PPCI术中血栓的管理

直接经皮冠状动脉介入治疗（PPCI）术中血栓的管理The Management of Thrombus in Primary Percutaneous Coronary intervention,武汉亚洲心脏病医院 苏 晞,Acute coronary syndromes,NSTEMI、STEMI: Path physiology,Ruptured plaque with non occlusive thrombus,Ruptured plaque with occlusive thrombus,?,Example of plaque rupture with thrombus in a pt with STEMI,OCT details plaque morphology with high accuracy,Thr.,FC Rupture,LP,Exp Rev. Doc. on OCT for assessment of atherosclerosis. Eur H J 2010.Cons. DOC on OCT JACC 2011,STEMI中血栓的存在,血栓形成与急性心肌梗死的发生有重要关系80-90STEMl患者症状出现后4-6h内行冠脉造影表现为血栓性闭塞,血栓负荷的重要性,Sianos G, et al.J Am Coll Cardiol，2007, 50(7)：573-583.,血栓负荷重使支架内血栓形成增加 血栓负荷重使MACE增加,与小血栓负荷（STB）相比，大血栓负荷（LTB）预示晚期支架内血栓形成，并增加MACE发生率,MBG and death or death/reinfarction,Lancet, 2008, 371:1915-1920.,冠脉内血栓增加了PPCI风险,High thrombus burden is known to be associated with an increased incidence of distal embolization, asignificant pathogenetic component of no-reflowMay limit reperfusion at tissue level as measured by MBG and STRHigh thrombus burden is associated with a higher frequency of MACE and is a strong independent predictor of long-term mortality,优化组织水平再灌注是重要的治疗目标,PPCI remains the most effective treatment strategy for patients presenting with STEMI It has become apparent that patency of IRA after reperfusion is not a guarantee for adequate micro- vascular perfusionOptimizing tissue-level reperfusion is an important thera-peutic goal in the setting of PPCI,血栓的形成与管理,冠状动脉内血栓治疗的进展,冠状动脉内血栓治疗策略,药物治疗患者转移；不能开展PCI的医院栓塞保护器滤器球囊封堵手动抽吸抽吸导管（Export等）机械血栓切除术AngioJet,血栓抽吸在STEMI急性期介入治疗中的价值,指南推荐,血栓清除装置的分类,Adjunctive devices have been developed in an attempt to improve clinical outcomes by removing thrombi and to protect against distal embolization during PCI Classes of devices include: Catheter aspiration thrombectomy devices Mechanical thrombectomy devices Embolic protection devices,Adjunctive Devices ,That Remove Thrombi and Protect Against Distal Embolization During PCI,Explanation of Thrombectomy Devices,Catheter Aspiration Thrombectomy,Mechanical Thrombectomy,特点：操作迅速、简便且价格低廉,特点：由位于导管顶端的真空泵完成血栓抽吸,Explanation of Thrombectomy Devices,Occlusion balloon is advanced over a guidewire proximal to the thrombus Angioplasty or stenting procedures take place Thrombotic debris is trapped by the balloon and aspirated,Explanation of Proximal Balloon Embolic Protection Devices,Occlusion balloon is advanced over a guidewire distal to the thrombus Angioplasty or stenting procedures take plac Thrombotic debris is trapped by the balloon and aspirated,Explanation of Distal Balloon Embolic Protection Devices,Filter is advanced over a guidewire distal to the thrombus Angioplasty or stenting procedures take placeThrombotic debris is aspirated or trapped by the filter and removed,Explanation of Distal Filter Embolic Protection Devices,血栓抽吸在STEMI急性期介入治疗中的价值,STEMI患者血栓抽吸的临床证据,手工血栓抽吸的临床证据,DEAR-MI研究,J Am coll cardiol.2006,48(8):1552-1559,TAPAS 研究 最大的前瞻性随机对照单中心研究，具有里程碑意义,Lancet, 2008, 371:1915-1920.,Am J Cardiol. 