TRI常见并发症与解决策略

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,Numbers of PCI Fu Wai Each Year,91.3% in 2011,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,ACCESS,Subclavian & Coronary Cannulation,Removal of Sheath/Catheter,Anatomical VariationsRadial Artery SpasmPerforation,Traversing Subclavian TortuosityAnatomical VariationsRare but possible Complications,Radial Artery OcclusionHematoma / PseudoaneurysmBleeding/Compartment syndrome,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,经桡动脉冠脉介入治疗引起腕管综合征,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,There are classically 5 “Ps” associated with Compartment SyndromePAIN (out of proportion to expected)-疼痛Pallor-苍白Paralysis-麻痹Pulselessness-无脉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 measurablehematoma 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,外科切开减压减压效果确切处理要及时带来问题很多抗凝、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 withDigital 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,经桡动脉冠脉介入治疗引起颈部及纵隔血肿,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80RCA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 scanafter 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.,桡动脉闭塞,Radial Artery Occlusion Factors,Artery size: higher incidence with smaller artery Heparin dose: minimum 5000 units, even for cathArtery spasm: pretreatment with verapamilHemostasis 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,Retroperitoneal Hematoma after PCI(PCI术后的腹膜后血肿),Case 1,Baseline characteristics,73 yrs, maleStable agina pecteris for over 10 yearsEssential hypertensionintermittent 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，鞘管无法髂动脉重新穿刺，泥鳅导丝进入腹主动脉，用长鞘成功介入过程中，患者血压下降，面色苍白，打哈欠经推注多巴胺，维持600ug/min静滴，血压维持，但患者腰痛，刺激性排便，呕吐,What happened after PCI procedure?,多巴胺800ug/min，患者从导管室转运到CCU建立中心静脉通道急查血常规：Hg：12g（术前13g）快速补液，床旁超声：心包无异常局部穿刺处无异常2小时后，血压持续降低，反复多巴胺推注急查血常规：Hg：8g快速配血,What happened after that?,患者腹背痛，腹涨持续低血压，出现低血压休克超声发现腹膜后血肿外科以未明确出现点为由，拒绝手术患者剧烈腹涨，肠麻痹，膈肌上抬，呼吸困难血常规汇报：