脉与前降支狭窄远端搭桥20例,桡动脉与前降支狭窄远端搭桥16例。平均搭桥3~5（3.2±0.6）支。术后平均呼吸机辅助通气时间、监护室停留时间和住院时间分别为6~16（11.3±2.9） h、9~22（16.5±4.2） h和5~9（6.9±1.4） d。平均随访0.5~4.8（2.8±1.4）年,所有患者均存活,无心绞痛发作。结论前降支“双桥”技术可以安全用于冠状动脉前降支弥漫性长病变患者的不停跳冠脉搭桥手术治疗,疗效可靠。     

Drug-eluting stent for the treatment of small coronary lesion: comparison between sirolimus- and paclitaxel-eluting stent

Background  Patients with small coronary lesions are at increased risk for repeat interventions after coronary angioplasty and stenting. The efficacy of drug-eluting stents (DES) has been demonstrated to improve the outcomes of these patients and is a focus of interest. Currently, two platforms of DES are available (sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES)). However, it has less been known that DES, SES vs PES, is superior for the treatment of small coronary lesions.
Methods  In this retrospective study, 87 consecutive patients with 151 lesions underwent implantation of coronary SES (n=68) and PES (n=83). Quantitative coronary angiography (QCA) was performed at the time of stent implantation and subsequently at 8 months post-stenting. Small vessel disease was defined as lesions in vessels with diameter 2.5 mm measured by QCA. Major adverse cardiac events (MACE) including death, thrombosis, nonfatal myocardial infarction and target lesion revascularization (TLR) were compared between the two groups.
Results  Baseline clinical characteristics and angiographic parameters were similar between the two groups. At clinical and angiographic follow-up, overall thrombosis rates were similar in both groups (0 vs 1.2%, P>0.05). The TLR and in-segment restenosis were not significantly different (19.1% vs 25.3%; 10.3% vs 10.8%, P=0.365 and P=0.913 respectively) between the two groups. The in-stent restenosis rate, however, was significantly higher in the PES group (4.4% vs 21.7%; P=0.002). Similarly, the late loss was significantly higher in the PES group ((0.140.38) mm vs (0.490.61) mm; P<0.001).
Conclusions  In this small sample-size, non-randomized study, the data indicated that implantation of SES for the treatment of patients with small coronary lesion showed more favorable results in respect of restenosis compared with PES implantation.

     

大脑中动脉分叉处动脉瘤的显微外科手术

目的:总结显微外科手术夹闭大脑中动脉分叉处动脉瘤的临床经验和体会。方法:回顾性分析28例经显微外科手术治疗的大脑中动脉分叉处动脉瘤患者的临床资料、手术过程,总结经验。结果:28例患者共30个动脉瘤,其中5例伴有脑内血肿;根据计算机断层血管造影(computed tomography angiography,CTA)或数字减影血管造影(digital subtraction angiography,DSA)评估动脉瘤的大小、形态、朝向和与分叉血管的关系,精心设计显微手术;术后随访6~12月,格拉斯哥预后分级(Glasgow outcome scale,GOS)评分优良22例,中残4例,重残1例,植物生存状态1例。结论:对于大脑中动脉分叉处动脉瘤,应及早手术,术前影像学上的准确分析与评估、合适的手术入路、娴熟的手术技巧是有效夹闭大脑中动脉分叉处动脉瘤,提高术后疗效的关键。     

