1 provisional T stentingigakukai.marianna-u.ac.jp/idaishi/www/324/19-32... · 14 Louvard Y, Lefe...

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腉腌腊腆 臫腵腷腧腹腰腽膅膍臂臊 Vol. 32, pp. 389395, 2004 腇腉腈腆腅腝腀腁腐腊腗腜腒腋腚腙腛腃腕腀腂 腍腘腖腊腗腜腌腔腓腅腑腏腀腁 1 provisional T stenting 腄腍腎腉腖 腎腜 腔腞 腠腇 腔腎 腃腅 腟腕腈 腙腓 腋腢 腌腄 腊腢 腒腑 腆腒 腙腋 腟腜 腄腑 腜腍 腙腡 腔腑 腙腓 腐腆 腘腎 腞腔 腗腛 腠腇 腟腊 腚腝 腙腋 : 16 8 9 67 10 11 膩腡腣膠臖膬膟臣臝自膼膄膊腺腐腘腔膅臞膆臒臤臲膠臖膬腌腪腶腭腩臡臼腖腗腣腑腘臣致臩腄腡腛臚臙膒膈臇膣膝膎臸膀腘腔腾膎腔腸 RCA῍ῑ1 腘腔膏至膻膎腔腸臐膐LMT75膻膎腔腸臱膃 膴臈 LAD῍ῑ6 膜臇99膻膎腔腸膇臯臈 LCX῍ῑ12 75腟腐RCA 膜臇腅腢 bridging 腍腔 RCA 腋腢腘 LAD 臜腜臹膨膴腦膸膇腙臮膨膓腚 LMT 腅腢 LAD 膜臇腥腄腌腐膣膝膎腔腸腱腨腲腫臗腚膰膾腙膙膁腆腁腣膹腕腁腤腊腖腅 腢膧腦腐腔腸膦臦臗 PTCA腦臰LMT 腦膕腞腭腪腳腕腁腤腼 provisional T stenting 腦膲腌腐LMT 腅腢 LAD 腙膟臀腪腳腘臺腌腔3.016 mm NIR 腫腮腹腯7 膈腆腫腮腹腯膈腆LCX 膜臇腙膟臀臷腺腦腟腐NIR 腫腮腹腯腙腬腸腦腍腔 PTCA 腱腸腀腹腘腡腤膄膋腎腤腠 PTCA 腱腸腀腹腙腢膍腌腐腗膎腔腸腢腥腗腂腊腖腅腢 LCX 膜臇3.015 mm Multi-Link 腫腮腹腯腦臵腎腤腆NIR 腫腮 腹腯腙腬腸腦腍腔腙臵臕腌腐腭腪腳腘臺腎腤 provisional T stenting 腚膌腥腔腂腤腆腎腤腫腮腹腯腙膱臸腘腻腎腤腩膃腆腁腣膲臁腦膄腃膷腎腤腇腄腋腅 1腔腸臏膑2腫腮腹腯3膧膳腦腐膎臡膨膓膦臦臗 腂腀腃腁 膻膎腔腸臐膐left main trunk: LMT腦臮膓腖腎腤膝臥臣膢膰膾 acute myocardial infarc- tion: AMI膭腚腏腙膯腂膐膇臣膢腙臟膊腘 膗腓腈膻臎腴腹腳膛腠腏膃腄腡腛臉臥腘腡 膭腚膡腟腔腫膋腕腁腤 1LMT 腪腳腘臺腎 腤臍腚膎腔腸腱腨腲腫臗 coronary artery bypass graft: CABG腆膗腖腋腥腔腇腐腆腔腸 腫腮腹腯腦膅膂腌腐臍臦臭腙膮臠腅腢臣膛腠腏腙腗腂腷腫腩臝腕腙臻膚腦腐腔腸膦臦臗 percutaneous transluminal coronary angioplasty: PTCA膁腝腋腥腒腒腁腤 24AMI 腘腄腂 腔腚膣膝臑臗腝腕腙臌膔腐腻腁臶膚膽膐膇腩膃 臥腅腢膣膝腧腙腐 PTCA 腚膙腘膁腝腋腥腔腂腤膸膇 LMT 腦臮膨膓腖腎腤 AMI 腘腄腉腤 臫腵腷腧腹腰腽膅膅膍; 臙膒膖389 171

Transcript of 1 provisional T stentingigakukai.marianna-u.ac.jp/idaishi/www/324/19-32... · 14 Louvard Y, Lefe...

