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(優(yōu)選)TRI常見(jiàn)并發(fā)癥與解決策略目前一頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)NumbersofPCI@FuWaiEachYear91.3%in2011我們迎來(lái)了橈動(dòng)脈介入治療時(shí)代目前二頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)橈動(dòng)脈介入的優(yōu)勢(shì)TRI微創(chuàng)TRI使得患者感覺(jué)更加舒適TRI使得冠狀動(dòng)脈介入治療的并發(fā)癥更少(包括出血并發(fā)癥)目前三頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)橈動(dòng)脈介入治療真的使得并發(fā)癥減少了嗎?使那些常見(jiàn)的出血并發(fā)癥減少了(如股動(dòng)脈穿刺部位出血并發(fā)癥)但又給我們帶來(lái)了新的問(wèn)題(我們不熟悉,缺乏認(rèn)識(shí))目前四頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)TRA:可能出現(xiàn)的問(wèn)題ACCESSSubclavian&CoronaryCannulationRemovalofSheath/CatheterAnatomicalVariationsRadialArterySpasmPerforationTraversingSubclavianTortuosityAnatomicalVariationsRarebutpossibleComplicationsRadialArteryOcclusionHematoma/PseudoaneurysmBleeding/Compartmentsyndrome目前五頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)橈動(dòng)脈痙攣目前六頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Dieters,RS,CatheterizationandCardiovascularInterventions58:478–480(2003)嚴(yán)重的痙攣可導(dǎo)致橈動(dòng)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(dòng)脈痙攣和防治目前七頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)經(jīng)橈動(dòng)脈冠脈介入治療引起腕管綜合征目前八頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)腕管解剖結(jié)構(gòu)與橈動(dòng)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(wú)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(dòng)脈穿刺引起腕管綜合征目前九頁(yè)\總數(shù)七十九頁(yè)\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(wú)脈Poikilothermia(failuretothermoregulate)-溫度異常