不适宜冠状动脉旁路移植术复杂小血管病变的冠状动脉介入治疗

目的 探讨对伴左心室射血分数(LVEF)降低的小血管复杂病变行冠状动脉介入(PCI)治疗的安全性和有效性.方法 观察已行PCI治疗实现部分或完全血运重建的16例伴LVEF降低小血管复杂病变患者的手术即刻成功率、并发症,住院时间,术后12个月心功能、LVEF和左心室舒张末内径(LVDd)的改善,主要不良心脏事件(包括心源性死亡、心肌梗死、靶病变血运重建).结果 16例患者行PCI治疗即刻全部成功,无一例死亡,无严重并发症发生,住院时间(11±5)d.患者行PCI治疗后随访12个月,无主要不良心脏事件发生,心功能由术前Ⅲ～Ⅳ级改善为Ⅰ～Ⅱ级,LVEF由术前25%～45%[(29±8)%]提高到32%～48%[(37±7)%],LVDd由术前52～79(66±11)mm缩短至49～68(58 ±8)mm.术后12个月14例患者复查冠状动脉造影,无支架内血栓形成,2例患者出现支架内再狭窄.结论 对伴LVEF降低小血管复杂病变患者,行PCI治疗是安全有效的.有利于降低冠心病心力衰竭的病死率,改善患者长期预后.     

球囊支架对吻术治疗冠状动脉分叉病变的疗效观察

目的 观察球囊支架对吻术治疗冠状动脉分叉病变的临床疗效。方法 连续入选2015年5月至2016年4月45例于同济大学附属东方医院心内科行球囊支架对吻术的冠状动脉分叉病变的患者,观察患者的临床特点、术中病变特点及术后影像学及短期临床事件情况的发生。结果 45例患者共有48处分叉病变处成功进行了球囊支架对吻治疗。其中大多数病变为(70.8%)为Medina1,1,1型。术后即刻TIMI3级血流,主支为100%,分支为96%。2例患者边支置入支架。术中边支内被拘禁的导丝及球囊均能顺利撤出。住院期间及出院1月内无明显的主要心脏不良事件发生。结论 在单支架方法(必要时分支置入支架)治疗分叉病变时,球囊支架对吻术是一种可行、有效的技术,能有效降低边支闭塞的风险,降低住院期间的主要心脏不良事件的发生率。     

Double kissing crush technique for treatment of true coronary bifurcation lesions: two-year clinical outcomes from DKCRUSH-1 study

Standards for treating bifurcation lesions are crucial due to poor outcomes by percutaneous implantation of either bare metal stents or drug-eluting stents, even with several modified double-stent techniques including ＂T＂, ＂V＂, ＂Y＂, ＂culotte＂ and ＂simultaneous kissing stents （SKS）＂. Understanding the drawbacks in classical crush techniques, we proposed a novel double kissing （DK） crush technique being testified in our previous serial studies]＇2 The results from these randomized and pilot studies are describing a fantastic story---DK crush technique, by final kissing balloon inflation （FKBI） in 100% of lesions and high quality of kissing as assessed by both angiography and intravascular ultrasound, significantly improved the clinical outcome at a relative short-term follow-up. However, whether the advantage of the DK crush technique was sustained or not at a long-term remains unclear. The present study aimed to extend clinical follow-up and verify the differences between DK and classic crush techniques.     

血管内超声和血流储备分数测定在冠状动脉临界病变治疗中的作用

目的 比较血管内超声检查(IVUS)和血流储备分数测定(FFR)在指导冠状动脉临界病变治疗中的临床效果.方法 将94例行冠状动脉造影提示冠状动脉临界病变的患者分为IVUS组和FFR组,分别接受IVUS或FFR检查,并以此为依据指导冠状动脉介入治疗.在IVUS组中,如MLA＜4 mm2或冠状动脉狭窄虽不足,但IVUS显示为不稳定斑块,则行冠状动脉介入治疗(PCI);在FFR组中,以FFR＜0.75作为行冠状动脉支架置入术的指征.术后随访6个月,比较两组患者心血管不良事件的发生情况.结果 (1)两组患者病史等一般信息及冠状动脉造影情况差异无统计学意义(P＞0.05).(2) IVUS组行介入治疗的比例高于FFR组(P＜0.01).(3)两组间不良事件的发生情况差异无统计学意义(P＞0.05).结论 IVUS和FFR检查均可用于指导冠状动脉临界病变的介入治疗,受准确性的限制IVUS不能取代FFR检查的地位.