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PTCA ����� ���������� ����������������� �����������

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� �: 67�� ���� �: ����: �!�����"����: �� 10� 2#���� �� 5#�$%��� �: &'(���� ������� &)'*���� &�+'*���� ,-��������: �� 10� 11#./0 12��3������4567�8�9� �� 12# 3 �4:!;"#�$% 12�� <=>?&'�"0�()*�@A� +B�,-.��/���C01D�(2E34 �percutaneous cardiopulmonarysupport: PCPS� F/G.��HIJ�K�L �in-traaortic balloon pumping: IABP� �56�@A�� 56�'�M7NOPQ� RS�8TJIU3 �coronary angiography: CAG� �V9:��/0WX�CAG9� V��� �right coronary artery : RCA�Y �1Z[�;%� bridging �<\� RCA =]N��^���_->'X�?`P �Fig. 1�� ^����Fa�� LMT 75� bc� ^���@dXe�left anterior descending coronary artery: LAD� Y�6fAA� 99�bc� F/G^���gBe �leftcircumflex coronary artery: LCX�Y �12 75�� �1150� bc�?`� hg CD'iY LMT ��LAD fAA�EF�P �Fig. 2�� �$% jk������ F/G<=>?&'Z������RSCABG �GHOl PTCA �GH�P�PTCA ��PTCA Y� mnoTJI 7F JL3.5 �Med-

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LAD����P4�����1!P �Fig. 3A�� QzOY 3.5�15 mm Lynx PTCA HIJ� �Cardio-Vascular Dynamics pI� qrsT� �� 20�(50RWX�P� ��P4+Q/0 LCX �11fAA bcS��?`� ���'T Ud�?`P�Fig. 3B�C�� provisional T stenting ��� NIR�� �I�<\�V�HIJ�zO�WXZ�{P�� 3.0�20 mm Hayate PTCA HIJ�Y<�1!lYP� 2.0�20 mm VIVA PTCA HIJ��<��zONOPQ� 3.0�20 mm Hayate PTCAHIJ���Z56�zONO��HIJ�[\�!�P �Fig. 3D�� [\�P PTCAHIJ�YNIR���[]NOl�^������1!P� ����_Y�`��F0V�������WX�EF �Fig. 3E�, NIR �� �I<��a��P���bc�!���"� 3.0�15 mmMulti-Link ���P4�����1!P �Fig.3F�� ��d���� e�"�zOF/G�'T�f��P����?�� ����g��P �Fig. 4��� Q56�' M7��f��hi PCPS "�G� IABP ��_b�����1!P�

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Topaz �5��/��� 24545 � ���d�U39 0.07� �j� LMT bc�K�?`��P�LMT �k���� PTCA Y� 1982� Von Es-sen R�6��/0 CABGl�# S���$%*m�k��X �P� ���HIJ� � PTCA ¡n� ¢L� CABG �£om¤:Y¥¦�N���P7�� � pq��� 1� ��rT§�¨�HIJ�zO# ©'��'X�'�ª«1!ls¡¬ zO��­�­®aZ����� 2� PTCA# S�s}nI�f�0¯�a��� 3�$% �;%�t°����_��$%± ²³��&a��� 4� Hn´~"µ�/0�'T �uN��a"a unprotected LMT PTCA�Fa�v�¶*`w 36��Ua���·¸���8�� � Q����_ ¹x� S�s}nI�yz���� 1!�������º��N�P�� �� LMT�KY¥¦�N���P� Macaya�9�Y CABG¥¦�� PTCA �GH�P LMT *m�Fa�� HIJ�zOQ S�s}nI�k��������56�e�"�¶����`���P� 2001� ULTIMA �unprotected left main trunk inter-

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vention multicenter� registry �46�� CABG���������� �� �������� 13.7�� 1 ����� 24.2� ����� ��� � 1���� 3.4� ������ !"#$%&'()*+�,-./"0� ���10��12� LMT34�056789:;� <=>34�?@��"� DeLezo 211��� <=>34�?@� PTCA �ABCDEFG9H"9IJ:;K"� Lefe◊vre 212��<=>34L 6 MN�<N:�O���P�Q type 2 9RS./"� <=>34� !")*+TUV�� 1� WX�YZ�

)*+[\:]�^�"_`�)*+L[\!"type A TU� 2� WX�^�"_`�)*+[\:� 5K YZabLcKdeH2)*+Lfg!" type B TU �provisional T stenting�� 3� Yhi� 2O�)*+LjZ�[\!" type CTU�4� <=>kl� 2O�)*+L[\:mn�0deH2fg)*+[\Lco type D TU��"13��pqr��� Lefe◊vre <N type 2� LMT 34�

:; provisional T stenting Lsc:�� provi-sional T stenting �<=>34� :;� W0tu

Figure 1. Right coronary arteriogram.

Right coronary artery in �A� LAO and �B� AP cranial view, showingtotal occlusion sending large collaterals to left coronary artery

�arrow�.LAO: left anterior oblique, AP: anteroposterior.

Figure 2. Left coronary angiogram.

Left coronary artery in �A� RAO caudal showing 99� ostial stenosisof the LAD �arrow� and the ostium of the obtuse marginal artery ofthe LCX, and �B� LAO cranial view showing moderate stenosis ofthe distal part of the LMT �arrow�.RAO: right anterior oblique, LAO: left anterior oblique, LAD: left

anterior descending coronary artery, LCX: left circumflex coronary

artery, LMT: left main trunk

LMT 34� !"&'()*+[\v 391

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Figure 3. Percutaneous transluminal coronary angioplasty �PTCA�.A: The lesion was stenting with a 3.0�16 mm NIR stent from LMT to LAD. B andC: After stenting, there was aggravation of the LCX ostial stenosis. D: An

additional balloon dilatation using a 3.0�20 mm Hayate PTCA balloon was

performed through the metallic structure of the NIR stent struts. E: After balloon

dilatation, there was still aggravation. F: A 3.0�15 mmMulti-Link stent was implant-ed across the metallic structure of the NIR stent.

