應(yīng)用PTCA導(dǎo)絲經(jīng)橈動(dòng)脈環(huán)冠狀動(dòng)脈造影

王 磊，劉惠亮，馬東星， 羅建平，韓 瑋，劉 英，楊勝利

應(yīng)用PTCA導(dǎo)絲經(jīng)橈動(dòng)脈環(huán)冠狀動(dòng)脈造影

王 磊，劉惠亮，馬東星， 羅建平，韓 瑋，劉 英，楊勝利

目的研究應(yīng)用經(jīng)皮腔內(nèi)冠狀動(dòng)脈成形術(shù)(percutaneous transluminal coronary angioplasty，PTCA)導(dǎo)絲經(jīng)橈動(dòng)脈環(huán)完成冠狀動(dòng)脈造影的可行性。方法2012-01至2012-12我院行經(jīng)橈動(dòng)脈冠狀動(dòng)脈造影2600例，對超滑導(dǎo)絲推送困難或遇到阻力者通過造影導(dǎo)管行橈動(dòng)脈或上肢動(dòng)脈造影，對發(fā)現(xiàn)的橈動(dòng)脈環(huán)隨機(jī)分為兩組，PTCA導(dǎo)絲組改用PTCA導(dǎo)絲嘗試通過橈動(dòng)脈環(huán)完成冠脈造影，改股動(dòng)脈組直接改為股動(dòng)脈入路行冠脈造影，比較兩組成功率、操作時(shí)間、放射線劑量(dose area product, DAP)、造影劑用量情況等。結(jié)果經(jīng)橈動(dòng)脈造影確認(rèn)橈動(dòng)脈環(huán)52例，兩組患者完成冠脈造影成功率差異無統(tǒng)計(jì)學(xué)意義(92%vs100%，P=0.15)，PTCA導(dǎo)絲組操作時(shí)間、放射線劑量高于改股動(dòng)脈組[(922.8±124.2) svs(699.2±99.5) s,P<0.001; (27288.1±6420.2 ) mGy/cm2vs(22711.9±4850.4 )mGy/cm2,P<0.05 ]，造影劑用量差異無統(tǒng)計(jì)學(xué)意義[(49.5±5.9) mlvs(45.1±6.2) ml,P>0.05]。結(jié)論經(jīng)橈動(dòng)脈造影遇到橈動(dòng)脈環(huán)時(shí)通過改用PTCA導(dǎo)絲仍可順利完成冠脈造影，一定程度增加操作時(shí)間及放射線劑量。

橈動(dòng)脈環(huán)；冠狀動(dòng)脈造影;經(jīng)皮腔內(nèi)冠狀動(dòng)脈成形術(shù)導(dǎo)絲

經(jīng)橈動(dòng)脈冠狀動(dòng)脈造影可以減少穿刺部位并發(fā)癥，術(shù)后不需要嚴(yán)格臥床，縮短住院時(shí)間[1,2]，目前已被廣泛應(yīng)用。但由于橈動(dòng)脈解剖學(xué)變異(包括橈動(dòng)脈環(huán))、穿刺不成功、橈動(dòng)脈痙攣等因素可導(dǎo)致操作失敗，文獻(xiàn)[2,3]報(bào)道橈動(dòng)脈環(huán)致操作失敗比例達(dá)35%～72.7%。經(jīng)上肢血管造影明確橈動(dòng)脈環(huán)走行后，調(diào)整超滑導(dǎo)絲一般可以通過并拉直橈動(dòng)脈環(huán)完成冠狀動(dòng)脈造影，而改用PTCA導(dǎo)絲通過并拉直橈動(dòng)脈環(huán)或紆曲動(dòng)脈環(huán)可進(jìn)一步提高成功率。我中心進(jìn)行了改用PTCA導(dǎo)絲與直接改經(jīng)股動(dòng)脈入路完成冠狀動(dòng)脈造影的對比。

1 對象與方法

1.1 對象 2013-01至2013-12在我院行經(jīng)橈動(dòng)脈冠狀動(dòng)脈造影術(shù)患者共2600例，術(shù)中發(fā)現(xiàn)橈動(dòng)脈環(huán)52例。

