急性心梗患者急诊经桡动脉行PCI-策略和技巧英文版课件

1、Emergent PCI in AMI Patientswith transradial approachStrategy and SkillsWeimin Li, MDThe First Affiliated Hospital Harbin Medical University, Harbin, ChinaIntroduction At the beginning,TRA tended to be avoided in AMI patients. Major concern was anexpected longer time for arterial cannulation . Many

2、studies have now demonstrated the safety, feasibility and good outcomes of primary PCI performed with TRA,and with a drastic reduction in vascular complications and length of in-hospital stays. According to the most recent guidelines, patients with TFA undergo aggressive anticoagulation, which leads

3、 eventually to an increased incidence of bleeding(up to 7%). However, the combination of GP IIb/IIIa inhibitors and catheterisation withTRA is virtually avoid from serious bleeding.Introduction Louvard et al. in the first 50 cases, demonstrated that any operator will have a failure of about 10%, whi

4、ch will drop to 3-4% after other 500 cases, however procedural failure will stabilise after 1000 procedures at less than 1%. A operator who performed 500 cases may be regarded as the experienced operator for emergent TRA PCI. Indeed,TRA may find its most suitable application in patients with ACS/ ST

5、EMI.IntroductionA 47-year-old male Severe chest pain for 3 hoursA history of hypertension, hyperlipidemiaECG: precordial leads showing up to 3 mm ST elevation in leads V1V4 Case 1The incidence of slow flow and no-reflow after Primary PCI is up to 10%-20%, especially high in lesions with large thromb

6、us burden Case 1Case 1Ryujin 2.5 x 20Case 1DIVER CECase 1Case 1Case 1If aspirate the thrombus first, the result maybe better.A 72-year-old maleSevere chest pain for 3 hoursTri-chamber pacemaker implantation two years agoECG: ST-segment elevation in leads II, III, aVFDirect stenting strategy is feasi

7、ble in most of emergent PCI cases after thrombus aspiration.Case 2Case 2Case 2Nitroglycerin200gCase 2Direct stentingTAPAS In the thrombus-aspiration group, direct stent implantation were performed in 55.1% cases. In the conventional- PCI group, 98.8% cases need balloon predilation.PCR 2008It has bee

8、n reported that more than half of the culprit lesions(66%) in AMI patients with stenosis 5mm Non-occluded thrombus with linear dimension 3 RVDFloating thrombus (proximal to the occlusion);Persistent dye stasis (distal to the obstruction). Wall motion integration TIMI grade of IRALack angina before A

9、MINumber of leads with pathological Q wave Case 3A 62-year-old male Severe chest pain for 5 hoursA history of diabetes , hypercholesterolemia,smokingECG:sinus brandycardia, ST-segment elevation in leads V1-V5BP:75/55mmHgSome complex lesions can be performed with transradial approach in STEMI patient

10、s.Case 3Case 32.0 15mm Ryujin(6atm)Case 3Case 3Case 33.0 20mm RyujinCase 33.5 33mmFirebird IICase 3Case 3Kissing DilationCase 3A: The stent is advanced to the ostial branch lesion and a second balloon is placed in the main branchB: The main branch balloon is inflated at low atmospheres and the stent

11、 gently pulled backStent pull back techniquestentballoonOstial stenosisMain branchSide branchBalloon inflatedC: The stent is deployment at high pressuresD: The main branch balloon and the stent balloon are removed Stent deployedFinal stent positionStent pull back techniqueWhen needed, and in selecte

12、d patients,such as males with good pulsation,the radial artery can acommodate also 7F or 8F catheters. Case 4A 72-year-old male substernal squeezing pain for 3 hours A history of diabetes, renal failure for 2 years ECG:sinus bradycardia, ST-segment elevation in leads II, III, and aVFPrevention is be

13、tter than cure with CIN patients in emergent PCI Case 4Voyger 2.520mmCypher selected plus 3.033mmCypher selected plus 3.518mmCase 4Case 4Ryujin 1.515mmCase 4Voyger 2.520mmCase 4Partner 2.7536mmCase 42007-3-11 Pre-PCI2009-3-13Pre-PCI2009-6-9Pre-PCI2009-6-154d Pre-PCI2009-6-171d Post-PCISCr mol/L201 4

14、21.6563.3484.8413.8 SCrmol/L75Def. Of CIN: 44.3mol/ L or 25% increase Cr at 48 hoursCINLodixanol100mlRisk Factors for CINPatient-related Risk FactorsRenal insufficiencyDiabetes mellitusAge (70)Volume depletion / Low cardiac output / HypotensionClass IV CHFOther nephrotoxinsRenal transplantAnemiaProc

15、edure-related Risk FactorsMultiple CM injection (72h) Intra-arterial injectionHigh volume of CMHigh osmolality of CMHigh VISCOSITY Contrast medium (Selection) IOCM & LOCM OSMOLALITY & VISCOSITY ?Screening high-risk patients.Adequate hydration during contrast medium exposure and after the procedure.S

16、electing low osmolar and less Viscosity contrast.Use lower doses of contrast.Case 5A 72-year-old female substernal squeezing pain for 3 hours A history of diabetes ECG:sinus bradycardia, ST-segment elevation in leads II, III, and aVF,Q wavesSometimes the regular projections can not give you the true

17、 angiograghic imagine, taking pictrues with multi- projections may reduce missed diagnosis. Case 5Case 5CAUCase 5Ryujin 2.520mmCase 5Case 5Case 5Nitrate 200ugTirofiban 5mlI.CCase 5Intracoronary administration of tirofiban followed by intravenous infusion is associated with an improved TIMI flow and

18、TMPG, and reduced thrombus scores following primary PCI.Circ J2008; 72:16051609Nowadays there is virtually no anatomical limitation for performing complex PCI procedures using the TRA.Six-French-widelumen guiding catheters,low-profile balloons and stents,and high- performance wires are available ,even the advanced