冠状动脉分叉病变的分型、评估和治疗

doi:10.3969/j.issn.1674-490X.2021.04.002

摘要/Abstract

摘要： 冠状动脉分叉病变在冠状动脉介入治疗中较为常见,由于冠状动脉分叉病变个体差异极大、手术操作复杂、术中风险高、术后并发症多、远期预后差,所以很难遵循一套标准流程解决所有的分叉病变。通过分型规则、评估方法和治疗策略进行系统性回顾,以期更全面地认识冠状动脉分叉病变。

关键词: 冠状动脉分叉病变, 经皮冠状动脉介入, 分型, 评估, 治疗

Abstract: Coronary artery bifurcation lesions are common in coronary intervention. Due to the greatly individual differentiation of coronary artery bifurcation lesions, complex surgical procedures, high intraoperative risk, many postoperative complications, and poor long-term prognosis, a standard process is hard to follow to solve all bifurcation lesions. The classification rules, evaluation methods, and treatment strategies of coronary bifurcation lesions are systematically reviewed in order to get more comprehensively understanding of coronary bifurcation lesions.

Key words: coronary bifurcation lesions, percutaneous coronary intervention, classification, evaluation, treatment

中图分类号:

江永正,何花,吴志豪,贾辛未. 冠状动脉分叉病变的分型、评估和治疗[J]. 医学研究与教育, 2021, 38(4): 8-17.

