纳米粒子携带地塞米松局部腔内注射预防球囊损伤后再狭窄的实验研究

目的探讨地塞米松纳米粒子局部腔内灌注在球囊损伤后再狭窄预防中的应用.方法球囊损伤兔髂动脉后在损伤局部单次注射(共3min)纳米粒子、生理盐水或单纯损伤,观察纳米粒子的生物相容性.纳米粒子包被地塞米松在同样动物模型中局部单次给药,在术后3h、3d、7d和14d采用免疫分析法分别测定局部组织和血浆地塞米松浓度.球囊损伤兔髂动脉,分别给予局部纳米粒子(包被地塞米松)、静脉纳米粒子(包被地塞米松)治疗,在术后21d观察损伤血管内膜的增生.结果纳米粒子局部单次注射并未引起过度的内膜增生.局部单次注射纳米粒子,局部组织地塞米松药物浓度在术后3h>5?000ng/mg干重组织;药物在局部组织持续达14d之久;而血浆药物浓度在局部注射3小时后后即不能测定.局部纳米粒子(包被地塞米松)治疗组与静脉给药组与对照组比较能明显减轻内膜增生,且内膜/中膜比减少37.9%.结论纳米粒子具有很好的生物相容性;纳米粒子携带地塞米松局部单次给药能够延长局部药物作用时间达14d,并能有效减少新生内膜的形成.     

球囊与支架对吻技术在冠状动脉分叉病变中的疗效观察

目的观察冠状动脉分叉病变中分支血管直径2.5mm时,主支血管支架置入同时与分支血管保护球囊低压力扩张对吻技术保护分支血管的疗效。方法选择冠心病患者102例,随机分为试验组51例(主支血管支架置入同时与分支血管保护球囊低压力扩张对吻);对照组51例(主支血管支架置入同时分支血管采用导丝保护)。比较2组术中并发症、术后6个月主要不良心血管事件(MACE)发生率。结果试验组术中并发症和术后MACE发生率明显低于对照组(9.8%vs 29.4%,P0.05;9.8%vs 27.5%,P0.05)。结论在分叉病变处理中,球囊-支架对吻技术保护分支血管成功率高,有效降低分支血管闭塞、术中并发症和MACE。     

无球囊对吻单支架植入术治疗分叉病变的近期疗效

目的：通过比较分叉病变经皮冠状动脉介入治疗术（PCI）3种处理方法的近期疗效,探讨最简单处理方法-无球囊对吻单支架植入术的安全性及有效性。方法：入选主支血管即刻造影成功PCI患者81例,分成三组：无球囊对吻单支架组,主支血管植入药物洗脱支架（DES）后,边支血管不予任何处理;球囊对吻单支架组,主支植入DES后,边支血管予球囊对吻扩张;球囊对吻双支架组,主支和边支均植入DES后,予球囊对吻。6个月临床随访观察主要不良心血管事件（MACE）发生情况,以及定量冠状动脉造影（QCA）评价血管再狭窄率和血管狭窄程度。结果：术后6个月,虽然三组间边支血管开口狭窄程度[（65．3±19．6）％、（59．9±17．7）％和（46．8±11．5）％,P〈0．001]有显著性差异,但是三组间MACE发生率（12．1％、14．8％和19．0％,P〉0．05）和主支血管再狭窄率（6．1％、7．4％和9．5％,P〉0．05）差异无显著性。结论：主支血管即刻造影成功PCI患者3种处理方法的近期临床疗效并无显著性差异,提示无球囊对吻单支架植入术治疗分叉病变安全有效。     

'Navius' kissing stents for coronary bifurcation stenosis,recreating a new metallic carina: an IVUS-assessed case report

We report a case of implantation of a new design of stent which allows creation of a double-hemispheric lumen for the treatment of a bifurcational stenosis. The unfavourable outcome following the implantation of this stent is described.     

