超声能量对体外血栓的溶解作用

目的观察低频、高强度超声能量对体外血栓的溶解作用。方法取１５０～２００ｍｇ全血凝块２０份，吸入直径为３．０ｍｍ的塑料管中。共分四组：（１）超声溶栓组，（２）尿激酶溶栓组，（３）超声＋尿激酶溶栓组，（４）球囊扩张组，每组５份标本。观察分析溶解后碎片直径。结果显示：超声溶栓组：在平均溶栓３６０秒后，５份血凝块均剩下１０％左右体积不能溶解。尿激酶溶栓组和超声＋尿激酶溶栓组５份血标本全部溶解，时间分别为（４８±５）分钟和（２５０±３０）秒。球囊扩张组：平均扩张（４００±２０）秒后，血栓全部溶解。光学显微镜下可见超声溶栓组的红细胞无损伤，呈散在分布，不能溶解的血凝块呈网状结构。尿激酶溶栓组和超声＋尿激酶溶栓组的红细胞也呈散在分布，碎片直径９０％＜红细胞。球囊扩张组可见红细胞相互堆集，并可见许多未能溶解的小血凝块。结论低频、高强度超声能量能溶解血栓，且加速尿激酶对血栓的溶解作用。球囊扩张可能引起闭塞远端血管的栓塞。     

大剂量尿激酶静脉溶栓治疗急性心梗30例临床观察

目的：探讨大剂量尿激酶（UK）静脉溶栓治疗老年急性心肌梗死的疗效。方法：采用大剂量静脉溶栓疗法，首剂150万U，以后每天50万U静脉点滴，4－7天，总计量300－450万U。结果：冠脉再通率80％（24／30），再梗率13．33％（4／30）,出血并发症13．33％（4／30）病死率13．33％。结论：大剂量尿激酶静脉溶栓治疗老年急性心肌梗死（AMI）病人，可以提高相关血管的再通率，降低病死率；溶栓治疗年龄不限；尿激酶150万／U是老年AMI溶栓治疗较适当剂量。     

52例急性下壁心肌梗死患者的冠状动脉造影特征

目的：探讨临床传统方法诊断为急性下壁心肌梗死（AIMI）患冠状动脉的特征。方法：对52例急性胸痛伴心电图Ⅱ，Ⅲ,aVF导联ST段抬高患行急诊冠状动脉造影，观察，分析相关血管的改变情况。结果：冠脉造影证实48例AIMI中相关病变血管为右冠脉（RCA）为37例（77．1％，37／48），其中闭塞为25例（占52．1％），左回旋支（LCX）病变20例（41．7％），其中闭塞10例（占20．8％），左前降支（LAD）不同程度狭窄6例（闭塞3例），左主干（LM）病变2例。4例冠脉造影无异常。结论：急性下壁心肌梗死相关病变血管主要为右冠状动脉和左冠状动脉回旋支。     

尿激酶血栓局部注射治疗下肢深静脉血栓观察

目的探讨在彩色多普勒引导下经皮局部注射尿激酶治疗下肢深静脉血栓形成的疗效。方法将下肢深静脉血栓形成病人随机分成3组,治疗组在彩色多普勒引导下用75万U的尿激酶注射到血栓局部与对照一组尿激酶75万U患肢静推和对照二组尿激酶全身持续静滴对比,观察栓塞血管再通情况和副反应发生情况。结果血栓局部注射尿激酶组效果最好,副反应最少。结论在彩色多普勒引导下血栓局部注射尿激酶治疗下肢深静脉血栓形成疗效显著。     

远端保护装置在介入治疗中的应用进展

对急性ST段抬高性心肌梗死闭塞血管采用球囊扩张和支架植入等急诊冠脉内介入治疗时,常常会引起血栓碎裂、脱落而阻塞远端小血管及毛细血管,导致远端血流缓慢,发生病变血管再通后血流缓慢,甚至发生“无复流现象”。远端保护装置可安全、有效地用于急性心肌梗死等血管内存在大量血栓时的介入治疗,具有良好的应用前景。作者对近年来远端保护装置在介入治疗中的应用进展情况作一综述。     

