经导管冠状动脉介入治疗引起冠状动脉穿孔10例临床分析(1)
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【摘要】 目的 探讨冠状动脉介入治疗(PCI)并发冠状动脉穿孔的临床特点和处理方法。方法 对我院2004~2010年10例PCI并发冠状动脉穿孔患者的穿孔原因、造影影像特点、处理方法及结果进行回顾性分析。结果 穿孔血管为前降支5例、回旋支3例、右冠状动脉2例,其中C型病变5例、B型病变4例、A型病变1例。球囊扩张或支架释放压力过大致血管撕裂3例、导丝穿出血管7例;4例并发心包填塞。6例行球囊长时间低压扩张压迫、4例行心包穿刺引流。无一例死亡,无Q波性心肌梗死及急诊冠状动脉搭桥者。结论 冠状动脉穿孔是PCI少见并发症、但可导致严重临床后果,及时诊断、积极处理是减少恶性心脏事件的关键。
【关键词】 冠状动脉介入治疗;心包填塞;并发症
Management of coronary artery perforation during percutaneous coronary intervention
WANG Cheng-quan,WU Hai-xia,FENG Xue-ying,et al.
Department of Cardiology,The DaQing Longnan Hospital,Daqing 163453,China
【Abstract】 Objective To investigate the cause and therapeutic method of coronary artery perforation during percutaneous coronary intervention(PCI).Methods To analyze retrospectively the angiographic appearance,cause,treatment,and outcome of coronary artery perforation complicating PCI in five patients between 2004 and 2010. Results Two of the perforations were in right coronary artery,five in left anterior descending,and three in left circumflex.Five of the aim lesions were C type,Four of the aim lesions were B type,one A type.Of the ten perforations,three were caused by high-pressure inflation,seven by guide wire trauma and four by balloon oversizing; six cases complicated by pericardial tamponade.Four patients were treated by prolonged balloon inflation.There was no death,no Q-wave myocardial infarction,no emergency bypass surgery.Conclusion Coronary artery perforation is an uncommon but serious complication following PCI.Rapid diagnolosis and active treatment are key points to reduce fatal cardiac events.
【Key words】 Percutaneous coronary intervention;Pericardial tamponade;Complication
冠状动脉穿孔是冠状动脉介入治疗(PCI)少见而严重的并发症之一,可引起急性心包填塞、急性心肌梗死、或需紧急冠状动脉搭桥等,若发现不及时或处理不当可导致死亡,远期有形成假性动脉瘤、甚至破裂的可能。现将我院PCI并发冠状动脉穿孔情况报告如下,并分析其原因和探讨恰当的处理策略。
1 资料与方法
1.1 一般资料
2004~2010年共5例患者并发冠状动脉穿孔,男8例、女2例,年龄55~69岁。不稳定性心绞痛7例,陈旧性心肌梗死2例,急性心肌梗死恢复期1例。回顾性分析10例患者的临床和冠状动脉造影资料,根据穿孔的影像特征进行Ellis分型,并对穿孔原因及处理方法进行分析和评价。Ellis[1]分型:根据冠状动脉造影征象分为3型:Ⅰ型:造影剂呈“龛影”突出于血管腔外,但无外漏;Ⅱ型:造影剂漏至心包或心肌,但无喷射状漏出;Ⅲ型:造影剂通过直径>1 mm的破口,呈喷射状漏入心包、心腔或冠状静脉。
1.2 冠状动脉造影结果 5例患者三支病变3例、双支病变5例、单支病变2例。穿孔累及前降支5例、回旋支3例、右冠状动脉2例,靶病变形态为C型病变5例、B型病变4例、A型病变1例。
1.3 Ellis分型及穿孔原因 Ⅰ型穿孔3例,因为亲水性指引导丝穿出血管所致;Ⅱ型穿孔4例,为亲水性指引导丝穿出血管所致,POLLT 150导丝1例,POLLT 50导丝1例;Ⅲ型穿孔3例,因支架、球囊过大导致血管破裂。
1.4 处理 3例患者术中发现造影剂漏入心包后,立即用同一球囊在穿孔处或近端2~4个大气压长时间低压扩张压迫,每次30~300 s直至穿孔封闭,累积球囊扩张时间20~70 min。同时行心包穿刺引流,引流液体500~800 ml。4例患者术中造影剂漏至心肌,其中2例患者因局部造影剂外渗明显经球囊扩张压迫后停止外渗,未出现心包填塞 ......
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