TRI常见并发症与解决策略

中国医学科学院阜外心血管病医院高展NumbersofPCI@FuWaiEachYear41519674778106003706383396800200040006000800010000120001998200320072011TotalPCIRadial91.3%in2011我们迎来了桡动脉介入治疗时代桡动脉介入的优势TRI微创TRI使得患者感觉更加舒适TRI使得冠状动脉介入治疗的并发症更少（包括出血并发症）桡动脉介入治疗真的使得并发症减少了吗？使那些常见的出血并发症减少了（如股动脉穿刺部位出血并发症）但又给我们带来了新的问题（我们不熟悉，缺乏认识）TRA:可能出现的问题ACCESSSubclavian&CoronaryCannulationRemovalofSheath/CatheterAnatomicalVariationsRadialArterySpasmPerforationTraversingSubclavianTortuosityAnatomicalVariationsRarebutpossibleComplicationsRadialArteryOcclusionHematoma/PseudoaneurysmBleeding/Compartmentsyndrome桡动脉痉挛Dieters,RS,CatheterizationandCardiovascularInterventions58:478–480(2003)严重的痉挛可导致桡动脉剥脱.防治方法:•穿刺轻柔•亲水鞘•扩血管药物（Cocktail）•镇静•更换其他入径桡动脉痉挛和防治腕管解剖结构与桡动脉穿刺腕管综合征定义：腕管狭窄，食指、中指疼痛或麻木，拇指肌肉无力感，手指或手掌有麻痹或僵硬感，手腕疼痛。病因：腕管内屈肌腱炎和滑膜炎，累积性创伤失调急性创伤的原因如Colles骨折畸形愈合，腕部扭伤出血血肿等经桡动脉穿刺引起腕管综合征腕管综合征的表现Thereareclassically5“Ps”associatedwithCompartmentSyndrome1.PAIN(outofproportiontoexpected)-疼痛2.Pallor-苍白3.Paralysis-麻痹4.Pulselessness-无脉5.Poikilothermia(failuretothermoregulate)-温度异常腕管综合征的后果腕管综合征的处理Leecheswereeffectiveintreatingamassivehematomacausingrightforearmcompartmentsyndrome.Thepatienthadbeentreatedwithanticoagulantsbeforecardiaccatheterizationviatheradialartery.Hardeninganddiscolorationoftheforearmwasfollowedbymotorandsensorydeficitsofthehand.Thirteenleechesremovedabout145mlofblood,withresolutionofsymptomsandsigns.JNeurolNeurosurgPsychiatr2005;76:1465JNeurolNeurosurgPsychiatr2005;76:1465JNeurolNeurosurgPsychiatr2005;76:1465Exampleofaforearmwrappedwithanelasticbandageatthesiteofasuspectedmicropunctureinthemidportionoftheforearm.Thestandardhemostasisdeviceisseeninplaceintheforeground.TherewasnovisibleormeasurablehematomaafterremovaloftheelasticwrapthathadbeenplacedduringtheinitialaccessprocedureGilchrist,I.CARDIACINTERVENTIONSTODAYJANUARY/FEBRUARY2008pp39-42腕管综合征的处理外科切开减压1.减压效果确切2.处理要及时3.带来问题很多抗凝、抗血小板感染腕管综合征治疗新策略：前臂皮肤针刺减压另外两例患者均用针刺减压方法避免了外科手术及早发现腕管综合征的迹象，用18号粗针头在前臂扎上百个针眼，可见淤血渗出，起到减压的作用，随着肝素作用的逐渐减弱，淤血外渗停止，可重复该操作。观察手的感觉和运动，同时用指指压法判断动脉供血的恢复。诊断与治疗勤观察，早诊断，早治疗根据病情调整抗凝、抗血小板药物剂量。如果术中桡动脉穿刺不顺利，术后要尽量减少或不用抗凝和静脉抗血小板药物腕管切开减压术是可供选择的治疗方法，6小时内前臂皮肤针刺减压：有效的办法锁骨下畸形动脉（ArteriaLusoria）Yiu,K.