超选择动脉内溶栓治疗脑急性缺血性卒中

目的探讨脑急性缺血性卒中患者动脉内溶栓治疗的安全性和有效性。方法回顾1997年7月至2002年7月脑急性缺血性卒中患者165例，男97例，女68例。年龄32～74岁，平均为58岁。采用超选择动脉内溶栓方法，起病距溶栓的时间为2～24h。尿激酶以1～1．2万U／min持续泵入，总量为50万-130万U，平均85万U。结果颈内动脉系统血管闭塞108例，椎-基底动脉系统闭塞27例，脑血管造影未见明显异常30例。闭塞血管再通者，颈内动脉14例，大脑中动脉27例，大脑中动脉分支28例，椎-基底动脉系统19例。10例因明显的血管狭窄，溶栓后给予球囊扩张、支架置入术。神经系统症状完全恢复正常或明显好转105例，并发脑出血6例，消化道出血13例。结论超选择动脉内溶栓可使血栓局部迅速达到较高的血药浓度，用药总量小，疗效好，见效快，是治疗脑急性缺血性卒中的有效方法。     

尿激酶溶栓联合介入术治疗急性脑梗死51例

目的评价急性脑梗死动脉内溶栓结合动脉溶栓后残余狭窄球囊扩张、支架置入术治疗的疗效。方法 51例急性脑梗死病人采取超选择接触性溶栓,尿激酶(UK)用微量泵以1×104U/min持续泵入,总量为60×104U～100×104U。在泵入尿激酶的过程中,通过导引导管造影,了解闭塞血管再通情况。结果颈动脉系统血管闭塞43例,椎-基底动脉系统闭塞2例。脑血管造影未发现明显的血管闭塞6例。颈内动脉闭塞再通率为63.64%;大脑中动脉闭塞再通率为63.63%;大脑中动脉分支闭塞再通率为55.56%;大脑前动脉闭塞(前交通动脉未开放)的1例再通;椎-基底动脉系统闭塞2例全部部分再通。动脉溶栓后颈内动脉残余明显狭窄3例行球囊扩张支架置入术。临床症状完全恢复正常或有明显好转的33例(64.71%)。结论动脉内接触性溶栓结合动脉溶栓后残余狭窄球囊扩张、支架置入术治疗急性脑梗死能明显提高治愈率,减少致残率,是安全、可靠、有效的治疗方法。     

青少年冠状动脉慢性完全闭塞病变1例

<正>近年来,冠状动脉粥样硬化性心脏病（冠心病）的发病年龄逐渐趋于年轻化。青年冠心病患者冠状动脉（冠脉）病变特点及发病危险因素与中老年人有明显的不同。其病因除动脉粥样硬化外,尚可见于大动脉炎、川崎病后遗症等。现报道1例由川崎病后遗症导致的冠脉慢性完全闭塞病变,以提高临床对于此疾病的认识。1病例患者男性,18岁,因“发作性胸痛3月余”入院。患者3月余前晨起后突发胸痛症状,持续不缓解,就诊当地医院,心电图显示：Ⅱ、Ⅲ、aVF导联ST段抬高0.5 mV,诊断为“急性ST段抬高型下壁心肌梗死”,急诊行冠脉造影示：左主干（LM）、前降支（LAD）、回旋支（LCX）未见异常,右冠脉（RCA）自近段闭塞,行血栓抽吸及球囊扩张后,近中段可见大量血栓,远端血流TIMI 2级,未植入支架。术后给予“阿司匹林肠溶片0.1 g,替格瑞洛片180 mg,瑞舒伐他汀钙片10 mg,美托洛尔缓释片47.5 mg,沙库巴曲缬沙坦钠片100 mg”等治疗。患者间断出现胸闷症状,持续数分钟可缓解。     

