TRI常見并發(fā)癥與解決策略

（優(yōu)選）TRI常見并發(fā)癥與解決策略目前一頁\總數(shù)七十九頁\編于十七點(diǎn)NumbersofPCI@FuWaiEachYear91.3%in2011我們迎來了橈動脈介入治療時代目前二頁\總數(shù)七十九頁\編于十七點(diǎn)橈動脈介入的優(yōu)勢TRI微創(chuàng)TRI使得患者感覺更加舒適TRI使得冠狀動脈介入治療的并發(fā)癥更少（包括出血并發(fā)癥）目前三頁\總數(shù)七十九頁\編于十七點(diǎn)橈動脈介入治療真的使得并發(fā)癥減少了嗎？使那些常見的出血并發(fā)癥減少了（如股動脈穿刺部位出血并發(fā)癥）但又給我們帶來了新的問題（我們不熟悉，缺乏認(rèn)識）目前四頁\總數(shù)七十九頁\編于十七點(diǎn)TRA:可能出現(xiàn)的問題ACCESSSubclavian&CoronaryCannulationRemovalofSheath/CatheterAnatomicalVariationsRadialArterySpasmPerforationTraversingSubclavianTortuosityAnatomicalVariationsRarebutpossibleComplicationsRadialArteryOcclusionHematoma/PseudoaneurysmBleeding/Compartmentsyndrome目前五頁\總數(shù)七十九頁\編于十七點(diǎn)橈動脈痙攣目前六頁\總數(shù)七十九頁\編于十七點(diǎn)Dieters,RS,CatheterizationandCardiovascularInterventions58:478–480(2003)嚴(yán)重的痙攣可導(dǎo)致橈動脈剝脫.防治方法:穿刺輕柔親水鞘擴(kuò)血管藥物（Cocktail）鎮(zhèn)靜更換其他入徑橈動脈痙攣和防治目前七頁\總數(shù)七十九頁\編于十七點(diǎn)經(jīng)橈動脈冠脈介入治療引起腕管綜合征目前八頁\總數(shù)七十九頁\編于十七點(diǎn)腕管解剖結(jié)構(gòu)與橈動脈穿刺腕管綜合征定義：腕管狹窄，食指、中指疼痛或麻木，拇指肌肉無力感，手指或手掌有麻痹或僵硬感，手腕疼痛。病因：腕管內(nèi)屈肌腱炎和滑膜炎，累積性創(chuàng)傷失調(diào)急性創(chuàng)傷的原因如Colles骨折畸形愈合，腕部扭傷出血血腫等經(jīng)橈動脈穿刺引起腕管綜合征目前九頁\總數(shù)七十九頁\編于十七點(diǎn)腕管綜合征的表現(xiàn)Thereareclassically5“Ps”associatedwithCompartmentSyndromePAIN(outofproportiontoexpected)-疼痛Pallor-蒼白Paralysis-麻痹Pulselessness-無脈Poikilothermia(failuretothermoregulate)-溫度異常

目前十頁\總數(shù)七十九頁\編于十七點(diǎn)腕管綜合征的后果目前十一頁\總數(shù)七十九頁\編于十七點(diǎn)腕管綜合征的處理Leecheswereeffectiveintreatingamassivehematomacausingrightforearmcompartmentsyndrome.Thepatienthadbeentreatedwithanticoagulantsbeforecardiaccatheterizationviatheradialartery.Hardeninganddiscolorationoftheforearmwasfollowedbymotorandsensorydeficitsofthehand.Thirteenleechesremovedabout145mlofblood,withresolutionofsymptomsandsigns.JNeurolNeurosurgPsychiatr2005;76:1465JNeurolNeurosurgPsychiatr2005;76:1465JNeurolNeurosurgPsychiatr2005;76:1465Exampleofaforearmwrappedwithanelasticbandageatthesiteofasuspectedmicropunctureinthemidportionoftheforearm.Thestandardhemostasisdeviceisseeninplaceintheforeground.TherewasnovisibleormeasurablehematomaafterremovaloftheelasticwrapthathadbeenplacedduringtheinitialaccessprocedureGilchrist,I.CARDIACINTERVENTIONSTODAYJANUARY/FEBRUARY2008pp39-42目前十二頁\總數(shù)七十九頁\編于十七點(diǎn)腕管綜合征的處理外科切開減壓減壓效果確切處理要及時帶來問題很多抗凝、抗血小板感染目前十三頁\總數(shù)七十九頁\編于十七點(diǎn)腕管綜合征治療新策略：前臂皮膚針刺減壓另外兩例患者均用針刺減壓方法避免了外科手術(shù)及早發(fā)現(xiàn)腕管綜合征的跡象，用18號粗針頭在前臂扎上百個針眼，可見淤血滲出，起到減壓的作用，隨著肝素作用的逐漸減弱，淤血外滲停止，可重復(fù)該操作。