急诊PCI的特殊问题罪犯血管的罪犯病变和非罪犯病变.pptVIP

急诊PCI的特殊问题——罪犯血管的罪犯病变和非罪犯病变 信栓力 博士 主任医师 xinkexuan@163.com Case baseline data MV-PCI:罪犯血管和非罪犯血管—因支施救：除非有血流动力学紊乱并且非罪犯病变狭窄大于90%时，一般只处理罪犯病变。 韩雅玲教授的观点：在有缺血证据的前提下，在同次住院期内处理非罪犯血管。 关注支中重点：罪犯血管的罪犯病变和非罪犯病变：tandem病变、多处病变 急性心肌梗塞时血管容易痉挛、机体处于高凝状态 Tandem病变或弥漫性长病变一个支架不能完全覆盖时，怎么办？一个和多个支架植入对预后的影响是什么？瑞金医院张奇做了初步研究。 当罪犯血管存在tandem病变或弥漫性长病变时，如果一个支架不能完全覆盖，建议只处理罪犯病变。 且看我院的三个病例 Our hospital case01 Overall views of this puzzle patient image01 Emergency PCI Indicates a ostial total occlusion of LAD---2012.3.26 The patient’s RCA Initial dilation of the culprit lesion Shows the result post initial dilation Cranial projection of LAD Findings: The right proximal lesion is 85% stenosis There is “normal segment” of 5mm in length but may be not a tandem lesion on this view TIMI flow o grade distal to Diago1 After dilation we can see a second lesion----who is the culprit? Someone suspected thrombus in the distal lesion and think the culprit is right here What about your opinion ? For the proximal lesion, why it is not the culprit lesion ? Initial cine shows total occlusion Seriously stenosis after dilation Two culprit lesion? Why the proximal lesion is total occluded? Thrombosis ? Spasm? Both? Why the distal lesion also total occluded? A real CTO or sub-acute total occlusion? Total occluded by thrombus from the upstream lesion on base of stenosis? Which is the primary? which is the secondary? Why? How to cope with them? What should we do for next step? Merely Implanted partner stent in the distal lesion! Right? 2012.4.8 selective pci …. Final results after stent implantation on 8 April 2012 case02罪犯血管的长病变的处理 Post Dilatation …… Avoiding long stent implantation Final result case03 Investigation after dilation More carefully investigation 1、Predilate 2、stent position 3、implantation Cope with proximal segment Implantation and postdilation Final cine But symptom developed… Dissection? Finished 思考 诸如此类的病例和病变到底如何处理？ 是理性的考虑？医生个体经验基于患者个体的判断？还是基于循证医学的证据？ 如何才能兼顾医疗安全和患者安全？ * *