急性心肌梗死患者PCI术中球囊扩张度与术后无复流的关系

目的研究急性心肌梗死患者经皮冠状动脉介入术(PCI)中球囊扩张度与术后无复流发生的相关性。方法将本院收治的94例急性心肌梗死患者作为研究对象,分为观察组和对照组各47例。两组术前均进行常规治疗(服用氯吡格雷300mg,阿司匹林300mg等),且急诊PCI证实病变血管远端完全闭塞。其中,对照组经小球囊和低强度扩张后,可部分恢复闭塞血管远端血流,之后行支架植入术;观察组经小球囊和低压力预扩张后,可部分恢复闭塞血管远端血流,接着通过大球囊及强度扩张后行支架植入术。比较两组患者临床基线资料(性别、年龄、体质量指数、糖尿病史、高血压史、吸烟史等)、病变血管部位(右冠状动脉、回旋支、前降支)、血管开通时间及无复流的发生情况。结果两组患者临床基线资料比较,均无统计学意义(均P0. 05)。两组患者病变血管部位和血管开通时间的比较,无统计学意义(均P0. 05)。观察组无复流发生率为19例(40. 43%),较对照组5例(10. 64%)显著升高,差异有统计学意义(P 0. 05)。结论经小球囊和低压力预扩张,部分恢复闭塞血管远端血流后,通过大球囊及高强度扩张后行支架植入术,会增加急性心肌梗死患者PCI后病变血管无复流的发生率,提示术中球囊扩张度与术后无复流的发生率密切相关。     

小冠状动脉狭窄性病变的介入治疗

目的 :探讨小冠状动脉 （直径 <3 mm）狭窄性病变实施普通球囊、切割球囊或小支架介入治疗的疗效和并发症。方法 :小冠脉狭窄性病变介入治疗 （PCI）患者 13 6（男 87,女 49）例 ,年龄 3 2～ 85（54± 17）岁。根据手术方法分为普通球囊组、切割球囊组和小支架组。残余狭窄率 <3 0 %且无动脉夹层、撕裂等并发症者为手术成功 ,术后 6个月复查冠脉造影。结果 :普通球囊组 3 2例 ,手术成功 2 6例 （81% ） ,出现动脉夹层或扩张不满意改支架术 6例 （2 4% ）。切割球囊组 48例 ,手术成功 43例 （90 % ） ,出现动脉夹层或扩张不满意改支架术 3例 ,出现造影剂血管外漏 2例。支架组 56例 ,手术成功 53例 （95% ） ,出现造影剂血管外漏 2例 ,出现心包填塞抢救成功 1例。3组均未出现血管急性闭塞。术后 6个月 ,切割球囊组、小支架组、普通球囊组冠脉造影狭窄率分别为 2 3 % （11例 ）、16% （9例 ）、3 8% （12例 ）。结论 :小冠脉狭窄性病变实施介入治疗能取得显著效果 ,小支架术优于普通球囊扩张术 ,切割球囊扩张与普通球囊扩张具有近似疗效     

Treatment of acute stent thrombosis with local urokinase therapy using catheter-based,drug delivery systems: A case report

Abrupt thrombotic stent closure remains a difficult problem to treat in the cardiac catheterization laboratory. A 63-yr-old white female initially underwent successful placement of a Palmaz-Schatz biliary stent in the proximal RCA following failed coronary angioplasty. One week later, the patient represented with an acute inferior infarction and thrombotic occlusion of the stent site in spite of adequate anticoagulation. A new, local drug infusion catheter (the Dispatch? catheter) was placed at the angioplasty site and 150,000 units of urokinase were locally infused, with immediate restoration of normal distal flow and a subsequent marked decrease in angiographic thrombus. A small, residual thrombotic filling defect was further treated with a urokinase-coated hydrogel balloon (Hydro Plus?). Following local urokinase delivery with the Dispatch catheter and hydrogel balloon, there was complete resolution of angiographic thrombus with TIMI 3 flow and no evidence of distal embolization or no-reflow. Local urokinase delivery directly to the site of thrombus with catheter-based drug delivery systems may be a useful technique for rapidly lysing intracoronary clot and re-establishing coronary flow in the setting of acute stent thrombosis.     

