TRI常見并發(fā)癥與解決策略

（優(yōu)選）TRI常見并發(fā)癥與解決策略目前一頁\總數(shù)七十九頁\編于十七點(diǎn)NumbersofPCI@FuWaiEachYear91.3%in2011我們迎來了橈動(dòng)脈介入治療時(shí)代目前二頁\總數(shù)七十九頁\編于十七點(diǎn)橈動(dòng)脈介入的優(yōu)勢TRI微創(chuàng)TRI使得患者感覺更加舒適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\總數(shù)七十九頁\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）但又給我們帶來了新的問題（我們不熟悉，缺乏認(rèn)識(shí)）目前四頁\總數(shù)七十九頁\編于十七點(diǎn)TRA:可能出現(xiàn)的問題ACCESSSubclavian&CoronaryCannulationRemovalofSheath/CatheterAnatomicalVariationsRadialArterySpasmPerforationTraversingSubclavianTortuosityAnatomicalVariationsRarebutpossibleComplicationsRadialArteryOcclusionHematoma/PseudoaneurysmBleeding/Compartmentsyndrome目前五頁\總數(shù)七十九頁\編于十七點(diǎn)橈動(dòng)脈痙攣目前六頁\總數(shù)七十九頁\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\總數(shù)七十九頁\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\總數(shù)七十九頁\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\總數(shù)七十九頁\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-無脈Poikilothermia(failuretothermoregulate)-溫度異常

目前十頁\總數(shù)七十九頁\編于十七點(diǎn)腕管綜合征的后果目前十一頁\總數(shù)七十九頁\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\總數(shù)七十九頁\編于十七點(diǎn)腕管綜合征的處理外科切開減壓減壓效果確切處理要及時(shí)帶來問題很多抗凝、抗血小板感染目前十三頁\總數(shù)七十九頁\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\總數(shù)七十九頁\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\總數(shù)七十九頁\編于十七點(diǎn)鎖骨下畸形動(dòng)脈（ArteriaLusoria）目前十六頁\總數(shù)七十九頁\編于十七點(diǎn)Yiu,K.-H.etal.JAmCollCardiolIntv2010;3:880-881ArchAortogramandMRAoftheMajorArteriesoftheUpperBodyAbnormaloriginofright(RT)subclavianarteryarisingdirectingfromthedescendingaortainsteadoftherightinnominateartery目前十七頁\總數(shù)七十九頁\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\總數(shù)七十九頁\編于十七點(diǎn)心因性聲帶麻痹目前十九頁\總數(shù)七十九頁\編于十七點(diǎn)Severalminutesaftertheprocedure,thepatientdevelopedacardiovocalsyndromewithdysphonia,perceivedashoarsenessandbreathiness.Subsequentlyanimportantdysphagiaaffectingherfeedingpatternoccurred.Duringthediagnosticprocedure,becauseofevidenttortuosityoftherightsubclavianandinnominatearteries,asupportiveangiographicguideandanaccuratemanipulationwereneededtoadvanceandrotatecatheters.目前二十頁\總數(shù)七十九頁\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\總數(shù)七十九頁\編于十七點(diǎn)Schemeshowingthecourseoftherecurrentlaryngealnerves.TheRLNontherightsidehooksaroundbehindthesubclavianartery,whileontheleftsidethisnervepassesaroundbehindtheaorticarchbeforeascendingintheneck目前二十二頁\總數(shù)七十九頁\編于十七點(diǎn)Basalextremetortuosityofrightsubclavianandinnominatearteriespreventinganycathetermanipulation.目前二十三頁\總數(shù)七十九頁\編于十七點(diǎn)Subclavianandinnominatearteriesstraighteningafterdiagnosticcatheterintroduction;asupportiveangiographicguidewasrequiredtorotateandadvancethecatheterinthecoronaryostium.Thestraighteningdeterminedbythecatheterintroductioninthetortuousrightsubclavianandinnominatearterieslikelycausedanunfavorableanatomicalchangeleadingtoatemporarycompression/stretchofrightRLN目前二十四頁\總數(shù)七十九頁\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\總數(shù)七十九頁\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\總數(shù)七十九頁\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、糖尿病（2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?。?型）及高脂血癥

