经桡动脉介入诊疗术后桡动脉闭塞的机制及预防措施

目前我国已经成为冠状动脉介入诊疗大国,桡动脉入路为国内最常选择的血管入路。而桡动脉闭塞是经桡动脉冠状动脉介入诊疗术后的特有并发症之一。随着桡动脉入路的广泛应用,该并发症在临床诊疗过程中并非少见,甚至部分病例产生了严重的不良后果。该并发症的危险因素经大样本荟萃分析,已经基本明确,但其发生机制仍未肯定。目前普遍认为,该并发症的发生与炎性反应及血栓形成有关。由此,临床工作者也采取了相应的预防手段与治疗措施,并取得了一定成就。现就相关内容进行综述,以提高广大介入医师对该并发症的认识及重视。     

经桡动脉途径行冠状动脉介入术在冠心病治疗中的应用

目的研究经桡动脉途径行冠状动脉介入术的特点。方法桡动脉Allen试验阳性患者，择期经桡动脉径路行冠状动脉介入术患者40例。结果经桡动脉介入手术成功率高，术后外周血管并发症低，患者舒适，易接受。结论经桡动脉介入是冠心病介入的一种安全、有效方法，但手术操作有一定难度。     

桡动脉穿刺冠状动脉内介入治疗的临床应用

目的：探讨经桡动脉穿刺选择性冠状动脉造影及冠状动脉腔内成形术（PTCA）及支架术的临床意义。方法：对102例具备冠状动脉造影适应证的患者,采用经桡动脉穿刺法行右、左冠状动脉造影,并根据冠状动脉造影结果决定是否行经皮冠状动脉腔内成形术（PTCA）及支架术。结果：冠状动脉狭窄（50-70）％21例（21／102,占21％）,〉75％以上68例（68／102,占67％）,68例行PTCA及支架植入术,〈50％13例（13／102,占12％）,冠状动脉正常25例（25／70,占35．5％）。结论：通过冠状动脉造影,可以定性诊断,指导治疗;桡动脉穿刺具有出血并发症少等优点。     

经桡动脉行冠状动脉介入中血管解痉药物的对比研究

目的 观察血管解痉药乌拉地尔和硝酸甘油对桡动脉痉挛的效果。方法 选取2005年1月～2006年12月Au。。实验阳性并经桡动脉途径行冠状动脉造影及经皮冠状动脉介入治疗的患者180例，其中男性160例，女性20例；平均年龄68±11（37～78）岁。将患者随机分为A组和B组，两组间年龄、性别差异无显著性（P〉0．05）。A组为乌拉地尔组（90例），B组为硝酸甘油组（90例）。桡动脉穿刺成功后，A组常规鞘入乌拉地尔12．5mg，B组常规鞘入硝酸甘油200μg，然后行CAG和PCI术，观察桡动脉痉挛发生率。结果 A组桡动脉痉挛发生率2．22％（2／90），B组桡动脉痉挛发生率12．22％（11／90），两组间桡动脉痉挛发生率差异有显著性（P〈0．05）。结论 乌拉地尔对缓解桡动脉痉挛作用效果好。     

经尺动脉和桡动脉径路行冠状动脉介入诊治的对比研究

  探讨经尺动脉径路行冠状动脉介入诊治的可行性和安全性。经尺动脉径路行冠脉介入诊治是桡动脉途径以外的一种安全、有效的介入路径。     

经股动脉介入治疗术后压迫止血方法的探讨

目的探讨经股动脉介入治疗术后的压迫止血方法,减少局部并发症的发生。方法将125例经股动脉穿刺行介入治疗的患者随即分为观察组63例,穿刺部位采用绷带卷按压3M胶布固定止血法,对照组62例采用传统压迫止血法,观察两组出血并发症发生率、卧床制动时间和不良反应。结果观察组出血并发症、卧床制动时间及全身不适发生率明显低于对照组（P〈0．05）。结论应用绷带卷按压3M胶布固定止血法,能有效减少出血并发症,缩短卧床制动时间,减轻全身不适感。     

A Comparison of the Transradial and Transfemoral Approaches for the Angiography and Intervention in Patients with a History of Coronary Artery Bypass Surgery: In-hospital and 1-year Follow-up Results

Background:

Percutaneous coronary intervention (PCI) through transradial approach (TRA) has shown to be safe and effective as transfemoral approach (TFA) among unselected patients. However, very few studies have compared the outcomes between TRA and TFA specifically in patients with a history of coronary artery bypass grafting surgery (CABG).