2010,106:624-629.,与常规直接PCI相比，采用普通抽吸导管策略可以使 TIMI 3级血流和MBG 3级比率提高7.3和64（P0.0001）、远端栓塞率降低60（P0.0001）、术后1个月死亡减少45（P=0.04）,Eur Heart J,2008,29:3002-3010.,ATTEMPT 荟萃分析,Clinical impact of thrombectomy in acute Stelevation myocardial infarction: an individual patient-data pooled analysis of 11 trials,STUDYAntoniucci et al.REMEDIAX-AMINE-STNoel et al.DEAR-MIVAMPIREKaltoft et al.De Luca et al.PIHRATEEXPIRATAPAS,ESC Congress 2009. Session number: 5021-5022.,结论：STEMI患者可从手动血栓抽吸策略中获益,血栓抽吸联合GP Iib/IIIa能进一步改善预后,Upfront Thrombus Aspiration in Primary Coronary Intervention for Patients With ST-Segment Elevation Acute Myocardial InfarctionReport of the VAMPIRE (VAcuuM asPIration thrombus REmoval) Trial,结论：术中接受手动抽吸者术后MBG3级患者构成比显著升高（46.0%比20.5%，P70%患者构成比两者无统计学意义。PPCI术前常规吸栓并不能挽救更多的存活心肌，也不能有效限制梗死区的延展，反而会增加心肌梗死的面积,Controlled Trial,Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction( The INFUSE-AMI Randomized Trial ),结论：与常规直接PCI相比，导管抽吸组在梗死面积、绝对梗死质量、室壁运动异常评分等均无显着性差异,JAMA.2012 May 2;307(17):1817-26.,2013年 ESC公布的TASTE研究结果， PCI前人工血栓抽吸与单纯PCI相比，对STEMI患者早期死亡率的影响。文章发表在新英格兰医学杂志,N. Engl. J. Med. 2013 doi:10.1056/NEJMoa1308789,结果：30天时，抽吸+PCI组和单纯PCI组的支架内血栓形成率(0.2% vs. 0.5%)、靶病变血运重建率(1.2% vs. 1.6%)和靶血管血运重建率(1.8% vs. 2.2%)相似，全因死亡率(主要终点)分别为2.8%和3.0%，差异不显著,有效与无效的争论,DEAR-MI Trial,TAPAS Trial,EXPIRA Trial,ATTEMPT Meta,CONTROLLED Trial,TASTE Trial,VAMPIRE Trial,INFUSE Trial,STEMI患者血栓抽吸的临床证据,机械血栓抽吸装置的临床证据 AngioJet技术,对比了AngioJet装置(AngioJet组)与冠状动脉内注射尿激酶(尿液酶组)在治疗冠状动脉造影检查示大血栓的自身血管和桥血管患者(180例比169例)的有效性和安全性AngioJet组围术期MI和大出血的发生率分别为12.8%和2.8%,显著低于尿激酶组的30.3%和11.2%(P值均0.001）；住院天数为4.2d，显著短于尿激酶组的4.9d(P=0.02),VeGAS-1研究,Cohen D J et al.Am Heart J,2006,142(4):648-656,Grines CL等荟萃分析,Post-ptocedural TIMI 3 Flow,Short-term motality,Short-term MACE,结论: AngioJet血栓清除术在低风险心肌梗死患者中能达到与直接支架植入术类似的临床以及影像学结果。AngioJet因能降低罪犯血管血栓负荷而进一步降低由血栓引起的临床风险,1999年1月至2007年1月期间发表的AMI相关研究， AngioJet 数据包括11项研究和1018 例患者. PCI数据包括81项研究和24076例患者,Angela Migliorini et al.JACC,2010,56(16):1298-1306,AngioJet+PCI和直接PCI的比较，全球此领域中，入组病人最多的试验，全球多中心、前瞻性、随机对照试验,JETSTENT研究,Study Design,SMART-PCI 研究,Guido Parodi et al. Circ Cardiovasc Interv,2013,224-230,RCT比较了AngioJet与手动抽吸导管治疗STEMI的效果 OCT 观察作为临床终点和临床随访,与手动抽吸相比，AngioJet能更有效地取出血栓，且与更好的心肌再灌注有关。 OCT 终点表明了更支持AngioJet的趋势，与手动抽吸相比，AngioJet 治疗后含有血栓的冠脉象限数更少,结论：,AIMI 研究（2006）,未达到减少梗死面积的主要终点 AngioJet组的梗死面积更大，MACE和死亡率更高,480例STEMI患者，随机分为传统PCI组及AngioJet组。主要研究终点为在术后14-28d核素测得的心肌梗死面积,MUSTELA 研究,Marco De Carlo et al.JACC,2012,1223-30,Study Design,Randomized (n=208),No aspiration (n=104),Aspiration (n=104),Rheolytic (n=54),No MRI (n=29) Dead (n=2) Refused MRI (n=25) Lost at f-up (n=1) Claustrofobia (n=1),3-month MRI(n=41),3-month MRI (n=75),Primary endpoint analysis (n=79),Primary endpoint analysis (n=75),1-year follow-up n=68,Manual (n=50),No MRI (n=25) Dead (n=3) Refused MRI (n=21) Lost at f-up (n=1),1-year follow-up n=73,3-month MRI(n=38),机械血栓清除与STR高的发生率有关 机械血栓清除和PCI治疗的梗死面积无差异 12个月MACE发生率无差异,Procedural Results,Infarct Size and Transmurality,Freedom From MACE,武汉亚洲心脏病医院的经验,与Export组比较： 血栓积分在AngioJet组显著降低（11.2 vs. 2.21.7，p=0.024） 主要终点STR50%比例在AngioJet组显著升高（93.3% vs. 56.3%， p=0.049）,VeGAS-1研究,AIMI 研究,Grines CL等荟萃分析,JETSTENT研究,MUSTELA 研究,SMART-PCI 研究,血栓抽吸在STEMI急性期介入治疗中的价值,指南推荐,指南推荐,指南推荐,冠状动脉内血栓治疗策略,药物治疗 GP II bIll a受体拮抗剂 +栓塞保护器 滤器 + 球囊封堵 手动抽吸 抽吸导管 +机械血栓切除术 AngioJet +,Mild ResidualStenosisTimi 3 flow,Large MLAat OCT,LAD TotalOcclusion,35 Y/O Male with Anterior STEMI