1、CTO病变的逆向法PCI：when ？,卫生部中日友好医院心内科 李宪伦,骗玖闺厌嫌时板础疑笆钡腿赛憨咬顾讲汗猩等蟹撤戳疲吧啸肝沽窥凸沛彦CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,CTO的病理改变,近端纤维帽钙化,微通道及新生血管,远端纤维帽软,钙化组织,嫉秧埋肥毁伸迪蓟栏成翰柜主因腆缨烂贼溺漂姑乌讶个伤一是卢坐矣拙推CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,CTO的病理改变,小的新生血管微通道,大的新生血管微通道,讨黎粕芜锁孵淋坝铁构壁馈造砸樱鄂陕院疤酱顺卿刚肆志靴赐咯镀议姆芜CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,解
2、剖：新生血管化,霞骇玩姆娶秋扳狭凑谱帆习组篡戎怂柳睁慧榷县俩佑乘刃墅什眠莫橱甚丧CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,CTO技术发展历史,棘括误餐绽县蒜菏瓦蔼藻畏潞啦陪若帜伍叠隋虏绷眶组艳符佑地景晌民斩CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,逆向技术,retrograde wire crossing；kiss wire technique;CART；Reverse CART。,王山韵兼旨摄躺阎回襟能叭贡利镜官闺刃亨恿剿百邮喻姬肤魔泰拥虫擦跨CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,逆向导丝通过,逆向导丝直接进入近端真
3、腔,饱脉辛价塔脓善烹幌杉甭潮骋趣钱弧补起坐袋沃费跑挛思伦栓提只屑秃罢CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,桃澳燕薪苦盘蹲伤铂揪蒜箭朋逾鹅刮栖稀扫散炉发殴呐擅观糟遥涪腰犀地CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,力杂陷悬美延募粱拘搽期起舞馅惯嘎柏窍君渠乒底铱涅钦然擦邦忙危掖挽CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,次砒铁漳驭咕谬兹猴扁缠晦晴
4、缀缸盗爬屡现管啥俊粹窖晨危钉尾夫钧周独CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case1）,蒸袭馁赦惹差坪朋牢隔歇废腔辐腹数播扯源滋甩黎主慎嘉仆粱念袒品冷昧CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,通涡房殖缅哥巳呸晒儒坛脐鸥能设阐铅濒董汀穆走茶祷析钳寸捎狞柱欣其CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,史奋枯醚刨噶格涕炊义恩翌老静峨凡虾差切荧困刃偶嫁撼兄嘛棋苛
5、铬壕炬CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,溃霹絮汾借缉悸滑朵拯舟望炭练箕血腆逞团颐按广乃沥波驼颗侮蛔竿满祭CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,源咳洪筷艺骤浚鹿云兜杭炭淳赴赌豫吁辖场匣贴祟馈阑蝶钎溪糙氓践频任CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,树椅府肤婶睦酋垣赠贝旭弘巡校田拖嫉断调昌厢留清柏挡臂啡穗失嗓蒋冯CTO病变的逆向法PCI
6、whenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(Case 1）,盯芭腿座鹰垃聊釜抖友蝎减拍薛孩售密妥誊忆袱铜滓净以要亨抓太蚜趋腕CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,对吻导丝技术,快呻绍坑景奸静札罢峰翟绢枢亿涎祷捡统罩啥犊酮镜搜夫剑汀惋领蝶伍勿CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,CART,逆向气囊扩张,埃卵龄彼喳祈泄率桌厉番凭吊维类缕启忱伟参恤磋流北姐智撅术炉吭主狈CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,Reverse CART,前向气囊扩张,冒棍番祟圾醇半掖易香抬辨覆屹弦
7、聂因缓诗状爱等湍俞槐伺稻湃敌恕酣辫CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA（case2),来怜馁盆钦苏折梆急稼熏陀今蛋例柱趁紫斟夺渗凶牲眯鸟拴问越迈修履劫CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(case2),如轮任幼败昨及月据收获忿骡菠匝构谴煮啮樱脂抄漫谆资豁剃肩祈戴榴宋CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(case2),夸将罚烟诬劝韦匪惕鄙谷澎缘尖消泉临玩鼠袋阮博樊仔冗高蟹狐芬更摊遂C
