急性心?；颊呒痹\經(jīng)橈動脈行PCI-策略和技巧(英文版)課件

Emergent

PCI in

AMI

Patientswith

transradial

approach—Strategy

and

SkillsWeimin

Li,MDThe

First

Affiliated

HospitalHarbin

Medical

University,

Harbin,

ChinaIntroductionAt

the

beginning,TRA

tended

to

be

avoided

in

AMIpatients.

Major

concern

was

anexpected

longer

timefor

arterial

cannulation

.Many

studies

have

now

demonstrated

the

safety,feasibility

and

good

outcomes

of

primary

PCIperformed

with

TRA,and

with

a

drastic

reductioninvascular

complications

and

length

of

in-hospitalstays.According

to

the

most

recent

guidelines,

patientswith

TFA

undergo

aggressive

anticoagulation,which

leads

eventually

to

an

increased

incidenceof

bleeding(up

to7%).However,

the

combination

of

GP

IIb/IIIa

inhibitorsand

catheterisation

withTRA

is

virtually

avoid

fromserious

bleeding.IntroductionLouvard

et

al.

in

the

first

50

cases,

demonstratedthatany

operator

will

have

a

failure

of

about

10%,

whichwill

drop

to

3-4%

after

other

500

cases,

howeverprocedural

failure

will

stabilise

after

1000procedures

at

less

than

1%.A

operator

who

performed

500

cases

may

beregarded

as

the

experienced

operator foremergentTRA

PCI.Indeed,TRA

may

find

its

most

suitable

applicationin

patients

with

ACS/

STEMI.IntroductionA47-year-old

maleSevere

chest

pain

for

3

hoursA

history

of

hypertension,

hyperlipidemiaECG:

precordial

leads

showing

up

to

3

mm ST

elevation

in

leads

V1–V4Case

1The

incidence

of slow

flow

and

no-reflow

after

Primary

PCI

is

upto

10%-20%,

especially

high

in

lesions

with

large

thrombus

burdenCase

1Case

1Ryujin

2.5

x

20Case

1Case

1Case

1DIVERCECase

1Case

1Case

1Case

1Case

1OM

thrombusaspirationCase

1If

aspirate

the

thrombus

first,the

result

maybe

better.A72-year-old

maleSevere

chest

pain

for

3

hoursTri-chamber

pacemaker

implantation

two

years

agoECG:

ST-segment

elevation

in

leads

II,

III,

aVFDirect

stenting

strategy

is

feasible

in

most

of

emergent

PCIcases

after

thrombus

aspiration.Case

2Case

2Case

2DIVERCECase

2Nitroglycerin200μgCase

2Direct

stentingTAPASIn

thethrombus-aspiration

group,directstent

implantation

were

performed

in55.1%

cases.In

the

conventional-

PCI

group,98.8%cases

need

balloon

predilation.PCR

2019It

has

been

reported

that

more

than

half

ofthe

culprit

lesions(66%)

in

AMI

patients

withstenosis

<50%

and

in

majority

patients(97%)the

stenosis

were

less

than70%.WC

Little,et

al.

Circulation1988;78;1157-1166Diver

CE

aspirationcatheterDistal

radiopaquemarker

band:1

mmproximal

to

the

tipOblique

aspiration

tip:lumen

ID=0.9mmSide

hole

diameter:1.5mmThe

proximal

segment(20cm)

has

a

hydrophilia

coatingPrevention

is

better

than

cure.Risk

features.(clinical

and angiographic

features)

LargeIRA(≥3.5mm)

Cut-off

pattern

Accumulated

thrombus

>5mm

Non-occluded

thrombus

with

linear

dimension

>3

RVD

Floating

thrombus

(proximal

to

the

occlusion);

Persistent

dye

stasis

(distal

to

the

obstruction).

Wall

motionintegration

TIMI

grade

ofIRA

Lackangina

before

AMI

Number

of

leads

withpathological

QwaveCase

3A62-year-old

maleSevere

chest

pain

for

5

hoursA

history

of

diabetes

,

hypercholesterolemia,smokingECG:sinus

brandycardia,ST-segment

elevation

in

leadsV1-V5BP:75/55mmHgSome

complex

lesions

can

be

performed

with

transradialapproach

in

STEMI

patients.Case

3Case

32.0

×15mm

Ryujin(6atm)Case

3Case

3Case

33.0

×20mm

RyujinCase

33.5

×33mmFirebird

IICase

3Case

3Kissing

DilationCase

3A:

The

stent

is

advancedto

the

ostial

branchlesion

and

a

secondballoon

is

placed

in

themain

branchB:

The

main

branchballoon

is

inflated

at

lowatmospheres

and

thestent

gently

pulled

backStent

pull

back

techniqueOstialstenosis

SidebranchstentballoonMainbranchBalloon

inflatedC:

The

stent

isdeployment

at

highpressuresD:

The

main

branch

balloonand

the

stent

balloon

areremovedStentdeployedFinalstentpositionStent

pull

back

technique

When

needed,

and

in

selected

patients,suchasmales

with

good

pulsation,the

radial

artery

canacommodate

also

7F

or

8F

catheters.Case

4A72-year-old

malesubsternal

squeezing

pain

for

3

hoursA

history

of

diabetes,

renal

failure

for

2

yearsECG:sinus

bradycardia,ST-segment

elevation

in

leads

II,

III,

and

aVFPrevention

is

better

than

cure

with

CIN

patients

in

emergentPCICase

4Voyger

2.5×20mmCypher

selected

plus3.0×33mmCypher

selected

plus3.5×18mmCase

4Case

4Ryujin

1.5×15mmCase

4Voyger

2.5×20mmCase

4Partner

2.75×36mmCase

42019-3-11Pre-PCI2009-3-13Pre-PCI2009-6-9Pre-PCI2009-6-154d

Pre-PCI2009-6-171d

Post-PCISCrμmol/L201421.6563.3484.8413.8ΔSCrμmol/L75Def.

Of

CIN:

>

44.3μmol/

L

or

>25%

increase

Cr

at

48

hoursCINLodixanol100mlRisk

Factors

for

CINPatient-related

Risk

FactorsRenal

insufficiencyDiabetes

mellitusAge

(>70)Volume

depletion

/Low

cardiac

output

/HypotensionClass

IV

CHFOther

nephrotoxinsRenal

transplantAnemiaProcedure-relatedRisk

FactorsMultiple

CM

injection(<72h)Intra-arterial

injectionHigh

volume

of

CMHigh

osmolality

of

CMHigh

VISCOSITYContrast

medium

(Selection)IOCM

&

LOCMOSMOLALITY

&

VISCOSITY?Screening

high-riskpatients.Adequate

hydration

during

contrast

mediumexposure

and

after

the

procedure.Selecting

low

osmolar

and

less

Viscosity

contrast.Use

lower

doses

of

contrast.Case

5A72-year-old

femalesubsternal

squeezing

pain

for

3

hoursA

history

of

diabetesECG:sinus

bradycardia,ST-segment

elevation

in

leads

II,

III,

and

aVF,QwavesSometimes

the

regular

projections

can

not

give

you

thetrueangiograghic

imagine,

taking

pictrues

with

multi-

projectionsmay

reduce

missed

diagnosis.Case

5Case

5CAUCase

5Ryujin

2.5×20mmCase

5Case

5Case

5Nitrate

200ugTirofiban

5mlI.CCase

5Intracoronary

administration

of

tirofibanfollowed

by

intravenous

infusionisassociated

with

an

im