Balloon angioplasty of coronary bifurcation lesions: the kissing balloon technique

Initial experience with the technique of "kissing balloon" angioplasty is described in 52 patients undergoing coronary angioplasty. Guiding catheters employing both the femoral and brachial approach were used in all but two of the coronary angioplasties and, in addition, the bilateral femoral approach was used in the renal and peripheral angioplasties. Initial success was achieved in 51 (98%) patients. Abrupt closure requiring urgent coronary revascularization occurred in one patient six hours following the completion of the procedure. Another patient developed a new Q-wave on the electrocardiogram and moderate elevation of CPK-MB fraction following the procedure due to loss of a diagonal branch. No deaths occurred in this series. Angiographic restenosis developed in ten patients. In the recurrence group, five had repeat kissing balloon angioplasty, two had repeat single vessel angioplasty, and three patients chose elective surgical revascularization. Based on our experience, the technique of kissing balloon coronary angioplasty can be performed safely utilizing the brachio-femoral technique. The risk of major side branch occlusion can be minimized with this technique and the overall complication rate does not significantly differ from that of our experience in single vessel coronary angioplasty. Patient selection criteria are based upon the angiographic relationship of the major branch to the side branch and is important in determining the initial and long-term success of this technique.     

Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using fractional flow reserve.

AIMS: This study was performed to evaluate the functional outcomes of fractional flow reserve (FFR)-guided jailed side-branch (SB) intervention strategy. METHODS AND RESULTS: One hundred and ten patients treated by provisional strategy were consecutively enrolled and SB FFR was measured in 91 patients. SB intervention was allowed when FFR was <0.75. FFR measurement was repeated after SB intervention and at 6-month follow-up angiography. In 26 of 28 SB lesions with FFR <0.75, balloon angioplasty (SB balloon/artery ratio = 0.84 +/- 0.14) was performed and FFR >or=0.75 was achieved in 92% of the lesions although the mean residual stenosis was 69 +/- 10%. During follow-up, there were no changes in SB FFR in lesions with (0.86 +/- 0.05 to 0.84 +/- 0.01, P = 0.4) and without SB angioplasty (0.87 +/- 0.06 to 0.89 +/- 0.07, P = 0.1). Functional restenosis (FFR <0.75) rate was only 8% (5/65). When clinical outcomes of these patients were compared with 110 patients with similar bifurcation lesions treated without FFR-guidance, there was no difference in 9-month cardiac event rates (4.6 vs. 3.7%, P = 0.7) between the two groups. CONCLUSION: In conclusion, FFR-guided SB intervention strategy resulted in good functional outcomes.     

The glider balloon: A useful device for the treatment of bifurcation lesions

Background

Final kissing balloon dilatation (FKBD) is a recommended final step in case of treatment of bifurcation lesions by two stents approaches. Furthermore, dilatation of the side branch (SB) may be necessary following main vessel (MV) stenting. Occasionally, recrossing the stent struts with a balloon is hampered because the tip hits a stent strut.

Methods

The Glider (TriReme Medical, Pleasanton, CA) is a dedicated balloon designed for crossing through struts of deployed stents toward a SB. From October 2010 to January 2012, FKBD was attempted in 236 consecutive bifurcation lesions treated in our Institution. FKBD was successfully performed by conventional balloon catheters in 221 (93.5%) lesions (Conventional group). In the remaining 15 (6.5%) lesions, where a conventional balloon failed to cross the stent strut, the Glider balloon was attempted (Glider group).

Results

The angle beta (between the axis of the MV after the branch point and the SB axis at the point of divergence) was wider in the Glider group (83 ± 17° versus 65 ± 27°; p = 0.032). A trend toward an higher rate of the true bifurcation lesions was observed in the Glider group (93% versus 70.5%; p = 0.07). The Glider balloon successfully crossed through MV stent struts toward a SB in 12 patients (80%), whereas failed in the remaining 3 patients.

Conclusions

The Glider balloon represents an unique bail-out device which offers an effective rescue strategy for recrossing stent struts during complex bifurcation stenting.     

Sequential vs. kissing balloon angioplasty for stenting of bifurcation coronary lesions.