参考文献

[1] LOUVARD Y, THOMAS M, DZAVIK V, et al. Classification of coronary artery bifurcation lesions and treatments: time for a consensus![J]. Catheter Cardiovasc Interv, 2008, 71(2): 175-183. DOI: 10.1002/ccd.21314.
[2] LOUVARD Y, MEDINA A. Definitions and classifications of bifurcation lesions and treatment[J]. EuroIntervention, 2015, 11(Suppl V): V23-V26. DOI: 10.4244/EIJV11SVA5.
[3] SUN Z H, CHAICHANA T. An investigation of correlation between left coronary bifurcation angle and hemodynamic changes in coronary Stenosis by coronary computed tomography angiography-derived computational fluid dynamics[J]. Quant Imaging Med Surg, 2017, 7(5): 537-548. DOI: 10.21037/qims.2017.10.03.
[4] LEFÈVRE T, LOUVARD Y, MORICE M C, et al. Stenting of bifurcation lesions: classification, treatments, and results[J]. Catheter Cardiovasc Interv, 2000, 49(3): 274-283. DOI: 10.1002/(sici)1522-726x(200003)49:3<274::aid-ccd11>3.0.co;2-n.
[5] 陈纪林.分叉病变分型和治疗策略探讨[J].中华心血管病杂志, 2006, 34(6): 551-552. DOI: 10.3760/j:issn:0253-3758.2006.06.019.
[6] 陈纪林.对分叉病变分型及治疗策略的探讨[J].中国介入心脏病学杂志, 2007, 15(5): 295-297. DOI: 10.3969/j.issn.1004-8812.2007.05.022.
[7] 王冠男,张健,石宇杰,等.直径分型法及其指导下的冠状动脉分叉病变介入治疗临床观察[J].中国循证心血管医学杂志, 2016, 8(4): 403-407. DOI: 10.3969/j.issn.1674-4055.2016.04.06.
[8] 霍勇.冠状动脉分叉病变分型及术式选择:对直径分型法指导PCI实践的评价[J].中国循证心血管医学杂志, 2016, 8(4): 385. DOI: 10.3969/j.issn.1674-4055.2016.04.01.
[9] GIRASIS C, SCHUURBIERS J C, MURAMATSU T, et al. Advanced three-dimensional quantitative coronary angiographic assessment of bifurcation lesions: methodology and phantom validation[J]. EuroIntervention, 2013, 8(12): 1451-1460. DOI: 10.4244/EIJV8I12A219.
[10] TU S X, JING J, HOLM N R, et al. In vivo assessment of bifurcation optimal viewing angles and bifurcation angles by three-dimensional(3D)quantitative coronary angiography[J]. Int J Cardiovasc Imaging, 2012, 28(7): 1617-1625. DOI: 10.1007/s10554-011-9996-x.
[11] GRUNDEKEN M J, COLLET C, ISHIBASHI Y, et al. Visual estimation versus different quantitative coronary angiography methods to assess lesion severity in bifurcation lesions[J]. Catheter Cardiovasc Interv, 2018, 91(7): 1263-1270. DOI: 10.1002/ccd.27243.
[12] GRUNDEKEN M J, GARCIA-GARCIA H M, KUMSARS I, et al. Segmental comparison between a dedicated bifurcation stent and balloon angioplasty using intravascular ultrasound and three-dimensional quantitative coronary angiography: a subgroup analysis of the Tryton IDE randomized trial[J]. Catheter Cardiovasc Interv, 2017, 89(2): E53-E63. DOI: 10.1002/ccd.26527.
[13] 李珊,盖鲁粤,杨庭树,等.冠状动脉分叉病变斑块分布特点的血管内超声研究[J].中国循环杂志, 2007, 22(5): 329-332.
[14] KOTANI J, MINTZ G S, CASTAGNA M T, et al. Intravascular ultrasound analysis of infarct-related and non-infarct-related arteries in patients who presented with an acute myocardial infarction[J]. Circulation, 2003, 107(23): 2889-2893. DOI: 10.1161/01.CIR.0000072768.80031.74.
[15] DI MARIO C, IAKOVOU I, VAN DER GIESSEN W J, et al. Optical coherence tomography for guidance in bifurcation lesion treatment[J]. EuroIntervention, 2010, 6(Suppl J): J99-J106. DOI: 10.4244/EIJV6SUPJA16.
[16] KUBO T, SHIMAMURA K, INO Y, et al. Superficial calcium fracture after PCI as assessed by OCT[J]. JACC Cardiovasc Imaging, 2015, 8(10): 1228-1229. DOI: 10.1016/j.jcmg.2014.11.012.
[17] 张云梅,张宏,赵燕,等.FD-OCT在急性冠状动脉综合征介入诊治中的应用研究[J].临床心血管病杂志, 2014, 30(3): 219-222. DOI: 10.13201/j.issn.1001-1439.2014.03.012.
[18] TONINO P A, DE BRUYNE B, PIJLS N H, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention[J]. N Engl J Med, 2009, 360(3): 213-224. DOI: 10.1056/nejmoa0807611.
[19] CHEN S L, ZHANG J J, HAN Y L, et al. Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial[J]. J Am Coll Cardiol, 2017, 70(21): 2605-2617. DOI: 10.1016/j.jacc.2017.09.1066.
[20] LEE J M, KOO B K, KUMSARS I, et al. Coronary fractional flow reserve in bifurcation stenoses: what have we learned?[J]. EuroIntervention, 2015, 11(Suppl V): V59-V63. DOI: 10.4244/EIJV11SVA13.
[21] 宋敏青.FFR指导下分叉病变边支治疗临床疗效回顾性分析[D].南昌:南昌大学, 2013: 8-15.
[22] 王晓腾,王海曙,宋安,等.PCI后FFR值对冠状动脉中度狭窄患者主要心脏不良事件发生的预测价值[J].精准医学杂志, 2020, 35(2): 142-145. DOI: 10.13362/j.jpmed.202002012.
