经皮冠状动脉介入治疗术中冠状动脉穿孔32例临床分析

Clinical study of coronary artery perforation during percutaneous coronary interventions

目的总结经皮冠状动脉介入治疗(PCI)术中冠状动脉穿孔的临床特点。方法回顾性分析2004年4月至2006年8月阜外心血管病医院PCI术中发生的32例冠状动脉穿孔患者的临床资料。结果32例冠状动脉穿孔患者占同期7102例PCI患者的0.5%。病变特点按美国心脏病学会(ACC)/美国心脏协会(AHA)标准进行分型,其中B2+C型病变占81.3%,慢性完全闭塞病变占62.5%。冠状动脉穿孔的Ellis分型:Ⅰ型14例(43.8%),Ⅱ型10例(31.2%),Ⅲ型8例(25.0%)。发生原因:钢丝引起21例(65.6%),球囊预扩张引起6例(18.8%),球囊后扩张引起3例(9.4%),支架置入引起2例(6.2%)。处理措施:鱼精蛋白中和肝素14例(43.8%),穿孔近端球囊封堵9例(28.1%),心包穿刺引流7例(21.9%),置入带膜支架4例(12.5%),急诊外科修补加冠状动脉旁路移植术(CABG)2例(6.2%)。预后:死亡3例(9.4%),急诊外科修补加CABG2例(6.2%),急性心脏压塞6例(18.8%),迟发性心脏压塞1例(3.1%),急性心肌梗死9例(28.1%)。结论Ⅲ型冠状动脉穿孔后果严重,需积极处理。

Objective To summarize clinical characteristics of coronary artery perforation during pereutaneous coronary interventions. Methods Retrospective analysis of consecutive 32 patients who had coronary artery perforation in Fu Wai Hospital from April, 2004 to August, 2006 was carried out. Results Thirty-two cases of coronary perforation occurred during 7102 PCI procedures performed within this period （incidence ：0. 5% ）. These cases are comparatively complicated lesions including 81.3 % of type B2 ＋ C and 62. 5 % of chronic total occlusion （ CTO ） lesions. Ellis classification ： type Ⅰ ： 14 （43.8%） ,type Ⅱ ： 10 （ 31.2% ）, type Ⅲ ：8 （ 25.0% ）, type Ⅳ .0. Mechanism of coronary artery perforation： guiding wire ：21 （ 65.6% ） , predilatation： 6 （ 18.8% ）, postdilatation ： 3 （ 9.4% ） , stent implantation： 2 （ 6.2% ）. Clinical consequence ： death ： 3 （ 9.4% ） , cardiac temponade ： 7 （ 21.9 % ） , acute myocardial infarction （ AMI ） ：9 （ 28. 1% ）. Treatment ： reversal of heparin-induced anticoagulation by application of protamine： 14 （ 43. 8% ） , prolonged balloon inflation： 9 （28.1% ） , pereardiocentesis ：7 （21.9% ） , implantation of membrane covered stent ：4 （ 12. 5% ） , bail-out surgical repair ：2 （6. 2% ）. Conclusion Coronary perforation during PCI is a rare complication;type Ⅲ perforation is associated with significant morbidity and mortality, which needs urgent and intensive treatment.