Coronary angioplasty of bifurcation lesions remains a technical challenge and is believed to result in low procedural success associated with the risk of side-branch occlusion. Furthermore, long-term results are associated with a high rate of reintervention. The aim of the study was to evaluate the immediate and long-term clinical and angiographic results of sequential vs. simultaneous balloon angioplasty (kissing balloon technique) for stenting of bifurcation coronary lesions. Between December 1999 and January 2001, 59 patients underwent coronary angioplasty because of symptomatic bifurcation lesions type III (i.e., side branch originates from within the target lesion of the main vessel, and both main and side branch are angiographically narrowed more than 50%). Twenty-six patients were treated with simultaneous and 33 patients with sequential balloon angioplasty. Main-vessel stent placement was mandatory; side-branch stenting and platelet IIb/IIIa antagonists were allowed at the discretion of the operator. Kissing balloon technique offered no advantage in terms of procedural success or need for repeat target vessel revascularization due to restenosis at 6-month follow-up. Using sequential balloon angioplasty, permanent or transient side-branch compromise rate (TIMI flow < 3) was significantly higher than after kissing balloon technique (33% vs. 0%, respectively; P = 0.003). Major clinical events in-hospital or at 6-month follow-up, however, showed no significant differences. Kissing balloon angioplasty reduces the rate of transient side-branch occlusion compared to sequential PTCA but does not improve immediate or long-term outcome compared to sequential PTCA for stenting of bifurcation lesions.     

双导丝球囊治疗冠状动脉分叉病变的影响因素

目的:分析双导丝球囊治疗冠状动脉分叉病变中影像学效果的影响因素。方法:回顾性分析冠状动脉分叉病变210例,分别按照主支/边支血管参考直径、成角对边支血管即刻管径获得进行亚组分析。结果:球囊扩张主支血管后,在绝大多数病例中,双导丝球囊组边支血管即刻管径获得的绝对值比普通球囊组小(P0.05)。而在主支血管置入支架后,只有在主支血管狭窄程度最重的≥95%[-0.25±0.26)mm vs(-0.54±0.40)mm,P0.01]、边支血管参考直径较小的2.0~2.4mm[(-0.29±0.28)vs(-0.52±0.31)mm,P0.01]、边支血管狭窄程度相对较轻的50%[(-0.09±0.13)mm vs(-0.14±0.06)mm,P0.05]、主支和边支血管成角较小的70°[(-0.30±0.35)mm vs(-0.60±0.37)mm,P0.01]这部分病例中,可以观察到边支血管即刻管径获得的绝对值比普通球囊组小。结论:双导丝球囊用于分叉病变预处理可以在一定程度上减轻主支血管斑块向边支血管位移的程度,特别是对于主支血管狭窄程度较重、边支血管较细、边支血管狭窄程度较轻、Y型分叉病变,即便是在主支血管置入支架后仍然可以观察到双导丝球囊预处理分叉病变后的获益。     

经皮切割球囊成形术治疗老年冠心病患者冠状动脉支架内再狭窄69例分析

目的　观察切割球囊对老年冠心病患者支架内再狭窄的即刻和 6个月时治疗效果。　方法　 6 9例支架内再狭窄患者分配到切割球囊 (38例 )和普通球囊 (31例 )治疗组。球囊扩张前及扩张后即刻 ,用定量冠状动脉造影和冠状动脉内超声测定相关参数。随访 6个月时临床改善及冠状动脉造影结果。研究终点包括出现心肌梗死、需要冠状动脉旁路移植或再介入治疗。　结果　两组的手术成功率为 10 0 %。切割球囊组 1例患者扩张后在支架的远端出现夹层。平均随访 (6 7± 0 3)个月。切割球囊组于术后 3和 6个月时的再狭窄率显著低于普通球囊组 (分别为 15 %对 38%及 18%对4 3% ,均为P <0 0 0 1)。扩张后即刻血管直径获得值在切割球囊组和普通球囊组分别为 (1 72± 0 5 2 )mm和 (1 15± 0 5 4 )mm ,而 3和 6个月后切割球囊组的血管直径晚期丢失值为 (0 2 6± 0 0 5 )mm及(0 38± 0 0 6 )mm ,普通球囊组丢失值为 (0 78± 0 19)mm及 (0 89± 0 16 )mm(均为P <0 0 0 1)。　结论　切割球囊治疗老年冠心病患者支架内再狭窄效果可靠、安全 ,容易操作 ,再狭窄率低 ,易于被患者接受 ,是一个较有前途的治疗手段。     

Modified crush technique with double kissing balloon inflation (sleeve technique): a novel technique for coronary bifurcation lesions.

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3-5 mm of proximal stent segment into the main vessel. At the same time, a size-matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side-branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.     