Treatment of intracoronary thrombus with local urokinase infusion using a new,site-specific drug delivery system: The Dispatch™ catheter

Background: The presence of intracoronary thrombus significantly increases the risk of conventional balloon angioplasty because of a high incidence of abrupt closure, distal embolization, and no-reflow phenomenon. The purpose of this study was to assess a new technique for treating intracoronary thrombus consisting of the local delivery of urokinase directly to the angioplasty site with a novel, catheter-based, drug delivery system. Methods: The Dispatch catheter is a new local, drug-delivery device that allows for the prolonged infusion of therapeutic agents at an angioplasty site while still maintaining distal coronary perfusion. Six patients with angiographic or clinical evidence of intracoronary thrombus were treated with 150,000 units of urokinase over a 30-min period using this device prior to or following conventional balloon angioplasty and/or directional atherectomy. Results: Successful delivery of urokinase directly to the angioplasty site was achieved in all 6 patients without hemodynamic or electrocardiographic compromise. In all six cases, local urokinase therapy resulted in complete dissolution of angiographic intracoronary thrombus and/or reduction of the coronary stenosis. Limited ischemia due to sidebranch occlusion by the catheter's coils was noted in one patient. Distal embolization or no-reflow phenomenon were not observed in any case. CONCLUSION: The local drug-delivery catheter used in this study was able to successfully and rapidly achieve intracoronary thrombolysis by delivering limited quantities of urokinase directly to the angioplasty site, while still maintaining distal coronary perfusion. This technique of local, thrombolytic drug delivery may be useful in the percutaneous treatment of intracoronary thrombus and thrombus-containing stenoses. © Wiley-Liss, Inc.     

降低急性心梗急诊PCI后无复流／慢血流方法探讨（附89例报告）

目的：探索降低急诊PCI后无复流／慢血流的方法。方法：急诊PCI病人分两组：常规PCI组（49例）,出现无复流／慢血流后予以血小板Ⅱb／Ⅲa受体拮抗剂（替罗非班）和／或血栓抽吸导管处理;预处理组（30例）在球囊扩张前予以替罗非班和／或血栓抽吸预处理。结果：预处理组未出现无复流／慢血流;与常规PCI组比较,预处理组无复流／慢血流发生率明显降低（10．2％比0,P〈0．05）。结论：在常规药物治疗的基础上预防性使用替罗非班和／或血栓抽吸可以明显降低急诊PCI术后无复流／慢血流的发生。     

Treatment of thrombotic saphenous vein bypass grafts using local urokinase infusion therapy with the Dispatch catheter

Percutaneous treatment of thrombotic stenoses or total occlusions in aged saphenous vein bypass grafts is associated with a significant incidence of complications primarily related to distal embolization. The purpose of this study was to assess the efficacy of local urokinase delivery with the Dispatch catheter prior to balloon angioplasty and/or intragraft stent placement as a new technique of vein graft revascularization. Local urokinase delivery with the Dispatch catheter was performed in 15 saphenous vein grafts (mean age = 11.7 ± 2.5 yr) in 13 patients with unstable or postinfarction angina. The target lesion was a total occlusion in 5 of the procedures and a severe vein graft stenosis in the remaining 10. In all cases, urokinase was administered directly to the site of the stenosis/occlusion via the Dispatch catheter at 0.5 cc/min and at a concentration of 30,000 units/cc. The mean urokinase infusion time for the 15 procedures was 33 ± 10 min (range = 10–60 min) and the mean urokinase dose was 495,000 ± 158,000 units (range = 150,000–900,000 units). Following Dispatch therapy, mean minimal lumen diameter increased from 0.34 ± 0.32 to 1.81 ± 0.78 mm (P < 0.01), mean TIMI flow increased from 1.9 ± 1.4 to 2.8 ± 0.8 (P < 0.06), and mean thrombus score was reduced from 2.3 ± 0.6 to 0.3 ± 0.8 (P < 0.01). Mild no reflow was noted in two cases, although no patient demonstrated angiographic evidence of gross distal embolization. One of the patients with no reflow also demonstrated a small increase in cardiac enzymes. Subsequent balloon angioplasty/stent placement was successful in 14 of the 15 procedures (93% success rate). This preliminary report suggests that pretreatment of thrombotic saphenous vein graft stenoses with local urokinase delivery via the Dispatch catheter may decrease intragraft thrombus and possibly decrease the incidence of vascular complications associated with percutaneous intervention. This technique may allow for recanalization of totally occluded vein grafts with large clot burdens by using significantly less urokinase and shorter drug administration times than conventional infusion protocols. Cathet. Cardiovasc. Diagn. 41:261–267, 1997. © 1997 Wiley-Liss, Inc.     