1.2 方法

1.2.1 常規(guī)冠狀動(dòng)脈造影操作 應(yīng)用Cordis公司橈動(dòng)脈鞘管(21G穿刺針、0.021inch導(dǎo)絲、11cm6F動(dòng)脈鞘)常規(guī)選擇右橈動(dòng)脈，置入動(dòng)脈鞘管后沿側(cè)管注入硝酸甘油200 μg和維拉帕米(異搏定)0.5 mg，靜脈補(bǔ)充普通肝素3000 U，對需介入治療者補(bǔ)充肝素至總量100 U/kg。操作應(yīng)用超滑導(dǎo)絲(0.035 inch×180 cm)，造影導(dǎo)管選用5F TIG造影導(dǎo)管，對到位困難者根據(jù)情況改用Judkins或Amplaz導(dǎo)管(Cordis公司)，左冠狀動(dòng)脈采用5～6個(gè)體位，右冠狀動(dòng)脈采用2～3個(gè)體位。

1.2.2 分組 對超滑導(dǎo)絲至肘關(guān)節(jié)推送困難難以送至肱動(dòng)脈，或超滑導(dǎo)絲順利越過肘關(guān)節(jié)但造影導(dǎo)管推送阻力較大不能通過肘關(guān)節(jié)者，經(jīng)造影管注入5～8 ml造影劑行橈動(dòng)脈造影明確橈動(dòng)脈走行(有時(shí)需不同體位投照)。如發(fā)現(xiàn)橈動(dòng)脈環(huán)，則履行告知義務(wù)，簽署知情同意書，隨機(jī)分為：PTCA導(dǎo)絲組和改股動(dòng)脈組，每組26例。

1.2.3 操作過程 PTCA導(dǎo)絲組嘗試PTCA導(dǎo)絲(Runthrough Terumo，日本產(chǎn))在造影導(dǎo)管連接Y閥后，通過操控PTCA導(dǎo)絲或在少量注射造影劑指引下通過橈動(dòng)脈環(huán)，拉直橈動(dòng)脈環(huán)將造影導(dǎo)管送至肱動(dòng)脈后交換為超滑導(dǎo)絲完成冠狀動(dòng)脈造影(圖1)。如PTCA導(dǎo)絲不能拉直橈動(dòng)脈環(huán)或?qū)Ч懿荒芡ㄟ^橈動(dòng)脈環(huán)則改為經(jīng)股動(dòng)脈入路。術(shù)畢即刻拔除動(dòng)脈鞘管，應(yīng)用橈動(dòng)脈止血夾加壓止血，術(shù)后4～6 h逐漸減壓至解除加壓包扎。改股動(dòng)脈組直接改為股動(dòng)脈入路完成冠狀動(dòng)脈造影，應(yīng)用Cordis公司6F股動(dòng)脈鞘管，常規(guī)選擇右股動(dòng)脈，置入動(dòng)脈鞘管后分別應(yīng)用6F Judkins左右4.0造影導(dǎo)管完成冠脈造影，單純冠脈造影即刻拔除股動(dòng)脈鞘管，彈力繃帶加壓包扎，沙袋壓迫8 h，右下肢制動(dòng)24 h，行介入治療者術(shù)后4～6 h拔除股動(dòng)脈鞘管。

1.3 數(shù)據(jù)收集 兩組一般情況無統(tǒng)計(jì)學(xué)差異(表1)。收集兩組成功率、操作時(shí)間、放射線劑量(dose area product， DAP)、造影劑用量情況、血管并發(fā)癥，有無造影劑腎病發(fā)生等。血腫定義為：穿刺部位皮膚組織下的血液積聚，根據(jù)直徑分為小血腫(5～10 cm)和大血腫(>10 cm)。

1.4 統(tǒng)計(jì)學(xué)處理 采用SPSS 18.0 軟件進(jìn)行統(tǒng)計(jì)學(xué)分析處理。兩組間數(shù)據(jù)采用t檢驗(yàn)，計(jì)數(shù)資料采用χ2檢驗(yàn)。以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

A.橈動(dòng)脈造影見橈動(dòng)脈環(huán)(箭頭所指)；B.操控PTCA導(dǎo)絲通過橈動(dòng)脈環(huán)；C.繼續(xù)推送PTCA導(dǎo)絲幾乎拉直橈動(dòng)脈環(huán)；D.推送造影導(dǎo)管通過橈動(dòng)脈環(huán)至肱動(dòng)脈

