本文關(guān)鍵詞：高危出血患者經(jīng)橈動(dòng)脈冠狀動(dòng)脈介入術(shù)后延遲拔除動(dòng)脈鞘管對(duì)前壁并發(fā)癥的影響　出處：《河北醫(yī)科大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 出血 橈動(dòng)脈 冠狀動(dòng)脈介入 動(dòng)脈鞘管 穿刺點(diǎn)并發(fā)癥

【摘要】：目的:探討高危出血患者經(jīng)橈動(dòng)脈入徑冠狀動(dòng)脈介入術(shù)后延遲拔除動(dòng)脈鞘管對(duì)穿刺點(diǎn)并發(fā)癥的影響。方法:選取2013年12月至2014年12月在河北醫(yī)科大學(xué)第二醫(yī)院心內(nèi)五科因冠心病接受經(jīng)橈動(dòng)脈入徑冠狀動(dòng)脈介入診斷和治療,且CRUSADE評(píng)分大于31分的連續(xù)病例。所有患者改良Allen’s試驗(yàn)正常。排除標(biāo)準(zhǔn):(1)造影劑、肝素使用禁忌;(2)嚴(yán)重肝腎功能衰竭;(3)心原性休克及心肌梗死后并發(fā)心臟破裂、乳頭肌斷裂;(4)嚴(yán)重的心臟瓣膜病;(5)惡性腫瘤及嚴(yán)重的其他系統(tǒng)疾病;(6)前臂畸形、外傷史及手術(shù)史;(7)雷諾氏病;(8)冠狀動(dòng)脈介入術(shù)后維持普通肝素泵入;(9)未簽署手術(shù)知情同意書(shū)。入選患者隨機(jī)分為術(shù)后立即拔除鞘管組(immediately remove sheath group IRS)和術(shù)后延遲拔除鞘管組(delay remove sheath group DRS)。所有患者術(shù)前給予常規(guī)藥物治療。所有患者均選擇橈動(dòng)脈入徑,穿刺成功后均置入6F動(dòng)脈鞘管,鞘管置入后給予肝素3000U,硝酸甘油200ug,冠狀動(dòng)脈造影使用4F造影導(dǎo)管,需置入支架的患者補(bǔ)充肝素至100U/kg,手術(shù)時(shí)間每超過(guò)1小時(shí),追加肝素2000-3000U,并監(jiān)測(cè)活化凝血時(shí)間(activated coagulation time ACT),ACT維持在250-300s。介入術(shù)中使用器械如指引導(dǎo)管、導(dǎo)絲、球囊、支架等,由術(shù)者根據(jù)患者病情決定。術(shù)中記錄患者的穿刺次數(shù)、介入手術(shù)操作總時(shí)間、PCI治療的比例、指引導(dǎo)管型號(hào)、置入支架數(shù)量。IRS組于手術(shù)完成時(shí),導(dǎo)管撤出動(dòng)脈鞘管后立即拔除動(dòng)脈鞘管,并加壓包扎約6小時(shí);DRS組于手術(shù)完成后,導(dǎo)管撤出動(dòng)脈鞘管時(shí)開(kāi)始計(jì)算,2小時(shí)后拔除動(dòng)脈鞘管,并加壓包扎約4小時(shí)。術(shù)后記錄患者穿刺點(diǎn)并發(fā)癥,并于術(shù)后第3天和第30天行前臂動(dòng)脈超聲多普勒檢查,明確患者橈動(dòng)脈穿刺后情況。隨訪患者術(shù)后1個(gè)月內(nèi)的主要不良心血管事件(major adverse cardiac events MACEs)發(fā)生率。應(yīng)用Logistic回歸分析,探討患者穿刺點(diǎn)血腫的獨(dú)立危險(xiǎn)因素。所有數(shù)據(jù)使用SPSS 20.0統(tǒng)計(jì)分析軟件進(jìn)行統(tǒng)計(jì)學(xué)分析。P0.05有統(tǒng)計(jì)學(xué)差異。結(jié)果:1本研究共入選病例數(shù)82例,分為IRS組40例,DRS組42例。兩組患者性別、年齡、收縮壓、舒張壓、心率、體重指數(shù)(BMI)、糖尿病史、吸煙史、飲酒史、既往血管疾病史、心肌梗死病史、疾病類型、左室射血分?jǐn)?shù)、紅細(xì)胞計(jì)數(shù)、血紅蛋白含量、紅細(xì)胞壓積、血小板計(jì)數(shù)、活化部分凝血活酶時(shí)間、血肌酐、藥物使用情況、橈動(dòng)脈直徑無(wú)顯著性差異(ALL P0.05)。