扩张球囊碎栓治疗脑静脉窦血栓的临床观察

目的 观察扩张球囊在介入溶栓治疗脑静脉窦血栓形成（CVST）机械碎栓的效果及安全性.方法 数字减影血管造影（DSA）确诊的35例患者,在介入溶栓治疗中使用扩张球囊进行碎栓,观察其疗效、可行性及并发症,术后随访3～9个月.结果 35例患者球囊均顺利到位并成功碎栓,术中即刻病变静脉窦开通良好.所有患者术后1周内临床症状完全消失,腰椎穿刺压力恢复正常或接近正常,出院时Glasgow昏迷评分（GCS）由术前平均11分提高到14分.术中2例患者出现并发症,球囊破裂1例,浅静脉栓塞1例.随访半年仅1例患者因未规范服华法林而复发.结论 扩张球囊在血管内介入溶栓治疗脑静脉窦血栓形成中安全可行,疗效显著.并发症主要与操作和球囊选择不当有关.     

Intracoronary thrombolysis followed by directional atherectomy: a combined approach for thrombotic vein graft lesions considered unsuitable for angioplasty.

Eccentric complex vein graft lesions with abundant luminal thrombus have been generally considered unfavorable for balloon angioplasty. We present 3 patients in whom such lesions were successfully treated by a combined approach: intracoronary urokinase (1 million units over 1 hr) administered in the catheterization laboratory followed by directional atherectomy of the residual lesions in 2 separate procedures; with the patients maintained on heparin infusion between the 2 stages. No distal embolizations were encountered. Two of the 3 patients developed a groin hematoma without vascular compromise. This combined approach may prove to be an attractive alternative to reoperation in select patients with unfavorable vein graft lesions.     

Intracoronary thrombolysis followed by directional atherectomy: A combined approach for thrombotic vein graft lesions considered unsuitable for angioplasty

Eccentric complex vein graft lesions with abundant luminal thrombus have been generally considered unfavorable for balloon angioplasty. We present 3 patients in whom such lesions were successfully treated by a combined approach: intracoronary urokinase (1 million units over 1 hr) administered in the catheterization laboratory followed by directional atherectomy of the residual lesions in 2 separate procedures; with the patients maintained on heparin infusion between the 2 stages. No distal embolizations were encountered. Two of the 3 patients developed a groin hematoma without vascular compromise. This combined approach may prove to be an attractive alternative to reoperation in select patients with unfavorable vein graft lesions. © 1992 Wiley-Liss, Inc.     

EST术联合EPBD术治疗非扩张性肝外胆管结石患者临床研究*

目的 探讨采用十二指肠镜下乳头括约肌切开（EST）联合十二指肠镜下乳头气囊扩张（EPBD）术治疗非扩张性肝外胆管结石患者的临床效果。方法 回顾性分析我院诊治的124例非扩张性肝外胆管结石患者的临床资料,联合组采用EST术联合EPBD术（n=49）、观察组采用单纯EST术（n=31）和对照组采用胆总管切开T管引流术（n=44）治疗。结果 术后48 h时,联合组血清淀粉酶水平为（107.1±34.6） U/L,超敏C-反应蛋白水平为（37.2±8.9） mg/L,观察组分别为（113.9±35.2） U/L和（38.1±9.4） mg/L,均显著低于对照组[分别为（221.5±54.8） U/L和（73.2±16.2） mg/L,P<0.05];联合组手术时间为（95.2±14.8） min,观察组为（113.6±12.7） min,均显著长于对照组[（84.8±12.1）,P<0.05];联合组胰腺炎和反流性胆管炎发生率分别为2.0%和4.1%,显著低于观察组的19.4%和22.6%或对照组的18.2%和22.7%（P<0.05）。结论 采用EST联合EPBD术治疗非扩张性肝外胆管结石患者操作易行,效果好,术后恢复快,近远期并发症发生率低,有较高的临床应用价值。     