[23] XU B, TU S X, QIAO S B, et al. Diagnostic accuracy of angiography-based quantitative flow ratio measurements for online assessment of coronary Stenosis[J]. J Am Coll Cardiol, 2017, 70(25): 3077-3087. DOI: 10.1016/j.jacc.2017.10.035.
[24] WESTRA J, ANDERSEN B K, CAMPO G, et al. Diagnostic performance of in-procedure angiography-derived quantitative flow reserve compared to pressure-derived fractional flow reserve: the FAVOR II Europe-Japan study[J]. J Am Heart Assoc, 2018, 7(14): e009603. DOI: 10.1161/JAHA.118.009603.
[25] BOERS I, MUSKIET F A, BERKELAAR E, et al. Favourable effects of consuming a Palaeolithic-type diet on characteristics of the metabolic syndrome: a randomized controlled pilot-study[J]. Lipids Health Dis, 2014, 13: 160. DOI: 10.1186/1476-511x-13-160.
[26] WESTRA J, TU S X, WINTHER S, et al. Evaluation of coronary artery Stenosis by quantitative flow ratio during invasive coronary angiography: the WIFI II study(wire-free functional imaging II)[J]. Circ Cardiovasc Imaging, 2018, 11(3): e007107. DOI: 10.1161/CIRCIMAGING.117.007107.
[27] NIJJER S S, DE WAARD G A, SEN S Y, et al. Coronary pressure and flow relationships in humans: phasic analysis of normal and pathological vessels and the implications for Stenosis assessment: a report from the Iberian-Dutch-English(IDEAL)collaborators[J]. Eur Heart J, 2016, 37(26): 2069-2080. DOI: 10.1093/eurheartj/ehv626.
[28] PETRACO R, ESCANED J, SEN S, et al. Classification performance of instantaneous wave-free ratio(iFR)and fractional flow reserve in a clinical population of intermediate coronary stenoses: results of the ADVISE registry[J]. Eurolntervention, 2013, 9(1): 91-101. DOI: 10.4244/eijv9i1a14.
[29] DAVIES J E, SEN S, DEHBI H M, et al. Use of the instantaneous wave-free ratio or fractional flow reserve in PCI[J]. N Engl J Med, 2017, 376(19): 1824-1834. DOI: 10.1056/nejmoa1700445.
[30] GÖTBERG M, CHRISTIANSEN E H, GUDMUNDSDOTTIR I J, et al. Instantaneous wave-free ratio versus fractional flow reserve to guide PCI[J]. N Engl J Med, 2017, 376(19): 1813-1823. DOI: 10.1056/NEJMoa1616540.
[31] ZHANG D, YIN D, SONG C X, et al. A randomised comparison of Conventional versus Intentional straTegy in patients with high Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion: rationale and design of the CIT-RESOLVE trial[J]. BMJ Open, 2017, 7(6): e016044. DOI: 10.1136/bmjopen-2017-016044.
[32] DOU K F, ZHANG D, PAN H W, et al. Active SB-P versus conventional approach to the protection of high-risk side branches: the CIT-RESOLVE trial[J]. JACC Cardiovasc Interv, 2020, 13(9): 1112-1122. DOI: 10.1016/j.jcin.2020.01.233.
[33] GIRASIS C, ONUMA Y, SCHUURBIERS J C, et al. Validity and variability in visual assessment of Stenosis severity in phantom bifurcation lesions: a survey in experts during the fifth meeting of the European Bifurcation Club[J]. Catheter Cardiovasc Interv, 2012, 79(3): 361-368. DOI: 10.1002/ccd.23213.
[34] ROMAGNOLI E, DE SERVI S, TAMBURINO C, et al. Real-world outcome of coronary bifurcation lesions in the drug-eluting stent era: results from the 4, 314-patient Italian Society of Invasive Cardiology(SICI-GISE)Italian Multicenter Registry on Bifurcations(I-BIGIS)[J]. Am Heart J, 2010, 160(3): 535-542.e1. DOI: 10.1016/j.ahj.2010.06.028.
[35] MAENG M, HOLM N R, ERGLIS A, et al. Long-term results after simple versus complex stenting of coronary artery bifurcation lesions: Nordic Bifurcation Study 5-year follow-up results[J]. J Am Coll Cardiol, 2013, 62(1): 30-34. DOI: 10.1016/j.jacc.2013.04.015.
[36] VON KORN H, STEFAN V, VAN EWIJK R, et al. Treatment of coronary bifurcation lesions: stent-covering of the side branch with and without PCI of the side branch: a retrospective analysis of all consecutive patients[J]. BMC Cardiovasc Disord, 2013, 13: 27. DOI: 10.1186/1471-2261-13-27.
[37] BANNING A P, LASSEN J F, BURZOTTA F, et al. Percutaneous coronary intervention for obstructive bifurcation lesions: the 14th consensus document from the European Bifurcation Club[J]. EuroIntervention, 2019, 15(1): 90-98. DOI: 10.4244/EIJ-D-19-00144.
