经皮冠状动脉介入术联合经皮血栓吸除术治疗急性心肌梗死的临床评价

目的 评价经皮冠状动脉介入术(PCI)联合经皮血栓吸除术治疗急性心肌梗死(AMI)的疗效.方法 56例AMI患者随机分为PCI组(n=28)和PCI联合血栓吸除术组(n=28).于PCI术后24小时、1周行实时心肌声学造影(RT-MCE),记录各组灌注对比积分指数(CSI)、室壁运动积分指数(WMSI)、透壁性对比缺损长度(CDL)和严重室壁运动异常长度(WML).采用免疫散射比浊法测定血浆超敏C-反应蛋白(hs-CRP)水平,酶联免疫吸附法测定血浆N-末端脑利钠肽(NT-ProBNP)和基质金属蛋白酶-9(MMP-9)水平.结果 各时间点PCI联合血栓吸除术组CSI、WMSI、CDL和WML明显低于PCI组(P＜0.05).术后1周PCI联合血栓吸除术组血浆hs-CPR和NT-ProBNP水平低于对照组[(4.56±1.98)mg/L比(5.96±2.03)mg/L,P＜0.05;(544.7±185.3)pmol/L比(897.6±215.9)pmol/L,P＜0.01],血浆MMP-9无明显升高[(672.7±175.9)μg/L比(609.6±196.5)μg/L,P＞0.05].结论 与PCI组相比,PCI联合经皮血栓吸除术可明显减少术后无再流的发生,改善微循环和心脏功能,是治疗AMI的有效方法.     

Meta-analysis of randomized trials comparing anti-embolic devices with standard PCI for improving myocardial reperfusion in patients with acute myocardial infarction.

BACKGROUND: Failure to achieve adequate myocardial reperfusion often occurs during PCI in patients with STEMI. This is in part due to atheromatous and thrombotic distal embolization. Several anti-embolic devices have been developed to protect against distal embolization during percutaneous coronary interventions (PCI) to improve myocardial reperfusion and enhance event free survival. Evidence from current studies has not shown a consistent benefit, but anti-embolic devices continue to be used. METHODS: We conducted a systemic overview (meta-analysis) of randomized trials of thrombectomy or distal protection devices versus standard PCI to evaluate the effects of reducing distal embolization during PCI for native vessel acute myocardial infarction (AMI). We identified randomized trials by searching PubMed, OVID, the Cochrane databases, references of articles, and abstracts of conference proceedings (all from September 2000 to October 2005). Each trial tested the hypothesis that anti-embolic therapy would result in better clinical or angiographic results than standard PCI alone. RESULTS: Fourteen trials (n = 2630) were identified comparing a distal protection device or a thrombectomy device (n = 1320) versus standard PCI (n = 1310). When the studies were combined, primary endpoints of death or reinfarction were not improved by the use of anti-embolic devices (4% [52/1309] vs. 4.5% [59/1303], odds ratio [OR] 0.82 [95% CI 0.55 to 1.24, P= 0.35]). In subgroup analysis, analyzing the class of device separately, use of thrombectomy devices (4.4% [33/758 vs. 4.2% [32/763], OR 0.98 CI 0.53 to 1.83, P = 0.95]), and the use of distal protection device 3.5% [19/551] vs. 5% [27/540], OR 0.68 CI 0.37 to 1.23, P = 0.20]) during PCI for native vessel AMI did not improve the clinical outcome of death or reinfarction. The secondary endpoints of death, reinfarction, and major adverse cardiac events did not improve with the use of anti-embolic devices. CONCLUSION: The combined experience from randomized trials suggests that the use of anti-embolic devices does not decrease early mortality or reinfarction during PCI for native vessel AMI. Whether their use improves longer term outcomes is unknown. Further research is needed to clarify the indication and optimal devices for anti-embolic protection.     

急性股浅动脉支架内血栓形成的介入治疗

目的 探讨DSA引导下采用导引导管取栓和局部溶栓的方法,治疗下肢股浅动脉支架放置术后急性血栓的临床疗效.方法 2008年3月～2012年4月,8例下肢股浅动脉支架放置术后急性血栓形成患者,接受介入引导管取栓及局部溶栓治疗.结果 全组介入治疗成功率100％,无严重并发症.结论 DSA下导引导管取栓和局部溶栓治疗下肢动脉支架急性血栓形成,疗程短、成功率高、疗效显著、并发症少.     

A new thrombosuction catheter for coronary use: Initial results with clinical and angiographic follow-up in seven patients

The presence of thrombus in a coronary vessel during percutaneous revascularisation can prevent adequate restoration of flow; it is also associated with an increased risk of distal embolization. We report the acute results and longer-term outcome of seven patients who underwent treatment with a new hydrodynamic thrombectomy catheter (Hydrolyser®), designed for the rapid removal of acute, non-organised thrombus from coronary vessels. Three patients demonstrated total thrombotic occlusion of a coronary saphenous vein bypass graft (SVBG), whereas in four patients thrombus was present in a native coronary artery (NCA). In all seven patients, Hydrolyser thrombectomy resulted in removal of thrombus and restoration of flow through the occluded segment. Adjunctive balloon angioplasty or stent placement to treat residual stenosis was performed in five of the patients. Distal embolization of a free-floating thrombus mass occurred in one patient, without clinical sequelae. There were no procedure-related complications in any of the patients. One patient with a degenerated SVBG reoccluded after five days. The other six patients underwent angiographic follow-up after an interval of 3 to 8 months: A wide patent coronary artery, without restenosis, was seen in three of these patients, and the other three patients (two with treatment of an SVBG) underwent re-PTCA for restenosis. These data suggest that the Hydrolyser procedure, as reported in our experience, is safe and effective for the removal of acute thrombus in selected patients. Cathet. Cardiovasc. Diagn. 40:192–197, 1997. © 1997 Wiley-Liss, Inc.     