Site-specific intracoronary thrombolysis with urokinase-coated hydrogel balloons: Acute and follow-up studies in 95 patients

Conventional balloon angioplasty in the presence of intracoronary thrombus is associated with an elevated risk for acute myocardial infarction, emergency bypass surgery, and death. The purpose of this study was to assess the safety and efficacy of a new technique to treat thrombus-containing stenoses consisting of the local delivery of urokinase directly to the site of intraluminal clot with hydrogel-coated balloons. Ninety-five patients with angiographically apparent intracoronary thrombus were treated with urokinase-coated hydrogel balloons either prior to (n = 74) or following (n = 21) conventional balloon angioplasty. Clinical diagnoses for the study group included acute myocardial infarction in 50 patients, postinfarction angina in 23 patients, and unstable angina in 22 patients. All hydrogel balloons were initially coated with urokinase by immersing the inflated balloon in a concentrated Abbokinase solution (50,000 units/ml) for 60 s. All patients were subsequently treated with drug-coated balloons using a balloon:artery ratio of 1:1, a mean of 2.2 ± 1.2 inflations, and a mean total inflation time of 7.5 ± 4.9 min. Use of urokinase-coated balloons resulted in angiographic disappearance of intracoronary thrombus in 78 patients, improvement in 14, and no change in the remaining 3 patients. Following hydrogel balloon use for the entire 95 patients, TIMI flow increased from 1.4 ± 1.2 to 2.9 ± 0.4, minimal lumen diameter increased from 0.4 ± 0.4 to 2.0 ± 0.6 mm, and thrombus score decreased from 2.0 ± 0.9 to 0.2 ± 0.6 (all P < 0.01). Procedural and early in-hospital complications were noted in 7 of the 95 patients (7.4%) and included abrupt closure in 3 patients, distal embolization in 1 patient, no reflow in 1 patient, sidebranch occlusion in 1 patient, and late closure in 1 patient. Two of the 3 patients with abrupt closure and the single patient with late closure required intracoronary stenting to maintain vessel patency. Two of these 7 patients sustained small myocardial infarctions, although no patient required emergency bypass surgery or experienced a procedural death. Late clinical follow-up (mean = 8.3 ± 6.6 months; range = 2 wk to 29 mo) demonstrated adverse recurrent events in 29 of the 95 patients (30.5%), including death (n = 5), myocardial infarction (n = 2), and recurrence of angina (n = 22). The results of this study suggest that intracoronary thrombolysis can be safely and rapidly achieved by using limited quantities of urokinase delivered directly to the site of intraluminal clot with hydrogel balloons. Use of this technique may result in improved acute outcomes in comparison with conventional techniques currently being used to treat thrombus-containing stenoses. Cathet. Cardiovasc. Diagn. 41:246–253, 1997. © 1997 Wiley-Liss, Inc.     

Thrombus aspiration as a bailout procedure during percutaneous renal angioplasty.

PURPOSE: To present a case in which thrombus aspiration, urokinase, and abciximab were used to recanalize a sudden acute thrombotic occlusion of the right renal artery during percutaneous renal angioplasty. CASE REPORT: A 72-year-old man with severe arterial hypertension, impaired renal function, and peripheral artery disease was referred for interventional renal revascularization of a proximal stenosis of the right renal artery. Predilation was unsuccessful, and stent placement was followed by immediate occlusion of the distal renal artery, probably due to dislocation of a mural thrombus. Since intra-arterial administration of urokinase (300,000 IU) was ineffective, thrombus aspiration was performed using the 7-F guiding catheter. After successful removal of the thrombus, abciximab was given intravenously. Control angiograms showed recanalization of the stented segment and patency of the distal renal arteries, an outcome confirmed 8 months later by duplex ultrasound. CONCLUSIONS: As demonstrated in our case, thromboembolic complications can be rapidly and successfully treated on the table by combined measures, such as catheter thrombus extraction and pharmacological strategies.