病例4
●病史基本资料●
●患者女性，58岁，发作性胸闷5个月。
●危险因素：吸烟史（—），高血压病（—）、糖尿病（+）、高脂血症（+），否认既往心脏病史。
●实验室检查：心肌标志物（—），cTnI＜0.01 ng/ml，CK—MB 11 U/L；胆固醇5.79mmol/L；LDL 4.34mmol/L。
●心电图：窦性心律，大致正常心电图。
●心脏超声：左心房室 内径35mm，左心室舒张期末内径45mm。二尖瓣、三尖瓣口均见少量反流，左心室舒张功能减低，LVEF 62%。
●冠状动脉造影●
右桡动脉途径造影显示LAD中段弥漫性30%～40%狭窄，远段可见50%～60%狭窄，LCX远段可见60%狭窄，RCA起始部闭塞（图6—0—10）。
●治疗策略●
RCA起始部齐头闭塞，CTO段较长延续至后分叉起始部位，有较好的间隔支及心外膜侧支循环。治疗策略：首先前向使用内膜内或者内膜下尽可能在斑块内导丝通过技术，如果导丝不能顺利通过，可采用Knuckle等内膜下技术战场前移，接近CTO出口处采用LAST技术导丝进入CTO远段真腔，如果失败，快速转为逆向，由于出口位于分叉部位，来自间隔支侧支血管逆向进攻角度不佳，尽可能采用较硬导丝在斑块内进入CTO段，采用AGT技术尽快完成介入治疗。
●冠状动脉介入治疗过程●
见图6—0—11。
●小结●
1.该例患者右冠状动脉慢性完全闭塞，起始部齐头闭塞，延续至后三叉前，闭塞段长。对侧造影可见前降支经间隔支向右冠状动脉发出侧支循环，也可见回旋支至右冠状动脉发出的心外膜侧支循环。
2.该病例属于高难度CTO，RCA全程为CTO，伴有钙化、迂曲，开通长的迂曲、钙化病变需要多种技术联合使用，由于CTO出口位于逆向的分叉部位，前向治疗如进入内膜下，会导致边支的丢失，前向治疗必须在CTO分叉之前进入CTO段，或者需要逆向治疗。
3.在治疗过程中，为能高效地完成CTO开通，该病例采用支撑力较强的指引导管及微导管在内膜下快速地接近CTO远段，远段导丝虽然进入CTO远段，但是位于内膜下，遂为逆向AGT做好了准备，但由于“冲浪”等技术导丝无法通过侧支通道，此时前向IVUS指导导丝进入真腔成为最后的治疗手段。
图6—0—10 右冠状动脉慢性完全闭塞
右冠状动脉慢性完全闭塞，起始部齐头闭塞，延续至后三叉前，闭塞段长。对侧造影可见前降支经间隔支向右冠状动脉发出侧支循环，也可见回旋支至右冠状动脉发出的心外膜侧支循环
4.目前双腔超声微导管在CTO治疗中指导导丝由假腔进入真腔，目前国内外尚无报道，我们自制的RLS双腔微导管，由于外径小，在球囊的辅助下进入内膜下，并未造成大的血肿，IVUS能够明确穿刺导丝和真腔的位置关系，采用Conquest导丝在分叉前定向穿刺准确地进入斑块内，最终未导致血肿延展，未影响各个分支，从而取得了良好的效果。
图6—0—11 右冠状动脉慢性完全闭塞介入治疗过程（续后）
A.Corsair微导管支持下Fielder XT—R导丝顺利通过第一转折处；B.调整导丝方向，继续向前推送导丝，对侧造影发现导丝远端可能位于分支；C.Knuckle调整GAIA Third导丝试图进入远端真腔，但对侧造影提示导丝位置不明；再次Knuckle调整导丝试图进入远端真腔，退出Corsair微导管，发现Pilot 200导丝虽然进入后降支，但位于内膜下；D～E.改为逆向介入，反复通过Surfing技术寻找侧支，发现导丝虽然可通过间隔支侧支，但无法到达闭塞远段，心外膜侧支也无法顺利到达闭塞远端；F.再次正向介入，送入双腔微导管、GAIA Third导丝，寻找真腔；G～H.对侧造影提示导丝进入后降支远端；但对侧造影发现导丝走斑块下进入后降支；I.沿进入内膜下导丝送入超声双腔微导管；J.沿超声双腔微导管送入Conquest Pro导丝；K～L.超声探头位于内膜下，导丝逐渐接近真腔，最后进入真腔，真腔在左下象限6点到9点方向（白色箭头所示）；M.Conquest Pro 沿上一根导丝下缘进入真腔；N.IVUS观察导丝位置，证实后三叉处都在真腔，右冠状动脉中远段大部分位于内膜下，接近出口斑块处，近段位于真腔；O.RCA由远及近依次放入支架，最后结果(https://www.daowen.com)
（图6—0—11续图）
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