2 結(jié) 果

經(jīng)橈動(dòng)脈造影確認(rèn)橈動(dòng)脈環(huán)52例(2%)，操作成功率兩組差異無統(tǒng)計(jì)學(xué)意義，分別為PTCA導(dǎo)絲組92%，改股動(dòng)脈組100%(P=0.15)。PTCA導(dǎo)絲組1例因造影導(dǎo)管未能通過橈動(dòng)脈環(huán)，未能完成經(jīng)橈動(dòng)脈冠狀動(dòng)脈造影，后經(jīng)改為股動(dòng)脈途徑完成冠脈造影。由表2可見，操作時(shí)間PTCA導(dǎo)絲組長于改股動(dòng)脈組(P<0.001)。放射線量PTCA導(dǎo)絲組高于改股動(dòng)脈組(P=0.03)，造影劑用量兩組無統(tǒng)計(jì)學(xué)差異。血管并發(fā)癥PTCA導(dǎo)絲組顯著低于改股動(dòng)脈組(P<0.01)，PTCA導(dǎo)絲組僅發(fā)生1例橈動(dòng)脈痙攣，局部疼痛；改股動(dòng)脈組3例發(fā)生血腫，1例穿刺局部小血腫，2例大血腫。兩組均無造影劑腎病發(fā)生。PTCA導(dǎo)絲介入治療11例，均經(jīng)交換超滑導(dǎo)絲更換指引導(dǎo)管完成介入治療，改股動(dòng)脈組介入治療13例。

注：與改股動(dòng)脈組比較，①P<0.05

3 討 論

經(jīng)橈動(dòng)脈冠狀動(dòng)脈造影有許多優(yōu)點(diǎn)，包括穿刺部位出血性并發(fā)癥少、損傷神經(jīng)概率極低、術(shù)后臥床時(shí)間短或不需要嚴(yán)格臥床、縮短住院時(shí)間[1-3]，且使用1根導(dǎo)管可以完成左右冠狀動(dòng)脈造影，因而可減少費(fèi)用、節(jié)約時(shí)間、減少X線照射。但是，因其解剖特點(diǎn)會(huì)有一定缺陷，如穿刺失敗，橈動(dòng)脈發(fā)育異常、扭曲、橈動(dòng)脈痙攣，存在解剖變異等情況。研究表明一些解剖學(xué)變異，包括橈動(dòng)脈環(huán)是導(dǎo)致經(jīng)橈動(dòng)脈造影失敗的主要原因；有文獻(xiàn)提示存在橈動(dòng)脈環(huán)的情況不適合行經(jīng)橈動(dòng)脈冠狀動(dòng)脈造影，但有經(jīng)驗(yàn)的術(shù)者能通過調(diào)整超滑導(dǎo)絲通過橈動(dòng)脈環(huán)，然而可能誘發(fā)血管痙攣及疼痛[3,4]。本研究通過應(yīng)用PTCA導(dǎo)絲協(xié)助完成冠脈造影成功率為92%，高于目前報(bào)道的27.3%～65%[3,5]，僅1例PTCA導(dǎo)絲無法拉直橈動(dòng)脈環(huán)，且造影導(dǎo)管無法通過橈動(dòng)脈環(huán)，經(jīng)患者知情同意改為股動(dòng)脈入路完成冠脈造影。

發(fā)現(xiàn)橈動(dòng)脈環(huán)后繼續(xù)嘗試橈動(dòng)脈途徑缺點(diǎn)在于：通過對照發(fā)現(xiàn)PTCA導(dǎo)絲組操作時(shí)間較改股動(dòng)脈組增加32%左右，放射線劑量增加20%左右，因需要在透視下通過操控PTCA導(dǎo)絲通過橈動(dòng)脈環(huán)并拉直血管，推送造影導(dǎo)管通過拉直的橈動(dòng)脈環(huán)，到達(dá)肱動(dòng)脈后則交換超滑導(dǎo)絲繼續(xù)完成冠狀動(dòng)脈造影，因此操作時(shí)間與受放射線照射量會(huì)有一定程度增加。

