Acute gastrointestinal bleeding after percutaneous coronary intervention

Bleeding from the GI tract is a commonly encountered clinical problem after percutaneous coronary intervention. The GI tract is likely to become the most commonly encountered site of bleeding as cardiologists adopt smaller access sheath sizes, percutaneous closure devices and a radial artery approach, further reducing access-site bleeding. To appropriately manage gastrointestinal bleeding in this setting, the clinician must strike a balance between arresting hemorrhage and preventing ischemic coronary complications. To do so, an appreciation of both cardiovascular and gastrointestinal issues is required. This review aims to provide the required knowledge, as well as a series of recommendations from our practice, to assist in the management of this potentially fatal complication.     

冠状动脉病变患者429例经皮冠状动脉介入术后1年造影随访分析

目的 评价冠状动脉多支血管病变(MVD)通过经皮冠状动脉介入(PCI)进行血运重建的长期疗效.方法 2010年3月至2011年5月在第三军医大学附属西南医院成功接受PCI治疗的429例患者,术后约1年进行血管造影随访,并对其心绞痛复发率、造影复查再狭窄率和主要不良心脏事件(MACE)发生率进行回顾分析.结果 429例PCI患者完全性血运重建病例比率为95.8%,住院期间无心源性死亡病例,其心绞痛复发率、造影复查再狭窄率分别为10.1%、4.4%,MACE主要是1年内再次行血运重建的患者,发生率为3.5%.患者血运重建后心功能、每周心绞痛发作频次均有明显改善,显著提高了患者的生活质量及生存率.结论 PCI进行血运重建是治疗冠心病特别是MVD的有效方法,合理的PCI方案及药物洗脱支架的应用是改善患者远期预后的关键.     

经桡动脉冠脉介入治疗术后严重出血并发症的危险因素分析

目的 探讨经桡动脉冠状动脉介入治疗术后发生严重出血并发症的危险因素.方法 回顾性分析2011年12月至2013年12月廊坊市第四人民医院心内科收治的经桡动脉冠状动脉介入术后的患者669例,把其中26例严重出血患者设为出血组,随机抽取30例无严重出血患者为未出血组.使用Logistic回归分析发现与严重出血并发症相关的危险因素.结果 与未出血组比较,出血组患者高龄、男性、2型糖尿病、长期吸烟史、急诊PCI、动脉路径迂曲是严重出血发生的独立危险因素.结论 高龄、男性、2型糖尿病、长期吸烟史、急诊PCI、动脉路径迂曲可以作为预测PCI术后严重出血的危险因素.     

不稳定型心绞痛血运重建后氧化和抗氧化指标的动态变化

目的 :探讨不稳定型心绞痛 (UAP)患者经皮冠状动脉介入治疗后丙二醛 (MDA)和超氧化物歧化酶(SOD)水平的变化规律及临床意义。方法 :连续观察 2 5例UAP患者 (A组 )经皮冠状动脉治疗术前及术后 1、2 4、72h血液中MDA和SOD的变化。另设单纯行冠状动脉造影的UAP患者 (B组 ) 2 0例和健康者 2 0例作对照 ,MDA和SOD分别用硫代巴比妥酸法和黄嘌呤氧化酶法测定其血清含量 ,并随访术后 3个月心血管事件的发生情况。结果 :UAP患者中MDA浓度明显高于健康者 ,介入治疗后 1h进一步升高 ,持续至 2 4h(P <0 .0 5 ) ,72h回落至术前水平 ;B组术前与术后无明显改变。UAP患者中SOD的浓度明显低于健康者 (P <0 .0 5 ) ,介入治疗后进一步降低。结论 :UAP患者介入治疗后MDA和SOD在 72h内有动态变化 ,可能是术后早期心血管事件的危险因素     

Baseline bleeding risk and arterial access site practice in relation to procedural outcomes after percutaneous coronary intervention

Background Transradial access(TRA) has been associated with reduced access site-related bleeding complications and mortality after percutaneous coronary intervention(PCI). It is unclear, however, whether these observed benefits are influenced by baseline bleeding risk. Objectives This study investigated the relationship between baseline bleeding risk, TRA utilization, and procedure-related outcomes in patients undergoing PCI enrolled in the British Cardiovascular Intervention Society database. Methods Baseline bleeding risk was calculated by using modified Mehran bleeding risk scores in 348,689 PCI procedures performed between 2006 and 2011. Four categories for bleeding risk were defined for the modified Mehran risk score(MMRS): low( 10), moderate(10 to 14), high(15 to 19), and very high(≥20). The impact of baseline bleeding risk on 30-day mortality and its relationship with access site were studied. Results TRA was independently associated with a 35% reduction in 30-day mortality risk(odds ratio [OR]: 0.65 [95% confidence interval(CI):0.59 to 0.72]; P 0.0001), with the magnitude of mortality reduction related to baseline bleeding risk(MMRS 10, OR: 0.73 [95% CI: 0.62 to 0.86]; MMRS ≥20, OR: 0.53 [95% CI: 0.47 to 0.61]). In patients with an MMRS 10, TRA was used in 71,771(43.2%) of 166,083 PCI procedures; TRA was used in8,655(40.1%) of 21,559 PCI procedures in patients with an MMRS ≥20, illustrating that TRA was used less in those at highest risk from bleeding complications(P 0.0001). Conclusions TRA was independently associated with reduced 30-day mortality, and the magnitude of this effect was related to baseline bleeding risk; those at highest risk of bleeding complications gained the greatest benefit from adoption of TRA during PCI.     