Methods:

A total of 404 post-CABG patients who had undergone angiography or PCI were included in the study. The primary endpoint was defined as angiographic success and procedure success. The secondary endpoint was defined as in-hospital net adverse clinical events (NACEs), which included all cause of death, myocardial infarction (MI), stroke, repeat revascularization, and major bleeding. Patients were followed-up for 1-year. Major adverse cardiovascular events (MACEs), which included death, MI, and repeat revascularization, at 1-year follow-up were also compared.

Results:

The angiographic success was reached by 97.4% in the TRA group compared with 100% in the TFA group (P = 0.02). The procedure success was achieved in 99.1% in the TRA group and 97.9% in the TFA group (P = 0.68). The incidence rates of in-hospital NACE (2.7% vs. 2.7%, P = 1.00) and 1-year MACE (11.5% vs. 12.0%, P = 0.88) were similar between TRA and TFA. Meanwhile, TRA was associated with a lower rate of Bleeding Academic Research Consortium ≥2 bleeding (P = 0.02). In patients undergoing graft PCI, the procedure success was similar between TRA and TFA (100.0% vs. 98.7%, P = 1.00). The procedure time (25.0 min vs. 27.5 min, P = 0.53) was also similar. No significant difference was detected between TRA and TFA in terms of in-hospital NACE (0 vs. 0, P = 1.00) and 1-year MACE (21.4% vs. 10.3%, P = 0.19).

Conclusions:

Compared with TFA, TRA had lower angiographic success but had a similar procedure success in post-CABG patients. TRA was also associated with decreased bleeding and shortened hospital stay.     

桡动脉与股动脉途径冠心病介入治疗临床观察

目的探讨经桡动脉（Transradia approach coronary intervention,TRA）与经股动脉（Transfemoral approach coronary intervention,TFA）两种途径行冠心病（Coronary heart disease,CHD）介入治疗的临床效果差异。方法选择2010—2014年曾在该院接受治疗的冠心病患者1 000例,将患者随机分为数量相等的两组即观察组与对照组进,对照组中患者以经股动脉（TFA）冠状动脉介入方法进行治疗,观察组中患者以经桡动脉（TRA）冠状动脉介入方法进行治疗,观察两组患者所得到的临床效果。结果治疗结束后,观察组中患者的治疗成功率为96.0%,对照组中患者的治疗成功率为92.0%,两组患者之间差异显著;比较两组患者的穿刺时间、手术时间以及造影剂量：观察组中患者的穿刺时间及手术之间均短于对照组,观察组中患者的造影剂量少于对照组,两组患者之间差异较明显;观察组中患者的并发症发生率为4.0%,对照组中患者的并发症发生率为16.0%,两组患者直接差异较明显。结论经桡动脉途径行冠状动脉介入治疗是安全、有效的方法。桡动脉途径与股动脉途径冠状动脉介入冠心病均能够得到较好的效果,经桡动脉途径冠状动脉介入方法的穿刺时间、手术时间、术后并发症发生率均少于经股动脉冠状动脉介入方法,有利于患者尽快康复,临床上可优先选择经桡动脉途径行冠状动脉介入治疗。     

经桡动脉途径冠脉造影和介入治疗180例临床观察

目的：分析经桡动脉途径冠状动脉造影和介入治疗的可行性和安全性。方法：对我院2007年4月至2009年7月经桡动脉途径行冠状动脉造影（CAG）和经皮冠状动脉介入（PCI）治疗180例患者临床资料进行分析。结果：桡动脉穿刺成功率97.8%,经桡动脉冠脉造影成功率96.1%,经桡动脉脉介入治疗成功率97.8%。无桡动脉闭塞和其他严重并发症。结论：常规桡动脉途径行冠脉造影和介入治疗血管穿刺部位并发症少,患者术后体位及活动不受限制,可在临床推广使用。     

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease

Background:

There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events.

Methods:

All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups.

Results:

Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3–8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group.

Conclusions:

During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.     