A novel stenting technique for coronary artery bifurcation stenosis

A novel stenting technique, using one stent strategy, designed to treat type Medina 1,0,0 coronary bifurcation lesions, is described. The atherosclerotic plaque burden in this category of bifurcation lesions is located in the proximal segment of the main branch (MB) of a coronary bifurcation in which the side branch has a sharp angulation (T‐ or reverse‐shaped) relative to the MB. The advantages of this technique are the accurate placement of the stent tailored to cover solely the bifurcation lesion, shoving the plaque burden away from the side branch ostium during stent expansion and the ability to maintain guide wire access in the branch at highest risk of occlusion obviating the need for more cumbersome and time consuming percutaneous coronary intervention procedure. © 2009 Wiley‐Liss, Inc.     

The kissing balloon in angioplasty of coronary stenosis involving the bifurcation of a major branch

A case of severe effort angina treated with Percutaneous Transluminal Coronary Angioplasty (PTCA) is described. The critical coronary lesion involved the left anterior descending coronary artery and the origin of a first diagonal branch. The "kissing balloon" technique was used. After a year, the immediate positive angiographic results remained unchanged.     

药物涂层球囊在冠状动脉分叉病变边支介入治疗中的临床应用

目的探讨药物涂层球囊应用于冠状动脉分叉病变边支血管保护的可行性分析。方法选择2015年3月~2016年3月在解放军总医院经冠状动脉造影证实冠状动脉分叉病变患者20例,Medina分型1,1,1;1,0,1;0,1,1,分别为11、5、4例。行PCI,于主支血管置入药物洗脱支架,边支血管用药物涂层球囊主动保护技术处理,术后即刻冠状动脉造影检查。术后6个月临床随访,统计患者主要心脑血管不良事件。结果20例患者PCI成功率为100%。20例患者主支置入药物洗脱支架,边支血管用药物涂层球囊主动保护技术处理,主支血管最小管腔直径由术前(1.49±0.46)mm增加至术后(3.20±0.53)mm(P=0.001),分支血管由术前(1.36±0.66)mm增加至术后(1.78±0.61)mm(P=0.048)。术后6个月患者无主要心脑血管不良事件发生。结论药物涂层球囊主动保护技术应用于冠状动脉分叉病变边支血管保护安全、有效。     

Simultaneous kissing stents (SKS) technique for treating bifurcation lesions in medium-to-large size coronary arteries

The treatment of bifurcation lesions (BLs) is associated with high procedural complication and restenosis rates. Two techniques of BL interventions were compared: the simultaneous kissing stents (SKS) technique, involving 2 stents, 1 in the main vessel and 1 in the side branch (n = 100), and the conventional stent strategy (CSS) technique, involving a stent in the main vessel and provisional stenting for the side branch (n = 100). In-hospital and 30-day major adverse cardiac events were greater in the CSS group, with significantly less procedure time with the SKS technique. The incidence of target lesion revascularization was 5% in the SKS group and 18% in the CSS group (p = 0.007). Therefore, the SKS technique seems to be rapid, safe, and effective for the treatment of medium- to large-size BLs, with a trend toward fewer acute complications and promising mid-term results.     

Long-term outcome of simultaneous kissing stenting technique with sirolimus-eluting stent for large bifurcation coronary lesions.

OBJECTIVES: This study was conducted to evaluate the outcomes of simultaneous kissing stenting with sirolimus-eluting stent (SES). BACKGROUND: Percutaneous intervention for bifurcation coronary lesions is still challenging. METHODS: This study was designed to evaluate the long-term outcomes of 36 consecutive patients with large bifurcation coronary lesions who underwent simultaneous kissing stenting with SES. RESULTS: Lesion location was unprotected left main in 29 patients (81%) and anterior descending artery in 7 (19%). The patients received a combination of aspirin and clopidogrel for 6 months and cilostazol for 1 month. Mean proximal reference diameter was 4.05 +/- 0.68 mm. Compared with the side branch (SB), the main vessel (MV) involved longer lesions (25.8 +/- 17.0 mm vs. 10.2 +/- 10.8 mm, P < 0.001) and smaller preprocedural minimal lumen diameters (1.02 +/- 0.53 mm vs. 1.46 +/- 0.78 mm, P = 0.006) and was treated with larger stents (3.1 +/- 0.3 mm vs. 3.0 +/- 0.3 mm, P = 0.006). Angiographic success rate was 100%. Over the follow-up of 26.7 +/- 8.6 months, no deaths, myocardial infarctions or stent thromboses occurred. Target lesion revascularization was performed in five patients (14%). Overall angiographic restenosis occurred in 5/30 patients (17%), consisting of 4 (13%) at MV and 3 (10%) at SB. At follow-up angiography, a membranous diaphragm at the carina was identified in 14 patients (47%), but only one of whom was associated with angiographic restenosis. CONCLUSION: Simultaneous kissing stenting with SES appears a feasible stenting technique in large bifurcation coronary lesions. However, a new angiographic structure of carinal membrane developed in a half of patients at follow-up and its influence needs to be further investigated.     