Incidence of diverticular bleeding: a population-based study

Objective: To determine the incidence of diverticular bleeding (DB) and examine the time trend of the incidence. Furthermore to study prognosis with regard to therapy and rebleeding.

Methods: A retrospective, population-based study of patients with DB in a National University Hospital from 2006 to 2016. Patients were identified in an electronically stored colonoscopy database. Definite diverticular bleeding was defined as active bleeding, a nonbleeding visible vessel or adherent clot. Presumptive diverticular bleeding was defined as acute painless rectal bleeding leading to hospitalization with visible diverticula but no evidence of bleeding and no other colonic lesions or bleeding sites identified on endoscopy. A 30-day re-bleeding was determined after discharge.

Results: A total of 3683 colonoscopy reports were reviewed, including 345 patients (males 51%) with presumptive 95% (n?=?327) or definitive 5% (n?=?18) diverticular bleeding. Overall 96% were treated conservatively, 3% endoscopically and 0.3% surgically. Only 5.8% of patients had a 30-day rebleed. After exclusion, 315 patients were included in the incidence calculations. The mean cumulative incidence of diverticular bleeding was 14/100,000 inhabitants per year. A time trend analysis of the incidence of DB revealed no significant change in incidence during the study period.

Conclusions: The mean incidence of colonic diverticular bleeding was found to be approximately 14 cases per 100,000 inhabitants and year. The incidence does not seem to have changed in the past decade. The vast majority of patients with diverticular bleeding did not require endoscopic therapy and could be managed with conservative treatment.     

Prognostic value of coronary artery calcium score in patients with stable an-gina pectoris after percutaneous coronary intervention

Objectives To evaluate the prognostic value of the coronary artery calcium （CAC） score in patients with stable angina pectoris （SAP） who underwent percutaneous coronary intervention （PCI）. Methods A total of 334 consecutive patients with SAP who underwent first PCI following multi-slice computer tomography （MSCT） were enrolled from our institution between January 2007 and June 2012. The CAC score was calculated according to the standard Agatston calcium scoring algorithm. Complex PCI was defined as use of high pressure bal-loon, kissing balloon and/or rotablator. Procedure-related complications included dissection, occlusion, perforation, no/slow flow and emer-gency coronary artery bypass grafting. Main adverse cardiac events （MACE） were defined as a combined end point of death, non-fatal myo-cardial infarction, target lesion revascularization and rehospitalization for cardiac ischemic events. Results Patients with a CAC score〉300 （n=145） had significantly higher PCI complexity （13.1%vs. 5.8%, P=0.017） and rate of procedure-related complications （17.2%vs. 7.4%, P=0.005） than patients with a CAC score≤300 （n=189）. After a median follow-up of 22.5 months （4-72 months）, patients with a CAC score≤300 differ greatly than those patients with CAC score＆gt;300 in cumulative non-events survival rates （88.9 vs. 79.0%, Log rank 4.577, P=0.032）. After adjusted for other factors, the risk of MACE was significantly higher [hazard ratio （HR）：4.3, 95%confidence inter-val （95%CI）：2.4-8.2, P=0.038] in patients with a CAC score〉300 compared to patients with a lower CAC score. Conclusions The CAC score is an independent predictor for MACE in SAP patients who underwent PCI and indicates complexity of PCI and proce-dure-related complications.     

Active gastrointestinal diverticulum bleeding diagnosed by computed tomography angiography

A diverticulum is a bulging sack in any portion of the gastrointestinal tract. Small intestine diverticular disease is much less common than colonic diverticular disease. The most common symptoms include non-specific epigastric pain and a bloating sensation. Major complications include diverticulitis, gastrointestinal bleeding, acute perforation, intestinal obstruction, intestinal perforation, localized abscess, malabsorption, anemia, volvulus and bacterial overgrowth. We report one case of massive jejunal diverticula bleeding and one case of massive colonic diverticula bleeding, both diagnosed by acute abdominal computed tomography angiography and treated successfully by surgery.     

高龄PCI术后并发下消化道出血1例

高龄冠心病患者是一个特殊的群体,特别是年龄>75岁的冠心病患者PCI围手术期发生消化道出血的防治尚无统一标准供临床医生借鉴。国内外学者对此类患者的治疗进行了一些探索,但仍未提出明确的治疗指南。本文所报道的高龄女性PCI术后消化道出血,经积极治疗后,好转出院,1年后随访情况良好。现报道如下。     

Inhospital and delayed mortality after upper gastrointestinal bleeding: an analysis of risk factors in a prospective series

Background: Detailed analyses of mortality after upper gastrointestinal (GI) bleeding are lacking. Follow-up rarely extends beyond 30 days.