经桡动脉途径急诊PCI治疗的安全性临床分析

目的探讨经桡动脉途径急诊经皮冠脉介入治疗（PCI）的安全性及可行性。方法回顾性分析皖北煤电集团总医院2006年11月-2009年6月对76例急性心肌梗死患者采用经桡动脉途径行急诊PCI治疗的临床资料。观察造影成功率、入院-球囊扩张时间、梗塞相关动脉的开通率、血流情况、术中并发症,住院期间主要心血管事件。结果经桡动脉造影成功率为100%;入院-球囊扩张时间（55±18）min;梗塞相关动脉的开通率为97.4%;血流情况：TIMI3级93.4%;皮下瘀斑的发生率为3.8%;前臂血肿的发生率为2.9%;桡动脉闭塞的发生率为1.0%;平均术后住院天数（5.9±1.4）d;2例出现围手术期死亡。结论经桡动脉途径直接PCI治疗急性心肌梗死安全有效,在有条件的医院可首选经桡动脉途径PCI作为急性心肌梗死（AMI）治疗的方法。     

经桡动脉途径行冠脉造影和介入治疗1324例的临床分析

目的研究经桡动脉对患者行冠状动脉造影（CAG）和经皮冠状动脉介入（PCI）治疗的可行性和安全性。方at2009年10月～2012年12月的经桡动脉行冠状动脉造影（CAG）和经皮冠状动脉介入（PCI）治疗1324例患者临床资料进行分析。结果经桡动脉穿刺成功1324例,成功率为100％;桡动脉插管成功1320例,成功率为99．70％,其中623例病人成功行冠状动脉介入治疗。术中、术后并发症：血管迷走反射2例,桡动脉痉挛21例,术后穿刺部位小血肿2例,前臂肿胀7例,未见其他不良并发症。结论经桡动脉行冠状动脉介入诊疗安全可行,不仅创伤小,且成功率高、并发症少,值得临床推广应用。     

Effect of Transcatheter Embolization by Autologous Fat Particles in the Treatment of Coronary Artery Perforation During Percutaneous Coronary Intervention

Background:

Coronary artery perforation (CAP) is a rare but severe complication of percutaneous coronary intervention (PCI). The aim of our study was to evaluate the effect and safety of transcatheter embolization by autologous fat particles in the treatment of CAP.

Methods:

Once the CAP was confirmed, a little autologous subcutaneous fatty tissue was obtained from the groin of the patient and then was made into 1 mm × 1 mm fat particles. The perforated vessel was embolized by fat particles via a micro-catheter. There were eight patients undergoing transcatheter embolization by autologous fat particles in the treatment of CAP during PCI in Peking University Third Hospital from February 2009 to June 2014, and the clinical data of these patients were collected and analyzed retrospectively.

Results:

The lesion morphology of the patients was classified based on the American College of Cardiology/American Heart Association Task Force classification, there were one patient with Class B2 lesion and seven patients with Class C lesions (there were five patients with chronic total occlusion lesions). According to the Ellis classification of CAP, there were six patients with Class II perforations and two patients with Class III perforations. The causes of perforation included that seven patients induced by guide wire and one patient by balloon predilation. Three patients had pericardial effusion. All of the eight patients with CAP underwent transcatheter embolization by autologous fat particles. Coronary angiography confirmed that all of them were embolized successfully. There was no severe complication after the procedure. The coronary angiography of one patient at 1 week and another patient at 2 years after the embolization showed that the embolized arteries had recanalized. The median follow-up time was 20.3 months (8.8–50.2 months), the event-free survival rate was 100%.

Conclusions:

Transcatheter embolization by autologous fat particles was an effective, safe, cheap, and easy way to treat the perforation of small vessels during PCI.     

Clinical and Angiographic Predictors of Major Side Branch Occlusion after Main Vessel Stenting in Coronary Bifurcation Lesions

Background:

Major side branch (SB) occlusion is one of the most serious complications during percutaneous coronary intervention (PCI) for bifurcation lesions. We aimed to characterize the incidence and predictors of major SB occlusion during coronary bifurcation intervention.

Methods:

We selected consecutive patients undergoing PCI (using one stent or provisional two stent strategy) for bifurcation lesions with major SB. All clinical characteristics, coronary angiography findings, PCI procedural factors and quantitative coronary angiographic analysis data were collected. Multivariate logistic regression analysis was performed to identify independent predictors of SB occlusion. SB occlusion after main vessel (MV) stenting was defined as no blood flow or any thrombolysis in myocardial infarction (TIMI) flow grade decrease in SB after MV stenting.

