PPCI术中血栓的管理

直接经皮冠状动脉介入治疗（PPCI）术中血栓的管理TheManagementofThrombusinPrimaryPercutaneousCoronaryintervention武汉亚洲心脏病医院苏晞AcutecoronarysyndromesNSTEMI、STEMI:PathphysiologyRupturedplaquewithnonocclusivethrombusRupturedplaquewithocclusivethrombus?ExampleofplaquerupturewiththrombusinaptwithSTEMIOCTdetailsplaquemorphologywithhighaccuracyThr.FCRuptureLPExpRev.Doc.onOCTforassessmentofatherosclerosis.EurHJ2010.Cons.DOConOCTJACC2011STEMI中血栓的存在血栓形成与急性心肌梗死的发生有重要关系80-90％STEMl患者症状出现后4-6h内行冠脉造影表现为血栓性闭塞血栓负荷的重要性SianosG,etal.JAmCollCardiol，2007,50(7)：573-583.血栓负荷重使支架内血栓形成增加血栓负荷重使MACE增加与小血栓负荷（STB）相比，大血栓负荷（LTB）预示晚期支架内血栓形成，并增加MACE发生率MBGanddeathordeath/reinfarctionLancet,2008,371:1915-1920.冠脉内血栓增加了PPCI风险*Highthrombusburdenisknowntobeassociatedwithanincreasedincidenceofdistalembolization,asignificantpathogeneticcomponentofno-reflow*MaylimitreperfusionattissuelevelasmeasuredbyMBGandSTR*HighthrombusburdenisassociatedwithahigherfrequencyofMACEandisastrongindependentpredictoroflong-termmortality优化组织水平再灌注是重要的治疗目标PPCIremainsthemosteffectivetreatmentstrategyforpatientspresentingwithSTEMIIthasbecomeapparentthatpatencyofIRAafterreperfusionisnotaguaranteeforadequatemicro-vascularperfusionOptimizingtissue-levelreperfusionisanimportantthera-peuticgoalinthesettingofPPCI血栓的形成与管理冠状动脉内血栓治疗的进展年份1980-19901990-19951996-19992000成功率80%80–85%88–90%90%MACE25%15–25%10–15%10%药物UKtPAUKtPA阿昔单抗替罗非班依替巴肽阿昔单抗替罗非班/依替巴肽抗血小板药器械球囊TEC支架TECAngioJet支架AngioJet抽吸导管远端保护装置支架冠状动脉内血栓治疗策略药物治疗患者转移；不能开展PCI的医院栓塞保护器滤器球囊封堵手动抽吸抽吸导管（Export等）机械血栓切除术AngioJet血栓抽吸在STEMI急性期介入治疗中的价值血栓抽吸装置的分类STEMI患者血栓抽吸的临床证据AngioJet血栓清除系统操作技巧指南推荐血栓清除装置的分类AdjunctivedeviceshavebeendevelopedinanattempttoimproveclinicaloutcomesbyremovingthrombiandtoprotectagainstdistalembolizationduringPCIClassesofdevicesinclude:CatheteraspirationthrombectomydevicesMechanicalthrombectomydevicesEmbolicprotectiondevicesAdjunctiveDevices,ThatRemoveThrombiandProtectAgainstDistalEmbolizationDuringPCIExplanationofThrombectomyDevicesCatheterAspirationThrombectomyMechanicalThrombectomy•特点：操作迅速、简便且价格低廉•特点：由位于导管顶端的真空泵完成血栓抽吸ExplanationofThrombectomyDevicesOcclusionballoonisadvancedoveraguidewireproximaltothethrombusAngioplastyorstentingprocedurestakeplaceThromboticdebrisistrappedbytheballoonandaspiratedExplanationofProximalBalloonEmbolicProtectionDevicesOcclusionballoonisadvancedoveraguidewiredistaltothethrombusAngioplastyorstentingprocedurestakeplacThromboticdebrisistrappedbytheballoonandaspiratedExplanationofDistalBalloonEmbolicProtectionDevicesFilterisadvancedoveraguidewiredistaltothethrombusAngioplastyorstentingprocedurestakeplaceThromboticdebrisisaspiratedortrappedbythefilterandremovedExplanationofDistalFilterEmbolicProtectionDevices血栓抽吸装置的分类STEMI患者血栓抽吸的临床证据AngioJet血栓清除系统操作技巧血栓抽吸在STEMI急性期介入治疗中的价值STEMI患者血栓抽吸的临床证据手工血栓抽吸的临床证据DEAR-MI研究JAmcollcardiol.2006,48(8):1552-1559结果：STR50％与68％（P0.05）;MBG-344％与88％（P0.0001）;TIMI血流3级78％比89％（P=NS），校正的TIMI帧计数21.5±12比17.3±6（P0.01）;无复流的15％与3％（P0.05）;血管造影栓塞19％与5％（P0.05）;直接支架置入24％和70％（P0.0001），医院临床事件二组相似。多因素分析显示血栓抽吸是一个完整的STR和MBG-3的独立预测因子。结论：PPCI术前行手动抽栓能显著改善微血管灌注，获得更好的心肌组织灌注，降低远端栓塞和无复流的发生率，两组患者住院期间的MACE发生率相似TAPAS研究最大的前瞻性随机对照单中心研究，具有里程碑意义Lancet,2008,371:1915-1920.结论：与常规PCI组比较，抽吸组心肌再灌注指标明显改善，1年全因死亡减少38％（P=0.04）、心源性死亡下降46％（P=0.02）、再梗死事件降低49％（P=0.05）、心源性死亡或非致命性再梗死事件减少43％（P=0.009），心肌再灌注指标（心肌呈色分级、ST段回落程度）改善与预后（心源性死亡、全因死亡、心源性死亡或再梗死）改善相关（P≤0.004～0.0001）(EXPIRATrial)AmJCardiol.2010,106:624-629.结果：24个月的主要心脏不良事件分别为13.7%和4.5%（P=0.038）和心脏猝死是6.8%和0%（P=0.012）。心脏猝死的发生率和组织灌注参数之间存在着相关性（术后心肌灌注分级和ST段）。结论：手动血栓抽吸术在选定的STEMI患者，可以改善心肌灌注，明显降低心源性死亡和主要不良心脏事件发生率。与常规直接PCI相比，采用普通抽吸导管策略可以使TIMI3级血流和MBG3级比率提高7.3％和64％（P＜0.0001）、远端栓塞率降低60％（P＜0.0001）、术后1个月死亡减少45％（P=0.04）EurHeartJ,2008,29:3002-3010.ATTEMPT荟萃分析ClinicalimpactofthrombectomyinacuteStelevationmyocardialinfarction:anindividualpatient-datapooledanalysisof11trialsSTUDYAntoniuccietal.REMEDIAX-AMINE-STNoeletal.DEAR-MIVAMPIREKaltoftetal.DeLucaetal.PIHRATEEXPIRATAPASESCCongress2009.Sessionnumber:5021-5022.结论：STEMI患者可从手动血栓抽吸策略中获益血栓抽吸联合GPIib/IIIa能进一步改善预后UpfrontThrombusAspirationinPrimaryCoronaryInterventionforPatientsWithST-SegmentElevationAcuteMyocardialInfarctionReportoftheVAMPIRE(VAcuuMasPIrationthrombusREmoval)Trial结论：术中接受手动抽吸者术后MBG3级患者构成比显著升高（46.0%比20.5%，P0.001）,两组间手术成功率、并发症发生率、导管室至恢复TIMI2-3级血流时间、手术时间、院内NACE发生率的差异均无统计学意义。应用抽吸导管未能显著改善左室功能及降低心源性病死率JAmCollCardiolIntv.2008;1(4):424-431.doi:10.1016Dateofdownload:10/4/2013Copyright©TheAmericanCollegeofCardiology.Allrightsreserved.From:UpfrontThrombusAspirationinPrimaryCoronaryInterventionforPatientsWithST-SegmentElevationAcuteMyocardialInfarction:ReportoftheVAMPIRE(VAcuuMasPIrationthrombusREmoval)TrialJAmCollCardiolIntv.2008;1(4):424-431.doi:10.1016/j.jcin.2008.06.004CoronaryFlowImmediatelyAftertheProcedureFigureshowstheendpointresultsfortheTransVascularAspirationCatheter(TVAC)groupversusnon-TVACgroup.(A)Theprimaryendpointofthisstudy:complicationrateofslowflowornoreflow(p=0.07).(B)Thesecondaryendpoint:myocardialblushgrade(p0.001).FigureLegend:AnneKaltoftetal.Circulation,2006,114(1):40-47结论：抽吸组心梗面积（15%）显著大于直接PCI组，STSR70%