如何看造影片子狭窄段和扩张段

病例1：左主干杂交技术（图1-19，图1-20）

患者资料

女性，53岁

主诉：间断胸痛1年，加重3个月

既往史：高血压（＋），糖尿病（-），吸烟（-）

入院诊断：不稳定型心绞痛

图1-19　冠脉造影

A～C．此患者在行LCX大隐静脉主动脉冠状动脉旁路移植术后即刻行LM至LAD的PCI术，造影提示，LM末端狭窄90%，LAD开口狭窄90%，LCX开口、近段狭窄95%，可见LCX大隐静脉桥血管影，RCA动脉硬化

图1-20　左主干介入治疗

A、B．右侧股动脉途径，指引导管为7Fr EBU3．5，导丝为runthrough和route，应用Ryujin　2．0mm×15mm球囊于病变处行预扩张，残余狭窄50%；C、D．于LM至LAD置入支架，Cypher　3．0mm×28mm，造影提示支架膨胀良好，残余狭窄小于10%；E、F．应用Ryujin　2．0mm×15mm球囊扩张LCX开口；G、H．应用Qvantom　3．0mm× 10mm球囊（LM至LAD），Ryujin　2．0mm×15mm球囊（LAD至LCX）于左主干分叉处行球囊对吻扩张（Crossover术）；I．最终造影提示，支架膨胀良好，无明显残余狭窄和血栓形成；J．桥血管造影提示，桥血管通常

病例2：左主干分叉病变（图1-21，图1-22，图1-23）

患者资料

男性，65岁

主诉：活动后胸闷3年

既往史：高血压（＋），陈旧前壁心肌梗死（＋），吸烟（-）

超声心动图：轻度二尖瓣、三尖瓣反流，EF：60%～65%

入院诊断：不稳定型心绞痛，陈旧前壁心肌梗死

图1-21　冠脉造影

A～C．造影提示，LM狭窄70%～80%，LAD近段、中段狭窄90%～95%，远段完全闭塞，LCX开口狭窄70%

图1-22　LAD介入治疗过程

A～D．右侧股动脉途径，导引导管为8Fr JL4SH，导丝为BMW，应用Ottimo　2．0mm×15mm球囊序贯预扩张LAD；E、F．随后，应用Maestro　2．5mm×14mm球囊预扩张LAD；G～I．LAD置入支架（1～3），Taxus　2．75mm×20mm，Taxus　3．0mm×32mm，Taxus　4．0mm×28mm3枚支架首尾相接，并覆盖至LM开口；J、K．LM至LAD支架置入后造影结果，LCX开口受累，TIMI血流2级

图1-23　LCX介入治疗过程

A、B．LM末端分叉部位应用Crossover术式，先后应用Ottimo　2．0mm×15mm，Ryujin　3．0mm× 15mm球囊于LCX开口进行扩张；C．LM末端分叉部位最终对吻球囊扩张，LM至LAD：Quantum　4．5mm ×8mm，LM至LCX：Ryujin　3．0mm×15mm；D．应用Quantum　4．5mm×8mm球囊于LM开口行后扩张；E、F．最终造影结果

评论

图1-24　冠脉造影

LM末端狭窄90%，LAD开口狭窄80%

1．术后行FFR检查，LM至LAD FFR＝0．92。

2．FFR在受累的LCX开口FFR＝0．88，所以并没有置入支架。

3．此患者亦可行CABG治疗。

4．应用IVUS进行辅助与检测。

5．此患者应强化抗血小板治疗。

病例3：左主干分叉病变Crossover术结合平行球囊技术（图1-24，图1-25）

患者资料

女性，68岁

主诉：间断胸痛5年，加重6个月

既往史：糖尿病（＋）

入院诊断：不稳定型心绞痛

图1-25　左主干介入治疗过程

A、B．右侧桡动脉途径，指引导管为6Fr EBU3．5，导丝为BMW，应用arashi　3．0mm×15mm球囊于病变处行预扩张，残余狭窄70%；C、D．于LM至LAD置入支架，Cypher　3．5mm×33mm，LCX开口受累，狭窄80%；E．应用Extensor　4．0mm×10mm球囊与支架内球囊与LM支架内行平行球囊扩张；F、G．应用arashi　3．0mm×15mm球囊于LCX开口行Crossover扩张；H、I．应用Extensor　4．0mm×10mm球囊（LM至LAD）与arashi　3．0mm×15mm球囊（LM至LCX）于LM分叉处行最终对吻球囊扩张

病例4：左主干对吻支架技术（图1-26，图1-27，图1-28）

患者资料

男性，63岁

主诉：间断胸闷2年

既往史：高血压（＋），高脂血症（＋），吸烟（-）

入院诊断：稳定型心绞痛

图1-26　冠脉造影

A、B．造影提示，LM末端狭窄80%，LAD与LCX弥漫动脉硬化，狭窄40%～60%

图1-27　左主干介入治疗过程

A．右侧股动脉途径，指引导管为7FJL4．0，导丝为BMW，于LM直接置入支架，Cypher　3．0mm×28mm（LM至LAD），Cypher　3．0mm×23mm（LM至LCX）行对吻支架技术；B、C．支架置入后造影提示，支架膨胀良好，无明显残余狭窄

