血液透析患者冠心病介入治疗的临床应用-附4例临床报告

目的探讨血液透析患者冠状动脉造影、经皮冠状动脉成形术及支架置入术的近期疗效。方法对4例血液透析冠心病患者在强化透析及水化治疗基础上应用非离子型低渗造影剂行冠状动脉造影术(PTCA)。结果4例冠状动脉造影术患者,2例为多支病变,行PTCA置放支架4个,1例行钝缘支血管瘤栓塞。术后心绞痛症状缓解,肾功能无进一步恶化。结论血液透析患者中行心脏介入性治疗,可提高透析患者生存质量,降低心血管病因的病死率。     

血液透析患者与心脏介入性诊断治疗

目的探讨尿毒症血液透析患者进行冠状动脉造影术及经皮冠状动脉腔内成形术(PTCA)及支架置入术(Stent)的可行性及近期疗效.方法 5例血液透析患者,频繁心绞痛发作,常规药物治疗效果不佳;在血液透析及水化治疗配合下,应用非离子型低渗造影剂(优维显)行冠状动脉造影术,继之3例患者行冠状动脉球囊扩张及支架置入术. 结果 5例冠状动脉造影术患者,4例有显著冠状动脉狭窄,其中2例为单支血管病变,2例为多支血管病变;3例患者行PTCA,置放支架1～4个,术后心绞痛症状明显缓解,肾功能无进一步恶化倾向,随访11～24个月,无其它并发症.结论在血液透析患者中进行心脏介入性诊断和治疗是可行的,安全的,可显著提高透析患者生存质量,降低心血管病因的死亡率.     

冠状动脉介入治疗及循证医学评价

1引言 1977年,Gruentzig成功研制了一种能在冠状动脉内进行扩张的球囊导管,并在临床上首先应用经皮穿刺法,将球囊导管送入冠状动脉内,成功地扩张了狭窄的冠状动脉,解除了患者的心绞痛症状,从而开创了经皮腔内冠状动脉成形术(percutaneous transluminal coronary angioplasty,PTCA)治疗冠状动脉粥样硬化性心脏病(冠心病)的新时代.近30年来,冠状动脉介入治疗取得了重大进展,在PTCA的基础上,相继出现了冠状动脉内支架术和斑块消蚀术(包括斑块旋切术和旋磨术、激光血管成形术)等新技术,特别是药物涂层支架的诞生显著降低了介入治疗的难题即再狭窄的发生率,也是近年来介入心脏病学所取得的一个突破性进展.PTCA和冠状动脉内支架术是冠状动脉介入治疗的核心技术,两者相辅相成,冠状动脉支架术大多需在术前行PTCA,冠状动脉支架术可降低PTCA术后即刻严重并发症(冠状动脉撕裂或闭塞)和再狭窄率,提高手术的安全性,而其它新的介入技术仅在某些特殊情况下作为PTCA和冠状动脉支架术的辅助治疗.     

不同方法行单支架处理右冠状动脉后三叉病变的临床分析

目的 对比研究不同步骤方法单支架治疗右冠状动脉后三叉真性分叉病变的临床有效性和安全性。方法 选取行冠状动脉造影显示为右冠状动脉后三叉真性分叉病变,并且为冠状动脉单支病变的冠心病患者,根据介入手术步骤分为球囊对吻扩张组（A组）和无球囊对吻扩张组（B组）;A组又分为支架前球囊对吻扩张组（A1组）、支架后球囊对吻扩张组（A2组）。观察介入并发症发生率、X线暴露时间及造影剂用量、术后1年的临床主要不良心脏事件及术后1年支架内再狭窄情况。结果 A2组比A1组术中并发症慢血流、心绞痛及术后1年造影显示冠状动脉血流不达TIMI3级发生率更低（P＜0.05）。A组较B组术中并发症慢血流、心绞痛及术后1年造影显示冠状动脉血流不达TIMI3级发生率更低（P＜0.05）。各组介入X线暴露时间及造影剂用量差异无统计学意义。结论 单支架治疗右冠后三叉真性分叉病变时采取球囊对吻扩张较无球囊对吻扩张治疗术后1年临床主要不良心脏事件发生率更低;其中支架后球囊对吻扩张较支架前球囊对吻扩张的介入方法并发症发生率及术后1年的临床主要不良心脏事件发生率更低。     

