经皮冠状动脉介入治疗时无再流现象的处理

Treatmant of no-reflow phenomenon during percutaneous coronary intervention

目的初步探讨冠状动脉(冠脉)内注射尿激酶及地尔硫对经皮冠状动脉介入治疗(PCI)中“靶血管”病变无再流现象的临床疗效。方法86例急性冠脉综合征患者实施介入治疗出现靶血管的无再流,首先给予冠脉内硝酸甘油,其78例血流无改善,并将其分为3组:A组26例,交替给予尿激酶及地尔硫冠脉内注射,尿激酶最大量20×104U,地尔硫最大量2mg;B组24例,给予地尔硫冠脉内注射,每次500μg,最大量2mg;C组28例,给予尿激酶冠脉内注射,最大量20×104U。结果A组26例TIMI血流明显改善,P<0.01。B组18例TIMI血流改善,P<0.05;6例无改善者继续予尿激酶1×105～2×105U推注后TIMI血流3级者4例,TIMI血流2级者2例。C组20例TIMI血流改善,P<0.05;8例无改善者继续予地尔硫500μg～2mg推注后TIMI血流3级者6例,TIMI血流1级者2例,其中术后24小时死亡1例。3组相比,术后A组TIMI血流改善更为显著,P<0.05。结论无再流现象与靶血管远端的冠脉微血栓形成及痉挛均有关,PCI中给予冠脉内小剂量尿激酶及地尔硫安全有效,应在今后处理中推广应用。

Objective To evaluate the effect of injecting UK and Herbesser into the target coronary artery where no-reflow happened during pereutaneous coronary intervention. Methods Among the 820 acute coronary syndrome （ACS） patients who underwent PCI from Jan. 1990 to Apr. 2004, no-reflow phenomenon occurred in 86 patients, Three hundred cases with acute myocardial infraction （AMI） underwent primary PCI, no-reflow phenomenon occurred in 50 cases. In the other 520 unstable angina pectoris （UAP） cases, no-reflow phenomenon occurred in 36 cases during PCI. All the 86 patients with no-reflow were given intra-coronary arteries nitroglycerin but 78 of them showed no improvement in coronary perfusion and were in areas devided into 3 groups randomly. Group A （ n = 26） was given intra-vessel UK and Herbesser alternately. The maximan dosage of UK was 2 × 10^5 U kIU and 2 mg for Herbesser. Group B （ n = 24） was given intra-eoronary Herbesser 500 pg each time until the maximum amount reached 2 mg. Group C （ n = 28） was given UK which maximun dosage was 2×10^5 U. Results All the 26 cases in Group A showed significant improvement in blood flow （ P 〈0.005）; 18 cases in Group B showed improvement in TIM] grading （ P 〈 0.05）. The remaining 6 cases were given 1 × 10^5 U - 2 × 10^5 U of UK and among them, 4 cases reached TIMI 3 flow and 2 cases reached TIMI 2 flow. In Group C, 20 patients showed TIMI improvement and the other 8 cases were given 0.5 - 2 mg of Herbesser. 6 cases achieved TIMI 3 flow and 2 achieved TIMI 1 flow but 1 patient died 24 h after PCI. Group A showed the most obvious improvement in TIMI flow among the 3 groups （ P 〈 0.05）. Conclusion The no-reflow phenomenon during PCI is associated with vessel spasm and thrombosis in the coronary microvasculatmre. Intra coronary arteries injection of UK and Herbesser may be a feasiable treatment.