经皮冠状动脉介入治疗术后出血风险评估研究进展

经皮冠状动脉介入治疗(PCI)是一种广泛应用的获得心肌血运重建的策略。PCI术后的抗栓治疗已成为治疗冠心病的基石，能有效防止支架内血栓形成和缺血事件的发生。然而与抗栓治疗相关的各种出血并发症也成为关注的热点。目前已有多个出血评分系统可用于预测患者在不同时期的出血风险，指导临床医生更全面地评估PCI术后出血风险，改善患者预后。现将出血风险评估模型结合其临床应用及最新研究进展做一综述，为临床实践提供参考。     

PCI术后消化道出血的原因及防治分析

目的探讨冠心病经皮冠动脉介入治疗(PCI)术后消化道出血的原因及防治。方法选择2017年12月-2018年11月来我院接收的PCI术后消化道出血患者共50例,研究分析出血的原因以及防治措施。结果对高风险患者给予术后个性化监测和预测,并改善术后管理系统,可改善患者预后。结论应准确分析PCI术后消化道出血的原因,结合患者的实际情况落实护理对策,以便巩固治疗的效果。     

冠状动脉介入治疗术后严重出血并发症的危险因素分析

目的探讨经皮冠状动脉介入治疗(PCI)术后严重出血并发症的危险因素。方法回顾分析2105例PCI患者中41例严重出血患者(出血组)和随机抽取的50例无严重出血患者(未出血组),使用logistic回归分析与严重出血并发症相关的危险因素。结果与未出血组比较,出血组患者年龄和基础血肌酐水平较高,体重较低。年龄偏大、体重轻和基础血肌酐水平升高是增加PCI术后严重出血风险的独立危险因素。结论年龄、体重和血肌酐水平可以作为预测PCI术后严重出血风险的指标。     

冠状动脉介入治疗后出血原因分析及护理

目的：探讨冠状动脉介入治疗术(PCI)后出血的相关因素及护理。方法：回颐性分析9例PCI后出血病人的资料。结果：发生PCI后出血的原因与年龄、伤口处理不当、过早活动、疾病因素和抗凝药的使用等因素有关。结论：加强术后的观察与护理，掌握预防出血的护理要点．可以预防、减少冠状动脉介入治疗术后出血的发生。     

经皮冠状动脉介入治疗围手术期出血的危险因素、预后及管理

出血是经皮冠状动脉介入治疗(PCI)围手术期最常见的并发症之一。PCI围手术期出血与主要不良心血管事件(MACE)相关。实施出血风险分层管理,以减少PCI围手术期出血并发症,已成为临床工作的重点。该文主要介绍PCI围手术期出血的危险因素、预后及管理。     

盐酸替罗非班在急性心肌梗死患者急诊冠状动脉介入治疗中的有效性和安全性评价

目的:评价血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂盐酸替罗非班在急性心肌梗死(AMI)患者急诊冠状动脉介入治疗(PCI)中的有效性和安全性。方法:将106例AMI患者随机分为替罗非班组(替罗非班+直接PCI,55例)和对照组(直接PCI,51例)。比较2组患者梗死相关动脉PCI后即刻TIMI血流,术后90 min心电图ST段回落百分比(sumSTR),术后6 h、12 h肌酸激酶同工酶变化,术后1周左室射血分数,术后30 d内不良心脏事件(心绞痛、心肌梗死、死亡)及出血和血小板减少的发生率。结果:2组基础临床情况和冠状动脉造影特征无明显差异。替罗非班组梗死相关动脉PCI术后即刻TIMI血流、术后90 min sumSTR均显著高于对照组;术后30 d内不良心脏事件明显少于对照组;术后6 h、12 h肌酸激酶同工酶变化、术后1周左室射血分数与对照组相比差异无统计学意义。替罗非班组轻度出血发生率高于对照组,但未发生严重出血和血小板减少症。结论:替罗非班能明显降低AMI患者PCI后缺血事件的发生,在急诊PCI中是有效而安全的。     

替罗非班对急性心肌梗死急诊PCI术后心肌灌注及临床预后的影响

目的探讨替罗非班对急性心肌梗死（AMI）急诊经皮冠状动脉介入治疗（PCI）术后心肌灌注及临床预后的影响。方法 104例AMI患者随机分为观察组和对照组,观察组给予替罗非班＋PCI治疗,对照组直接PCI治疗。结果观察组PCI术后即刻TIMI 3级血流发生率高于对照组（P〈0.05）;观察组PCI术后90 min ST段抬高总和回落百分比高于对照组（P〈0.05）;观察组术后71、4 d肌酸激酶同工酶低于对照组（P〈0.05）,左室射血分数高于对照组（P〈0.05）;术后观察组患者心绞痛、心律失常发生率低于对照组（P〈0.05）,轻度出血（皮肤、黏膜出血）发生率高于对照组（P〈0.05）。结论替罗非班可有效改善AMI患者PCI术后心肌灌注,降低术后部分不良心脏事件的发生,且无严重不良反应,可在临床推广使用。     

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.     

