PCI冠脉穿孔常见原因和防治策略.ppt

* * * * * * * * * * * * * * * * * * * * * * * 球囊原位封堵（3ATM）30min，心脏超声显示心尖部7mm心包积液 手术过程 最终造影 手术过程 不同PCI技术的冠脉穿孔发生率 技术 穿孔发生率 stent 0.10%~1.14% 冠脉内旋磨术 0.0%~1.3% 冠脉内定向旋切术 1.9%~2.0% 准分子激光冠脉成形术 1.9%~2.0% guidewire 20% Smith SJ.et al. JACC. 2001; 37:2215-38 冠脉穿孔的Ellis分型 *还有将破入心腔或冠状静脉窦的Ⅲ（CS）型另称为Ⅳ型 Ⅰ型：血管外龛影，无造影剂外泄 Ⅱ型：心包或心肌染色，但未见到 ≥1mm的造影剂喷射样外泄 Ⅲ型：造影剂经破口（≥1mm）持 续外溢；溢入心腔；破入心 腔或冠状静脉窦 旋切装置导致的I 型穿孔 支架植入后远端II型穿孔 右冠CTO病变导丝引起II型穿孔 CTO病变时导丝引起的III型穿孔 导丝，球囊与支架引起冠脉穿孔 Spectrum of pathology … wire exit distal branch perforation mid-vessel rupture Tamponade is bad news Study Year Number Perforation Tamponade Mortality Von Sohsten 2000 6999 15 (0.2%) 0 Gruberg 2000 30746 84 (0.3%) 26 (0.1%) 8 Fejka 2002 25697 31 (0.1%) 14 Fukutomi 2002 7443 69 (0.93%) 26 (0.3%) 0 Gunning 2002 6245 52 (0.8%) 24 (0.4%) 6 Fasseas 2003 16298 95 (0.6%) 11 (0.1%) 7 Eggebrecht 2004 6433 19 (0.3%) 3 (0.05%) 2 Witzke 2004 12658 39 (0.3%) 7 (0.05%) 1 Ramana 2005 4886 25 (0.5%) 4 (0.01%) 2 Javaid 2006 38559 72 (0.2%) 14 (0.03%) 12 Shirakabe 2007 3415 12 (0.4%) 3 (0.01%) 1 Perforation Mortality Late presentation of tamponade 2 hours post-procedure Frequency 10 - 60% of documented perforations Retrospectively associated with wire perforation Associated with abciximab (80% Gunning et al) so does GPIIb/IIIa use confer risk? Gunning et al Heart 2002 No. patients with haemodynamically significant coronary perforation Management .. ? Depends on grade / severity Wire perforation Often benign Often unreported hydrophilic wires May respond to reversal of heparin obser