TRI常见并发症

. Femoral Complication Waiting to Happen! Femoral Complication Waiting to Happen! 我们进入桡动脉介入治疗时代 2013: 91% transradial 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 ACCESS Subclavian 7:142-147. Image courtesy of Tift Mann, MD. Verapamil 3mg in 10 ml saline Radial Artery Spasm Sheath Selection Hydrophilic sheaths NO benefit of long sheaths Optimal sheath size/artery size ratio Rathore S et al. JACC Inter 2010;3:47583. Chugh SK et al. CCI 2013;82:6473. Spasm Impeding device passage Vasodilators Nitroglycerin: 100 mcg IA Verapamil: 2.5 - 5 mg IA Diltiazem: 100 mcg IA Adenosine: 20-30 mcg IA Nitroprusside: 100 mcg IA Sedation Fentanyl Midazolam 23 Severe Spasm Catheter Entrapment Propofol-based sedation General anesthesia Regional nerve block Surgical extraction Arm Pain = Spasm Repeat the Verapamil Dose! Radial Artery Spasm Solutions Prevention is the best “therapy” Patiencewait 5-10 minutes Sedation and pain control Stick more proximal if pulse palpable Subcutaneous or topical nitroglycerin (?) Switch to other arm 26 桡动脉痉挛 Dieters, RS, Catheterization and Cardiovascular Interventions 58:478480 (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 There are classically 5 “Ps” associated with Compartment Syndrome 1.PAIN (out of proportion to expected)-疼痛 2.Pallor-苍白 3.Paralysis-麻痹 4.Pulselessness-无脉 5.Poikilothermia (failure to thermoregulate)-温度异常 腕管综合征的后果 腕管综合征的处理 Leeches were effective in treating a massive hematoma causing right forearm compartment syndrome. The patient had been treated with anticoagulants before cardiac catheterization via the radial artery. Hardening and discoloration of the forearm was followed by motor and sensory deficits of the hand. Thirteen leeches removed about 145 ml of blood, with resolution of symptoms and signs. J Neurol Neurosurg Psychiatr2005;76: 1465 J Neurol Neurosurg Psychiatr2005;76: 1465 J Neurol Neurosurg Psychiatr2005;76: 1465 Example of a forearm wrapped with an elastic bandage at the site of a suspected micropuncture in the midportion of the forearm. The standard hemostasis device is seen in place in the foreground. There was no visible or measurable hematoma after removal of the elastic wrap that had been placed during the initial access procedure Gilchrist, I. CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2008 pp 39-42 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 （Arteria Lusoria） Yiu, K.-H. et al. J Am Coll Cardiol Intv 2010;3:880-881 Arch Aortogram and MRA of the Major Arteries of the Upper Body Abnormal origin of right (RT) subclavian artery arising directing from the descending aorta instead of the right innominate artery aberrant right subclavian artery Forms an acute angle (70) with the proximal aortic arch the false lumen with retained contrast medium 锁骨下畸形动脉导致主动脉夹层 Huang, I, J Chin Med Assoc July 2009 Vol 72 No 7 心因性声带麻痹 Several minutes after the procedure, the patient developed a cardiovocal syndrome with dysphonia, perceived as hoarseness and breathiness. Subsequently an important dysphagia affecting her feeding pattern occurred. During the diagnostic procedure, because of evident tortuosity of the right subclavian and innominate arteries, a supportive angiographic guide and an accurate manipulation were needed to advance and rotate catheters. An ear nose and throat physical examination with fiberoptic laryngoscopy revealed right hemi laryngeal palsy without intra laryngeal edema, likely due to right recurrent laryngeal nerve (RLN) stupor. Fig. 