经皮冠状动脉成形术与支架植入术91例临床分析

目的分析经皮冠状动脉成形术(PTCA)与支架植入术(支架术)治疗冠心病的临床疗效。方法91例冠心病患者,稳定型心绞痛20例,不稳定型心绞痛29例,心肌梗死42例。单支血管病变29例,双支血管病变41例,三支血管病变21例。共处理病变血管176处,置入支架170枚。其中左前降支88处,右冠46处,左回旋支35处,第一对角支6处,左室后支1处。观察PTCA与支架术的成功率及临床成功率。结果PTCA与支架术成功率100%,临床成功率98.3%。结论PTCA与支架术是一种安全、有效的介入性治疗技术,成功率高,疗效良好,并发症少。     

96例经皮腔内冠状动脉成形术及支架术病人的健康教育评价

经皮腔内冠状动脉成形术 (PTCA)系采用经皮穿刺动脉法将球囊导管逆行送入冠状动脉的病变部分 ,加压充盈球囊以扩张狭窄处 ,使血管内径增大从而改善心肌供血、缓解症状并减少心肌梗死发生的一种内科介入治疗技术。支架术是指在PTCA基础上置入一种由医用高分子物质或医用金属材料     

经皮冠状动脉腔内成形及支架术治疗不稳定心绞痛

不稳定心绞痛2例病人经常规内科治疗包括抗凝等心绞痛不能有效控制,后行经皮冠状动脉腔内成形术(PTCA)及支架术临床治愈。2例病人PTCA前冠状动脉造影显示以左前降支狭窄(99％)为主的多支病变,成功PTCA及支架术后狭窄消失,经随访未再发作心绞痛。     

四例尿毒症患者冠脉支架术分析

目的：探讨尿毒症血液透析合并冠心病心绞痛患者冠脉介入治疗的近期疗效。方法；对4例不稳定心绞痛的血液透析患者在适当水化和强化透析基础上，应用非离子型造影剂行冠状动脉造影术，并对符合介入治疗指征的病变进行血管重建术。结果；单支病变1例，双支病变2例，三支病变（多处）1例，4例均于造影后同台进行冠脉支架置入术，成功置入1～2枚支架。术后临床随访6～18个月，患者心绞痛症状明显减轻或消除，肾功能无明显恶化。结论；对血液透析患者行冠状动脉造影及介入治疗是安全、有效、可行的。     

皮腔内冠状动脉成形术和支架植入术的临床应用

目的 :探讨经皮腔内冠状动脉成形术 (PTCA)和支架植入在冠心病治疗中的应用。方法 :总结 68例已行PT CA和支架植入的冠心病患者治疗效果 ,其中 82处病变进行PTCA术 ,76处病变植入支架 ,2例术后 1个半月至 4月再发心绞痛 ,1例术后出现上消化道大出血及下腹腔血肿 ,无其他严重的并发症及死亡发生。结论 :PTCA和支架植入术是冠心病患者安全有效的治疗方法     

经皮冠状动脉介入治疗术后并发症的观察及护理

2004年12月~2005年12月,我院对580例冠心病患者行经皮冠状动脉介入治疗术(PCI),经精心护理,效果满意。现将术后并发症的观察及护理体会报告如下。1资料与方法1.1临床资料本组580例,男360例,女220例,35~78岁,平均56.5岁,急性心肌梗塞102例,不稳定性心绞痛280例,稳定性心绞痛198例,其中行冠状动脉造影400例,经皮冠状动脉腔内成形术(PTCA)及支架术180例。1.2方法在局麻下做股动脉穿刺行冠脉造影,然后根据病变部位、性质和程度选择PTCA及支架植入方法。术中肝素化,术后继续抗凝治疗,行心电监护,术侧肢体制动,严密观察生命体征和病情变化,预…     

血透合并冠心病患者冠状动脉介入治疗疗效及护理

目的探讨血透合并冠心病患者冠状动脉介入治疗疗效及护理。方法回顾分析6例7次血透合并冠心病患者冠状动脉介入治疗疗效、并发症及残余肾功能情况。结果治疗后6例次心绞痛症状明显缓解,冠状动脉介入治疗前后行血透及水化治疗减少了残余肾功能损害。结论术前加强心理护理及术前准备,合理安排适当的水化治疗,术前、后安排血液透析及做好透析护理,严密观察病情变化是保证治疗成功的关键。     

Fate of collateral circulation after successful coronary angioplasty of total occlusion assessed by coronary angiography and myocardial contrast echocardiography.