Treatment of renal artery bifurcation stenosis due to fibromuscular dysplasia by kissing balloon technique and intrarenal stent deployment: A case report

Renal artery stenosis due to fibromuscular dysplasia is well treated by PTA, but in some cases repeat PTA or stent placement may be necessary. In this paper, we report a case of distal renal arterial lesion affecting both branches of the renal artery and complicated with a bifurcation aneurysm which was treated by kissing PTA and intrarenal stent placement in a hypertensive patient. Satisfactory angiographic result was achieved and the patient remained normotensive on no medication for nine months follow up period. In rare ocasions, renal artery stent placement even into intrarenal branches can be used safely and effectively.     

A dietary approach to increase in-stent stenosis and face validity of a rat model for arterial angioplasty and stenting

Objective

To expedite the investigation of new devices for inhibiting restenosis, we aimed to develop a modified model of arterial angioplasty and stenting in rats that showed greater face validity than the traditional rat model.

Methods

Carotid arteries from Sprague-Dawley rats fed a normal or an atherogenic diet containing a low dose of cholate underwent balloon pre-dilation followed by placement of a bare metal stent. Vessel patency was followed for 28 d using ultrasound. Stented vessels were then harvested and were subjected to histologic analysis. Plasma lipid profiles and biomarkers of endothelial dysfunction, inflammation and thrombosis were assessed.

Results

There was significant interaction between stenting injury and the atherogenic diet, leading to higher levels of markers for inflammation, platelet activation, and endothelial dysfunction, as well as neointimal hyperplasia, compared with stented rats on normal chow. There was a significant correlation between plasma IL-6 and TXB₂ in stented rats, a relationship which may have contributed to exaggerated vessel remodeling with increased platelet sensitivity. Compared to normal chow, the atherogenic diet also increased fibrin and proteoglycan deposition near stent struts.

Conclusions

Arterial stenting, in combination with the atherogenic diet, led to exacerbated endothelial dysfunction, inflammation, platelet activation, and vascular remodeling compared with stented rats on normal chow. By reproducing key features of clinical restenosis that are lacking in other rat models, this modified rat model may serve as a valuable screening tool to rapidly evaluate new coatings and devices before moving candidates into expensive, more time-consuming rabbit or porcine models.     

拘禁球囊技术在冠状动脉分叉病变中应用的临床疗效观察

目的总结拘禁球囊技术治疗冠状动脉分叉病变的经验,并分析其安全性和疗效。方法选择2014年6月至2016年4月在南京医科大学附属南京医院行冠状动脉造影证实为真性分叉病变的患者50例,按随机数字表法分为两组:拘禁导丝组(25例)和拘禁球囊组(25例),比较两组患者分支夹层或闭塞发生率、置入支架数量、手术时间和造影剂用量等,并对主要不良心血管事件(MACE)、病变血管再狭窄情况进行随访,对其有效性和安全性进行评价。结果拘禁导丝组4例发生分支闭塞或夹层,共置入5枚支架,拘禁球囊组1例发生分支夹层,置入1枚支架,且拘禁导丝组的手术时间和造影剂用量均明显高于拘禁球囊组,差异有统计学意义[(84.5±13.4)min比(53.2±9.8)min,t=2.84,P=0.009;(135.3±12.5)ml比(106.8±11.7)ml,t=8.33,P=0.001]。术后1年,复查冠状动脉造影并行冠状动脉造影定量分析检查,两组主支和边支血管管腔丢失差异均无统计学意义(均为P0.05)。随访期间,拘禁球囊组有1例患者因心力衰竭发作入院,拘禁导丝组有1例患者因心绞痛再发入院,并行靶血管血运重建治疗,余无其他MACE事件。结论拘禁球囊技术是一种治疗冠状动脉分叉病变的有效方法,与传统保护导丝比较,拘禁球囊技术能够有效防止重要分支闭塞,且手术时间和曝光时间短、造影剂用量少,是一种安全、可行的方法。