应用抽吸导管的循证学证据20100723.pptxVIP

应用血栓抽吸导管的循证学依据陈某，男、51yr赵汉军 颜红兵首都医科大学附属北京安贞医院北京市心肺血管疾病研究所No-Reflow Doubles Mortality Risk in STEMI Pts Out to 5 Yrs ?No Reflow(n = 410)Reflow(n = 996)OR(95% CI)P ValueDeath18.2%9.5%2.02(1.44-2.82) 0.001Cardiovascular Death12.4%6.3%2.18(1.46-3.27) 0.001Almost 30% of STEMI pts found to have no reflow after primary PCINo reflow raises risk of all-cause, cardiovascular mortality out to 5 yrsClinicians lack effective treatment for conditionNdrepepa G. J Am Coll Cardiol. 2010;55:2383-2389.血栓抽吸与远端保护装置的分类抽吸导管(Diver CE) 机械抽吸装置 (X-Sizer) 远端阻塞保护装置 PercuSurge GuardWire远端滤过保护装置 FilterWire近端阻塞保护装置ProxisMeta-analysis of the Impact of Thrombectomy DPD on Mortality30 Studies, 6415 patients, weighted mean FU of 5 months6p = 0.055.3p =0.018p = 0.894.443.43.1Mortality (%)2.82.7Device2PCIAlone0AspirationMechanicalEmbolicThrombectomyProtectionBavry AA et al, Eur Heart J 2008; 29: 2989-3001 Thrombus Aspiration During PCI for STEMI 建议IIa：益处危险。需要对相关问题进一步研究；有理由完成或实施治疗 证据B：有限人群评估。数据来自单个随机试验或非随机试验ACC/AHA指南的依据： -2项临床随机试验：TAPAS和EXPIRA -1项荟萃分析（Bavry et al） -1项对随机试验的荟萃分析（ ATTEMPT） 限于手工抽吸导管不适合机械性装置 (例如 Angiojet)AMI血栓病理研究支持血栓抽吸几点结论血栓负荷是直接PCI再灌注不良的独立预测因素陈旧血栓是影响预后的独立因素血栓抽吸清除斑块物质是血栓抽吸获益的主要机制Impact of Thrombus Burden on Stent Thrombosis after DES for AMI (2yr FU)12Cumulative IRADES Thrombosis (%)(n=792 patients)19Large Thrombus Burden8.2%Large thrombus burden: ≧2 vessel diameters5.8%6p 0.001 Total Population3.2%2.7%3.2%32.1%1.4%Small Thrombus Burden1.1%1.3%0.7%0.5%0013691215182124Follow-Up (months)Smaller Thrombus Burden is Associated with Reduced DES ThrombosisSianos G et al, J Am Coll Cardiol 2007; 50:573-83AMI冠脉血栓：时项多样性freshAcute STEMI ? Thrombus Agelyticorgnizedorgnized51% of thrombi several days to several weeks oldcapillarySaskia ZH. Circulation 2005;111:1160-1165.中华心血管病杂志2009,37(9):785-789陈旧血栓是影响预后的独立因素Circulation 2008;118:1810-1816Thickened intimaFibrous plaqueLipid-rich plaqueRuptured plaqueAMI冠脉抽吸物成分：多样性肉眼可见物质（血栓或斑块）：65.9%有斑块成分：57.1%；仅有斑块成分: 6.1% 2.0%6.1%红血栓斑块物质8.2%83.7%血浆析出物白血栓黑箭头：红血栓；白箭头：白