目前十頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)腕管綜合征的后果目前十一頁(yè)\總數(shù)七十九頁(yè)\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(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)腕管綜合征的處理外科切開(kāi)減壓減壓效果確切處理要及時(shí)帶來(lái)問(wèn)題很多抗凝、抗血小板感染目前十三頁(yè)\總數(shù)七十九頁(yè)\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(hào)粗針頭在前臂扎上百個(gè)針眼,可見(jiàn)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(jué)和運(yùn)動(dòng),同時(shí)用指指壓法判斷動(dòng)脈供血的恢復(fù)。目前十四頁(yè)\總數(shù)七十九頁(yè)\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(dòng)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(kāi)減壓術(shù)是可供選擇的治療方法,6小時(shí)內(nèi)前臂皮膚針刺減壓:有效的辦法目前十五頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)鎖骨下畸形動(dòng)脈(ArteriaLusoria)目前十六頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Yiu,K.-H.etal.JAmCollCardiolIntv2010;3:880-881ArchAortogramandMRAoftheMajorArteriesoftheUpperBodyAbnormaloriginofright(RT)subclavianarteryarisingdirectingfromthedescendingaortainsteadoftherightinnominateartery目前十七頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)aberrantrightsubclavianarteryFormsanacuteangle(70°)withtheproximalaorticarchthefalselumenwithretainedcontrastmedium鎖骨下畸形動(dòng)脈導(dǎo)致主動(dòng)脈夾層Huang,I,JChinMedAssoc?July2009?Vol72?No7目前十八頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)心因性聲帶麻痹目前十九頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Severalminutesaftertheprocedure,thepatientdevelopedacardiovocalsyndromewithdysphonia,perceivedashoarsenessandbreathiness.Subsequentlyanimportantdysphagiaaffectingherfeedingpatternoccurred.Duringthediagnosticprocedure,becauseofevidenttortuosityoftherightsubclavianandinnominatearteries,asupportiveangiographicguideandanaccuratemanipulationwereneededtoadvanceandrotatecatheters.目前二十頁(yè)\總數(shù)七十九頁(yè)\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(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Schemeshowingthecourseoftherecurrentlaryngealnerves.TheRLNontherightsidehooksaroundbehindthesubclavianartery,whileontheleftsidethisnervepassesaroundbehindtheaorticarchbeforeascendingintheneck目前二十二頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Basalextremetortuosityofrightsubclavianandinnominatearteriespreventinganycathetermanipulation.目前二十三頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Subclavianandinnominatearteriesstraighteningafterdiagnosticcatheterintroduction;asupportiveangiographicguidewasrequiredtorotateandadvancethecatheterinthecoronaryostium.Thestraighteningdeterminedbythecatheterintroductioninthetortuousrightsubclavianandinnominatearterieslikelycausedanunfavorableanatomicalchangeleadingtoatemporarycompression/stretchofrightRLN目前二十四頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)經(jīng)橈動(dòng)脈冠脈介入治療引起頸部及縱隔血腫目前二十五頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)經(jīng)橈動(dòng)脈進(jìn)管路徑的解剖圖目前二十六頁(yè)\總數(shù)七十九頁(yè)\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(dòng)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(dòng)脈穿刺);2004年12月心絞痛加重右橈動(dòng)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(yè)\總數(shù)七十九頁(yè)\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(dòng)脈行冠狀動(dòng)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(yè)\總數(shù)七十九頁(yè)\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(wú)搏動(dòng)感,無(wú)血管雜音急查超聲:未見(jiàn)頸動(dòng)脈破裂或夾層,未見(jiàn)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(dòng)脈滲血。目前二十九頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前三十頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前三十一頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)治療觀察活動(dòng)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(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)轉(zhuǎn)歸第二天起頸部腫脹沒(méi)有進(jìn)行性加重,血色素?zé)o進(jìn)行性下降,沒(méi)有活動(dòng)性出血,開(kāi)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(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)病例2男性,54歲入院診斷:冠狀動(dòng)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(dòng)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(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)入院后第二日于局麻下經(jīng)右橈動(dòng)脈行冠狀動(dòng)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(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)術(shù)后并發(fā)癥診斷癥狀:術(shù)后當(dāng)時(shí)患者訴胸骨后隱痛,吸氣時(shí)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(cè)不清,心電示波竇性心動(dòng)過(guò)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(yè)\總數(shù)七十九頁(yè)\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(jiàn)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(wú)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(dòng)未見(jiàn)擴(kuò)張,管腔內(nèi)無(wú)內(nèi)膜影;頭臂動(dòng)脈、腹主動(dòng)脈及各分支,及腎動(dòng)脈均未見(jiàn)明顯異常;診斷前縱隔血腫。床旁超聲心動(dòng)圖亦提示:縱隔血腫目前三十七頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前三十八頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前三十九頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)治療觀察活動(dòng)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(yè)\總數(shù)七十九頁(yè)\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(yè)\總數(shù)七十九頁(yè)\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(jì)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%。患者胸痛癥狀消失,體溫正常,病情平穩(wěn),出院。目前四十二頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Vascularinjuryresultinginasmallleakinthebranchesoftheinnominatearteryisapossiblecomplicationofthetransradialapproach.目前四十三頁(yè)\總數(shù)七十九頁(yè)\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(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)AchestCTscanshowingalargehematomaintheanteriormediastinumaroundtheaorticarch.FollowupchestCTscanafterrecurredchestpainshowingincreasedhematomaintheanteriormediastinum.目前四十五頁(yè)\總數(shù)七十九頁(yè)\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(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)縱膈血腫Fromthetwocasespresentedhere,vascularinjuryresultinginasmallleakinthebranchesoftheinnominatearteryisapossiblecomplicationofthetransradialapproach. Therefore,extracautionandcarefulmaneuveringoftheguidewireiswarrantedduringthetransradialapproach.Inaddition,theuseofanticoagulationseemstobeimportantincontinuousextravasationaftertheinitialbreakinvascularintegrity.目前四十七頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)橈動(dòng)脈閉塞目前四十八頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)RadialArteryOcclusionFactorsArterysize:higherincidencewithsmallerarteryHeparindose:minimum5000units,evenforcathArteryspasm:pretreatmentwithverapamilHemostasisdevice:minimizecompression目前四十九頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)RadialOcclusionvsHeparinDoseRadialOcclusionvsSheathSizeRadialArteryOcclusionFactorsSpauldingC,etal.CathetCardiovascDiag1996;39:365-370.目前五十頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)DevicesusedforradialcompressionHemobandTRBand目前五十一頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)動(dòng)靜脈瘺和假性動(dòng)脈瘤目前五十二頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)橈動(dòng)脈介入泥鰍導(dǎo)絲導(dǎo)致冠狀動(dòng)脈損傷目前五十三頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Male,56yrs,CHDAP目前五十四頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前五十五頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前五十六頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前五十七頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)2hourslater,chestpain,ST2,3,aVFelevating目前五十八頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前五十九頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前六十頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)RetroperitonealHematomaafterPCI

(PCI術(shù)后的腹膜后血腫)目前六十一頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Case1目前六十二頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前六十三頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前六十四頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前六十五頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前六十六頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)目前六十七頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)Baselinecharacteristics73yrs,maleStableaginapecterisforover10yearsEssentialhypertensionintermittentclaudication目前六十八頁(yè)\總數(shù)七十九頁(yè)\編于十七點(diǎn)WhathappenedduringPCIprocedure?因撓動(dòng)脈迂曲導(dǎo)致?lián)蟿?dòng)脈入徑失敗進(jìn)入股動(dòng)脈穿刺成功后,鞘管無(wú)法髂動(dòng)脈重新穿刺,泥鰍導(dǎo)絲進(jìn)入腹主動(dòng)脈,用長(zhǎng)鞘成功介入過(guò)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(yè)\總數(shù)七十九頁(yè)\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(wú)異常局部穿刺處無(wú)異常2小時(shí)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(yè)\總數(shù)七十九頁(yè)\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(bào):Hg=5g/dlPC

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