医源性冠状动脉夹层的危险因素分析及急诊处理

【摘要】 目的 探讨医源性冠状动脉夹层的危险因素及如何避免或减少其发生。方法 我院2012年1月至2013年1月行选择性冠状动脉造影及支架植入术528例,其中共发生医源性冠状动脉夹层94例。根据NHLBI分型,将A、B型夹层分为轻型夹层,C、D、E、F四型及长夹层（＞10 mm）或真腔狭窄＞50%夹层分为重型夹层。对与夹层相关的解剖因素、器械因素、胸痛发作、支架植入例数、成功例数、手术时间、住院时间、随访2年全因死亡率、生存时间等进行比较。结果 医源性冠状动脉夹层发生率17.80%,其中轻型夹层占70.21%,重型夹层占29.79%。无论是何种夹层,冠状动脉的解剖因素均是造成医源性夹层的重要因素。相对而言,重型夹层更容易发生于器械选择或使用不当（64.28% 比25.75%,χ2=12.49**）,术中胸痛发作多（85.71% 比 46.97%,χ2=12.16**）,绝大多数需行支架植入（92.86% 比 57.58%,χ2=11.26**）,手术成功率相对较低（69.23% 比 92.11%,χ2=5.65*）,手术时间［（66.61±21.00）min 比 （57.27±20.02）min,t =2.04*）］和住院时间［（7.71±1.56）d 比 (6.91±1.63)d,t =2.21*）］更长,2年全因死亡率更高（42.86% 比 18.18%,χ2=6.30*）而中位生存时间更短（13.31个月 比 17.59个月,χ2=4.51*）。结论 大多数医源性冠状动脉夹层可以取得良好疗效,重视冠脉的解剖特点,恰当选择介入器械,及时有效的血运重建能减少严重并发症的发生。     

Significant left main coronary artery disease from iatrogenic dissection during coronary angiography

Though atherosclerotic obstruction is the major cause of the obstructive left main coronary artery (LMCA) disease, it can be associated with iatrogenic dissection during coronary angiography. Here we report a case with severe LMCA stenosis due to catheter induced dissection in a 77-year-old man which was detected 9 months later. By careful review of the angiogram had taken at 9 months ago, the LMCA was injured by the diagnostic left Judkin's catheter during the first coronary angiography. The initial lesion was neglected and the dissection got worse with time. The patient was successfully treated with two drug-eluting stents by crushing technique and discharged without further complication.     

自发性冠状动脉夹层合并冠状动脉狭窄二例

1临床资料患者女性,39岁,入院半个月前无明显诱因突然发生胸痛,位于胸骨后方向左肩及向背部放射,呈剧痛。口服硝酸甘油后10min缓解。在当地医院行胸部CT未见异常。既往体健,无高血压和糖尿病病史。     

Successful endovascular treatment of iatrogenic coronary artery dissection extending into the entire ascending aorta

Iatrogenic acute dissection of the ascending aorta during percutaneous coronary intervention occurs rarely. Localized aortic dissections may be treated by sealing the entry with a coronary stent. However, extensive dissections may require a surgical intervention. A case of iatrogenic coronary dissection with extensive propagation into the ascending aorta during angioplasty of the right coronary artery is presented. The aortic dissection was successfully treated by stenting at the right coronary artery ostium. Follow-up computed tomography and coronary angiography showed complete resolution of aortic dissection.     

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a relatively rare and unexplored type of coronary disease. Although atherosclerosis, hormonal changes during pregnancy and connective tissue disorders might represent a sufficiently convincing explanation for some patients with SCAD, the many remaining cases display only a weak relationship with these causes. While on one side the clinical heterogeneity of SCAD masks a full understanding of their underlying pathophysiologic process, on the other side paucity of data and misleading presentations hamper the quick diagnosis and optimal management of this condition. A definite diagnosis of SCAD can be significantly facilitated by endovascular imaging techniques. In fact, intravascular ultrasound (IVUS) and optical coherence tomography (OCT) overcome the limitations of coronary angiography providing detailed endovascular morphologic information. In contrast, optimal treatment strategies for SCAD still represent a burning controversial question. Herein, we review the published data examining possible causes and investigating the best therapy for SCAD in different clinical scenarios.     

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) should be considered as a cause of the acute coronary syndrome in young patients with few apparent risk factors for coronary artery disease, in females in the peripartum period, and in patients who are at a higher risk for this condition. SCAD can also present as sudden death and cardiogenic shock. Several mechanisms have been described in the pathophysiology of this condition. Urgent coronary angiography is indicated if SCAD is suspected. Percutaneous coronary artery stenting and coronary artery bypass grafting are the main treatment strategies.     

Primary coronary artery dissection

Three patients had angiographic appearance of chronic primary coronary artery dissection with features that differed from other patients with this entity studied at autopsy; they were men, greater than or equal to 40 years of age, had angina pectoris and severe coronary artery disease. The right coronary artery, which was the artery involved with dissection, had only mild atherosclerosis. Further studies are needed to determine the natural history of this angiographic finding.     