目前二十七頁\總數(shù)七十九頁\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\總數(shù)七十九頁\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，無搏動(dòng)感，無血管雜音急查超聲:未見頸動(dòng)脈破裂或夾層，未見明顯液體、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\總數(shù)七十九頁\編于十七點(diǎn)目前三十頁\總數(shù)七十九頁\編于十七點(diǎn)目前三十一頁\總數(shù)七十九頁\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\總數(shù)七十九頁\編于十七點(diǎn)轉(zhuǎn)歸第二天起頸部腫脹沒有進(jìn)行性加重，血色素?zé)o進(jìn)行性下降,沒有活動(dòng)性出血，開始服用阿司匹林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\總數(shù)七十九頁\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\總數(shù)七十九頁\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\總數(shù)七十九頁\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，血壓測不清，心電示波竇性心動(dòng)過緩，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\總數(shù)七十九頁\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)未見擴(kuò)張，管腔內(nèi)無內(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\總數(shù)七十九頁\編于十七點(diǎn)目前三十八頁\總數(shù)七十九頁\編于十七點(diǎn)目前三十九頁\總數(shù)七十九頁\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\總數(shù)七十九頁\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\總數(shù)七十九頁\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%?；颊咝赝窗Y狀消失，體溫正常，病情平穩(wěn)，出院。目前四十二頁\總數(shù)七十九頁\編于十七點(diǎn)Vascularinjuryresultinginasmallleakinthebranchesoftheinnominatearteryisapossiblecomplicationofthetransradialapproach.目前四十三頁\總數(shù)七十九頁\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\總數(shù)七十九頁\編于十七點(diǎn)AchestCTscanshowingalargehematomaintheanteriormediastinumaroundtheaorticarch.FollowupchestCTscanafterrecurredchestpainshowingincreasedhematomaintheanteriormediastinum.目前四十五頁\總數(shù)七十九頁\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\總數(shù)七十九頁\編于十七點(diǎn)縱膈血腫Fromthetwocasespresentedhere,vascularinjuryresultinginasmallleakinthebranchesoftheinnominatearteryisapossiblecomplicationofthetransradialapproach. Therefore,extracautionandcarefulmaneuveringoftheguidewireiswarrantedduringthetransradialapproach.Inaddition,theuseofanticoagulationseemstobeimportantincontinuousextravasationaftertheinitialbreakinvascularintegrity.目前四十七頁\總數(shù)七十九頁\編于十七點(diǎn)橈動(dòng)脈閉塞目前四十八頁\總數(shù)七十九頁\編于十七點(diǎn)RadialArteryOcclusionFactorsArterysize:higherincidencewithsmallerarteryHeparindose:minimum5000units,evenforcathArteryspasm:pretreatmentwithverapamilHemostasisdevice:minimizecompression目前四十九頁\總數(shù)七十九頁\編于十七點(diǎn)RadialOcclusionvsHeparinDoseRadialOcclusionvsSheathSizeRadialArteryOcclusionFactorsSpauldingC,etal.CathetCardiovascDiag1996;39:365-370.目前五十頁\總數(shù)七十九頁\編于十七點(diǎn)DevicesusedforradialcompressionHemobandTRBand目前五十一頁\總數(shù)七十九頁\編于十七點(diǎn)動(dòng)靜脈瘺和假性動(dòng)脈瘤目前五十二頁\總數(shù)七十九頁\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\總數(shù)七十九頁\編于十七點(diǎn)Male,56yrs,CHDAP目前五十四頁\總數(shù)七十九頁\編于十七點(diǎn)目前五十五頁\總數(shù)七十九頁\編于十七點(diǎn)目前五十六頁\總數(shù)七十九頁\編于十七點(diǎn)目前五十七頁\總數(shù)七十九頁\編于十七點(diǎn)2hourslater,chestpain,ST2,3,aVFelevating目前五十八頁\總數(shù)七十九頁\編于十七點(diǎn)目前五十九頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十頁\總數(shù)七十九頁\編于十七點(diǎn)RetroperitonealHematomaafterPCI

(PCI術(shù)后的腹膜后血腫)目前六十一頁\總數(shù)七十九頁\編于十七點(diǎn)Case1目前六十二頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十三頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十四頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十五頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十六頁\總數(shù)七十九頁\編于十七點(diǎn)目前六十七頁\總數(shù)七十九頁\編于十七點(diǎn)Baselinecharacteristics73yrs,maleStableaginapecterisforover10yearsEssentialhypertensionintermittentclaudication目前六十八頁\總數(shù)七十九頁\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，鞘管無法髂動(dòng)脈重新穿刺，泥鰍導(dǎo)絲進(jìn)入腹主動(dòng)脈，用長鞘成功介入過程中，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\總數(shù)七十九頁\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：心包無異常局部穿刺處無異常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\總數(shù)七十九頁\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