血小板功能检测指导的个体化抗血小板治疗在冠心病患者中的临床应用

氯吡格雷使用后血小板高反应(High on-treatment platelet reactivity ,HTPR)在接受冠脉介入治疗患者中的发生率约为5%-44%,且被认为与CYP2C19基因型相关。目前关于HTPR与PCI术后心血管不良事件(MACE)发生率的相关关系及依据血小板聚集度及基因检测结果调整的个体化抗血小板方案能否改善PCI患者预后仍充满争议。本文综述了血小板功能检测方法及其结果与PCI术后患者预后相关的最新临床研究。     

急性心肌梗死患者在主动脉球囊反搏术支持下急诊经皮冠状动脉介入治疗预后的影响因素

目的:观察急性心肌梗死(AMI)急诊接受PCI患者在主动脉球囊支持下预后影响因素及护理对策。方法:回顾分析经绿色通道行急诊PCI治疗AMI后,应用主动脉球囊反搏患者27例,分析临床一般资料、临床特征及介入治疗情况。结果:年龄、性别、高血压、糖尿病吸烟史。梗死部位、LVEF无统计学差异,Killip1-2级、PCI术后无血流差异有统计学意义(P0.05)。结论:Killip1-2级、PCI术后无血流是影响患者预后的相关因素。     

老年冠状动脉介入治疗患者三种动脉止血方法术后舒适度的比较

目的比较冠状动脉介入治疗(PCI)三种动脉止血方法对老年患者术后舒适度的影响,探讨适宜的护理方案。方法 396例接受冠状动脉介入治疗的老年患者,按股动脉穿刺点止血方法分为手工压迫组(A组,n=162),Femostop压迫组(B组,n=106),和Perclose组(C组,n=128),监测各组患者入院时、术前、术后6h、术后1d内心率、血压变化,睡眠困难、胃肠道症状、躯体疼痛以及出血血栓事件的发生率。结果与手工压迫组比较,Per-close组患者术后生命体征波动小,睡眠困难、排尿障碍、胃肠道症状、躯体疼痛发生程度较轻;Femostop组术后舒适度各指标与手工压迫组相比无差异;Perclose组出血并发症明显低于Femostop压迫组及手工压迫组。三组血栓事件的发生率无明显差异。结论对接受PCI治疗的老年患者,Perclose止血方法可明显改善患者术后舒适程度;对接受不同止血方法的患者应采取不同的护理方案,以改进护理效率及质量。     

Endoscopic sphincterotomy in adult hemophiliac patients with choledocholithiasis

BACKGROUND: The aim of this study was to investigate the risk of bleeding in adult hemophiliac patients undergoing endoscopic sphincterotomy for choledocholithiasis. METHODS: From 1983 to 2002, 7 patients with hemophilia A and two with hemophilia B were referred for endoscopic sphincterotomy and extraction of bile duct stones. The degree of hemophilia was mild in 4 patients, moderate in 3, and severe in two. Pre-admission levels of blood clotting factors ranged from less than 1% to 18%. Levels of the deficient factors were monitored carefully before and after sphincterotomy, and the relevant factor was replaced to achieve 100% activity before and for 24 hours after endoscopic sphincterotomy. OBSERVATIONS: Seven patients had factor replacement every 8 hours, and two received continuous infusions. No patient developed bleeding after sphincterotomy. At discharge, 48 hours after the procedure, patients who had received continuous infusions had a factor level of greater than 90%; those who had received intermittent replacement had levels of greater than 50%. After discharge, the patients were treated with regular infusion of the deficient factor for 15 days. CONCLUSIONS: With adequate preoperative and post-procedure monitoring of clotting factors, meticulous attention to hemostasis during sphincterotomy, careful post-procedure monitoring, and timely replacement therapy, patients with hemophilia can undergo endoscopic sphincterotomy without bleeding complications.     