A well-developed collateral circulation is frequently observed in patients with total coronary occlusion. However, the fate of the collateral circulation after successful percutaneous transluminal coronary angioplasty (PTCA) has not been fully characterized. The purpose of this study was to compare the efficacy of coronary angiography and myocardial contrast echocardiography (MCE) in the evaluation of the collateral circulation after PTCA and to assess the temporal changes of the collateral circulation after successful PTCA of a totally occluded artery by using these 2 diagnostic methods. The study group was comprised of 20 consecutive patients (16 male, mean age 54 years) who underwent elective PTCA for total coronary occlusion. Coronary angiography was performed before, immediately after, and 24 hours after PTCA. MCE was also performed before, immediately after, and 24 hours after PTCA, by the intracoronary injection of sonicated radiographic contrast medium. According to the angiographic findings, the collateral circulation was graded on a scale of 0 to 3 as follows: 0 = no visible filling; 1 = collateral filling of side branches; 2 = partial collateral filling of the epicardial artery; 3 = complete filling of the epicardial artery. By MCE, myocardial perfusion by the collateral circulation was assessed by scoring the contrast pattern of collateral-dependent myocardial segments as follows: 0 = none; 0.5 = patchy or epicardial; 1 = homogeneous. The left anterior descending artery was occluded in 12 patients and the right coronary artery in 8 patients. Coronary angiographic collateral grades before PTCA were grade 2 in 5 patients and grade 3 in 15. PTCA with stenting was successfully performed in all patients without significant residual stenosis. Coronary angiography showed collateral circulation disappeared after PTCA in all patients. However, residual collateral perfusion was observed in 7 patients by MCE, performed immediately after PTCA (score 1 in 3 patients; score 0.5 in 4 patients). This residual collateral perfusion could be demonstrated even 24 hours after PTCA by MCE in 3 patients (all patients were 0.5 in myocardial perfusion score). In conclusion, successful PTCA with stenting of a totally occluded coronary artery leads to a disappearance of collateral vessels by coronary angiography in most of the patients. However, although angiographically not visible, coronary collateral circulation may persist even 24 hours after successful PTCA of a totally occluded artery demonstrated by MCE.     

Usefulness of the fusion imaging of 3D-CT and MRA for carotid artery stenting with minimum use of contrast medium in patient with renal dysfunction

Patients with severe internal carotid artery (ICA) stenosis with multiple medical problems generally undergo carotid artery stenting (CAS). However, it is difficult to perform CAS in some patients because iodinated contrast medium is hard to use. We report a patient with asymptomatic ICA stenosis and chronic renal failure, in whom successful treatment was achieved using CAS with minimal use of iodinated contrast medium. A 68-year-old man with severely chronic renal failure was consulted for treatment of left ICA stenosis. Magnetic resonance angiography (MRA) and carotid echography revealed left ICA severe stenosis, and systemic non-contrast MRA showed left femoral artery constriction, but right femoral artery to be intact. CAS was therefore performed through the right femoral artery, using non-contrast three-dimensional computed tomography (3D-CT) with MRA fusion imaging, intravascular ultrasonography, and a small amount of iodinated low-osmolar contrast medium. Postoperative course was uneventful with no aggravation of renal dysfunction, and he was discharged 7 days postoperatively. These techniques are very useful for patients with chronic renal failure, and this present case represents the first report of CAS treated by using non-contrast 3D-CT with MRA fusion image technique.     

