冠状动脉介入治疗的球囊和支架的应用-高展.ppt

冠状动脉介入治疗的冠状动脉介入治疗的球囊和支架的应用球囊和支架的应用中国医学科学院阜外心血管病医院高展冠状动脉介入治疗球冠状动脉介入治疗球囊的选择囊的选择球囊分类球囊分类n n整体交换球囊（OTW-over the wire)n n快速交换球囊(monorail)Rapid ExchangeRapid ExchangeGuidewireGuidewireInflation lumenInflation lumen&guidewire lumen&guidewire lumenInflation lumen onlyInflation lumen onlyInflation portInflation portOver-the-WireOver-the-WireGuidewireGuidewireInflation lumenInflation lumen&guidewire lumen&guidewire lumenInflation PortInflation Port球囊的结构球囊的结构n n球囊尖端n n球囊 n n推送杆球囊尖端球囊尖端n n外径：直头圆弧锥形n n尖端与球囊的连接：胶水黏结热焊接激光焊接球囊球囊n n球囊材料：尼龙、聚乙烯球囊顺应性n n折叠方式：三层折叠：利于回卷，后撤，低折叠减小通过半径n n标记方式：中央标记易于通过严重狭窄病变，双标记利于测量病变长度n n球囊肩部角度：球囊于尖部平滑过渡有利于通过病变n n球囊与中心杆的连接技术和材料：决定通过扭曲血管的能力球囊性能球囊性能n n外径（crossing profile)n n灵活性（flexibility)n n跟踪性（trackbility)n n推送性（pushbility)n n顺应性（compliance)球囊操作要领球囊操作要领预扩张预扩张n n有利于支架的植入有利于支架的植入n n有利于病变的测量有利于病变的测量n n选择小于血管直径选择小于血管直径0.5-1mm0.5-1mm的球囊进行预扩张，球的球囊进行预扩张，球囊长度应适当囊长度应适当n n预扩张应尽量减少对正常血管的损伤预扩张应尽量减少对正常血管的损伤n n为测量病变长度，使预扩张球囊在冠状动脉内进为测量病变长度，使预扩张球囊在冠状动脉内进行造影时，注射造影剂的力度不宜过大，以免加行造影时，注射造影剂的力度不宜过大，以免加重血管的撕裂重血管的撕裂n n对于狭窄程度重、较复杂的病变，预计支架通过对于狭窄程度重、较复杂的病变，预计支架通过较困难的病变应常规充分地预扩张，尤其对初学较困难的病变应常规充分地预扩张，尤其对初学者者后扩张后扩张n n防止支架贴壁不良，预防支架内血栓形成，降低再狭窄n n后扩张球囊可选择大一号的球囊或更高的压力n n后扩张时一定不能超出支架的边缘，尤其是的DESn n不可盲目追求所有病例的大球囊高压力的后扩张，以免增加无再流和冠状动脉破裂的风险不同类型病变的球囊选择 n nCTO 病变：常选择单标记、整体交换、小外径（1.5 mm）球囊，如Maverick等n n长病变：原则上选用较长的球囊，以防两端撕裂并减少扩张次数。n n分叉病变：可选双导丝球囊、切割球囊。目的：减少斑块移位、降低分支闭塞的概率。不同类型病变的球囊选择 n n小血管病变：宜选用外形小，推进性好的球囊。还可选用耐高压球囊。n n扭曲病变：应选择外形较小、推进性好的球囊。OTW球囊推进性较单轨球囊好，还有利于交换导丝n n钙化病变：应选择外形较小、推进性好的球囊。还可选用双导丝、耐高压乳突或切割球囊。常用的球囊特点常用的球囊特点Maverick PTCA Balloon Cathetersn nProprietary laser bonded technology creates an extraordinary TrakTip Design and precise,smooth bonds throughout the shaft.n nPush coil design and improved distal flexibility for enhanced trackability.n nOur 1.5 and 2.0 mm SoftLEAP Balloons offer enhanced crossability.Apex PTCA Dilatation Cathetern nSlope Outer Shaft smoothly transitions Slope Outer Shaft smoothly transitions from stiff to flexible,all in one piece,for from stiff to flexible,all in one piece,for more efficient push transmission more efficient push transmission n nBi-Segment Inner Shaft optimizes the Bi-Segment Inner Shaft optimizes the balance between push and track balance between push and track n nShorter,thinner marker bands increase Shorter,thinner marker bands increase distal flexibility distal flexibility n nRedesigned tip with improved flexibility and Redesigned tip with improved flexibility and wire movement;same ultra-low 0.017 profile wire movement;same ultra-low 0.017 profile n nOptiLEAPOptiLEAP Balloon with reduced waist Balloon with reduced waist thickness provides great sizing flexibility with thickness provides great sizing flexibility with lower profiles lower profiles n nNanoNano-composite materials adds structure and-composite materials adds structure and pushabilitypushability to the outer shaft to the outer shaft Quantum Maverick Balloonn nLow profile,full length 1.8F or 2.0F Monorail shaft n nLow profile 3.2F proximal over-the-wire