觀察手的感覺和運(yùn)動，同時用指指壓法判斷動脈供血的恢復(fù)。目前十四頁\總數(shù)七十九頁\編于十七點(diǎn)診斷與治療勤觀察，早診斷，早治療根據(jù)病情調(diào)整抗凝、抗血小板藥物劑量。如果術(shù)中橈動脈穿刺不順利，術(shù)后要盡量減少或不用抗凝和靜脈抗血小板藥物腕管切開減壓術(shù)是可供選擇的治療方法，6小時內(nèi)前臂皮膚針刺減壓：有效的辦法目前十五頁\總數(shù)七十九頁\編于十七點(diǎn)鎖骨下畸形動脈（ArteriaLusoria）目前十六頁\總數(shù)七十九頁\編于十七點(diǎn)Yiu,K.-H.etal.JAmCollCardiolIntv2010;3:880-881ArchAortogramandMRAoftheMajorArteriesoftheUpperBodyAbnormaloriginofright(RT)subclavianarteryarisingdirectingfromthedescendingaortainsteadoftherightinnominateartery目前十七頁\總數(shù)七十九頁\編于十七點(diǎn)aberrantrightsubclavianarteryFormsanacuteangle(70°)withtheproximalaorticarchthefalselumenwithretainedcontrastmedium鎖骨下畸形動脈導(dǎo)致主動脈夾層Huang,I,JChinMedAssoc?July2009?Vol72?No7目前十八頁\總數(shù)七十九頁\編于十七點(diǎn)心因性聲帶麻痹目前十九頁\總數(shù)七十九頁\編于十七點(diǎn)Severalminutesaftertheprocedure,thepatientdevelopedacardiovocalsyndromewithdysphonia,perceivedashoarsenessandbreathiness.Subsequentlyanimportantdysphagiaaffectingherfeedingpatternoccurred.Duringthediagnosticprocedure,becauseofevidenttortuosityoftherightsubclavianandinnominatearteries,asupportiveangiographicguideandanaccuratemanipulationwereneededtoadvanceandrotatecatheters.目前二十頁\總數(shù)七十九頁\編于十七點(diǎn)Anearnoseandthroatphysicalexaminationwithfiberopticlaryngoscopyrevealedrighthemilaryngealpalsywithoutintralaryngealedema,likelyduetorightrecurrentlaryngealnerve(RLN)stupor.Fig.1.Thefigureshowstherightvocalfoldfixedinabductionduringrespiration(A)andphonation(B)(imagesobtainedduringthevideoendoscopicexamwithDigitalVideoStroboscopySystem,byKayElemetricsCorporation).Intravenoussteroidtherapywasstartedandthenervedysfunctioncompleterecoveredasshownbyasecondlaryngoscopy.Atdischarge,despitethecompletesymptomresolution,avocalrehabilitationperiodwasrecommended.目前二十一頁\總數(shù)七十九頁\編于十七點(diǎn)Schemeshowingthecourseoftherecurrentlaryngealnerves.TheRLNontherightsidehooksaroundbehindthesubclavianartery,whileontheleftsidethisnervepassesaroundbehindtheaorticarchbeforeascendingintheneck目前二十二頁\總數(shù)七十九頁\編于十七點(diǎn)Basalextremetortuosityofrightsubclavianandinnominatearteriespreventinganycathetermanipulation.