1. The figure shows the right vocal fold fixed in abduction during respiration (A) and phonation (B) (images obtained during the videoendoscopic exam with Digital Video Stroboscopy System, by Kay Elemetrics Corporation). Intravenous steroid therapy was started and the nerve dysfunction complete recovered as shown by a second laryngoscopy. At discharge, despite the complete symptom resolution, a vocal rehabilitation period was recommended. Scheme showing the course of the recurrent laryngeal nerves. The RLN on the right side hooks around behind the subclavian artery, while on the left side this nerve passes around behind the aortic arch before ascending in the neck Basal extreme tortuosity of right subclavian and innominate arteries preventing any catheter manipulation. Subclavian and innominate arteries straightening after diagnostic catheter introduction; a supportive angiographic guide was required to rotate and advance the catheter in the coronary ostium. The straightening determined by the catheter introduction in the tortuous right subclavian and innominate arteries likely caused an unfavorable anatomical change leading to a temporary compression/stretch of right RLN . 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3.533mm的Cypher select支架,LAD远 段3.028mm的Cypher select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*33 mm，3.5*29 mm 导丝误入分支小血管 术后并发症诊断 症状： 术后当时患者诉胸骨后隐痛，吸气时明显， 20分钟未缓解，血压112/80mmHg，心率57 次/min。 术后50分钟，胸闷伴大汗，查体面色苍白， 神清，血压测不清，心电示波窦性心动过缓 ，交界性逸搏心率，最慢44次/min，予吸氧 ，静脉快速补液，静脉多巴胺200g/min持续 泵入，10分钟后血压改善 辅助检查： 急查床旁胸片：提示纵隔增宽，右心隔影可见三角形 阴影，右肋膈角钝 印象：右下肺部分肺段不张，左下肺斑片影，考虑炎 症，右侧少量胸腔积液，左侧少-中量胸腔积液。 急查血常规：红细胞无明显降低，血红蛋白从 131g/L降至122g/L。 急查胸部CT，提示：前纵隔明显增宽，内不规则中 等密度影；升主动未见扩张，管腔内无内膜影；头臂 动脉、腹主动脉及各分支，及肾动脉均未见明显异常 ；诊断前纵隔血肿。 床旁超声心动图亦提示：纵隔血肿 治疗 观察活动性出血： 血红细胞、血红蛋白 上腔静脉（颈静脉充盈）、气管受压 迫（呼吸困难）情况 予静脉抗生素预防感染 停用抗血小板药和抗凝药 第二日出现体温升高，最高38.7， 血白细胞 最 高达11.4*109/L，中性粒细胞比例82.6%，血糖 升高，考虑与出血、胸腔积液有关，予静脉 抗菌 素，口服降糖药治疗，逐渐改善。 术后第二日加服波利维75mg Qd 第三日恢复服用阿司匹林200mg Qd 术后第三日血红蛋白最低达90g/L 转归 手术一周后复查CT：前纵隔血肿较前吸收 ，累计范围较前缩小，主要位于右上纵隔， 两侧少-中量胸腔积液。 复查血常规，血红蛋白105g/L，白细胞 5.3*109/L,中性粒细胞比例76.1%。 患者胸痛症状消失，体温正常，病情平稳 ，出院。 Vascular injury resulting in a small leak in the branches of the innominate artery is a possible complication of the transradial approach. A 61 year-old male patient with diabetes mellitus. Diagnostic coronary angiography via the radial approach showed eccentric intermediate stenosis of the LAD ostium and a focal 99% tight stenosis in the distal LCx followed by segmental 70% stenosis. Approximately 30 min after the diagnostic procedure, the patient complained of severe anterior chest painno EKG change- unrelieved by Nitro- returned to cath lab for urgent PCI 2 stents placed in left circumflex post procedure patient still complaining of painECHO done negative- Chest X-ray showed widening of mediastinum A chest CT scan showing a large hematoma in the anterior mediastinum around the aortic arch. Follow up chest CT scan after recurred chest pain showing increased hematoma in the anterior mediastinum. A. Coronary angiogram (AP caudal projection) showing tight stenosis in the left circumflex coronary artery. B. Chest X-ray (AP view) C. Chest CT scan showing a huge mediastinal hematoma located left of the aortic arch. D. Follow up chest CT showing almost complete resorption of the previous hematoma. Second case is similar to the first 纵膈血肿 From the two cases presented here, vascular injury resulting in a small leak in the branches of the innominate artery is