shaft n nBioslide Coating on a PEBAX Distal Shaft n nLaser bonding technology n nQuantum LEAP Balloon Material n nTapered TrakTip Design with.017 lesion entry profile*Quantum Maverick BalloonNC sprintern n外形细小的外形细小的FasTracFasTrac头端技术头端技术-可在遇到可在遇到 较难通过的病变时提供极佳的通过能力；较难通过的病变时提供极佳的通过能力；n n柔软耐用的柔软耐用的Fulcrum PlusFulcrum Plus球囊材料和球囊材料和MiniWrapMiniWrap 折叠技术提供细小的外径和出色的再回抱能力；折叠技术提供细小的外径和出色的再回抱能力；n n 选择性的选择性的Dura-TracDura-Trac涂层使球囊在到达和通过涂层使球囊在到达和通过 病变的过程中保持持久的润滑，在球囊扩张病变的过程中保持持久的润滑，在球囊扩张 时保持稳定；时保持稳定；n n 渐细钢丝设计的推送杆增强了球囊的跟踪能渐细钢丝设计的推送杆增强了球囊的跟踪能 力和通过远端病变能力；力和通过远端病变能力；n n 光滑细小的导丝交换口使光滑细小的导丝交换口使3.5mm3.5mm以下的任何以下的任何 两个球囊可在两个球囊可在6F6F（0.0700.070）的指引导管里对吻。）的指引导管里对吻。n nSunflexSunflex Tip is superbly engineered to give a Tip is superbly engineered to give a perfect balance between flexibility and kink resistance.perfect balance between flexibility and kink resistance.Zero transition between the tip and wire for smoothest Zero transition between the tip and wire for smoothest entry profile.entry profile.n nTapered Tapered Tip:TheTip:The tapered soft tip combined with tapered soft tip combined with advanced laser welding technology provides the advanced laser welding technology provides the most competitive tip profile most competitive tip profilen nSlidematrixSlidematrix dual coating is specially formulated with dual coating is specially formulated with two unique proprietary blends.Hydrophilic and two unique proprietary blends.Hydrophilic and InvioInvio coatings are applied to the distal leading tip section coatings are applied to the distal leading tip section and the balloon/shaft section,respectively to provide and the balloon/shaft section,respectively to provide an optimal balance between lubricious crossing and an optimal balance between lubricious crossing and minimizing watermelon seeding minimizing watermelon seeding n nTight Fold processing results in a slenderTight Fold processing results in a slender primary profile for enhanced primary profile for enhanced crossabilitycrossability through tight lesions.through tight lesions.n nSapphire NCSapphire NCOrbusNeich n nThe IP Transition Zone of the The IP Transition Zone of the AvitaAvita PTCA Dilatation Catheter provides PTCA Dilatation Catheter provides intensified intensified pushabilitypushability.n nThe new tapered tip design with soft The new tapered tip design with soft material exhibits a flexible tip for smooth material exhibits a flexible tip for smooth lesion entry and minimal vessel trauma.lesion entry and minimal vessel trauma.n nThe The InvioInvio coating on the inner lumen coating on the inner lumen eliminates friction between the catheter eliminates friction between the catheter and and guidewireguidewire.InvioInvio is also applied to is also applied to the outer distal segment from the tip the outer distal segment from the tip to the exit marker zone for lubricious to the exit marker zone for lubricious crossabilitycrossability.n nAvitaAvita HP HPOrbusNeich Ruginn nCrossTipTMCrossTipTM 确保确保RyuginRyugin通过性可以达到的最高性能。