2兩組患者橈動(dòng)脈穿刺次數(shù)、介入手術(shù)操作總時(shí)間、PCI治療的比例、6F指引導(dǎo)管使用率、7F指引導(dǎo)管使用率、置入支架的數(shù)量無(wú)顯著性差異(ALL P0.05)。3與IRS組相比,DRS組穿刺點(diǎn)血腫的發(fā)生率更低(2例vs.8例,P=0.046)。IRS組有1例患者發(fā)生神經(jīng)損傷,DRS組未發(fā)生神經(jīng)損傷,兩組神經(jīng)損傷發(fā)生率無(wú)統(tǒng)計(jì)學(xué)差異(P0.05)。術(shù)后第3天行前臂動(dòng)脈超聲多普勒檢查,兩組患者橈動(dòng)脈狹窄、橈動(dòng)脈閉塞、假性動(dòng)脈瘤、動(dòng)靜脈瘺發(fā)生率無(wú)顯著性差異(ALL P0.05)。術(shù)后第30天對(duì)患者復(fù)查前臂動(dòng)脈超聲,IRS組復(fù)查人數(shù)34人(85%),DRS組復(fù)查人數(shù)37人(88.10%),兩組接受復(fù)查人數(shù)比較無(wú)統(tǒng)計(jì)學(xué)差異。兩組間橈動(dòng)脈狹窄、橈動(dòng)脈閉塞、假性動(dòng)脈瘤、動(dòng)靜脈瘺發(fā)生率無(wú)顯著性差異(ALL P0.05)。4隨訪術(shù)后30天MACEs發(fā)生率,兩組均未出現(xiàn)患者死亡。IRS組發(fā)生非致命性心肌梗死2例(5.0%),DRS組發(fā)生非致命性心肌梗死2例(4.76%),兩組比較無(wú)統(tǒng)計(jì)學(xué)差異。IRS組無(wú)MACEs患者38例(95%),DRS組無(wú)MACEs患者40例(95.24%),兩組比較無(wú)統(tǒng)計(jì)學(xué)差異。5將本研究中所有患者根據(jù)是否發(fā)生穿刺點(diǎn)血腫,分為穿刺點(diǎn)無(wú)血腫組72例和穿刺點(diǎn)血腫組10例。兩組性別、體重指數(shù)、7F指引導(dǎo)管使用率無(wú)顯著性差異(ALL P0.05)。與穿刺點(diǎn)無(wú)血腫組相比,穿刺點(diǎn)血腫組應(yīng)用替羅非班的比例更高(60%vs.9.72%,P=0.001),穿刺次數(shù)更多(3 vs.1,P=0.000),接受PCI治療比例更高(100%vs.55.56%,P=0.005),操作總時(shí)間更長(zhǎng)(106.00±31.43min vs.40.90±22.33min,P=0.000)。多因素Logistic回歸分析顯示:應(yīng)用替羅非班(OR=27.537,95%CI:1.020~743.43,P=0.049),穿刺次數(shù)過(guò)多(OR=5.554,95%CI:1.154~26.730,P=0.032)及操作時(shí)間過(guò)長(zhǎng)(OR=56.146,95%CI:1.284~2454.397,P=0.037)是穿刺點(diǎn)血腫發(fā)生的獨(dú)立危險(xiǎn)因素。結(jié)論:1高危出血患者經(jīng)橈動(dòng)脈入徑行冠狀動(dòng)脈介入診斷或治療,術(shù)后延遲拔除動(dòng)脈鞘管可以預(yù)防穿刺點(diǎn)血腫,并且不增加橈動(dòng)脈狹窄、橈動(dòng)脈閉塞、神經(jīng)損傷、假性動(dòng)脈瘤及動(dòng)靜脈瘺等穿刺點(diǎn)并發(fā)癥的發(fā)生率。2高危出血患者經(jīng)橈動(dòng)脈入徑行冠狀動(dòng)脈介入診斷或治療,術(shù)中穿刺次數(shù)多、手術(shù)時(shí)間長(zhǎng)及應(yīng)用替羅非班更易發(fā)生穿刺點(diǎn)血腫,建議術(shù)后延遲拔除動(dòng)脈鞘管以預(yù)防穿刺點(diǎn)血腫的發(fā)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.

【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R541.4

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本文編號(hào)：1362846