高危出血患者经桡动脉冠状动脉介入术后延迟拔除动脉鞘管对前壁并发症的影响

发布时间：2018-01-01 04:15

本文关键词：高危出血患者经桡动脉冠状动脉介入术后延迟拔除动脉鞘管对前壁并发症的影响　出处：《河北医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：目的:探讨高危出血患者经桡动脉入径冠状动脉介入术后延迟拔除动脉鞘管对穿刺点并发症的影响。方法:选取2013年12月至2014年12月在河北医科大学第二医院心内五科因冠心病接受经桡动脉入径冠状动脉介入诊断和治疗,且CRUSADE评分大于31分的连续病例。所有患者改良Allen’s试验正常。排除标准:(1)造影剂、肝素使用禁忌;(2)严重肝肾功能衰竭;(3)心原性休克及心肌梗死后并发心脏破裂、乳头肌断裂;(4)严重的心脏瓣膜病;(5)恶性肿瘤及严重的其他系统疾病;(6)前臂畸形、外伤史及手术史;(7)雷诺氏病;(8)冠状动脉介入术后维持普通肝素泵入;(9)未签署手术知情同意书。入选患者随机分为术后立即拔除鞘管组(immediately remove sheath group IRS)和术后延迟拔除鞘管组(delay remove sheath group DRS)。所有患者术前给予常规药物治疗。所有患者均选择桡动脉入径,穿刺成功后均置入6F动脉鞘管,鞘管置入后给予肝素3000U,硝酸甘油200ug,冠状动脉造影使用4F造影导管,需置入支架的患者补充肝素至100U/kg,手术时间每超过1小时,追加肝素2000-3000U,并监测活化凝血时间(activated coagulation time ACT),ACT维持在250-300s。介入术中使用器械如指引导管、导丝、球囊、支架等,由术者根据患者病情决定。术中记录患者的穿刺次数、介入手术操作总时间、PCI治疗的比例、指引导管型号、置入支架数量。IRS组于手术完成时,导管撤出动脉鞘管后立即拔除动脉鞘管,并加压包扎约6小时;DRS组于手术完成后,导管撤出动脉鞘管时开始计算,2小时后拔除动脉鞘管,并加压包扎约4小时。术后记录患者穿刺点并发症,并于术后第3天和第30天行前臂动脉超声多普勒检查,明确患者桡动脉穿刺后情况。随访患者术后1个月内的主要不良心血管事件(major adverse cardiac events MACEs)发生率。应用Logistic回归分析,探讨患者穿刺点血肿的独立危险因素。所有数据使用SPSS 20.0统计分析软件进行统计学分析。P0.05有统计学差异。结果:1本研究共入选病例数82例,分为IRS组40例,DRS组42例。两组患者性别、年龄、收缩压、舒张压、心率、体重指数(BMI)、糖尿病史、吸烟史、饮酒史、既往血管疾病史、心肌梗死病史、疾病类型、左室射血分数、红细胞计数、血红蛋白含量、红细胞压积、血小板计数、活化部分凝血活酶时间、血肌酐、药物使用情况、桡动脉直径无显著性差异(ALL P0.05)。2两组患者桡动脉穿刺次数、介入手术操作总时间、PCI治疗的比例、6F指引导管使用率、7F指引导管使用率、置入支架的数量无显著性差异(ALL P0.05)。3与IRS组相比,DRS组穿刺点血肿的发生率更低(2例vs.8例,P=0.046)。IRS组有1例患者发生神经损伤,DRS组未发生神经损伤,两组神经损伤发生率无统计学差异(P0.05)。术后第3天行前臂动脉超声多普勒检查,两组患者桡动脉狭窄、桡动脉闭塞、假性动脉瘤、动静脉瘘发生率无显著性差异(ALL P0.05)。术后第30天对患者复查前臂动脉超声,IRS组复查人数34人(85%),DRS组复查人数37人(88.10%),两组接受复查人数比较无统计学差异。两组间桡动脉狭窄、桡动脉闭塞、假性动脉瘤、动静脉瘘发生率无显著性差异(ALL P0.05)。4随访术后30天MACEs发生率,两组均未出现患者死亡。IRS组发生非致命性心肌梗死2例(5.0%),DRS组发生非致命性心肌梗死2例(4.76%),两组比较无统计学差异。IRS组无MACEs患者38例(95%),DRS组无MACEs患者40例(95.24%),两组比较无统计学差异。5将本研究中所有患者根据是否发生穿刺点血肿,分为穿刺点无血肿组72例和穿刺点血肿组10例。两组性别、体重指数、7F指引导管使用率无显著性差异(ALL P0.05)。与穿刺点无血肿组相比,穿刺点血肿组应用替罗非班的比例更高(60%vs.9.72%,P=0.001),穿刺次数更多(3 vs.1,P=0.000),接受PCI治疗比例更高(100%vs.55.56%,P=0.005),操作总时间更长(106.00±31.43min vs.40.90±22.33min,P=0.000)。多因素Logistic回归分析显示:应用替罗非班(OR=27.537,95%CI:1.020~743.43,P=0.049),穿刺次数过多(OR=5.554,95%CI:1.154~26.730,P=0.032)及操作时间过长(OR=56.146,95%CI:1.284~2454.397,P=0.037)是穿刺点血肿发生的独立危险因素。结论:1高危出血患者经桡动脉入径行冠状动脉介入诊断或治疗,术后延迟拔除动脉鞘管可以预防穿刺点血肿,并且不增加桡动脉狭窄、桡动脉闭塞、神经损伤、假性动脉瘤及动静脉瘘等穿刺点并发症的发生率。2高危出血患者经桡动脉入径行冠状动脉介入诊断或治疗,术中穿刺次数多、手术时间长及应用替罗非班更易发生穿刺点血肿,建议术后延迟拔除动脉鞘管以预防穿刺点血肿的发生。
[Abstract]:Objective: To investigate the patients with high risk of bleeding through radial artery diameter after coronary artery intervention effect on removal of artery sheath catheter puncture site complications delayed. Methods: from December 2013 to December 2014 in the second hospital of Hebei Medical University in five with coronary heart disease underwent transradial artery access for coronary artery interventional diagnosis and treatment, and CRUSADE scores were more than 31 consecutive cases all of the patients. The modified Allen 's test. Exclusion criteria: (1) contrast agent, heparin use taboo; (2) severe renal failure; (3) cardiac rupture in patients with cardiogenic shock and myocardial infarction after rupture