目前二十三頁\總數(shù)七十九頁\編于十七點(diǎn)Subclavianandinnominatearteriesstraighteningafterdiagnosticcatheterintroduction;asupportiveangiographicguidewasrequiredtorotateandadvancethecatheterinthecoronaryostium.Thestraighteningdeterminedbythecatheterintroductioninthetortuousrightsubclavianandinnominatearterieslikelycausedanunfavorableanatomicalchangeleadingtoatemporarycompression/stretchofrightRLN目前二十四頁\總數(shù)七十九頁\編于十七點(diǎn)經(jīng)橈動脈冠脈介入治療引起頸部及縱隔血腫目前二十五頁\總數(shù)七十九頁\編于十七點(diǎn)經(jīng)橈動脈進(jìn)管路徑的解剖圖目前二十六頁\總數(shù)七十九頁\編于十七點(diǎn)病例分析病例1男性，57歲入院診斷：1、冠狀動脈性心臟病，勞力性心絞痛，PCI術(shù)后，2、高血壓病，3、糖尿?。?型），4、高脂血癥2000年8月因“急性下壁心肌梗死”行急診RCA-PTCA+支架；2000年9月及2002年1月冠造（右股動脈穿刺）；2004年12月心絞痛加重右橈動脈LAD-PTCA+支架；2005年9月入院復(fù)查既往高血壓病史，糖尿病（2型）及高脂血癥

目前二十七頁\總數(shù)七十九頁\編于十七點(diǎn)常規(guī)藥物治療，包括阿司匹林，波立維。局麻下經(jīng)右橈動脈行冠狀動脈造影，LAD原支架后狹窄80％，RCA中段狹窄80％RCA中段3.533mm的Cypherselect支架,LAD遠(yuǎn)段3.028mm的Cypherselect支架，術(shù)中順利導(dǎo)絲誤入小分支血管目前二十八頁\總數(shù)七十九頁\編于十七點(diǎn)術(shù)后并發(fā)癥診斷術(shù)后45分鐘，訴胸痛，右頸部緊縮感，伴出汗，血壓110/80mmHg，心率63次/min，15分鐘后血壓160/80mmHg，心率80次/min，右側(cè)頸部明顯腫脹，無搏動感，無血管雜音急查超聲:未見頸動脈破裂或夾層，未見明顯液體、氣體。頸部MRI:提示右頸部出血性血腫，不除外右側(cè)頭臂靜脈回流受阻。血管外科：不除外頸動脈滲血。目前二十九頁\總數(shù)七十九頁\編于十七點(diǎn)目前三十頁\總數(shù)七十九頁\編于十七點(diǎn)目前三十一頁\總數(shù)七十九頁\編于十七點(diǎn)治療觀察活動性出血：血紅細(xì)胞、血紅蛋白頸部腫脹情況，氣管壓迫情況予靜脈抗生素預(yù)防感染停用抗血小板藥和抗凝藥目前三十二頁\總數(shù)七十九頁\編于十七點(diǎn)轉(zhuǎn)歸第二天起頸部腫脹沒有進(jìn)行性加重，血色素?zé)o進(jìn)行性下降,沒有活動性出血，開始服用阿司匹林300mg，Qd，波力維75mg，Qd。第三天頸部腫脹基本消除。術(shù)后兩周患者病情穩(wěn)定出院。目前三十三頁\總數(shù)七十九頁\編于十七點(diǎn)病例2男性，54歲入院診斷：冠狀動脈性心臟病，勞力性心絞痛，PCI術(shù)后，射頻消融術(shù)后2005年4月曾于外院行RCA支架術(shù)及Lp支架術(shù)，因活動后胸痛加重半年，于2006年2月入我院。既往：吸煙史30余年，飲酒史10余年，2002年外院射頻消融術(shù)。目前三十四頁\總數(shù)七十九頁\編于十七點(diǎn)入院后第二日于局麻下經(jīng)右橈動脈行冠狀動脈造影術(shù)，提示LAD近中段60-70%狹窄，RCA近段60%狹窄，中段原支架內(nèi)90%狹窄，遠(yuǎn)端80%狹窄同期完成RCA的介入治療，于RCA內(nèi)由遠(yuǎn)端至近段串聯(lián)置入Firebird支架3.0*23mm，3.0*33mm，3.5*29mm導(dǎo)絲誤入分支小血管目前三十五頁\總數(shù)七十九頁\編于十七點(diǎn)術(shù)后并發(fā)癥診斷癥狀：術(shù)后當(dāng)時患者訴胸骨后隱痛，吸氣時明顯，20分鐘未緩解，血壓112/80mmHg，心率57次/min。術(shù)后50分鐘，胸悶伴大汗，查體面色蒼白，神清，血壓測不清，心電示波竇性心動過緩，交界性逸搏心率，最慢44次/min，予吸氧，靜脈快速補(bǔ)液，靜脈多巴胺200μg/min持續(xù)泵入，10分鐘后血壓改善目前三十六頁\總數(shù)七十九頁\編于十七點(diǎn)輔助檢查：急查床旁胸片：提示縱隔增寬，右心隔影可見三角形陰影，右肋膈角鈍印象：右下肺部分肺段不張，左下肺斑片影，考慮炎癥，右側(cè)少量胸腔積液，左側(cè)少-中量胸腔積液。