Aims: Our aim was to analyze in-hospital and delayed 6-months mortality, identifying risk factors.

Methods: This was a prospective study on patients with upper GI bleeding over 36 months. Clinical outcomes were in-hospital and delayed-6 month-mortality.

Results: Four hundred and forty-none patients were included. Overall inpatient mortality was 9.8% but mortality directly related to bleeding was 5.1%. Patients who died presented lower systolic blood pressures, platelet recounts, prothrombin times and lower levels of hemoglobin, calcium, albumin, urea, creatinine and total proteins. Cirrhosis and neoplasms determined a higher in-hospital mortality. Albumin levels were protective, whereas creatinine and an active bleeding were risk factors for in-hospital death in multivariate analysis. Up to 12.6% of patients discharged died in the first 6 months. Neoplasms, chronic kidney disease, coronary disease and esophageal varices were related to delayed mortality. Coronary disease and neoplasms were independent risk factors for mortality, but albumin levels were protective in multivariate analysis.

Conclusion: Comorbidities were risk factors for delayed mortality, whereas albumin levels were a protective factor for in-hospital and delayed deaths. Six months mortality is proportionately as important as in-hospital mortality. Half of the delayed deaths might be preventable.     

Correlates and consequences of gastrointestinal bleeding complicating percutaneous coronary intervention

Gastrointestinal bleeding (GIB) complicating percutaneous coronary intervention (PCI) results in high mortality, but clinical factors associated with and long-term outcomes of GIB are poorly understood. We sought to examine clinical and procedural factors associated with GIB complicating PCI. We also examined the impact of GIB on 30-day mortality and 1-year major adverse cardiac events (MACEs). Patients undergoing PCI from January 2000 to January 2010 were retrospectively analyzed for the occurrence of in-hospital GIB. Multivariable logistic regression and Cox proportional hazards regression were used to identify predictors of in-hospital GIB and 30-day mortality. Landmark analysis of patients surviving to hospital discharge was performed to assess the impact of GIB on 1-year MACEs. Of 20,621 patients who underwent PCI, 147 (0.72%) who developed in-hospital GIB were identified. Variables associated with increased risk of GIB included older age, shock, acute myocardial infarction, chronic renal insufficiency, lower baseline hematocrit, and glycoprotein IIb/IIIa inhibitors; bivalirudin decreased the risk. Unadjusted 30-day mortality rate of patients with GIB was 20.5% compared to 2.4% of patients without GIB. After multivariable adjustment, GIB and shock (and an interaction between the 2) were the most important correlates of 30-day mortality. In the population surviving to discharge, however, GIB was not associated with adjusted mortality or MACEs. In conclusion, GIB complicating PCI has a dramatic impact on 30-day mortality, and bivalirudin was associated with lower rates of GIB.     

急诊胃镜对经皮冠状动脉介入术后合并上消化道出血的诊治价值

2015年6月—2020年 6月期间,因经皮冠状动脉介入术（percutaneous coronary intervention,PCI）术后合并上消化道出血,在武汉大学人民医院行急诊胃镜检查和治疗的52例患者纳入回顾性分析,主要观察急诊胃镜出血病因诊断、止血治疗结果和诊疗过程中并发症发生情况。其中,47 例（90.4...     

Lower gastrointestinal bleeding:Role of 64-row computed tomographic angiography in diagnosis and therapeutic planning

AIM: To determine the value of computed tomographic angiography(CTA) for diagnosis and therapeutic planning in lower gastrointestinal(GI) bleeding.METHODS: Sixty-three consecutive patients with acute lower GI bleeding underwent CTA before endovascular or surgical treatment. CTA was used to determine whether the lower GI bleeding was suitable for endovascular treatment, surgical resection, or conservative treatment in each patient. Treatment planning with CTA was compared with actual treatment decisions or endovascular or surgical treatment that had been carried out in each patient based on CTA findings.RESULTS: 64-row CTA detected active extravasation of contrast material in 57 patients and six patients had no demonstrable active bleeding, resulting in an accuracy of 90.5% in the detection of acute GI bleeding(57 of 63). In three of the six patients with no demonstrable active bleeding, active lower GI bleeding recurred within one week after CTA, and angiography revealed acute bleeding. The overall location-based accuracy, sensitivity, specificity, positive predictive value(PPV) and negative predictive value(NPV) for the detection of GI bleeding by 64-row CTA were 98.8%(249 of 252), 95.0%(57 of 60), 100%(192 of 192), 100%(57 of 57), and 98.5%(192 of 195), respectively. Treatment planning was correctly established on the basis of 64-row CTA with an accuracy, sensitivity, specificity, PPV and NPV of 98.4%(248 of 252), 93.3%(56 of 60), 100%(192 of 192), 100%(56 of 56), and 97.5%(192 of 196), respectively, in a location-based evaluation. CONCLUSION: 64-row CTA is safe and effective in making decisions regarding treatment, without performing digital subtraction angiography or surgery, in the majority of patients with lower GI bleeding.