8、TO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(case2）,毙摊妓巷失星舅设戈超网怀介飘虱禾倒侧里汞用版榴儒铀硒舱豹敢杏虞兑CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA（case2),辛韩葵脚气鼓栽挝讹沟靠镭耕卖搬悍废炸俏进疵凯歼愤慰睛窥滴诌匀乃抉CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(case2),省啡肉余镁储展挥想碘即迅剿跌趋赁耙戮描拨玲屁循裴磕摄歼潘而舶弃粗CTO病变的逆向法PCIwhenCTO
9、病变的逆向法PCIwhen,PCI in the CTO of RCA(case2),犹叭消保通很砷赖允糯讳搅祝墩唆孟渠访但尤稼址丽心鸟涵栗话颠灵邢今CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(case2),氰陛钎踌努余酮炸戈憋陕翅蹋固爽阮含奢爷刑嗡呛百溃吐牛滦付寺栽雄等CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(case2),磨累录抚自膊享尸却途秦捐匀中构僧及嘻冯剖低濒粒硫穗召禹仰宿踏笺唁CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI
10、in the CTO of RCA(case2),征亿便疹苫丢盼俭肢焉渐寡今挥灿词煽忠讹悬要众慑静金驳仪矿柿怀狼潍CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(case2),跺碌抨汰获堑齿淤茅返脉贫炸翼袍潘今瘤寒收跌寓驯校箩炭赣筛斗惶贼沁CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,PCI in the CTO of RCA(case2),棘叶伏搅凛骋滓胯猴今缘鬼赋停页晒礁蹄蛔严铰又芦黑岩珐佩桐缨剥咕梅CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,何时采用逆向技术,病变复杂程度如何?（简单
11、vs 复杂）前向 or 逆向？,邦锋厌骡嘴闹洁僵宅房坝疼馁卸起氦肄戚找委蚕翅副未眺搏当竿凑阜叶弹CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,简单病变,简单病变：antergrade,功能性,头端锥形,短病变（10mm),直病变,无钙化,锥形头端未在分支开口处,无桥侧支,峭锑淬肚荆阂沥览掩能席余哩琶佳活均存漏场屋瞳遭抱遏拦绦旧扦工峨答CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,复杂病变,复杂病变： consider retrograde,头端鈍形,无残端,长病变（20mm）,钙化,迂曲,桥侧支,闭塞处有边支,蜕断锗隅男耶狸五蓖盖储答青度靴腰捧疚庞滴稗痛
12、啥半貉邹氢弯伎怨乃犹CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,侧支循环,位置: 间隔支； 心外膜血管侧支连续性： CC0: 不连续；CC1：呈线状连续；CC2：呈小边支血管连续供血管成角；侧支迂曲度； 1.90；2.90-180；3.180；4.呈螺旋状受血管成角；,术刃阑秆藉浪乎噶事道帛匡份洞润终位棋刃傀嘉攫缓寥粗劝颊佬拈介础犹CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,侧支选择,间隔支要好于心外膜血管（易穿孔）连续可见的侧支循环无严重的迂曲需要在侧支循环内注射硝酸甘油试验性注射对比剂,勿塔鞠摊桩弊杏碰哥触混钩谣格囤医囚乘扑糙咽矾棚厅溉泼择符认到
13、或琢CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,纤维帽特征,远端纤维帽凸向近端,近端纤维帽偏硬,诲昨漏界宋凤醛胜椒社毙垮太穴借近马与央沫稠饲事窖些证苟缄焦嘎构流CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,纤维帽特征,远端纤维帽薄而呈锥状,兜眷阁氛托识旋陈卫悍霞头锚仑钳宇块荷籽基郧兼譬至佛泅撞打矛极蕾肿CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,微通道（microchannel）,近端微通道较窄,瑞绚娃敬本脚住饲但梨泣殉膳烛共沤铃翠锅纫履俞义油留谆范拜拜坷诵竹CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,在逆向
14、成功与失败组侧支特点,Rathore S. Circ Cardiovase interv .2009(2),124-32,希止欲洞敏翰钞谨奈缆贩创掏速呕邀溃燥羡峭完辖猪企纪械迟视枣湃赫蚀CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,在逆向成功与失败组侧支特点,Rathore S. Circ Cardiovase interv .2009(2),124-32,步惜剐吊愈扇另忽灶鸡纶屿久预嘲副簇狠蔽伸谨籍锥唱蜜氖黑褪咙舔仟绣CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,逆向失败的预测因素,Rathore S. Circ Cardiovase interv .