Results:

Among all 652 bifurcation lesions, 32 (4.91%) SBs occluded. No blood flow occurred in 18 lesions and TIMI flow grade decreasing occurred in 14 lesions. In multivariate analysis, diameter ratio between MV/SB (odds ratio [OR]: 7.71, 95% confidence interval [CI]: 1.53–38.85, P = 0.01), bifurcation angle (OR: 1.03, 95% CI: 1.02–1.05, P < 0.01), diameter stenosis of SB before MV stenting (OR: 1.05, 95% CI: 1.03–1.07, P < 0.01), TIMI flow grade of SB before MV stenting (OR: 3.59, 95% CI: 1.48–8.72, P < 0.01) and left ventricular eject fraction (LVEF) (OR: 1.06, 95% CI: 1.02–1.11, P < 0.01) were independent predictors of SB occlusion.

Conclusions:

Among clinical and angiographic findings, diameter ratio between MV/SB, bifurcation angle, diameter stenosis of SB before MV stenting, TIMI flow grade of SB before MV stenting and LVEF were predictive of major SB occlusion after MV stenting.     

经桡动脉行冠心病介入治疗的护理道德要求

冠心病介入治疗的广泛应用对临床护理道德提出了新的要求。实践证明：通过护理诊断、实施医嘱做好术前护理,术中配合医生做好全面护理,术后密切观察穿刺局部及全身情况并做好出院指导等,对提高经桡动脉穿刺行冠心病介入治疗的成功率,减少并发症,提高病人生命质量等均具有重要的作用。结合我科2006年5月～2010年5月对经桡动脉穿刺行冠心病介入治疗的300例患者护理实际,总结了经桡动脉行冠心病介入治疗的护理道德要求。     

急性冠脉综合征患者PCI术后桡动脉减压方案对穿刺部位并发症的影响

目的观察急性冠脉综合征患者经皮冠脉介入治疗(PCI)术后桡动脉充气止血绷带较快减压放气对桡动脉穿刺部位并发症的影响。方法急性冠脉综合征患者接受经桡动脉途径PCI术后即刻以桡动脉充气止血绷带压迫止血,术后1 h开始放气减压,每隔1 h放气2 ml,第4次开始增加放气量,术后6～8 h内撤除桡动脉充气止血绷带(观察组)。观察患者穿刺部位并发症发生情况,并与较晚较慢减压放气(对照组,在术后2 h开始放气,每隔2 h放气2ml,术后12～14 h撤除桡动脉充气止血绷带)比较。结果部分患者发生手部肿胀、手臂麻木或疼痛、术口少量渗血及局部水泡,其中,观察组手部中度肿胀及手臂麻木的发生均明显少于对照组(P<0.05),压迫止血过程中所监测的穿刺侧拇指血氧饱和度无明显差异(96.8±1.6%vs 96.6±1.6%,P>0.05)。结论较快减压放气安全、有效,能增加患者的舒适度。     

经桡动脉行冠状动脉造影及支架植入术的护理

目的：探讨经桡动脉行冠状动脉造影术及支架植入术的护理经验。方法：回顾总结282例经桡动脉穿刺行冠状动脉造影及支架植入求患者的术前、术中和术后的护理方法。结果：本组患者穿刺成功率100％,均顺利完戍手术,无任何并发症发生。结论：加强术前心理护理及充分准备,术后加强术侧肢体及穿刺口的观察护理,是减轻患者痛苦,减少并发症发生,确保手术成功率的重要措施。     