图1-28　随访

A、B．6个月随访造影提示，LM对吻支架处可见明显金属脊产生

病例5：左主干开口病变介入治疗（图1-29，图1-30）

患者资料

男性，61岁

主诉：间断胸痛1个月，加重1周

既往史：高血压（＋），吸烟（-）

入院诊断：不稳定型心绞痛

图1-29　冠脉造影

造影提示LM开口狭窄90%

图1-30　左主干介入治疗过程

A、B．右侧股动脉途径，指引导管为7Fr JL4．0，导丝为BMW，应用maverick　2．5mm× 20mm球囊行预扩张，残余狭窄80%；C、D．于LM开口置入支架，Cypher　3．5mm×8mm，造影提示支架膨胀良好，无明显残余狭窄

病例6：左主干开口病变介入治疗（图1-31，图1-32，图1-33）

患者资料

男性，53岁

主诉：间断胸痛2个月，加重3d

既往史：高血压（＋），吸烟（＋）

入院诊断：不稳定型心绞痛

图1-31　冠脉造影

造影提示，LM开口狭窄85%，LCX远段狭窄80%

图1-32　左主干介入治疗过程

A、B．右侧股动脉途径，指引导管为7Fr JL4．0，导丝为BMW，应用Sprinter　2．5mm× 12mm球囊于LM病变处行预扩张，残余狭窄70%；C、D．于LM置入支架，Taxus　3．5mm ×16mm，造影显示支架膨胀良好，残余狭窄小于10%；E．IVUS检测LM支架贴壁良好，无血栓形成

图1-33　随访

A、B．6个月造影随访提示，LM支架通常，无明显支架内再狭窄；C．6个月造影随访时行乙酰胆碱激发试验，示给予50μg乙酰胆碱冠脉注射后左冠出现弥漫性痉挛；D．示给予硝酸甘油冠脉注射后痉挛消失

病例7：左主干平行球囊技术（图1-34，图1-35，图1-36）

患者资料

男性，61岁

主诉：间断胸痛2年，加重6个月

既往史：高血压（＋），高脂血症（＋），吸烟（＋）

入院诊断：不稳定型心绞痛

图1-34　冠脉造影

A、B．造影提示，LM近段至远段严重狭窄80%，LAD、LCX、RCA轻度动脉硬化

图1-35　LM介入治疗过程

A、B．右侧股动脉途径，指引导管为6Fr JL4，导丝为BMW，应用Voyager　3．0mm×15mm球囊行预扩张，残余狭窄70%；C、D．于LM置入Cypher　3．5mm×13mm；E、F．应用Maestro　4．0mm× 8mm和Quantum　4．0mm×8mm球囊先后进行后扩张；G．球囊扩张后LM近段有锯齿样表现，但没有血栓，血流也未受限，IVUS检查显示为病变部位斑块组织经由支架网眼突出管腔，并无血栓形成；H、I．另外置入runthrough导丝，应用Quantum4．0mm×8mm和voyager　3．0mm×15mm球囊于LM支架内行平行球囊扩张；J～L．造影可见LM支架中段斑块突出管腔，与IVUS检查显示，LM支架MLD增大，但斑块突出管腔更为明显；M、N．最后应用JO　5．0mm×20mm球囊后扩张

图1-36　随访

A、B．6个月造影随访可见LM置入支架通常，无支架内再狭窄

病例8：左主干完全闭塞病变的介入治疗（图1-37，图1-38，图1-39）

患者资料

男性，48岁

主诉：劳力性胸痛6个月，加重1h

既往史：高血压（＋），吸烟（-）

ECG：V1～V3导联病理性Q波，V4～V6导联ST段压低

心肌酶：CK-MB　69．8ng／ml

超声心动图：左室前壁无动力运动，EF：40%

入院诊断：非ST段抬高型心肌梗死

图1-37　冠脉造影

A～C．造影提示，LM完全闭塞，RCA开口病变并为LAD提供侧支循环

图1-38　左冠介入治疗过程

A、B．右侧股动脉途径，指引导管为7Fr JL4．0，导引导丝为BMW，应用Mercury　2．0mm×14mm球囊于闭塞处行预扩张；C、D．于LAD中段置入支架（1），Taxus　2．5mm×24mm；E、F．于LM至LAD中段置入支架（2，3），LAD近段Taxus　2．75mm×16mm，LM至LAD Taxus　3．5mm×24mm，3枚支架首尾相接；G、H．于LM末端分叉处行球囊对吻扩张，LM至LAD：Yangtze　3．0mm×15mm，LM至LCX：Mercury　2．0mm×15mm；I．LAD中段IVUS表现；J．LM开口IVUS表现，IVUS提示支架贴壁良好，未见血栓形成；K．最终造影结果提示，LAD血流稍慢，LCX开口、近段、中段狭窄80%～90%；L．RCA为LAD所提供之侧支循环消失

图1-39　随访

A、B．术后1周造影随访提示，支架通畅无支架内再狭窄和血栓形成；C．术后1周IVUS提示，支架贴壁良好，无血栓形成

评论

1．这个患者的罪犯血管难以确定。

2．IVUS检查非常必要。

3．术中是否应使用IABP进行辅助。

4．患者应强化抗血小板治疗，防止支架内血栓形成。

病例9：左主干介入治疗（图1-40，图1-41，图1-42）

患者资料

男性，56岁

主诉：间断胸痛2个月，加重1d

既往史：高血压（＋），吸烟（＋）

ECG：窦性心律，胸前导联T波低平

入院诊断：不稳定型心绞痛

图1-40　冠脉造影

A、B．造影提示，LM狭窄60%

图1-41　左主干介入治疗过程

图1-42　随访

6个月造影随访提示，支架膨胀良好，未见明显支架内再狭窄和血栓形成

（党　群　杨俊华）

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