1、RCA Bifurcation,Jin Zening Beijing Anzhen Hospital Beijing, CHINA,History,Male, 54 Years 3 years history of increasing exertional chest pain despite of use Aspirin，Felodipine， Losartan， Metoprolol，Atorvastatin and Isosorbide Mononitrate 11 years history of hypertension 31 years history of ongoing to
2、bacco use No diabetes mellitus,Laboratory,CK: 148U/L，CKMB: 7U/L Troponin：negative TG：3.07mmol/L；TCHO：5.41mmol/L；HDL：0.9mmol/L；LDL-C：3.55mmol/L BUN：98mmol/L；Serum Creatinine：87umol/L ECG：Non specific ST-T change UCG：EF 53%; LV 35/49 mm,Coronary Angiography,Coronary Angiography,Coronary Angiography,Co
3、ronary Angiography,TCT 2005, Morice MC,1,1,1,1,1,0,1,0,1,0,1,1,1,0,0,0,1,0,0,0,1,Medina type,TECHNIQUES,Femoral Approach 7F Femoral Sheath Plan 7F AL 0.75 or XBRCA，but So 7F JR 3.5 Guide Wire：Cronus Moderate Support 0.014”*210cm Magnetic Navigating System 2 DES,The Cronus Guide Wire cant advance int
4、o PDA,The Cronus Guide Wire cant advance into PDA,3mm tip,Diameter 2.5mm,ASAHI Rinato and Whisper MS cant be advanced into PDA,ASAHI Rinato and Whisper MS cant advanced into PDA,Put ASAHI Rinato GW into PLA, Use Voyager 2.515 dilate （6atm10”）,Put ATW Marker Wire into PDA, then use Ryujin 1.515 and S
5、printer 2.515 dilate the ostium of PDA,But,The Guide catheters backup is not strong enough, we cant advance a Cypher select 2.7533 stent to the PLA. Deep seating, Buddy wire, Using a balloon as a slide trackDoesnt work! At last, we cant even advance a balloon into distal of RCA!,Finally,Change the g
6、uide catheter: 6F AL1 But the waveform damping on hemodynamic monitor, and the QRS wave of ECG becoming wide. Made a side hole on the AL1 catheter Re-cross both guide wire,Crush,1.Cypher 2.7533 (16atm),2.Cypher 2.513 (14atm),3.Voyager 2.515,4.Cypher 3.028 (20atm),Dissection of RCA by AL1,Cypher 3.02
7、8 (20atm),Final Result,Final Result,About 3 hours Contrast Agents: Iohexol 425ml One day after PCI: BUN:4.98mmol/L Creatinine:87umol/L ADP: 27% AA:11%,Techniques of Bifurcation,Louvard Y, Lefevre T, Morice MC, et al, Heart 2004; 90: 713-22,Classic T beginning SB,Modified T,Crush,Classic T beginning
8、MB,Provision T,Cullotte,Touching stents,Trouser legs and seat,Kissing stents,Skirt technique,3 randomized trials 1vs 2 stents: MACE, TVR and TLR,Colombo et al,(Circ 2004),Pan et al,(AHJ 2004),Nordic,(Circ 2006),n=91,n=413,n=85,6,month,n=91,6,month,n=413,6,month,19.0%,3.4%,10.6%,13.6%,2.9%,1.9%,6.3%,
9、9.0%,4.5%,2.1%,1.9%,11.4%,11.1%,9.0%,1.9%,9.5%,4.5%,1.0%,% of Patients,MACE,TVR,TLR,2 Stents,1Stent,2 Stents,1Stent,2 Stents,1Stent,Angiographic Restenosis,Colombo et al,(Circ 2004),Pan et al,(AHJ 2004),Nordic,(Circ 2006),n=91,n=413,n=85,6,month,n=91,6,month,n=413,6,month,% of Bifurcations,Bifurcati
10、on,Main Branch,Side Branch,18.7%,4.8%,14.2%,28.0%,5.7%,21.8%,7.0%,2.0%,5.0%,20.0%,15.0%,5.0%,4.6%,5.1%,22.5%,19.2%,16.0%,11.5%,2 Stents,1Stent,2 Stents,1Stent,2 Stents,1Stent,1 or 2 stents?,If the side branch is significantly diseased at its ostium or nearby, it is sufficiently large to be stented,
11、safety and duration of PCI are an issue: 2 stents In all other conditions 1 stents and then evaluateAt present time the most accepted and applied strategy is provisional SB stenting,The important of kissing ballon in Crush technique,9 Month Clinical Outcomes After Crush Stenting,Ge L, et al. JACC,2005;46:613-620,Morice. 2006 PCR,Strategy of DES for Bifurcation,Thank you!,