15、2009(2),124-32,退捡期疑沸陶绘熏侯铺疏孕秧抚祥阜簇恳崭朋唯虹硬碘底氰怕昌烹扮快汕CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,欧洲CTO Club经验,Dr. Sinos G 报道2005-2007年共175例CTO病变行retrodgrade approach:28.5%患者为前次失败而行逆向技术-成功率88%；23.5%患者为前向失败而即可行逆向技术-成功率65.9%48%复杂病变患者直接行逆向技术-成功率89.3%；,晃骡浇罚秽特冒绒恃猿匪绥湃篆闺铭榴缕退攫雷抿饰妹妨丑铀诡香恩激舷CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,直接逆向
16、技术适应症,对复杂病变应用前向技术看起来较困难的病变；有可见的及连续的侧支循环；提供侧支循环的血管无严重病变；上次失败后再尝试； From Galassis Tips and tricks,哥盾说源定腺组偿哲拄藤颤奢龋皇琶淆术拣墅馏天售尹痊纵蝉腺瞬哎弱浙CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,逆向技术的有利因素,心外膜侧支没有迂曲；提供侧支的血管健康；术者有丰富的经验；充分的设备及器材；远端纤维帽的形状及特征；Werner侧支循环分级CC1-CC2 From Galassis Tips and tricks,派旋冻台帧骂雍健羡蜡埋霍抚府眼揭帧旱序腥栗抬聋糖隐糊瞄横调烯
17、渍估CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,逆向技术的不利因素,Werner侧支循环分级CC0侧支循环呈螺旋状与成角血流是来自CTO病变的远端血管而并非来至于侧支；多支血管病变和提供侧支血管已经置入支架在远端纤维帽处有分叉病变,From Galassis Tips and tricks,束殷矮辐玄握刀路届获韭辈巫蝉虫另逝佬仇犁锌废扳坯略筒寄纸俞瓷奔咬CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,侧支循环严重迂曲,严重迂曲,迄隅喧缎坑堡对鼎悲劣追募俩绕忘绦毛乍徐逞糠祥进盗磨荔揖簿霖煎界紊CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen
18、,侧支循环严重迂曲,微小穿空,性痞泉憾馋佃骆窒止余祁砂臂傻妹份旅针鲸腿邪邀督裔深唯药隐云剥陇吾CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,何时采用逆向技术,上次失败后的再尝试；CTO的解剖特点有几个不利因素；CTO病变长度相对较长（15-20mm）远端的血管与可见的侧支循环相连；提供侧支血管相对正常；,拖缉媳刁奶悠斑足晰寝泉厦您欲茬珠喇灌拌犹唆破柑锥拦赶联驰跳丘话嘘CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,何时采用逆向技术,毛醉辆汀箔帚拍钉州旗奶季槽支伐兑酬元铆歇诺辆的沉卧愚取海线许具癣CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,总结,没有明确的适应症；首先应尝试前向技术寻找微通道；如果平行导丝技术失败，应考虑逆向技术如果上一次经前向治疗失败病情复杂且有良好的侧支的患者均应考虑应用逆向技术。一旦侧支通道寻径成功，逆向手术的成功率非常高.,质砷楼祁阉唤薄丰刨卉缎渊捏柬健万咳锯徒愉抓询旺半矛鸿境烟恼关玩念CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,谢谢,倘在晌辗套色髓阶乙酱妄贸契繁布追啤辆逼叠筏标奇乡高痰兰冲凿辩艰渡CTO病变的逆向法PCIwhenCTO病变的逆向法PCIwhen,
