TRI常見(jiàn)并發(fā)癥與解決策略課件

TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略NumbersofPCI@FuWaiEachYear91.3%in2011我們迎來(lái)了橈動(dòng)脈介入治療時(shí)代TRI常見(jiàn)并發(fā)癥與解決策略橈動(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）TRI常見(jiàn)并發(fā)癥與解決策略橈動(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)）TRI常見(jiàn)并發(fā)癥與解決策略TRA:可能出現(xiàn)的問(wèn)題ACCESSSubclavian&CoronaryCannulationRemovalofSheath/CatheterAnatomicalVariationsRadialArterySpasmPerforationTraversingSubclavianTortuosityAnatomicalVariationsRarebutpossibleComplicationsRadialArteryOcclusionHematoma/PseudoaneurysmBleeding/CompartmentsyndromeTRI常見(jiàn)并發(fā)癥與解決策略橈動(dòng)脈痙攣TRI常見(jiàn)并發(fā)癥與解決策略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TRI常見(jiàn)并發(fā)癥與解決策略經(jīng)橈動(dòng)脈冠脈介入治療引起腕管綜合征TRI常見(jiàn)并發(fā)癥與解決策略腕管解剖結(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TRI常見(jiàn)并發(fā)癥與解決策略腕管綜合征的表現(xiàn)Thereareclassically5“Ps”associatedwithCompartmentSyndromePAIN(outofproportiontoexpected)-疼痛Pallor-蒼白Paralysis-麻痹Pulselessness-無(wú)脈Poikilothermia(failuretothermoregulate)-溫度異常

TRI常見(jiàn)并發(fā)癥與解決策略腕管綜合征的后果TRI常見(jiàn)并發(fā)癥與解決策略腕管綜合征的處理Leecheswereeffectiveintreatingamassivehematomacausingrightforearmcompartmentsyndrome.Thepatienthadbeentreatedwithanticoagulantsbeforecardiaccatheterizationviatheradialartery.Hardeninganddiscolorationoftheforearmwasfollowedbymotorandsensorydeficitsofthehand.Thirteenleechesremovedabout145mlofblood,withresolutionofsymptomsandsigns.JNeurolNeurosurgPsychiatr2005;76:1465JNeurolNeurosurgPsychiatr2005;76:1465JNeurolNeurosurgPsychiatr2005;76:1465Exampleofaforearmwrappedwithanelasticbandageatthesiteofasuspectedmicropunctureinthemidportionoftheforearm.Thestandardhemostasisdeviceisseeninplaceintheforeground.TherewasnovisibleormeasurablehematomaafterremovaloftheelasticwrapthathadbeenplacedduringtheinitialaccessprocedureGilchrist,I.CARDIACINTERVENTIONSTODAYJANUARY/FEBRUARY2008pp39-42TRI常見(jiàn)并發(fā)癥與解決策略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TRI常見(jiàn)并發(fā)癥與解決策略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)。TRI常見(jiàn)并發(fā)癥與解決策略診斷與治療勤觀察，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TRI常見(jiàn)并發(fā)癥與解決策略鎖骨下畸形動(dòng)脈（ArteriaLusoria）TRI常見(jiàn)并發(fā)癥與解決策略Yiu,K.-H.etal.JAmCollCardiolIntv2010;3:880-881ArchAortogramandMRAoftheMajorArteriesoftheUpperBodyAbnormaloriginofright(RT)subclavianarteryarisingdirectingfromthedescendingaortainsteadoftherightinnominatearteryTRI常見(jiàn)并發(fā)癥與解決策略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?No7TRI常見(jiàn)并發(fā)癥與解決策略心因性聲帶麻痹TRI常見(jiàn)并發(fā)癥與解決策略Severalminutesaftertheprocedure,thepatientdevelopedacardiovocalsyndromewithdysphonia,perceivedashoarsenessandbreathiness.Subsequentlyanimportantdysphagiaaffectingherfeedingpatternoccurred.Duringthediagnosticprocedure,becauseofevidenttortuosityoftherightsubclavianandinnominatearteries,asupportiveangiographicguideandanaccuratemanipulationwereneededtoadvanceandrotatecatheters.TRI常見(jiàn)并發(fā)癥與解決策略Anearnoseandthroatphysicalexaminationwithfiberopticlaryngoscopyrevealedrighthemilaryngealpalsywithoutintralaryngealedema,likelyduetorightrecurrentlaryngealnerve(RLN)stupor.Fig.1.Thefigureshowstherightvocalfoldfixedinabductionduringrespiration(A)andphonation(B)(imagesobtainedduringthevideoendoscopicexamwithDigitalVideoStroboscopySystem,byKayElemetricsCorporation).Intravenoussteroidtherapywasstartedandthenervedysfunctioncompleterecoveredasshownbyasecondlaryngoscopy.Atdischarge,despitethecompletesymptomresolution,avocalrehabilitationperiodwasrecommended.TRI常見(jiàn)并發(fā)癥與解決策略Schemeshowingthecourseoftherecurrentlaryngealnerves.TheRLNontherightsidehooksaroundbehindthesubclavianartery,whileontheleftsidethisnervepassesaroundbehindtheaorticarchbeforeascendingintheneckTRI常見(jiàn)并發(fā)癥與解決策略Basalextremetortuosityofrightsubclavianandinnominatearteriespreventinganycathetermanipulation.TRI常見(jiàn)并發(fā)癥與解決策略Subclavianandinnominatearteriesstraighteningafterdiagnosticcatheterintroduction;asupportiveangiographicguidewasrequiredtorotateandadvancethecatheterinthecoronaryostium.Thestraighteningdeterminedbythecatheterintroductioninthetortuousrightsubclavianandinnominatearterieslikelycausedanunfavorableanatomicalchangeleadingtoatemporarycompression/stretchofrightRLNTRI常見(jiàn)并發(fā)癥與解決策略經(jīng)橈動(dòng)脈冠脈介入治療引起頸部及縱隔血腫TRI常見(jiàn)并發(fā)癥與解決策略經(jīng)橈動(dòng)脈進(jìn)管路徑的解剖圖TRI常見(jiàn)并發(fā)癥與解決策略病例分析病例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