通过性可以达到的最高性能。CrossTipTMCrossTipTM 是是由特殊混合的弹性塑料聚合物制作而成。由特殊混合的弹性塑料聚合物制作而成。0.017 0.017 英寸英寸(0.043(0.043毫米毫米)的入的入口外径确保了口外径确保了RyuginRyugin 在完全闭塞的病变的复杂管腔里的通过性。在完全闭塞的病变的复杂管腔里的通过性。CrossTipTMCrossTipTM 中等长度的柔韧前端能较易地通过移植支架处的病变并中等长度的柔韧前端能较易地通过移植支架处的病变并绷紧其钙化病变。绷紧其钙化病变。n n亲水涂层亲水涂层亲水涂层亲水涂层M-CoatingM-Coating，塑料聚合物的复合层和新一代金属合金的，塑料聚合物的复合层和新一代金属合金的HypotubeHypotube。使用。使用RyuginRyugin通过过度弯曲和大弯曲血管时，它能顺滑的到通过过度弯曲和大弯曲血管时，它能顺滑的到达目标病变部位，并且成功的处理其复杂闭塞病变。达目标病变部位，并且成功的处理其复杂闭塞病变。n n提供广泛有效的球囊直径选择范围提供广泛有效的球囊直径选择范围从超细的从超细的1.251.25毫米直径到毫米直径到4.04.0毫米毫米直径不等。直径不等。n n薄型聚酰胺球囊薄型聚酰胺球囊薄型聚酰胺球囊薄型聚酰胺球囊确保了其卓越的通过性确保了其卓越的通过性RyuginRyugin CrossTipCrossTip 是从尖端到薄是从尖端到薄型聚合物球囊的一段平滑过度部分，平滑柔韧的联合体能够通过各种型聚合物球囊的一段平滑过度部分，平滑柔韧的联合体能够通过各种复杂病变部位。复杂病变部位。n n泰尔茂新一代泰尔茂新一代泰尔茂新一代泰尔茂新一代FC(FlexibleFC(Flexible Corrugate)Corrugate)轴管轴管轴管轴管成为连接高弹性的前端轴管成为连接高弹性的前端轴管和具备强硬金属的和具备强硬金属的HypotubeHypotube 轴管之间的桥梁。轴管之间的桥梁。FC-shaft FC-shaft 是指经过加工是指经过加工的柔软的胶质轴，该技术实现了通过一个平衡轴加强力量的传输性和的柔软的胶质轴，该技术实现了通过一个平衡轴加强力量的传输性和弹性。弹性。Voyagern nSuperb Cross Tapered Tip DesignSuperb Cross Tapered Tip Design1.1.New tapered tip with.017”tip entry profile designed to cross tight lesions New tapered tip with.017”tip entry profile designed to cross tight lesions 2.2.Improved tip-to-wire conformability1 for confident track and cross Improved tip-to-wire conformability1 for confident track and cross 3.3.Polyurethane tip material is flexible yet durable for tough lesions Polyurethane tip material is flexible yet durable for tough lesions 4.4.Flexible tungsten marker technology allows catheter to conform to tortuous anatomy Flexible tungsten marker technology allows catheter to conform to tortuous anatomy n nMore Options Low Profile Shaft DesignMore Options Low Profile Shaft Design1.1.Versatile treatment in a 6F guide Versatile treatment in a 6F guide 2.2.Excellent track and push in tortuous anatomy with new Excellent track and push in tortuous anatomy with new hypotubehypotube design design 3.3.Reinforced mid-shaft design provides flexibility and additional support Reinforced mid-shaft design provides flexibility and additional support n nFlexibility with Visibility Proprietary Tungsten MarkerFlexibility with Visibility Proprietary Tungsten Marker1.1.New marker material comprised of tungsten polymer New marker material comprised of tungsten polymer 2.2.Flexible marker design allows the catheter to conform more easily to tortuous anatomy Flexible marker design allows the catheter to conform more easily to tortuous anatomy 3.3.Increased marker flexibility helps to reduce resistance when crossing tight lesions Increased marker flexibility helps to reduce resistance when crossing tight lesions n nPrecise Dilatation Proven Balloon PerformancePrecise Dilatation Proven Balloon Performance1.1.Short tapers allow for precise dilatation Short tapers allow for precise dilatation 2.2.Improved LOFOLD Balloon Technology processes allows for excellent rewrap and recross1 Improved LOFOLD Balloon Technology processes allows for excellent rewrap and recross1 