经皮冠状动脉成形术与凝血系统激活的相关研究

Haemostatic Changes Induced by Percutaneous Transluminal Angioplasty.

背景:PTCA后急性冠脉闭塞(abrupt closure)的发生率为(?)%～8%,是影响PTCA疗效的主要早期并发症.可引起死亡,非致命性心肌梗塞,不少病人需重新行PTCA或急诊冠状动脉搭桥手术(CABG).目的:观察经皮冠状动脉成形术后与急性术后冠状动脉闭塞相关的血栓、止血因素.材料和方法:连续28例PTCA病人,男21例、女7例,年龄60±10岁.稳定性心绞痛6人,不稳定性心绞痛12人,心肌梗塞14人.另有15例冠状动脉造影病人作为本研究的对照.在常规抗栓基础上,所有PTCA病人术前3日开始口服抵克力得250mg,每日两次,术后持续4周.常规PTCA操作,支架置放由术者根据需要确定.所有病人于插入动脉鞘管和注射肝素前、术扣即刻、术后2h、24h外周静脉穿刺采血,酶联免疫双抗体夹心法测定血浆FPA(纤维蛋白肽A)和TM(血栓调节蛋白)抗原含量.结果:PTCA组扩张的冠脉在左前降支/左旋支/右冠状动脉分别为16支、5支和11支,有8例病人安放了支架.平均扩张次数4次,置管时间102±38min.术中肝素用量10500±2000U,术后用肝素时间1—25h.PTCA组病人(包括支架植入),术后FPA值明显下降,与术前值比较有显著性差异,维持至少24h.PTCA后即刻血浆TM显著性增加,持续2h以上,24h观察值恢复正常.冠造组术前后血浆两参数无显著性变化.PTCA组有3例术后出现胸闷不适。

Background: Percutaneous transluminal angioplasty (PTCA) is an established modality in the treatment of stenosed coronary anery disease. The 4% - 8% incidence of postpro-cedural abrupt closure is causative to death, non-fatal myocardial infarction and emergency revas-cularization.Objective: Our present prospective study aims at discerning the haemostatic factors concerning abrupt closure after PTCA.Materials and methods : Consecutive 28 patients who undertook elective PTCA were enrolled in this study. The patient population included 6 with stable angina pectoris, 12 patents with unstable angina, and 14 with myocardial infarction. Another group of 15 who underwent diagnostic angiography served as control. Oral ticlopidine,250mg twice daily, was given to all PTCA patients 3 days before the procedure and maintained for Imonth. PTCA was performed routinely and in-travascular stenting was in the discretion of charged physician. Before (prior to arterial sheath inserting and heparinization), immediately after and 2 hours after the procedure, blood drawing via peripheral veins were exercised for the detection of fibrinopeptide A (FPA, marker of thrpmbin activity) and thrombomodulin (TM, markers of endothelial injury).Results: PTCA was carried out by routine measures, and stenting was in the discretion of the individual doctor according to the preproeedural and intraprocedural factors underlining abrupt closure. The target vessels dilated in this study were LAD/LCX/RCA of 16/5/11 with stem implanting in 8 patients. The mean dilatation times were 1 with mean catheter indwelling time 102 ± 108 min. Heparin dosing averaged 105000U during the procedure. In angioplasty patients, plasma FPA decreased significantly postoperatively. and sustained for at least 21 hours. In the meanwhile, markers of endothelial injury of TM increased and persisted for more than 2 hours. No significant changes of both parameters in control group were found. By monitoring before discharge, only 1 patients showed definite signs of suspected myocardial ischemia, which were relieved by aggressive anticoagulation.Condusion: In high-risk patients (unstable angina and early myocardial infarction) performing PTCA, ticlopicline pretrealment and optimized stem deployment result in reduced thrombin activity and favor a beneficial early prognosis. Thrombomodulin may be a reliable marker of endothelial injury, which is increased afier PTCA.