Biliary hemostasis using an endoscopic plastic stent placement for uncontrolled hemobilia caused by transpapillary forceps biopsy (with video)

A 78-year-old woman was referred to our hospital for the examination and treatment of jaundice. A transpapillary forceps biopsy for a long distal bile duct stricture was performed using endoscopic retrograde cholangiopancreatography. Immediately after the biopsy, massive bleeding was observed from the orifice of the papilla. Although hemobilia was pulsatile, an endoscopic biliary plastic stent placement was very effective in achieving hemostasis. However, a nasal biliary catheter was required because a blood clot clogged the stent on the following day. Although covered self-expandable metal stent (CSEMS) placement has been reported for achieving endoscopic hemostasis for bleeding, we chose to use a plastic stent to reduce the risk of post-procedure pancreatitis. The placement of both an endoscopic biliary plastic stent and a nasobiliary drainage catheter can be an alternative hemostatic tool to CSEMSs.     

Long-Term Outcomes and Associations With Major Adverse Limb Events After Peripheral Artery Revascularization

BackgroundLong-term cardiovascular and limb outcomes after revascularization for peripheral artery disease and, in particular, prognosis after post-procedure major adverse limb events (MALE) are not well-studied.ObjectivesThis study sought to describe outcomes after peripheral revascularization and assess relationships between post-procedure MALE hospitalization and subsequent events.MethodsPatients undergoing peripheral artery revascularization between January 1, 2009, and September 30, 2015, in the Premier Healthcare Database were examined for the co-primary outcomes of interest, composite myocardial infarction (MI) or stroke and composite major amputation or peripheral revascularization. Multivariable adjusted Cox proportional hazards models with post-procedure MALE hospitalization included as a time-dependent covariate were developed to estimate hazard ratios for outcomes.ResultsAmong 393,017 revascularized patients followed for a median of 2.7 years (interquartile range: 1.3 to 4.4 years), the cumulative incidence of MI or stroke was 9.8% and that of major amputation or peripheral revascularization was 41.9%. A total of 50,750 patients (12.9%) had at least 1 post-procedure MALE hospitalization. In time-dependent covariate adjusted models, post-procedure MALE hospitalization was associated with greater risk of subsequent MI or stroke (hazard ratio: 1.34; 95% confidence interval: 1.28 to 1.40) and major amputation or peripheral revascularization (hazard ratio: 8.13; 95% confidence interval: 7.96 to 8.29). After peripheral revascularization with or without post-procedure MALE hospitalization, risk of limb events increased rapidly post-procedure and more slowly after the first year, whereas cardiac risk increased steadily during follow-up.ConclusionsRevascularized peripheral artery disease patients face earlier limb and later cardiovascular ischemic risk that is heightened among patients with post-procedure MALE hospitalization. Increased provider awareness of these long-term risks may guide efforts to improve post-procedural outcomes.     

Successful percutaneous coronary intervention in a patient with severe haemophilia A using bivalirudin as the sole procedural anticoagulant

This article presents the case of a patient with severe haemophilia A who underwent successful multivessel percutaneous coronary intervention (PCI). Patients with haemophilia who are diagnosed with coronary artery disease (CAD) and require intervention present a challenge to doctors due to the high risks of bleeding. The patient was administered recombinant factor VIII pre- and post-procedure. Anticoagulation during PCI was maintained with bivalirudin, a thrombin-specific anticoagulant. There were no complications and the patient tolerated the procedure well. This case suggests that bivalirudin as the sole procedural anticoagulant can be safely used in patients with a very high risk of bleeding undergoing PCI.     

Rationale and design of VENTURE-AF: a randomized,open-label,active-controlled multicenter study to evaluate the safety of rivaroxaban and vitamin K antagonists in subjects undergoing catheter ablation for atrial fibrillation

Purpose

To evaluate the safety of uninterrupted rivaroxaban, a novel oral anticoagulant that directly inhibits factor Xa, and a vitamin K antagonist (VKA) in eligible adult patients with nonvalvular AF (NVAF) who are scheduled for a catheter ablation.

Methods/design

This is a prospective, randomized, open-label, active-controlled, global multicenter safety study of up to 250 randomized patients. Eligible patients with paroxysmal or persistent NVAF, a left ventricular ejection fraction >40 %, and a creatinine clearance >50 mL/min will be randomized 1:1 to rivaroxaban 20 mg orally once daily or to dose-adjusted oral VKA (recommended international normalized ratio (INR) 2.0–3.0) and stabilized on anticoagulation therapy for 1–7 days (if no intracardiac thrombus on transesophageal echocardiogram (TEE) immediately prerandomization/post-randomization or if 3 weeks of sufficient anticoagulation is documented) or for 4–5 weeks (if no TEE, no documented 3 weeks of sufficient anticoagulation, or by patient choice). During catheter ablation, heparin will be administered (ACT-targeted range?=?300–400 s) after catheter ablation, and VKA will be managed per usual care. The next dose of rivaroxaban will be provided at least 6 h after establishment of hemostasis. The primary endpoint will be the incidence of post-procedure major bleeding events observed during the first 30?±?5 days post-ablation. Secondary endpoints will include post-procedure thromboembolic events, additional bleeding, time-to-event, and medication adherence.