of papillary muscle; (4) severe valvular heart disease; (5) malignant serious tumor and other diseases; (6) the forearm deformity, trauma and surgery; (7) Raynaud's disease; (8) after percutaneous coronary intervention to maintain heparin pump; (9) did not sign the informed consent procedure. Patients were randomly divided into Operation immediately after sheath removal group (immediately remove sheath group IRS) and postoperative delayed sheath removal group (delay remove sheath group DRS). All patients received routine drug therapy. All patients were selected for radial artery diameter, after successful puncture were implanted 6F arterial sheath, sheath after implantation of heparin 3000U, nitroglycerin 200ug coronary angiography with 4F catheter and stent patients need added heparin to 100U/kg, operation time more than 1 hours each, an additional heparin 2000-3000U, and monitoring the activated clotting time (activated coagulation time ACT), ACT maintained at 250-300s. using interventional devices such as guiding catheter, guidewire, balloon. Support operation, determined by the patients according to the patient's condition. The number of puncture patients were recorded, interventional operation time, the proportion of PCI treatment, the guiding catheter placed in the model, the number of stent in group.IRS surgery When completed, the withdrawal of the arterial sheath catheter immediately after removal of artery sheath catheter and compression bandage for about 6 hours; in the DRS group after surgery, catheter withdrawal arterial sheath at the start of calculation, 2 hours after the removal of artery sheath catheter and compression bandage for about 4 hours. The puncture point records of patients with complications after operation, and in after third days and thirtieth days after forearm artery Doppler ultrasound, clear radial artery after biopsies. Patients were followed up within 1 months of major adverse cardiovascular events (major adverse cardiac events MACEs). The incidence of Logistic regression analysis was applied to investigate the independent risk factors of the patients with hematoma puncture points. All data using SPSS there were significant differences in statistical analysis.P0.05 20 statistical analysis software. Results: 1 were enrolled in the study. 82 cases were divided into IRS group, 40 cases, 42 cases in DRS group. The two groups of patients with gender, age, systolic blood pressure, diastolic blood pressure, heart rate, body Weight index (BMI), history of diabetes, smoking history, drinking history, past history of vascular disease, myocardial infarction, type of disease, left ventricular ejection fraction, erythrocyte count, hemoglobin, hematocrit, platelet count, activated partial thromboplastin time, blood creatinine, drug use, no significant the difference of radial artery diameter (ALL P0.05).2 two groups of patients with radial artery puncture times, interventional operation time, the proportion of PCI treatment, 6F guiding catheter usage 7F guiding catheter usage rate, no significant