经皮冠状动脉成形术中的冠状动脉破裂原因分析

Risk Factors of Coronary Perforation Following Percutaneous Coronary Intervention

目的：探讨冠状动脉成形术中冠状动脉破裂的可能原因。方法：对所有介入治疗前的靶病变行定性和定量造影分析,并选择在发生冠状动脉破裂前最近一次的血管内超声（IVUS）图像进行分析。结果：在5个心脏介入中心总共1 506例经皮冠状动脉成形术（PCI）患者中,发生冠状动脉破裂15例（1.0%）,其中6例与操作导丝相关,1例与单纯球囊扩张相关,8例与支架植入相关。6例与导丝相关的破裂均由亲水涂层或中等硬度导丝所致,靶病变包括3例闭塞、4例偏心和3例分叉病变。与球囊或支架相关冠状动脉破裂包括6例偏心、6例中等至严重钙化病变。有血管内超声分析的5例,其病变偏心率均小于0.4,钙化弓在42~109度。除了单纯球囊破裂病例,在所有支架植入导致的破裂,球囊/管腔比值均超过1.3。所有与导丝相关冠状动脉破裂属于EllisⅡ级,与球囊或支架相关的2例属Ⅱ级,7例属Ⅲ级。结论：导丝相关的冠状动脉破裂常发生在采用亲水涂层或中等硬度导丝对偏心、分叉或闭塞病变进行操作;球囊或支架相关冠状动脉破裂经常与球囊尺寸过大或压力过大有关,常发生在偏心和伴钙化的病变处。

Objective：To analysis coronary perforation following percutaneous coronary intervention（PCI） using quantitative coronary angiography（QCA） and intravascular ultrasound（IVUS） of target lesion and procedure characteristics.Methods： All target lesions before intervention and the latest IVUS images before coronary perforation were analysis.Results： Between 5 institutions,15 coronary perforation cases（1.0%） occurred in 1,506 PCI cases.Of these,6 perforations occurred during guide wire maneuvering,1 case was related to balloon angioplasty（PTCA）,and 8 cases involved stent implantation.In the 6 guide wire coronary perforation cases,only hydrophilic-coated or intermediate guide wires were used.All target lesions were ACC/AHA type B2 or C,including 3 total occlusions,4 eccentric,and 3 bifurcated lesions.In the PTCA and stent coronary perforation cases,all target lesions were ACC/AHA type B2 or C,including 6 eccentric and 6 moderate to severe calcification lesions.IVUS analysis revealed the eccentricity rate was 0.4 and the maximum calcium arc was 42 to 109 degrees.In the PCI procedures,the balloon：artery ratio was over 1.3,except in one PTCA coronary perforation case.All guide wire coronary perforation cases were classified as Ellis II,and most PTCA or stent coronary perforation groups were classified as Ellis III.Conclusions： Guide wire coronary perforation occurre more often with the use of hydrophilic-coated or intermediate guide wires involving treatment of eccentric or bifurcation lesions.Perforations resulting from PTCA or stenting are more often associated with balloon over-sized inflations at eccentric and spotty calcified lesions.