3.3.XCELON S Balloon Material achieves superb flexibility XCELON S Balloon Material achieves superb flexibility Powersailn nPLATEAU Balloon MaterialPLATEAU Balloon Material1.1.Provides non-compliance at high pressure without compromising Provides non-compliance at high pressure without compromising performance performance 2.2.Flexibility and conformability for excellent deliverability Flexibility and conformability for excellent deliverability n nLOFOLD Balloon TechnologyLOFOLD Balloon Technology1.1.Provides a low crossing profile for exceptional lesion cross Provides a low crossing profile for exceptional lesion cross 2.2.LOFOLD balloon technology for improved balloon rewrap LOFOLD balloon technology for improved balloon rewrap n nSoft Tip DesignSoft Tip Design1.1.Tapered tip design creates a low entry profile and excellent tip-to-wire Tapered tip design creates a low entry profile and excellent tip-to-wire conformability for easy lesion access conformability for easy lesion access 2.2.Soft tip provides flexibility for negotiating Soft tip provides flexibility for negotiating tortuositytortuosity and crossing and crossing stentstent struts struts n nDual Swaged MarkersDual Swaged Markers1.1.Provide lower profiles than conventional markers Provide lower profiles than conventional markers n nSafeCutSafeCut uses dual wire mechanism to create uses dual wire mechanism to create focused force.It has a built-in 0.011 integral focused force.It has a built-in 0.011 integral wire external to the balloon to help track wire external to the balloon to help track tortuous vessels with great efficiency.tortuous vessels with great efficiency.n nA standard 0.014 A standard 0.014 guidewireguidewire that delivers the that delivers the catheter to the target lesion also participates catheter to the target lesion also participates in the dilatation process.The in the dilatation process.The guidewireguidewire exit exit port is located at the proximal part of the balloon.port is located at the proximal part of the balloon.n nDuring balloon dilatation,the standard During balloon dilatation,the standard guidewireguidewire and integral wire apply controlled force and integral wire apply controlled force to facilitate plaque fractures at low inflation pressures.The same application also helps to facilitate plaque fractures at low inflation pressures.The same application also helps minimize balloon slippage.minimize balloon slippage.n nSafeCutsSafeCuts distal leading tip profile is 0.032 tapered to 0.028 which is smaller than those distal leading tip profile is 0.032 tapered to 0.028 which is smaller than those of other focused force balloons.of other focused force balloons.n nBalloons with embedded blades for scoring the vessel have high crossing profiles due to Balloons with embedded blades for scoring the vessel have high crossing profiles due to the nature of the balloon materials and blades.the nature of the balloon materials and blades.n nThe integral wire and standard The