Intracoronary thrombolytic therapy: A Treatment Option for Failed Mechanical Thrombectomy

The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have “failed” thrombectomy characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 66‐year‐old woman who was admitted to our institution with chest pain associated with inferior ST segment elevation. Coronary angiography showed a thrombotic occlusion of the right coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with intracoronary tenecteplase. Repeat coronary angiography 18 hr later revealed marked thrombus resolution with thrombolysis in myocardial infarction (TIMI) grade 3 anterograde flow and patency of the infarct‐related artery was maintained at 2‐month follow up. This case demonstrates the potential for intracoronary thrombolytic therapy as a treatment option for the management of patients following failed thrombectomy in PPCI. © 2011 Wiley Periodicals, Inc.     

Acute extensive portal and mesenteric venous thrombosis after splenectomy： Treated by interventional thrombolysis with transjugular approach

AIM： To present a series of cases with symptomatic acute extensive portal vein （PV） and superior mesenteric vein （SMV） thrombosis after splenectomy treated by transjugular intrahepatic approach catheter-directed thrombolysis.
METHODS： A total of 6 patients with acute extensive PV-SMV thrombosis after splenectomy were treated by transjugular approach catheter-directed thrombolysis. The mean age of the patients was 41.2 years. After access to the portal system via the transjugular approach, pigtail catheter fragmentation of clots, local urokinase injection, and manual aspiration thrombectomy were used for the initial treatment of PV-SMV thrombosis, followed by continuous thrombolytic therapy via an indwelling infusion catheter in the SMV, which was performed for three to six days. Adequate anticoagulation was given during treatment, throughout hospitalization, and after discharge.
RESULTS： Technical success was achieved in all 6 patients. Clinical improvement was seen in these patients within 12-24 h of the procedure. No complications were observed. The 6 patients were discharged 6-14 d （8 ± 2.5 d） after admission. The mean duration of follow-up after hospital discharge was 40 ± 16.5 mo. Ultrasound and contrast-enhanced computed tomography confirmed patency of the PV and SMV, and no recurrent episodes of PV-SMV thrombosis developed during the follow-up period.
CONCLUSION： Catheter-directed thrombolysis via transjugular intrahepatic access is a safe and effective therapy for the management of patients with symptomatic acute extensive PV-SMV thrombosis.     

Initial experience with the Endicor X-sizer thrombectomy device in patients with ST segment elevation myocardial infarction

Summary We investigated 16 patients with ST segment elevation myocardial infarction who had an occluded coronary artery (TIMI 0) at initial angiogram. Instead of balloon angioplasty and stenting, patients were subjected to thrombectomy (Endicor X-sizer) and stenting. In 15/16 patients the occlusion could be crossed by the thrombectomy device resulting in TIMI flow 3 in all of them. Thereafter, stenting was performed. At final angiogram all 15 patients continued to show TIMI flow grade 3. Twelve-lead ECG was performed prior to and post-intervention. ST elevation was measured as the sum of eight leads for anterior infarction and of five leads for inferior infarction. In 13/15 patients, ECG analysis was possible (2 developed bundle branch block post-intervention). In all 13 patients, a >50% ST decrease of the initial amount of ST elevation was observed reaching a >70% reduction in 11 patients. Procedural complications were low (one coronary dissection after thrombectomy) and 30 days follow-up was uneventful. Thrombectomy using the Endicor X-Sizer device may become an attractive mechanical reperfusion strategy for patients with acute myocardial infarction. Received: 29 September 2001 Accepted: 5 December 2001     

Revascularization in acute ischaemic stroke using the penumbra system: the first single center experience

Background and purpose:  This is the first single center experience illustrating the effectiveness of the penumbra system (PS) in the treatment of large vessel occlusive disease in the arena of acute ischaemic stroke. The PS is an innovative mechanical thrombectomy device, employed in the revascularization of large cerebral vessel occlusions in patients via the utilization of an aspiration platform.
Methods:  This is a prospective, non-randomized controlled trial evaluating the clinical and functional outcome in 29 patients with acute intra-cranial occlusions consequent to mechanical thrombectomy by the PS either as mono-therapy or as an adjunct to current standard of care. Patients were evaluated by a neurologist and treated by our in house interventional neuro-radiologists. Primary end-points were revascularization of the occluded target vessel to TIMI grade 2 or 3 and neurological outcome as measured by an improvement in the NIH Stroke Scale (NIHSS) score after the procedure.
Results:  Complete revascularization (TIMI 3) was achieved in 21/29 (72.4%) of patients. Partial revascularization (TIMI 2) was established in 4/29 (13.8%) of patients. Revascularization failed in four (13.8%) patients. Nineteen (19) patients (65.5%) had at least a four-point improvement in NIHSS scores. Modified Rankin scale scores of ≤2 were seen in 37.9% of patients. There were no device-related adverse events. Symptomatic intra-cranial hemorrhage occurred in 7% of patients.
Conclusions:  The PS has the potential of exercising a significant impact in the interventional treatment of ischaemic stroke in the future.