Relevance

This study is intended to provide information about the safety characteristics of rivaroxaban in patients with NVAF undergoing catheter ablation.     

经皮股动脉穿刺冠状动脉介入诊疗术后人工压迫止血早期下地活动的临床观察

目的:观察经皮股动脉穿刺冠状动脉介入诊疗术后患者早期下地活动的可行性和安全性。方法:130例行冠状动脉介入诊断和治疗的患者在拔除6F动脉鞘管6h后下地活动,观察其穿刺点并发症的发生。结果:130例141个穿刺部位中发生小血肿8处,皮下淤血8处,小渗血3处,发生腹膜后血肿1处,随访1~3d,无严重出血并发症。结论:经皮股动脉穿刺冠状动脉介入诊疗术后6h下地活动是可行和安全的,可以减少患者的不适和降低患者住院费用。     

Use of self-expanding metal stents for difficult variceal bleed

Background/Aim

Patients with variceal band ligation (VBL)-induced ulcer bleeding and those with persisting bleeding in spite of VBL carry a high mortality. Balloon tamponade and transjugular intrahepatic portosystemic shunt have limitations in terms of complications, cost, and availability. The aim was to evaluate the efficacy of Sx-Ella Danis stent in persistent or complicated variceal bleeding.

Methods

Twelve patients with either persistent variceal bleeding or VBL-induced ulcer bleeding were treated with the placement of Sx-Ella Danis stents. The patients were followed up for mortality, complications, and efficacy to control bleeding.

Results

Stents were inserted successfully in all 12 patients (with immediate hemostasis). There was an immediate cessation of bleeding in all 12 patients with no stent-related complication. Five out of 12 patients died during 30 days post-procedure due to worsening encephalopathy or sepsis. Enteral feeding could be started in all 12 patients 6 h after stent placement. One patient had bleeding 10 days after stent removal and was re-stented but expired 7 days later. Stents were removed in eight patients at a mean duration of 17.5 days. (range 7 to 30 days).

Conclusions

Sx-Ella Danis stent is a useful modality to control persistent variceal bleeding as well VBL-related ulcer bleeding.

     

Successful endoscopic sphincterotomy for choledocholithiasis in a patient with severe hemophilia A and inhibitors

Endoscopic sphincterotomy (ES) is a standard procedure for bile duct stone removal. However, the safety of ES in patients with hemophilia remains unknown. We treated a 46-year-old man who had choledocholithiasis and severe hemophilia A with high-responding inhibitors during immune tolerance induction therapy. Since coagulation factor VIII inhibitors neutralize and inactivate endogenous and exogenous factor VIII, bleeding risk is higher in hemophilia A patients with inhibitors than in those without inhibitors. With adequate pre- and post-procedure monitoring of the clotting factor and supplemented clotting factor, the patient could safely undergo ES without bleeding complications. ES can be also an effective and safe first-line therapy for choledocholithiasis in patients with hemophilia and inhibitors under the condition of appropriate management.     

Bleeding portal-hypertensive gastropathy managed successfully by partial splenic embolization

The use of partial splenic embolization to decrease portal pressure and reduce gastric bleeding from portal-hypertensive gastropathy, a complication of liver cirrhosis, is described. A 62-year-old man with hepatic cirrhosis secondary to hepatitis C and documented portal hypertension was admitted with hypersplenism and bleeding esophageal varices. Endoscopic ligation successfully controlled acute bleeding, but blood loss continued over the next 45 days. Bleeding secondary to portal-hypertensive gastropathy was diagnosed endoscopically. The patient's poor surgical status precluded a portosystemic shunt procedure, so partial splenic embolization was performed radiologically by the injection of Gelfoam squares. Splenic volume decreased 50% following partial embolization. Over 3 weeks, the hemoglobin concentration increased from 8.5 g/dL to 9.8 g/dL, and the platelet count increased from 41,000 to 90,000/microL. Repeat endoscopy found no gastric bleeding 18 days post-procedure. Partial splenic embolization is a radiologic procedure which can be performed safely in patients too ill to undergo portosystemic shunt. This report documents its successful use to manage hypersplenism and reduce portal pressure in a cirrhotic patient with portal-hypertensive gastropathy and hypersplenism.