TRI常見(jiàn)并發(fā)癥與解決策略常規(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3.5

33mm的Cypherselect支架,LAD遠(yuǎn)段3.0

28mm的Cypherselect支架，術(shù)中順利導(dǎo)絲誤入小分支血管TRI常見(jiàn)并發(fā)癥與解決策略術(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。TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略治療觀察活動(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TRI常見(jiàn)并發(fā)癥與解決策略轉(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。TRI常見(jiàn)并發(fā)癥與解決策略病例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)。TRI常見(jiàn)并發(fā)癥與解決策略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TRI常見(jiàn)并發(fā)癥與解決策略術(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TRI常見(jiàn)并發(fā)癥與解決策略輔助檢查：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TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略治療觀察活動(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TRI常見(jiàn)并發(fā)癥與解決策略第二日出現(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/LTRI常見(jiàn)并發(fā)癥與解決策略轉(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。TRI常見(jiàn)并發(fā)癥與解決策略Vascularinjuryresultinginasmallleakinthebranchesoftheinnominatearteryisapossiblecomplicationofthetransradialapproach.TRI常見(jiàn)并發(fā)癥與解決策略A61year-oldmalepatientwithdiabetesmellitus.DiagnosticcoronaryangiographyviatheradialapproachshowedeccentricintermediatestenosisoftheLADostiumandafocal99%tightstenosisinthedistalLCxfollowedbysegmental70%stenosis.Approximately30minafterthediagnosticprocedure,thepatientcomplainedofsevereanteriorchestpain—noEKGchange-unrelievedbyNitro-returnedtocathlabforurgentPCI–2stentsplacedinleftcircumflexpostprocedurepatientstillcomplainingofpainECHOdone–negative-

ChestX-rayshowedwideningofmediastinumTRI常見(jiàn)并發(fā)癥與解決策略AchestCTscanshowingalargehematomaintheanteriormediastinumaroundtheaorticarch.FollowupchestCTscanafterrecurredchestpainshowingincreasedhematomaintheanteriormediastinum.TRI常見(jiàn)并發(fā)癥與解決策略A.Coronaryangiogram(APcaudalprojection)showingtightstenosisintheleftcircumflexcoronaryartery.B.ChestX-ray(APview)C.ChestCTscanshowingahugemediastinalhematomalocatedleftoftheaorticarch.D.FollowupchestCTshowingalmostcompleteresorptionoftheprevioushematoma.SecondcaseissimilartothefirstTRI常見(jiàn)并發(fā)癥與解決策略縱膈血腫Fromthetwocasespresentedhere,vascularinjuryresultinginasmallleakinthebranchesoftheinnominatearteryisapossiblecomplicationofthetransradialapproach. Therefore,extracautionandcarefulmaneuveringoftheguidewireiswarrantedduringthetransradialapproach.Inaddition,theuseofanticoagulationseemstobeimportantincontinuousextravasationaftertheinitialbreakinvascularintegrity.TRI常見(jiàn)并發(fā)癥與解決策略橈動(dòng)脈閉塞TRI常見(jiàn)并發(fā)癥與解決策略RadialArteryOcclusionFactorsArterysize:higherincidencewithsmallerarteryHeparindose:minimum5000units,evenforcathArteryspasm:pretreatmentwithverapamilHemostasisdevice:minimizecompressionTRI常見(jiàn)并發(fā)癥與解決策略RadialOcclusionvsHeparinDoseRadialOcclusionvsSheathSizeRadialArteryOcclusionFactorsSpauldingC,etal.CathetCardiovascDiag1996;39:365-370.TRI常見(jiàn)并發(fā)癥與解決策略DevicesusedforradialcompressionHemobandTRBandTRI常見(jiàn)并發(fā)癥與解決策略動(dòng)靜脈瘺和假性動(dòng)脈瘤TRI常見(jiàn)并發(fā)癥與解決策略橈動(dòng)脈介入泥鰍導(dǎo)絲導(dǎo)致冠狀動(dòng)脈損傷TRI常見(jiàn)并發(fā)癥與解決策略Male,56yrs,CHDAPTRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略2hourslater,chestpain,ST2,3,aVFelevatingTRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略RetroperitonealHematomaafterPCI

(PCI術(shù)后的腹膜后血腫)TRI常見(jiàn)并發(fā)癥與解決策略Case1TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略TRI常見(jiàn)并發(fā)癥與解決策略Baselinecharacteristics73yrs,maleStableaginapecterisforover10yearsEssentialhypertensionintermittentclaudicationTRI常見(jiàn)并發(fā)癥與解決策略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TRI常見(jiàn)并發(fā)癥與解決策略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TRI常見(jiàn)并發(fā)癥與解決策略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/d