LAD: left anterior descending coronary artery, LCX: left circumflex coronary

artery, LMT: left main trunk

Figure 4. Left coronary angiogram after procedure.

Left coronary artery in �A� RAO caudal, and �B� LAO caudal view,showing successful stenting with no residual stenosis. RAO: right

anterior oblique, LAO: left anterior oblique,

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������������ �� ��������������������13�15�� � LMT!" LAD �!#�$%����&� Multi-Link

����16�'()*+,��� -����. �/��0123��!4�� 5'�6$%���780� 9:;<=>?@A!BCDE�FG� NIR����*HI��17�� NIR ����.�J��KLMNO@�*�P�QARS*T�� UVE*W��6' U XYZ���[\]^_*W��6'�`� C XYZ��!"3���� �Fig. 5��NIR ����.RSabc!" LMT de��&0f: �gh�ij���� $%��'klmA@�gh�no�� B��mA@�p*���� mA@�p'qr���� �� stuv'[\Ew� �� xyzgh�9� PTCA mA@�{'|}� �� ~�'��a��� � ����'�������"���� ���0. Fig. 3D������'QA/������ PTCA mA@��gh���0f:� NIR ����'�`� CXYZ��'���QARS'��*�n�� PTCA mA@�p'qr��4����"��� p��PTCA mA@�.���n!"���~�� ������f:� ������P���������������*�������� ���[\'�[�*; ���78E�f:� ¡�¢�£'¤��¥�*��P�6¦#�#�§�"��� NIR����.$%���78�������QARS'����n0f:� provisional T stenting�.�������"��� �¨ Be stent �Medtronic ©ª� «¬¢­�18�, Penta stent �Guidant ©ª� «¬

¢­�, Express stent �Boston©ª� «¬¢­�14���� LMT��/ ����������������� ®¯-�'���°��.� ±²����*HIP³������®z LMT *´µ[\�P� AMI ��' provi-

sional T stenting �¶��� 9:·�P�����'RS'¸¹�º»P³���������

����

1� Quigley RL, Milano CA, Smith LR, WhiteWD, Rankin JS and Glower DD. Prognosis

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Mario CD and Colombo A. Results and long-

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Figure 5. NIR stent.

A, Expanded NIR stent transforms into a diamond-like mesh of

cellular design. B, The stent cellular design was made from U joint

to obtain flexibility and thicker C joint to obtain rigid sca#olding of

the vessel wall.

LMT ��¼P����������~ 393

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Abstract

Provisional T Stenting for the Left Main Coronary

Trunk Lesion in a Patient with

Cardiogenic Shock

Tomoyuki Kunishima, Toshio Sasaki, Hideshi Aoyagi, Ken Kongoji,

Katsuhiko Tsuchiya, Masahiro Yamauchi, Hidetaka Tochiki,

Nobuyuki Hashimoto and Fumihiko Miyake

A 67-year-old man was referred to our hospital with angina pectoris. While in hospital, he suddenly

developed severe chest pain and shock. Cardiopulmonary resuscitation and circulatory support were started

immediately. Emergency coronary angiography showed chronic ostial occlusion of right coronary artery,

99� ostial stenosis of the left anterior descending coronary artery �LAD�, and moderate stenosis of the distalpart of the of left main trunk �LMT� and the ostium of the obtuse marginal artery. We decided that the targetcoronary arteries were the LAD and LMT. We chose percutaneous transluminal coronary angioplasty

�PTCA� rather than coronary bypass surgery because he had a history of cerebral infarction . The distalLMT and ostial LAD stenosis were dilated with a 3.0�16 mm NIR stent �7-cell�. After stent implantation,there was aggravation of the left circumflex ostial stenosis. But performance of additional balloon dilatation

through the metallic structure of the NIR stent was di$cult due to balloon rupture. A cellular design of the

NIR stent was made from U joint to obtain flexibility and thicker C joint to obtain rigid sca#olding of the

vessel wall. We thought that this structure caused balloon rupture and di$cult to provisional T stenting with

a Multi-Link stent �3.0�15 mm�. After the procedure, stabilization of homodynamic was obtained and thepatient was weaned form circulatory support. PCI had been increasingly applied to LMT lesions with

variable long-term success. In this case, the 7-cell NIR stent proved di$cult to perform provisional T

stenting. Provisional T stenting for LMT stenosis may be a better strategy compared with systematic T

stenting, but we must be careful about the stent configuration.

Division of Cardiology, Department of Internal Medicine,

St.Marianna University School of Medicine, Kawasaki, Japan.

LMT ���������� ��� 395

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