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1、TRI常见并发症与解决策略,中国医学科学院 阜外心血管病医院 高展,Numbers of PCI Fu Wai Each Year,91.3% in 2011,我们迎来了桡动脉介入治疗时代,桡动脉介入的优势,TRI 微创 TRI使得患者感觉更加舒适 TRI使得冠状动脉介入治疗的并发症更少（包括出血并发症）,桡动脉介入治疗真的使得并发症减少了吗？,使那些常见的出血并发症减少了（如股动脉穿刺部位出血并发症） 但又给我们带来了新的问题（我们不熟悉，缺乏认识）,TRA: 可能出现的问题,ACCESS,Subclavian & Coronary Cannulation,Removal of Sheath
2、/ Catheter,Anatomical Variations Radial Artery Spasm Perforation,Traversing Subclavian Tortuosity Anatomical Variations Rare but possible Complications,Radial Artery Occlusion Hematoma / Pseudoaneurysm Bleeding/Compartment syndrome,桡动脉痉挛,Dieters, RS, Catheterization and Cardiovascular Interventions
3、58:478480 (2003),严重的痉挛可导致桡动脉剥脱. 防治方法: 穿刺轻柔 亲水鞘 扩血管药物（ Cocktail） 镇静 更换其他入径,桡动脉痉挛和防治,经桡动脉冠脉介入治疗引起腕管综合征,腕管解剖结构与桡动脉穿刺,腕管综合征,定义：腕管狭窄，食指、中指疼痛或麻木，拇指肌肉无力感，手指或手掌有麻痹或僵硬感，手腕疼痛。,病因： 腕管内屈肌腱炎和滑膜炎 ，累积性创伤失调 急性创伤的原因如Colles骨折畸形愈合，腕部扭伤出血血肿等 经桡动脉穿刺引起腕管综合征,腕管综合征的表现,There are classically 5 “Ps” associated with Compartmen
4、t SyndromePAIN (out of proportion to expected)-疼痛 Pallor-苍白 Paralysis-麻痹 Pulselessness-无脉 Poikilothermia (failure to thermoregulate)-温度异常,腕管综合征的后果,腕管综合征的处理,Leeches were effective in treating a massive hematoma causing right forearm compartment syndrome. The patient had been treated with anticoagulan
5、ts before cardiac catheterization via the radial artery. Hardening and discoloration of the forearm was followed by motor and sensory deficits of the hand. Thirteen leeches removed about 145 ml of blood, with resolution of symptoms and signs.,J Neurol Neurosurg Psychiatr2005;76: 1465,J Neurol Neuros
6、urg Psychiatr2005;76: 1465,J Neurol Neurosurg Psychiatr2005;76: 1465,Example of a forearm wrapped with an elastic bandage at the site of a suspected micropuncture in the midportion of the forearm. The standard hemostasis device is seen in place in the foreground. There was no visible or measurable h
7、ematoma after removal of the elastic wrap that had been placed during the initial access procedure,Gilchrist, I. CARDIAC INTERVENTIONS TODAY JANUARY/FEBRUARY 2008 pp 39-42,腕管综合征的处理,外科切开减压减压效果确切 处理要及时 带来问题很多 抗凝、抗血小板 感染,腕管综合征治疗新策略：前臂皮肤针刺减压 另外两例患者均用针刺减压方法避免了外科手术,及早发现腕管综合征的迹象，用18号粗针头在前臂扎上百个针眼， 可见淤血渗出，起到
8、减压的作用，随着肝素作用的逐渐减弱， 淤血外渗停止，可重复该操作。观察手的感觉和运动，同时用指 指压法判断动脉供血的恢复。,诊断与治疗,勤观察，早诊断，早治疗 根据病情调整抗凝、抗血小板药物剂量。如果术中桡动脉穿刺不顺利，术后要尽量减少或不用抗凝和静脉抗血小板药物 腕管切开减压术是可供选择的治疗方法 ，6小时内 前臂皮肤针刺减压：有效的办法,锁骨下畸形动脉 （Arteria Lusoria）,Yiu, K.-H. et al. J Am Coll Cardiol Intv 2010;3:880-881,Arch Aortogram and MRA of the Major Arteries o
9、f the Upper Body,Abnormal origin of right (RT) subclavian artery arising directing from the descending aorta instead of the right innominate artery,aberrant right subclavian artery,Forms an acute angle (70) with the proximal aortic arch,the false lumen with retained contrast medium,锁骨下畸形动脉导致主动脉夹层,Hu
10、ang, I, J Chin Med Assoc July 2009 Vol 72 No 7,心因性声带麻痹,Several minutes after the procedure, the patient developed a cardiovocal syndrome with dysphonia, perceived as hoarseness and breathiness. Subsequently an important dysphagia affecting her feeding pattern occurred.,During the diagnostic procedur
11、e, because of evident tortuosity of the right subclavian and innominate arteries, a supportive angiographic guide and an accurate manipulation were needed to advance and rotate catheters.,An ear nose and throat physical examination with fiberoptic laryngoscopy revealed right hemi laryngeal palsy wit
12、hout intra laryngeal edema, likely due to right recurrent laryngeal nerve (RLN) stupor.,Fig. 1. The figure shows the right vocal fold fixed in abduction during respiration (A) and phonation (B) (images obtained during the videoendoscopic exam with Digital Video Stroboscopy System, by Kay Elemetrics
13、Corporation).,Intravenous steroid therapy was started and the nerve dysfunction complete recovered as shown by a second laryngoscopy. At discharge, despite the complete symptom resolution, a vocal rehabilitation period was recommended.,Scheme showing the course of the recurrent laryngeal nerves. The
14、 RLN on the right side hooks around behind the subclavian artery, while on the left side this nerve passes around behind the aortic arch before ascending in the neck,Basal extreme tortuosity of right subclavian and innominate arteries preventing any catheter manipulation.,Subclavian and innominate a
15、rteries straightening after diagnostic catheter introduction; a supportive angiographic guide was required to rotate and advance the catheter in the coronary ostium.,The straightening determined by the catheter introduction in the tortuous right subclavian and innominate arteries likely caused an un
16、favorable anatomical change leading to a temporary compression/stretch of right RLN,经桡动脉冠脉介入治疗引起颈部及纵隔血肿,经桡动脉进管路径的解剖图,病例分析,病例1 男性，57岁入院诊断：1、冠状动脉性心脏病，劳力性心绞痛，PCI术后，2、高血压病，3、糖尿病（2型），4、高脂血症2000年8月因“急性下壁心肌梗死”行急诊RCA-PTCA+支架；2000年9月及2002年1月冠造（右股动脉穿刺）； 2004年12月心绞痛加重右桡动脉LAD-PTCA+支架；2005年9月入院复查既往高血压病史，糖尿病（2型）及
17、高脂血症,常规药物治疗，包括阿司匹林，波立维。局麻下经右桡动脉行冠状动脉造影，LAD原支架后狭窄80，RCA中段狭窄80 RCA中段3.533mm的Cypher select支架,LAD远段3.028mm的Cypher select支架，术中顺利 导丝误入小分支血管,术后并发症诊断,术后45分钟，诉胸痛，右颈部紧缩感，伴出汗，血压110/80mmHg，心率63次/min，15分钟后血压160/80mmHg，心率80次/min，右侧颈部明显肿胀，无搏动感，无血管杂音 急查超声:未见颈动脉破裂或夹层，未见明显液体、气体。 颈部MRI:提示右颈部出血性血肿，不除外右侧头臂静脉回流受阻。 血管外科：不除外颈动脉渗血。,