-H.etal.JAmCollCardiolIntv2010;3:880-881ArchAortogramandMRAoftheMajorArteriesoftheUpperBodyAbnormaloriginofright(RT)subclavianarteryarisingdirectingfromthedescendingaortainsteadoftherightinnominatearteryaberrantrightsubclavianarteryFormsanacuteangle(70°)withtheproximalaorticarchthefalselumenwithretainedcontrastmedium锁骨下畸形动脉导致主动脉夹层Huang,I,JChinMedAssoc•July2009•Vol72•No7心因性声带麻痹Severalminutesaftertheprocedure,thepatientdevelopedacardiovocalsyndromewithdysphonia,perceivedashoarsenessandbreathiness.Subsequentlyanimportantdysphagiaaffectingherfeedingpatternoccurred.Duringthediagnosticprocedure,becauseofevidenttortuosityoftherightsubclavianandinnominatearteries,asupportiveangiographicguideandanaccuratemanipulationwereneededtoadvanceandrotatecatheters.Anearnoseandthroatphysicalexaminationwithfiberopticlaryngoscopyrevealedrighthemilaryngealpalsywithoutintralaryngealedema,likelyduetorightrecurrentlaryngealnerve(RLN)stupor.Fig.1.Thefigureshowstherightvocalfoldfixedinabductionduringrespiration(A)andphonation(B)(imagesobtainedduringthevideoendoscopicexamwithDigitalVideoStroboscopySystem,byKayElemetricsCorporation).Intravenoussteroidtherapywasstartedandthenervedysfunctioncompleterecoveredasshownbyasecondlaryngoscopy.Atdischarge,despitethecompletesymptomresolution,avocalrehabilitationperiodwasrecommended.Schemeshowingthecourseoftherecurrentlaryngealnerves.TheRLNontherightsidehooksaroundbehindthesubclavianartery,whileontheleftsidethisnervepassesaroundbehindtheaorticarchbeforeascendingintheneckBasalextremetortuosityofrightsubclavianandinnominatearteriespreventinganycathetermanipulation.Subclavianandinnominatearteriesstraighteningafterdiagnosticcatheterintroduction;asupportiveangiographicguidewasrequiredtorotateandadvancethecatheterinthecoronaryostium.Thestraighteningdeterminedbythecatheterintroductioninthetortuousrightsubclavianandinnominatearterieslikelycausedanunfavorableanatomicalchangeleadingtoatemporarycompression/stretchofrightRLN经桡动脉进管路径的解剖图病例分析病例1男性，57岁入院诊断：1、冠状动脉性心脏病，劳力性心绞痛，PCI术后，2、高血压病，3、糖尿病（2型），4、高脂血症2000年8月因“急性下壁心肌梗死”行急诊RCA-PTCA+支架；2000年9月及2002年1月冠造（右股动脉穿刺）；2004年12月心绞痛加重右桡动脉LAD-PTCA+支架；2005年9月入院复查既往高血压病史，糖尿病（2型）及高脂血症常规药物治疗，包括阿司匹林，波立维。局麻下经右桡动脉行冠状动脉造影，LAD原支架后狭窄80％，RCA中段狭窄80％RCA中段3.533mm的Cypherselect支架,LAD远段3.028mm的Cypherselect支架，术中顺利导丝误入小分支血管术后并发症诊断术后45分钟，诉胸痛，右颈部紧缩感，伴出汗，血压110/80mmHg，心率63次/min，15分钟后血压160/80mmHg，心率80次/min，右侧颈部明显肿胀，无搏动感，无血管杂音急查超声:未见颈动脉破裂或夹层，未见明显液体、气体。颈部MRI:提示右颈部出血性血肿，不除外右侧头臂静脉回流受阻。血管外科：不除外颈动脉渗血。治疗观察活动性出血：血红细胞、血红蛋白颈部肿胀情况，气管压迫情况予静脉抗生素预防感染停用抗血小板药和抗凝药转归第二天起颈部肿胀没有进行性加重，血色素无进行性下降,没有活动性出血，开始服用阿司匹林300mg，Qd，波力维75mg，Qd。第三天颈部肿胀基本消除。术后两周患者病情稳定出院。病例2男性，54岁入院诊断：冠状动脉性心脏病，劳力性心绞痛，PCI术后，射频消融术后2005年4月曾于外院行RCA支架术及Lp支架术，因活动后胸痛加重半年，于2006年2月入我院。既往：吸烟史30余年，饮酒史10余年，2002年外院射频消融术。入院后第二日于局麻下经右桡动脉行冠状动脉造影术，提示LAD近中段60-70%狭窄，RCA近段60%狭窄，中段原支架内90%狭窄，远端80%狭窄同期完成RCA的介入治疗，于RCA内由远端至近段串联置入Firebird支架3.0*23mm，3.0*33mm，3.5*29mm导丝误入分支小血管术后并发症诊断症状：术后当