a possible complication of the transradial approach. Therefore, extra caution and careful maneuvering of the guidewire is warranted during the transradial approach. In addition, the use of anticoagulation seems to be important in continuous extravasation after the initial break in vascular integrity. . Radial occlusion is usually silent Radial Artery Occlusion Facts Incidence low - 5-9% Usually clinically asymptomatic, may limit use of radial artery as future access site Factors that lead to radial artery occlusion Smaller radial artery, larger sheaths Prolonged, occlusive hemostasis Prior cannulation Prevention Anticoagulation Small sheaths Patent hemostasis 71 Spaulding C et al. CCVD 1996;39:365-370. Pancholy SB et al. Am J Cardio 2009;104:1083-1085. Heparin must be administered for all Transradial Procedures I.V. = I.A. Pneumatic Compression guided by MAP Cubero et al, CCVI 73:467, 2009 Image courtesy of Tift Mann, MD. Force of Compression TR Band Group A Group BP (n=176)(n=175) MAP (mm Hg)98 1595 18NS Pressure exerted (mm Hg)102 18185 210.0001 cc of Air9 215 00.0001 Compression time (min)208203NS Radial occlusion (N, %)2 (1%)21 (12%)0.0001 Cubero JM et al. CCVI 2009;73:467-472. % of Patients Patent Hemostasis Technique Pancholy SB et al. CCVI 2008;73:205. N=27N=5N=7N=4 Traditional Hold (Group I) Patent Hemostasis (Group II) P0.05P0.05 Radial Access Alternative Anticoagulation Plante S. et al. CCI 2010;76:654-658. Feray H. et al. J Thromb Thrombol 2010;29:322-325. Pancholy SB et al. Am J Cardiol 2014;113:211-214. BIVALIRUDIN = UF HEPARIN ENOXAPARIN = UF HEPARIN WARFARIN UF HEPARIN Radial Cocktail += ANTICOAGULATIONVASODILATOR Sheath Size Transradial procedures should be performed with smallest possible catheter Radial Occlusion (%) Saito et al, CCI 1999;46:173-178. Nagai et al, AJC 1999;83:180. 桡动脉闭塞 Radial Artery Occlusion Factors vArtery size: higher incidence with smaller artery vHeparin dose: minimum 5000 units, even for cath vArtery spasm: pretreatment with verapamil vHemostasis device: minimize compression Radial Occlusion vs Heparin Dose Radial Occlusion vs Sheath Size Radial Artery Occlusion Factors Spaulding C, et al. Cathet Cardiovasc Diag 1996;39:365-370. Devices used for radial compression Hemoband TR Band 动静脉瘘和假性动脉瘤 桡动脉介入泥鳅导丝导致冠状动脉损伤 . Male,56 yrs, CHD AP 2 hours later, chest pain, ST 2,3,aVF elevating RADIATION AND RADIAL ACCESS Radiation Exposure Multiple studies have documented increased radiation exposure usually related to increased procedure time Other factors include: suboptimal patient positioning, unnecessary fluoroscopy/angiography 93 Park EY et al. Eurointervention 2013;9:745-753. Radiation Exposure and TR Analysis of 6,000 cases Assessed operator radiation exposure Used air kerma measure of radiation energy absorbed in a unit of mass air (mGy) 94 JACC Cardiovasc Interv 2011;4:347-52. Radiation Exposure - Drape Radiation exposure to the operator due to scatter from table and patient Randomized trial of radiation protection drape over R wrist 95 Politi et al CCI 2012;70:97-102. Radiation Exposure - Drape 96 Radpad Use (n=30) Control (n=30) Fluoroscopy Time (min)3.52 2.763.46 2.82 Dose Area Product (Gycm2)50.5 31.245.8 18.3 Total radiation dose (Sv)282.8 32.55367.8 105.4 Politi et al CCI 2012;70:97-102. . Case 1 Baseline characteristics 73 yrs, male Stable agina pecteris for over 10 years Essential hypertension intermittent claudication What happened during PCI procedure? 因挠动脉迂曲导致挠动脉入径失败 进入股动脉穿刺成功后，鞘