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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3840_Библиотеки_им_академика_М_И_Перельмана
.pdf
(A)
(B)
Cypher 3.5 ×
Adjunctive balloon 4 ×
Figure 9 FFR-guided left main stenting in an ambiguous distal left main–LAD ostial lesion. (A) In an angiogram
of a 65-year-old male, intermediate stenosis at the distal left main–LAD ostium was found. (B)(
FFR measured at mid-LAD was 0.69. Pulling back the pressure wire from mid-LAD to left main ostium revealed
a significant pressure step-up across the lesion. (C)(
proximal LAD was performed. FFR was measured at a jailed left circumflex artery and found to be 0.67 (
FFR was measured again after kissing balloon inflation, and it was 0.83 (
a physiologically negative FFR, the operator felt that the LCx result was suboptimal and an additional stent was
implanted followed by kissing balloon inflation. Final FFR was 0.95 and 0.90 at LAD and LCx, respectively. (E)
Two years after stenting, follow-up angiography shows no significant restenosis.
23mm
10mm
FFR =
(C)
KBI: 3.5 ×
10 & 3 ×
See color insert
10
FFR =
See color insert
) Crossover stenting from left main to
right
). (D)(
See color insert
left
) Despite
)
).
(a)
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(c)
(b)
(d)
(e)
(B)
Figure 2.1B Representative histologic images of coronary plaque ina bifurcation lesion. (a) Longitudinal section
of trifurcation (left main/LAD/Ramus intermedicus/CX). There are atherosclerotic plaques in the lateral wall, while
the flow divider regions are spared (b). (c) Longitudinal section taken in the region of LCM/left obtuse marginal
bifurcation. Note, severe luminal narrowing proximaland atthe bifurcation. Low shearregions showatherosclerotic
plaque developmentincluding necroticcore formation whereas flow dividerregions showminimal intimalthickening
(d, e).
Source
: Adapted from Ref. 7. Courtesy of Virmani R et al.
(a)
(b)
(c) (d)
(C)
Figure 2.1C Three-dimensional reconstruction of the lumen (red) and outer vessel wall (green) of the left main
coronary artery, left main bifurcation, left anterior descending coronary artery (LAD), and circumflex coronary
artery (a). Detailed view of the left main bifurcation (white box) demonstrating the blood flow pattern in the lumen
with anarea (
endothelial shear stress (c) and increased plaque thickness (d) are found.
arrow
) ofdisturbed slow recirculating flow on the sideof the LAD (b), wherelower valuesof computed
Source
: Adapted from Ref. 9.
Figure 2.16 An illustration of the proximal rim, in-bifurcation, and distal rim of bifurcation cross-sections using
virtual histology and optical coherence tomography.
Source
: Adapted from Ref. 35.
MLD: 1.8 mm
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MLA: 3.0 mm
2
MLD: 1.8 mm
MLA: 3.1 mm
2
(A)
Figure 4.8A A 57-year-old man was admitted due to the abnormality in a radionuclide scan (
showed the stenoses located at the mid-LAD and proximal LAD bifurcation segments. By intravascular ultrasound,
minimal lumen area was 3.0 mm
2
at mid-LAD and 3.1 mm2at LAD ostium.
left
). Angiogram
Mid-LAD
Lt Main
Cypher 3.5 ×
13
(B)
Figure 4.8B FFR at distal LAD was 0.69. A significant pressure step up was found only at a LAD ostial lesion
in a pressure pull-back curve (
green line
). Therefore, additional stent was implanted at the LAD ostium.
(C)
Figure 4.8C A radioisotope scan six months after stent implantation shows no perfusion defect.
(B)
Figure 4.9B FFR measured at mid-LAD was 0.69. Pulling back the pressure wire from mid-LAD to left main
ostium revealed a significant pressure step-up across the lesion.
Cypher 3.5 ×
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Adjunctive balloon 4 ×
23mm
10mm
KBI: 3.5 ×
10 & 3 ×
10
right
).
LAD
FFR =
FFR =
FFR =
(C)
Figure 4.9C Crossover stenting from left main to proximal LAD was performed. FFR was measured at a jailed
left circumflex artery and found to be 0.67 (
was 0.83, which is below the successful angioplasty criterion of 0.9 (
left
). FFR was measured again after kissing balloon inflation, and it
LCx
TAXUS 3 ×
KBI: 3.5 ×
Figure 4.9D Additional stent was implanted at a circumflex artery followed by kissing balloon inflation. Final FFR
was 0.95 and 0.90 at LAD and LCx, respectively.
10 & 3 ×
(D)
12mm
10
(A)
Figure 4.10A A case with multiple jailed branches after left main to LAD crossover stenting. By angiogram, left
circumflex ostium and the os of three diagonal branches seem to have significant stenosis. FFR was 0.82 for LCx
ostium and 0.94 for 1st diagonal, 0.77 for the 2nd diagonal, and 0.82 for the 3rd diagonal branches.
STRESS
REST
(B)
Figure 4.10B A radioisotope scan after stenting shows no reversible perfusion defect at the territories of LCx
and diagonal branches.
STRESS
REST
Figure 4.11 Functional outcome of a nontreated jailed circumflex artery. Just after stenting, FFR was 0.87 at a
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
jailed circumflex artery (
functional late loss of 0.02 in this nontreated jailed circumflex artery.
left
). Nine months after stenting, FFR at LCx is still 0.85 (
right
). There was only a minimal
intermediate
(I)
Distal LM
Figure 8.17I We assessed the severity of LCX and RI lesions by IVUS and fractional flow reserve (FFR); both
the lesions were functionally significant with an FFR of 0.73 in the RI and 0.77 in LCX.
(A) (B)
Figure 9.5 Overlap of the balloons in the distal LMCA. Visual inspection of the LAD (
the LCX (
the anterior–posterior caudal (
blue
) balloon (A, upper panel), and the reverse relationship (B, upper panel). Fluoroscopic inspections in
middle panels
), and spider (
lower panels
) views. The arrows indicate the guidewire
red
) balloon located over
advanced from the LMCA into the LCX. The wire is visible on the myocardial side of the distal LMCA when the
LAD balloon is positioned over the LCX balloon (A, middle and lower panels), and on nonmyocardial side when
the overlapping is reversed (B, middle and lower panels).
(A) (B)
(E)
(F)
Source
: From Ref. 12.
(C)
(D)
(G)
(H)
Figure 9.16 MFCT images of T-stenting and protrusion (TAP) in the 3-D LMCA bifurcation model. Experiments
were performed using Driver (
upper panels
) and Bx Velocity stents (
lower panels
)fortheMV.(A, E) Long axis
3D image. (B, F) Cross-sectional view at the distal LMCA. Blue and red lines indicate the LCX and the LAD
stents, respectively. Wide opening of the orifice of the LCX stent was observed in the panel (B), whereas the
restriction of the stent expansion was observed in the panel (F). (C, G) Cross-sectional view corresponding to the
line “a” in the 3-D image. The squeezing of the LCX stent at the strut where the LCX stent was protruded into
the LMCA was small in the panel (C), whereas it was apparent in the panel (G)(
view corresponding to the line “b.” There was a gap at the distal carina in the panel (H)(
arrows
). (D, H) Cross-sectional
arrow
).
PHYSIOLOGIC GUIDANCE OF PROVISIONAL STENTING IN CORONARY BIFURCATION LESIONS
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79
LCx
TAXUS 3 ×
KBI: 3.5 ×
(D)
12mm
10 & 3 ×
10
LAD
FFR =
(E)
Figure 9 (
continued
)
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