改用PTCA導(dǎo)絲相對增加醫(yī)療費(fèi)用，但改用股動(dòng)脈入路需要更換股動(dòng)脈鞘管及JL、JR造影導(dǎo)管，股動(dòng)脈止血器等，同樣會(huì)增加醫(yī)療費(fèi)用。橈動(dòng)脈環(huán)比例在1.1%～2.3%[3,5,6]，如果不經(jīng)過橈動(dòng)脈造影常規(guī)體格檢查很難提前發(fā)現(xiàn)橈動(dòng)脈環(huán)。冠狀動(dòng)脈造影術(shù)前行橈動(dòng)脈超聲可以測量橈動(dòng)脈管徑，發(fā)現(xiàn)橈動(dòng)脈環(huán)及其他解剖學(xué)變異[7-9]。但由于橈動(dòng)脈環(huán)比例不高，而且行橈動(dòng)脈超聲檢查再次增加醫(yī)療費(fèi)用，應(yīng)用本方法完成冠狀動(dòng)脈造影操作成功率明顯提高，是否術(shù)前常規(guī)進(jìn)行橈動(dòng)脈超聲檢查需要進(jìn)一步探討。

本研究中應(yīng)用PTCA導(dǎo)絲大部分能夠通過橈動(dòng)脈環(huán)完成冠狀動(dòng)脈造影，操作時(shí)間PTCA導(dǎo)絲組長于改股動(dòng)脈組，放射線量PTCA導(dǎo)絲組高于改股動(dòng)脈組，但操作成功率無統(tǒng)計(jì)學(xué)差異，證明該方法是可行的。

此前國內(nèi)外均有報(bào)道應(yīng)用PTCA導(dǎo)絲輔助通過橈動(dòng)脈環(huán)完成經(jīng)橈動(dòng)脈冠狀動(dòng)脈造影，但例數(shù)不多，且成功率偏低，未進(jìn)行隨機(jī)對照比較[3,5,7]。本研究將發(fā)現(xiàn)的52例橈動(dòng)脈環(huán)患者隨機(jī)分為兩組進(jìn)行基本資料及研究數(shù)據(jù)對照，系統(tǒng)分析了PTCA導(dǎo)絲輔助完成經(jīng)橈動(dòng)脈冠狀動(dòng)脈造影的優(yōu)勢及缺點(diǎn)，認(rèn)為遇到不宜穿刺股動(dòng)脈患者如股動(dòng)脈閉塞或嚴(yán)重紆曲、較肥胖、合并腰骶部疾病、穿刺股動(dòng)脈出血風(fēng)險(xiǎn)較大的患者改用PTCA導(dǎo)絲可以順利完成冠狀動(dòng)脈造影。但樣本量較小，需今后多中心大樣本量研究。

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(2013-12-24收稿 2014-02-19修回)

(責(zé)任編輯 梁秋野)

Radioulnarloopanditsinfluenceontransradialcoronaryangiography

WANG Lei, LIU Huiliang, MA Dongxing, LUO Jianping, Han Wei, LIU Ying, and YANG Shengli. Department of Cardiology, General Hospital of Chinese People’s Armed Police Forces, Beijing 100039, China

ObjectiveTo study the feasibility of the transradial approach for coronary angiography using PTCA guidewire through the radioulnar loop.MethodsFrom January to December in 2012，a total of 2600 patients undergoing transradial coronary angiography were recruited.Retrogarde radial arteriography was performed when hydrophilic wire could not cross the radial artery, if we found radioulnar loop ,we randomized the patients into two groups,one group try to cross the radioulnar loop with PTCA guidewire,another group revert to transfemoral approach. Patient demographics，procedure duration, amount of contrast media usage, and dose area product(DAP) were recorded.Resultsradioulnar loops were noted in 52 patients(2 %),the success rate was notsignificantly different, procedue duration was longer in PTCA guidewire group, DAP was higher in PTCA guidewire group, the amount of contrast media usage and vascular complication rate was not significant.ConclusionsAlthough radioulnar loop prolongs the procedure duration and increases DAP, the success rate is nonsignifican.

radioulnar loop; coronary angiography; percutaneous transluminal coronary angioplasty guidewire

王 磊，碩士，主治醫(yī)師，E-mail: ngqdfl@163.com

100039北京，武警總醫(yī)院心內(nèi)科

馬東星，E-mail: madongxing2004@126.com

R541.4