CT冠状动脉血管成像判定心肌桥-壁冠状动脉形态学特征及其与冠状动脉粥样硬化病变关系

目的探讨采用CT冠状动脉血管成像观察心肌桥-壁冠状动脉的形态学特征,并分析其与冠状动脉粥样硬化病变的关系。方法选取100例经128层螺旋CT冠状动脉成像技术证实的单纯深在型心肌桥-壁冠状动脉患者(深在型)、100例心肌桥近端冠状动脉合并粥样硬化患者(硬化组)的CT冠状动脉成像数据进行统计分析,比较两组患者的影像学指标差异,并采用Logistic回归分析心肌桥-壁冠状动脉的形态学特征与冠脉粥样硬化的关系。结果深在型组和硬化组的心肌桥厚度、壁冠状动脉近端成角率差异无统计学意义(P0.05),两组间壁冠状动脉长度、壁冠状动脉两端平滑率、壁冠状动脉两端成角率、壁冠状动脉远端成角率差异均具有统计学意义(P0.05);壁近段冠状动脉粥样硬化的危险因素为年龄(OR=1.872)、两组间壁冠状动脉长度(OR=2.031)、壁冠状动脉两端成角(OR=1.376)、壁冠状动脉远端成角(OR=1.448),壁冠状动脉两端平滑是保护因素(OR=0.471)。结论心肌桥-壁冠状动脉复合体的形成与冠脉近段粥样硬化形成密切相关。     

人工压迫止血YM-GU动脉压迫止血器Angio-seal血管缝合器在冠脉介入术中应用对比

目的：观察人工压迫止血,YM-GU动脉压迫止血器,Angio-seal血管闭合器在冠脉介入术止血的安全性和有效性。方法：实验对象本单位共完成冠状动脉介人诊治406例,男171例,年龄（62.5±7.8）岁,女235例,年龄（64.2±8.9）岁。进行人工压迫止血174例,YM-GU一动脉压迫止血器127例,使用Angioseal血管缝合器止血105例。比较二组的止血时间、制动时间和血管并发症发生率。结果：两组患者与人工压迫法比较止血时间及下肢制动时间均显著缩短（P〈0.01,P〈0.01）：介入治疗中,Angio-seal血管闭合器血管并发症发生率为7.6%,YM-GU动脉压迫止血器为4.7%,均较人工压迫组9.2%,明显减少（P均〈0.05）,止血成功率各组间无明显差异。结论：Angio-seal血管缝合器,YM-GU一动脉压迫止血器有效缩短止血时间及下肢制动时间,而YM-GU一动脉压迫止血器适用性更广,并发症的发生率明显低于传统压迫止血方法。     

Predictive Ability of the SYNergy Between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery Score II for Long-term Mortality in Patients with Three-vessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention Treated with Second-generation Drug-eluting Stents

Background:

The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery Score II (SS-II) can well predict 4-year mortality in patients with complex coronary artery disease (CAD), and guide decision-making between coronary artery bypass graft surgery and percutaneous coronary intervention (PCI). However, there is lack of data regarding the utility of the SS-II in patients with three-vessel CAD undergoing PCI treated with second-generation drug-eluting stents (DES). The purpose of the present study was to evaluate the ability of the SS-II to predict long-term mortality in patients with three-vessel CAD undergoing PCI with second-generation DES.

Methods:

Totally, 573 consecutive patients with de novo three-vessel CAD who underwent PCI with second-generation DES were retrospectively studied. According to the tertiles of the SS-II, the patients were divided into three groups: The lowest SS-II tertile (SS-II ≤20), intermediate SS-II tertile (SS-II of 21–31), and the highest SS-II tertile (SS-II ≥32). The survival curves of the different groups were estimated by the Kaplan–Meier method. Univariate and multivariate Cox proportional hazard regression analyses were performed to evaluate the relationship between the SS-II and 5-year mortality. The performance of the SS-II with respect to predicting the rate of mortality was studied by calculating the area under the receiver operator characteristic (ROC) curve. The predictive ability of the SS-II for 5-year mortality was evaluated and compared with the SS alone.

Results:

The overall SS-II was 27.6 ± 9.0. Among patients in the lowest, intermediate and the highest SS-II tertiles, the 5-year rates of mortality were 1.6%, 3.2%, and 8.6%, respectively (P = 0.003); the cardiac mortality rates were 0.5%, 1.9%, and 5.2%, respectively (P = 0.014). By multivariable analysis, adjusting for the potential confounders, the SS-II was an independent predictor of 5-year mortality (hazard ratio: 2.45, 95% confidence interval: 1.38–4.36; P = 0.002). The SS-II demonstrated a higher predictive accuracy for 5-year mortality compared with the SS alone (the area under the ROC curve was 0.705 and 0.598, respectively).

Conclusion:

The SS-II is an independent predictor of 5-year mortality in patients with three-vessel CAD undergoing PCI treated with second-generation DES, and demonstrates a superior predictive ability over the SS alone.