急查血常規(guī)：紅細(xì)胞無明顯降低，血紅蛋白從131g/L降至122g/L。急查胸部CT，提示：前縱隔明顯增寬，內(nèi)不規(guī)則中等密度影；升主動未見擴(kuò)張，管腔內(nèi)無內(nèi)膜影；頭臂動脈、腹主動脈及各分支，及腎動脈均未見明顯異常；診斷前縱隔血腫。床旁超聲心動圖亦提示：縱隔血腫目前三十七頁\總數(shù)七十九頁\編于十七點(diǎn)目前三十八頁\總數(shù)七十九頁\編于十七點(diǎn)目前三十九頁\總數(shù)七十九頁\編于十七點(diǎn)治療觀察活動性出血：血紅細(xì)胞、血紅蛋白上腔靜脈（頸靜脈充盈）、氣管受壓迫（呼吸困難）情況予靜脈抗生素預(yù)防感染停用抗血小板藥和抗凝藥目前四十頁\總數(shù)七十九頁\編于十七點(diǎn)第二日出現(xiàn)體溫升高，最高38.7℃，血白細(xì)胞最高達(dá)11.4*109/L，中性粒細(xì)胞比例82.6%，血糖升高，考慮與出血、胸腔積液有關(guān)，予靜脈抗菌素，口服降糖藥治療，逐漸改善。術(shù)后第二日加服波利維75mgQd第三日恢復(fù)服用阿司匹林200mgQd術(shù)后第三日血紅蛋白最低達(dá)90g/L目前四十一頁\總數(shù)七十九頁\編于十七點(diǎn)轉(zhuǎn)歸手術(shù)一周后復(fù)查CT：前縱隔血腫較前吸收，累計范圍較前縮小，主要位于右上縱隔，兩側(cè)少-中量胸腔積液。復(fù)查血常規(guī)，血紅蛋白105g/L，白細(xì)胞5.3*109/L,中性粒細(xì)胞比例76.1%?；颊咝赝窗Y狀消失，體溫正常，病情平穩(wěn)，出院。目前四十二頁\總數(shù)七十九頁\編于十七點(diǎn)Vascularinjuryresultinginasmallleakinthebranchesoftheinnominatearteryisapossiblecomplicationofthetransradialapproach.目前四十三頁\總數(shù)七十九頁\編于十七點(diǎn)A61year-oldmalepatientwithdiabetesmellitus.DiagnosticcoronaryangiographyviatheradialapproachshowedeccentricintermediatestenosisoftheLADostiumandafocal99%tightstenosisinthedistalLCxfollowedbysegmental70%stenosis.Approximately30minafterthediagnosticprocedure,thepatientcomplainedofsevereanteriorchestpain—noEKGchange-unrelievedbyNitro-returnedtocathlabforurgentPCI–2stentsplacedinleftcircumflexpostprocedurepatientstillcomplainingofpainECHOdone–negative-ChestX-rayshowedwideningofmediastinum目前四十四頁\總數(shù)七十九頁\編于十七點(diǎn)AchestCTscanshowingalargehematomaintheanteriormediastinumaroundtheaorticarch.FollowupchestCTscanafterrecurredchestpainshowingincreasedhematomaintheanteriormediastinum.目前四十五頁\總數(shù)七十九頁\編于十七點(diǎn)A.Coronaryangiogram(APcaudalprojection)showingtightstenosisintheleftcircumflexcoronaryartery.B.ChestX-ray(APview)C.ChestCTscanshowingahugemediastinalhematomalocatedleftoftheaorticarch.D.FollowupchestCTshowingalmostcompleteresorptionoftheprevioushematoma.Secondcaseissimilartothefirst目前四十六頁\總數(shù)七十九頁\編于十七點(diǎn)縱膈血腫Fromthetwocasespresentedhere,vascularinjuryresultinginasmallleakinthebranchesoftheinnominatearteryisapossiblecomplicationofthetransradialapproach. Therefore,extracautionandcarefulmaneuveringoftheguidewireiswarrantedduringthetransradialapproach.Inaddition,theuseofanticoagulationseemstobeimportantincontinuousextravasationaftertheinitialbreakinvascularintegrity.