integral wire and standard guidewireguidewire apply evenly distributed force to facilitate apply evenly distributed force to facilitate controlled plaque at low pressures,reducing trauma to the vessel wall.controlled plaque at low pressures,reducing trauma to the vessel wall.n nOther balloons using the same focused force technology use blades which are much Other balloons using the same focused force technology use blades which are much more traumatic to the vessel wall.more traumatic to the vessel wall.OrbusNeich Cutting Balloonn nThe Flexibility You WantThe Flexibility You Want 1.1.Nylon balloon material designed to provide flexibility,superbNylon balloon material designed to provide flexibility,superb compliance and improved puncture resistance compliance and improved puncture resistance 1.1.Overall better deliverability to treat more complex lesions.Overall better deliverability to treat more complex lesions.n nThe Deliverability You NeedThe Deliverability You Need 1.1.30%more Deliverable than the Cutting Balloon Ultra2 Device*30%more Deliverable than the Cutting Balloon Ultra2 Device*2.2.50%improvement in re-cross compared to the Cutting Balloon Ultra2 50%improvement in re-cross compared to the Cutting Balloon Ultra2 Device*Device*n nThe Predictability You Rely OnThe Predictability You Rely On 1.1.Precise dilatation Precise dilatation 2.2.Scoring the plaque by severing the elastic and Scoring the plaque by severing the elastic and fibroticfibrotic continuity of the vessel continuity of the vessel wall wall 3.3.Dilating the lesion at lower pressures with less recoil Dilating the lesion at lower pressures with less recoil 4.4.Lumen gain through plaque compression instead of vessel wall expansionLumen gain through plaque compression instead of vessel wall expansion冠状动脉介入治疗支冠状动脉介入治疗支架的选择架的选择冠状动脉支架广泛应用的原因冠状动脉支架广泛应用的原因n n植入支架后影像好，急性期结果好 n n支架能够治疗急性或濒临闭塞，安全性明显提高 n n支架降低再狭窄率，改善患者的长期预后 n n植入支架容易操作 n n支架的应用可以减少操作时间 n n对于复杂病变，球囊扩张结果往往不理想，植入支架可以得到满意的结果 支架分类支架分类 n n根据设计不同，分为网状支架、管状支架、缠根据设计不同，分为网状支架、管状支架、缠绕型支架、环状支架绕型支架、环状支架 。n n根据材料不同，分为根据材料不同，分为316L316L不锈钢支架、钴支架、不锈钢支架、钴支架、铬支架、镍支架、钽支架。铬支架、镍支架、钽支架。n n根据输送方式的不同，分为球囊膨胀性支架和根据输送方式的不同，分为球囊膨胀性支架和自膨胀性支架。自膨胀性支架。n n根据特殊用途而设计不同的支架，如适合分叉根据特殊用途而设计不同的支架，如适合分叉病变的支架和适合分支的支架以及针对冠状动病变的支架和适合分支的支架以及针对冠状动脉瘤或穿孔的带膜支架脉瘤或穿孔的带膜支架n n根据是否带药，分为药物涂层支架和非药物支根据是否带药，分为药物涂层支架和非药物支架架 支架的性能特点支架的性能特点支架的开环和闭环设计支架的开环和闭环设计网眼大小微米微米支架丝厚度金属动脉比值支架可视性裸金属支架选择原则裸金属支架选择原则 n n针对不同病变和支架的特性选择不同的支架n n支架的直径与参照血管的直径比为1.0-1.1 n n长度将病变或夹层全部覆盖 n n避免过长支架和一支血管植入多个支架，多个支架不可避免时应可能减少支架过多重叠 Cordis Confidential-Internal Use Only药物药物聚合物聚合物支架支架雷帕霉素和紫杉醇雷帕霉素和紫杉醇理想药物理想药物聚合物聚合物最理想的释放系统最理想的释放系统 支架平台支架平台封闭单元式设计封闭单元式设计药物洗脱支架药物洗脱支架回缩和重塑内膜增生结果结果:安全性安全性,疗效性疗效性,输送性输送性DES与与BMS的比较的比较n n早期的临床试验随访早期的临床试验随访早期的临床试验随访早期的临床试验随访4 4年结果表明，年结果表明，年结果表明，年结果表明，DESDES与裸金属支架与裸金属支架与裸金属支架与裸金属支架（BMSBMS）比，明显降低再次血运重建率，但死亡和心肌梗）比，明显降低再次血运重建率，但死亡和心肌梗）比，明显降低再次血运重建率，但死亡和心肌梗）比，明显降低再次血运重建率，但死亡和心肌梗死（死（死（死（MIMI）两者没有差别。）两者没有差别。）两者没有差别。）两者没有差别。n n针对特定亚组患者的随机临床试验，如支架内再狭窄、慢针对特定亚组患者的随机临床试验，如支架内再狭窄、慢针对特定亚组患者的随机临床试验，如支架内再狭窄、慢针