difference in the number of stent (ALL P0.05.3) compared with IRS group, DRS group, lower incidence rate of puncture the hematoma (2 cases vs.8 cases, P=0.046) occurred in 1 cases of nerve injury in.IRS group, DRS group had no nerve injury, there was no significant difference between the two groups of nerve injury (P0.05). After third days of forearm artery Doppler ultrasound examination, two groups of patients with radial artery stenosis, Radial artery occlusion, pseudoaneurysm and arteriovenous fistula had no significant difference (ALL P0.05). After thirtieth days of ultrasonic forearm artery in patients with IRS group to review the review, the number of 34 people (85%), DRS group to review the number of 37 people (88.10%), the two group received follow-up compared to the number of no statistical differences. Between the two groups of radial artery, radial artery occlusion, pseudoaneurysm and arteriovenous fistula had no significant difference (ALL P0.05).4 follow-up after 30 days the incidence rate of MACEs, the two groups had no death of patients in.IRS group had nonfatal myocardial infarction in 2 cases (5%), DRS group had non fatal myocardial infarction in 2 cases (4.76%), the two groups had no significant difference in.IRS group MACEs 38 cases (95%), DRS group of 40 patients with MACEs (95.24%), the two groups had no significant difference in.5 of all patients in this study according to the occurrence of hematoma puncture points, divided into the puncture point without hematoma group 72 cases of hematoma and puncture point Group of 10 cases. The two groups of gender, BMI, 7F guiding catheter use was no significant difference (ALL P0.05). And no hematoma puncture point group, a higher proportion of puncture hematoma group application of tirofiban (60%vs.9.72%, P=0.001), the number of puncture more (3 vs.1, P=0.000, PCI) for a higher proportion (100%vs.55.56%, P=0.005), total operation time is longer (106 + 31.43min vs.40.90 + 22.33min, P=0.000). Logistic regression analysis showed that: application for Luo Fei class (OR=27.537,95%CI:1.020~743.43, P=0.049), the number of puncture too much (OR=5.554,95%CI:1.154~26.730, P=0.032) and operation time (OR=56.146,95%CI:1.284~2454.397, P=0.037) were independent risk factors puncture site hematoma. Conclusion: 1 patients with high risk of bleeding via radial artery access for coronary intervention diagnosis or treatment, removal of artery sheath catheter can prevent puncture hematoma after operation without delay. The increase of radial artery, radial artery occlusion, nerve injury, pseudoaneurysm and arteriovenous fistula puncture complications in.2 patients with high risk of bleeding via radial artery access for coronary intervention diagnosis or treatment, intraoperative puncture times, long operation time and application for Luo Fei class are more susceptible to puncture hematoma. Removal of artery sheath catheter to prevent puncture hematoma after delay.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R541.4

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