目前四十七頁\總數(shù)七十九頁\編于十七點(diǎn)橈動脈閉塞目前四十八頁\總數(shù)七十九頁\編于十七點(diǎn)RadialArteryOcclusionFactorsArterysize:higherincidencewithsmallerarteryHeparindose:minimum5000units,evenforcathArteryspasm:pretreatmentwithverapamilHemostasisdevice:minimizecompression目前四十九頁\總數(shù)七十九頁\編于十七點(diǎn)RadialOcclusionvsHeparinDoseRadialOcclusionvsSheathSizeRadialArteryOcclusionFactorsSpauldingC,etal.CathetCardiovascDiag1996;39:365-370.目前五十頁\總數(shù)七十九頁\編于十七點(diǎn)DevicesusedforradialcompressionHemobandTRBand目前五十一頁\總數(shù)七十九頁\編于十七點(diǎn)動靜脈瘺和假性動脈瘤目前五十二頁\總數(shù)七十九頁\編于十七點(diǎn)橈動脈介入泥鰍導(dǎo)絲導(dǎo)致冠狀動脈損傷目前五十三頁\總數(shù)七十九頁\編于十七點(diǎn)Male,56yrs,CHDAP目前五十四頁\總數(shù)七十九頁\編于十七點(diǎn)目前五十五頁\總數(shù)七十九頁\編于十七點(diǎn)目前五十六頁\總數(shù)七十九頁\編于十七點(diǎn)目前五十七頁\總數(shù)七十九頁\編于十七點(diǎn)2hourslater,chestpain,ST2,3,aVFelevating目前五十八頁\總數(shù)七十九頁\編于十七點(diǎn)目前五十九頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十頁\總數(shù)七十九頁\編于十七點(diǎn)RetroperitonealHematomaafterPCI

(PCI術(shù)后的腹膜后血腫)目前六十一頁\總數(shù)七十九頁\編于十七點(diǎn)Case1目前六十二頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十三頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十四頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十五頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十六頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十七頁\總數(shù)七十九頁\編于十七點(diǎn)Baselinecharacteristics73yrs,maleStableaginapecterisforover10yearsEssentialhypertensionintermittentclaudication目前六十八頁\總數(shù)七十九頁\編于十七點(diǎn)WhathappenedduringPCIprocedure?因撓動脈迂曲導(dǎo)致?lián)蟿用}入徑失敗進(jìn)入股動脈穿刺成功后，鞘管無法髂動脈重新穿刺，泥鰍導(dǎo)絲進(jìn)入腹主動脈，用長鞘成功介入過程中，患者血壓下降，面色蒼白，打哈欠經(jīng)推注多巴胺，維持600ug/min靜滴，血壓維持，但患者腰痛，刺激性排便，嘔吐目前六十九頁\總數(shù)七十九頁\編于十七點(diǎn)WhathappenedafterPCIprocedure?多巴胺800ug/min，患者從導(dǎo)管室轉(zhuǎn)運(yùn)到CCU建立中心靜脈通道急查血常規(guī)：Hg：12g（術(shù)前13g）快速補(bǔ)液，床旁超聲：心包無異常局部穿刺處無異常2小時后，血壓持續(xù)降低，反復(fù)多巴胺推注急查血常規(guī)：Hg：8g快速配血目前七十頁\總數(shù)七十九頁\編于十七點(diǎn)Whathappenedafterthat?患者腹背痛，腹?jié)q持續(xù)低血壓，出現(xiàn)低血壓休克超聲發(fā)現(xiàn)腹膜后血腫外科以未明確出現(xiàn)點(diǎn)為由，拒絕手術(shù)患者劇烈腹?jié)q，腸麻痹，膈肌上抬，呼吸困難血常規(guī)匯報：Hg＝5g/dlPC