Postpartum coronary artery dissection

A 27-year-old woman experienced anterior myocardial infarction three weeks after the delivery of her second child. Coronary arteriography subsequently showed primary dissection of the left coronary artery. This patient is believed to be the second reported survivor of angiographically proven peripartal left coronary artery dissection and the only such patient to achieve and maintain asymptomatic status for a prolonged period without operative intervention.     

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial ischemia with complex pathophysiology. This paper reviews the major diagnostic and therapeutic issues of this rare but important disease. The diagnosis of SCAD should be strongly considered in any patient who presents with symptoms suggestive of acute myocardial ischemia, particularly in young subjects without traditional risk factors for coronary artery disease (especially in young women during the peripartum period or in association with oral contraceptive use). Urgent coronary angiography is indicated to establish the diagnosis and to determine the appropriate therapeutic approach. The decision to pursue medical management, percutaneous coronary intervention, or surgical revascularization is based primarily on the clinical presentation, extent of dissection, and amount of ischemic myocardium at risk.     

自发性冠状动脉夹层的临床及影像学分析

目的 分析自发性冠状动脉夹层（SCAD）的临床、影像学特点及治疗情况。 方法 回顾性分析11例SCAD患者的临床特点、造影及其他腔内影像学资料、治疗方法及预后。 结果 11例SCAD患者均为女性,冠状动脉造影可见冠状动脉呈“鼠尾样”改变,血管内超声（IVUS）或光学干涉断层成像（OCT）可确诊,其中3人行PCI手术,1人在IVUS引导下进行,手术顺利,另外2人术中植入支架时血肿扩散至血管急性闭塞,其余8人药物保守治疗,11人预后均较好,一年随访无复发。 结论 SCAD好发于中年女性,预后较好,腔内影像引导可增加PCI手术成功率。     

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) should be considered as a cause of the acute coronary syndrome in young patients with few apparent risk factors for coronary artery disease, in females in the peripartum period, and in patients who are at a higher risk for this condition. SCAD can also present as sudden death and cardiogenic shock. Several mechanisms have been described in the pathophysiology of this condition. Urgent coronary angiography is indicated if SCAD is suspected. Percutaneous coronary artery stenting and coronary artery bypass grafting are the main treatment strategies.     

Spontaneous coronary artery dissection

Spontaneous coronary artery dissection is a rarely identified entity whose exact incidence, etiology, pathogenesis, medium-term evolution, and optimal treatment have not yet been firmly established. This article describes five new cases with additional specific characteristics. Five of 2,241 coronary arteriograms taken between September 1989 and November 1992 showed angiographic signs of coronary dissection. Three of the patients were treated pharmacologically, and two were operated on. All were evaluated angiographically 10–18 months after diagnosis and followed up clinically for ≥20 months. Three patients exhibited acute myocardial infarction, one showed effort angina and the fifth unstable angina. In four cases, coronary dissection was associated with coronary atherosclerosis, but in the fifth the coronary tree was apparently healthy except for the dissection. Dissection affected the right coronary artery in three cases and the left in two. Angiographic evolution varied among the five and was uncorrelated with treatment. Dissection disappeared in three; it persisted, with total obstruction of the artery in the middle of the dissected segment in one case; and advanced to affect the whole left coronary tree in the fifth. After an 18-month follow-up, none of the five patients experienced symptoms. These cases provide a good illustration of the variability of spontaneous coronary dissection as regards etiology, clinical presentation, treatment, and evolution. Coronary dissection is always caused by hemorrhage in the media of the arterial wall; its variability in evolution and in optimal treatment may be derived from the cause of the hemorrage, which possibly was not the same in all cases. © 1994 Wiley-Liss,Inc..     

自发性冠状动脉夹层研究进展

自发性冠状动脉夹层是一种少见的冠状动脉疾病,主要表现为冠状动脉内膜自发撕裂或冠状动脉壁内出血形成血管夹层,是年轻妇女、尤其是围产期妇女急性心肌梗死或猝死的重要原因。近年来,随着介入技术的发展,自发性冠状动脉夹层的研究进一步深入。自发性冠状动脉夹层发病机制复杂,临床多表现为危重急症,需尽早诊断和治疗。     

Spontaneous coronary artery dissection. An infrequent cause of acute coronary syndromes

Spontaneous coronary artery dissection is a rare condition that may produce severe myocardial ischemia. The growth of indications for cardiac catheterization have led to an increment in the number of cases identified in patients with acute coronary syndromes. Because the therapeutic approach and prognosis are uncertain, doubts often arise regarding the optimal management of these patients. We describe here the clinical and angiographic characteristics of 7 patients with spontaneous coronary artery dissection, as well as treatment and follow-up.