未肝素化冠状动脉造影600例安全性临床分析

目的评价未肝素化冠状动脉造影术的可行性及安全性。方法总结分析600例经股动脉行未肝素化冠状动脉造影术的患者的临床资料,记录手术时间、手术成功率及术中并发症。结果98．5％的病例行选择性冠状动脉造影成功,手术时间（从穿刺动脉到造影结束）8min至1h,平均（17．9±6．3）min。冠心病阳性率为38．8％,多支血管病变占20．3％。心室纤颤发生率0．5％,造影剂过敏发生率0．17％,造影导管内血栓形成0．83％;鞘管内血栓形成0．5％;皮下血肿,动静脉瘘,腹膜后血肿,脑卒中,急性心肌梗死及死亡等其他严重并发症发生率为0％。结论未肝素化冠状动脉造影术安全可靠,并发症少,可以在经验丰富的临床介入医生中使用,但不宜盲目推广。     

Coronary flow reserve after coronary intervention in similar in patients with preserved viability in previous myocardial infarction and in those with angina pectoris

The relationship between coronary flow reserve (CFR) and viability in the infarcted myocardium has not been fully clarified. We measured coronary blood flow velocity immediately after coronary intervention (with percutaneous transluminal coronary angioplasty [PTCA] or stenting) in 38 patients with previous myocardial infarction and preserved viability and 48 with angina pectoris. CFR was calculated and was similar between the two patient groups. No differences in the incidence of post-intervention CFR > 2.0 were detected; there were no differences in post-intervention CFR between patients with preserved myocardial viability and those with angina pectoris who underwent PTCA. Coronary stenting reduced the percentage diameter stenosis in both groups compared with PTCA and slightly increased the post-intervention CFR. No differences were, however, detected in post-intervention CFR between patients with preserved myocardial viability and those with angina pectoris who underwent additional stenting. These results reveal that in patients with preserved myocardial viability, post-intervention CFR was restored to values similar to those in patients with angina pectoris.     

Silent obstruction of the coronary stenosis between diagnostic angiography and later percutaneous transluminal coronary angioplasty without myocardial infarction

Among 204 patients with severe coronary artery stenosis amenable to percutaneous transluminal coronary angioplasty (PTCA), 5 (2.5%) developed new silent total coronary occlusion of the vessel to be dilated without any chest symptom during the period between diagnostic coronary angiography and repeat coronary angiography at the time of the operation. We evaluated the clinical and angiographical characteristics of the patients with silent obstruction of the coronary artery in a short time, compared with the patients with unstable angina pectoris, who is considered to be suffering from acute myocardial infarction with severe chest symptom. None of the clinical variables studied showed a significant difference between the two groups. Among the angiographic variables, the degree of collateral was higher and impaired coronary perfusion distal to the lesion was more frequently found in unstable angina group. These results suggest that unstable angina is in a later stage of the ischemic heart disease compared with the time of the diagnostic angiography in patients with silent obstruction. Silent obstruction of high degree coronary stenosis is presumably due to the development of collateral circulation.     

Clinical Outcome of Coronary Stenting in Patients with Variant Angina Refractory to Medical Treatment: A Consecutive Single-Center Analysis

Objective

To investigate the efficacy of coronary stenting in patients with variant angina refractory to medical treatment.

Subjects and Methods

Variant angina was diagnosed in 81 patients admitted to the Department of Cardiology between January 2003 and June 2011. However, coronary stenting was performed in 21 patients refractory to medical treatment, but coronary angiography and intravascular ultrasound were performed in all patients, and acetylcholine provocative test was performed in 11 of the 21 patients refractory to medical treatment. Coronary angiography was repeated after 9–12 months in the 21 patients with coronary stents. Clinical follow-up time was 2.5 ± 3.1 years (range 1–8).

Results

Of the 81 patients, coronary angiography and intravascular ultrasound did not reveal significant stenosis in 13 (16.0%), but revealed 20–75% fixed stenosis in the remaining 68 (84.0%) patients. The acetylcholine provocative test was positive in the 11 patients. Of the 21 patients with coronary stents, the spasm site was located in the right coronary artery in 16 (76.2%) and in the left anterior descending artery in the remaining 5 (23.8%) patients. During the 1- to 8-year follow-up period, 1 of the 21 patients with stents developed recurrent episodes of variant angina, 5 patients had occasional chest pain, and the other 15 were asymptomatic. Coronary angiography at 9–12 months after initial evaluation demonstrated no stenosis in 3 patients, 20–40% in-stent mild intimal hyperplasia in 15 patients, and 50–80% in-stent restenosis in 3 patients. Coronary stenting was performed again in 2 patients.