[38] KANG S J, KIM W J, LEE J Y, et al. Hemodynamic impact of changes in bifurcation geometry after single-stent cross-over technique assessed by intravascular ultrasound and fractional flow reserve[J]. Catheter Cardiovasc Interv, 2013, 82(7): 1075-1082. DOI: 10.1002/ccd.24956.
[39] DEPTA J P, PATEL Y, PATEL J S, et al. Long-term clinical outcomes with the use of a modified provisional jailed-balloon stenting technique for the treatment of nonleft main coronary bifurcation lesions[J]. Catheter Cardiovasc Interv, 2013, 82(5): E637-E646. DOI: 10.1002/ccd.24778.
[40] 范俊.改良拘禁球囊技术与拘禁球囊技术在非左主干Y型分叉病变中应用的临床观察[D]. 广州:南方医科大学, 2019: 16-23.
[41] NUMASAWA Y, HASE H, YAMAZAKI H, et al. Three-dimensional optical frequency domain imaging of a true bifurcation lesion after stent implantation using the jailed semi-inflated balloon technique[J]. SAGE Open Med Case Rep, 2017, 5: 2050313X17724711. DOI: 10.1177/2050313X17724711.
[42] KOO B K, PARK K W, KANG H J, et al. Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using fractional flow reserve[J]. Eur Heart J, 2008, 29(6): 726-732. DOI: 10.1093/eurheartj/ehn045.
[43] MOVAHED M R, KERN K, THAI H, et al. Coronary artery bifurcation lesions: a review and update on classification and interventional techniques[J]. Cardiovasc Revasc Med, 2008, 9(4): 263-268. DOI: 10.1016/j.carrev.2008.05.003.
[44] MOUSSA I, COSTA R A, LEON M B, et al. A prospective registry to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions using the “crush technique”[J]. Am J Cardiol, 2006, 97(9): 1317-1321. DOI: 10.1016/j.amjcard.2005.11.072.
[45] HONDA Y, FITZGERALD P J. Stent thrombosis: an issue revisited in a changing world[J]. Circulation, 2003, 108(1): 2-5. DOI: 10.1161/01.CIR.0000075929.79964.D8.
[46] MORRIS P D, GOSLING R, ROTHMAN A, et al. Double-kissing nanocrush for bifurcation lesions: development, bioengineering, fluid dynamics, and initial clinical testing[J]. Can J Cardiol, 2020, 36(6): 852-859. DOI: 10.1016/j.cjca.2019.08.037.
[47] 苑飞,宋现涛,柳弘,等.优化的Culotte术式在冠状动脉真性分叉病变中的应用[J].心肺血管病杂志, 2016, 35(7): 510-513. DOI: 10.3969/j.issn.1007-5062.2016.07.003.
[48] 王格社,唐方明,黄石安,等.DK mini-culotte支架术式治疗冠状动脉分叉病变疗效分析[J].右江民族医学院学报, 2018, 40(2): 116-118, 127.
[49] BURZOTTA F, DŽAVÍK V, FERENC M, et al. Technical aspects of the T And small Protrusion(TAP)technique[J]. EuroIntervention, 2015, 11(Suppl V): V91-V95. DOI: 10.4244/EIJV11SVA20.
[50] 成万钧,周玉杰,赵迎新,等.TAP技术与必要性支架术处理冠状动脉分叉病变的疗效对比[J].中华心血管病杂志, 2010, 38(2): 131-134. DOI: 10.3760/cma.j.issn.0253-3758.2010.02.009.
[51] 陈宗宁,赵渊,庄莉.TAP技术与单支架技术治疗冠状动脉分叉病变的中期效果对比[J].现代仪器与医疗, 2018, 24(1): 32-33. DOI: 10.11876/mimt201801012.
[52] MATSUDA Y, ASHIKAGA T, SASAOKA T, et al. Effectiveness of the proximal optimization technique for longitudinal stent elongation caused by post-balloon dilatation[J]. J Interv Cardiol, 2018, 31(5): 624-631. DOI: 10.1111/joic.12543.
[53] HAKIM D, CHATTERJEE A, ALLI O, et al. Role of proximal optimization technique guided by intravascular ultrasound on stent expansion, stent symmetry index, and side-branch hemodynamics in patients with coronary bifurcation lesions[J]. Circ Cardiovasc Interv, 2017, 10(10): e005535. DOI: 10.1161/CIRCINTERVENTIONS.117.005535.
[54] TZANIS G, KOLYVIRAS A, GIANNINI F, et al. POT-sideDCB-POT: a novel technique for treating coronary bifurcation lesions[J]. Hellenic J Cardiol, 2021, 62(2): 161-163. DOI: 10.1016/j.hjc.2020.04.017.
[55] MURASATO Y, MORI T, OKAMURA T, et al. Efficacy of the proximal optimization technique on crossover stenting in coronary bifurcation lesions in the 3D-OCT bifurcation registry[J]. Int J Cardiovasc Imaging, 2019, 35(6): 981-990. DOI: 10.1007/s10554-019-01581-1.
[56] KLEBER F X, RITTGER H, LUDWIG J, et al. Drug eluting balloons as stand alone procedure for coronary bifurcational lesions: results of the randomized multicenter PEPCAD-BIF trial[J]. Clin Res Cardiol, 2016, 105(7): 613-621. DOI: 10.1007/s00392-015-0957-6.
[57] 陈韵岱,王建安,刘斌,等.药物涂层球囊临床应用中国专家共识[J].中国介入心脏病学杂志, 2016, 24(2): 61-67.
[58] 张欣欣,沈青青,刘伟.药物涂层球囊与第二代药物洗脱支架治疗冠状动脉分叉病变效果比较[J].现代中西医结合杂志, 2020, 29(20): 2258-2261, 2265. DOI: 10.3969/j.issn.1008-8849.2020.20.021.