Conclusions

The present study showed that coronary stenting for severe refractory coronary vasospasm was effective and without serious complications. It can be an alternative and viable option for some patients who are refractory to medical therapy and at a high risk of acute coronary syndrome recurrence.Key Words: Variant angina, Coronary artery disease, Coronary angiography, Electrocardiography, Stenting, Ultrasonography, Angioplasty, Acetylcholine, Ischemia, Acute coronary syndrome     

非ST段抬高急性冠状动脉综合征患者的介入治疗

目的：分析急性冠脉综合征患者非ST段抬高时行经皮冠状动脉介入治疗术(PCI)的有效性和安全性。方法：从2001年1月至2003年10月在我院住院的72例非ST段抬高急性冠脉综合征病人，包括不稳定型心绞痛病人UAP)48例，非ST抬高急性心肌梗死(NSTEMI)病人24例，除常规内科治疗外，接受冠状动脉造影及介入治疗(PTCA和支架植入术)。造影提示单支血管病变31例(43．1％)，双支血管病变25例(34．7％)，三支血管病变16例(22．2％)，分别行PTCA和支架植入术。结果：介入治疗的成功率97．2％(70／72)，失败的两例患者主要是导丝不能通过闭塞病变所致。在70例患者中，共植入支架91枚。随访至术后30d，无症状或症状明显缓解的61例；2例发生ST段抬高急性心肌梗死；4例多支血管病变患者再次行介入治疗；3例患者转外科行CABG术；2例患者死亡。结论：经皮冠状动脉介入治疗是非ST段抬高急性冠脉综合征的有效和安全的治疗方法。     

不伴心肌梗死的冠状动脉完全闭塞病变心绞痛的临床分析

目的：探讨不伴心肌梗死的冠状动脉完全闭塞病变心绞痛患者的临床特点。方法：对24例不伴心肌梗死的冠状动脉完全闭塞患者的临床表现、心电图、超声心动图及冠状动脉造影资料进行回顾分析。结果：中、高危险组主要表现为静息心绞痛，低危险组和稳定性心绞痛组主要表现为劳力型心绞痛。冠状动脉造影显示左前降支闭塞10例（37％），右冠状动脉闭塞7例（26％），左回旋支闭塞6例（22％），合并多支血管病变23例（95．8％）。心电图ST段异常14例（58．3％）。62．5％的患者进行经皮冠脉血运重建术。结论：不伴心肌梗死的冠状动脉完全闭塞主要表现为劳力型心绞痛，心电图ST段异常是预测冠脉病变严重程度的主要危险因素。经皮冠状动脉介入治疗正成为慢性冠状动脉闭塞的主要手段之一。     

冠心病合并慢性肾功能不全介入诊断或治疗围术期的肾功能保护

目的　探讨慢性肾功能不全患者行冠状动脉介入诊断或治疗的安全性及疗效。方法　分析1994年 1月— 2 0 0 2年 7月收治的慢性肾功能不全且行冠状动脉造影术 ( SCA)或经皮冠状动脉腔内成形术( PTCA)及支架术患者围术期的肾功能变化。 90例患者分成 3组 :A组行 SCA,围术期无特殊治疗 ;B组行SCA,围术期给予多巴胺加水化疗法 ;C组行 PTCA及支架术 ,围术期给予多巴胺加水化疗法。结果　 90例患者均成功地完成了 SCA或 PTCA及支架术 ,2 8例出现造影剂相关性肾病 ( CAN ) ,其中 A组、B组及 C组发生率分别为 36 .7%、16 .7%和 4 0 .0 % ( 11、5和 12例 ) ,A组 >B组 ( P<0 .0 1)、C组 >B组 ( P<0 .0 1) ,无一例需透析治疗 ,均药物治疗好转而出院。心功能 ～ 级的心力衰竭患者较心功能 级的非心力衰竭患者 CAN发生率明显增加 ( 6 4 .5 %、2 0 / 31例 ;13.6 %、8/ 5 9例 ;P<0 .0 1) ;糖尿病较非糖尿病患者 CAN发生率明显增加 ( 4 2 .6 %、2 3/ 5 4例 ;13.9%、5 / 36例 ;P<0 .0 1)。结论　对慢性肾功能不全患者围术期采用小剂量多巴胺加水化疗法进行充分的治疗 ,可使其耐受 SCA或 PTCA及支架术治疗 ,具有较高的安全性和较理想的预后