不同入路冠狀動(dòng)脈介入治療術(shù)圍手術(shù)期周圍血管并發(fā)癥發(fā)生率的對(duì)比

張樹清，崔 磊，祁榮興，SANJEEV KUMAR P S，黃 勝，葛 莉，錢 澄

1. 南通大學(xué)第二附屬醫(yī)院心導(dǎo)管室，南通 226001 2. 南通大學(xué)第二附屬醫(yī)院影像科，南通 226001 3. PAREXEL國(guó)際公司醫(yī)學(xué)影像科，Waltham 02451 4. 南通大學(xué)第二附屬醫(yī)院圖書館，南通 226001

·短篇論著·

不同入路冠狀動(dòng)脈介入治療術(shù)圍手術(shù)期周圍血管并發(fā)癥發(fā)生率的對(duì)比

張樹清1，崔 磊2*，祁榮興2，SANJEEV KUMAR P S3，黃 勝2，葛 莉4，錢 澄4

1. 南通大學(xué)第二附屬醫(yī)院心導(dǎo)管室，南通 226001 2. 南通大學(xué)第二附屬醫(yī)院影像科，南通 226001 3. PAREXEL國(guó)際公司醫(yī)學(xué)影像科，Waltham 02451 4. 南通大學(xué)第二附屬醫(yī)院圖書館，南通 226001

目的比較經(jīng)股動(dòng)脈和橈動(dòng)脈入路冠狀動(dòng)脈介入治療(percutaneous coronary intervention, PCI)術(shù)中周圍血管并發(fā)癥的發(fā)生率，為其臨床診治提供參考。方法分析2014年7月至2016年12月在我院心血管介入治療中心進(jìn)行冠狀動(dòng)脈造影及介入治療的780例患者的臨床資料，比較周圍血管并發(fā)癥發(fā)生情況。結(jié)果經(jīng)股動(dòng)脈途徑471例，經(jīng)橈動(dòng)脈途徑309例。經(jīng)股動(dòng)脈途徑總體并發(fā)癥發(fā)生率13.2%，高于經(jīng)橈動(dòng)脈途徑的4.5%，差異有統(tǒng)計(jì)學(xué)意義(P<0.001)。經(jīng)股動(dòng)脈途徑出血并發(fā)癥發(fā)生率為7.9%，高于經(jīng)橈動(dòng)脈途徑2.6%，差異有統(tǒng)計(jì)學(xué)意義(P=0.002)。經(jīng)股動(dòng)脈途徑患者重大并發(fā)癥(后腹膜血腫、假性動(dòng)脈瘤、動(dòng)靜脈瘺、動(dòng)脈夾層形成)發(fā)生率高于經(jīng)橈動(dòng)脈途徑(2.1%vs0%)，但差異無統(tǒng)計(jì)學(xué)意義。結(jié)論經(jīng)股動(dòng)脈途徑冠狀動(dòng)脈介入治療術(shù)圍手術(shù)期周圍血管并發(fā)癥發(fā)生率高于經(jīng)橈動(dòng)脈途徑，臨床入路選擇時(shí)需綜合考慮。

經(jīng)皮冠狀動(dòng)脈介入治療；并發(fā)癥；手術(shù)入路

隨著醫(yī)療技術(shù)的進(jìn)步及醫(yī)用設(shè)備材料的發(fā)展，經(jīng)皮冠狀動(dòng)脈介入手術(shù)(percutaneous coronary intervention, PCI)安全性、有效性不斷提高，已經(jīng)成為冠心病患者較好的治療選擇，手術(shù)入路的選擇也更加積極，但手術(shù)操作的復(fù)雜程度也在不斷增加，其中周圍血管相關(guān)并發(fā)癥尤其明顯[1-3]。因此，本研究對(duì)我院2014年7月至2016年12月冠狀動(dòng)脈介入診療術(shù)圍術(shù)期周圍血管相關(guān)并發(fā)癥進(jìn)行總結(jié)，為其臨床防治提供參考。

1 資料與方法

1.1 一般資料 對(duì)2014年7月至2016年12月在我院心血管介入治療中心進(jìn)行冠狀動(dòng)脈介入治療的患者所有資料進(jìn)行分析。對(duì)于每例病例，介入醫(yī)師手術(shù)完畢后均詳細(xì)填寫冠狀動(dòng)脈造影記錄，包括患者的基本情況、手術(shù)過程、造影結(jié)果、并發(fā)癥發(fā)生情況等。

1.2 常規(guī)冠狀動(dòng)脈造影檢查和介入操作 采用Siemens公司冠狀動(dòng)脈造影設(shè)備(Angiopalsy 9800)，以改良Seldinger法穿刺右橈動(dòng)脈或右股動(dòng)脈分別進(jìn)行左、右冠狀動(dòng)脈造影，對(duì)比劑為歐乃派克(Omnipaque 350 mgI/mL，GE Healthcare)。動(dòng)脈穿刺成功后即刻經(jīng)動(dòng)脈鞘管注射肝素3 000 IU，手術(shù)結(jié)束時(shí)立即拔動(dòng)脈鞘管。

1.3 統(tǒng)計(jì)學(xué)處理 采用SPSS 16.0軟件，經(jīng)股動(dòng)脈途徑和經(jīng)橈動(dòng)脈途徑周圍血管并發(fā)癥發(fā)生率的比較采用χ2檢驗(yàn)。檢驗(yàn)水準(zhǔn)(α)為0.05。

2 結(jié) 果

2.1 基線資料的對(duì)比 共780例患者納入本研究，其中男性521例，女性259例，年齡39～82歲，平均(58.1±11.4)歲。單純冠狀動(dòng)脈造影392例，經(jīng)皮冠狀動(dòng)脈介入治療388例。經(jīng)股動(dòng)脈途徑471例，經(jīng)橈動(dòng)脈途徑309例。經(jīng)股動(dòng)脈途徑男性335例(71.1%)，平均(59.7±12.1)歲；經(jīng)橈動(dòng)脈途徑男性229例(74.1%)，平均(57.6±10.2)歲，2組間性別、年齡差異無統(tǒng)計(jì)學(xué)意義，具有可比性。

2.2 周圍血管并發(fā)癥類型及發(fā)生率的對(duì)比 結(jié)果(表1)表明：經(jīng)股動(dòng)脈途徑的總體并發(fā)癥發(fā)生率為13.2%，顯著高于經(jīng)橈動(dòng)脈途徑的4.5%，差異有統(tǒng)計(jì)學(xué)意義(P<0.001)；經(jīng)股動(dòng)脈途徑出血并發(fā)癥發(fā)生率為7.9%，顯著高于經(jīng)橈動(dòng)脈途徑的2.6%，差異有統(tǒng)計(jì)學(xué)意義(P=0.002)；經(jīng)股動(dòng)脈途徑患者重大并發(fā)癥(后腹膜血腫、假性動(dòng)脈瘤、動(dòng)靜脈瘺、動(dòng)脈夾層形成)發(fā)生率高于經(jīng)橈動(dòng)脈途徑(2.1%vs0%)，但差異無統(tǒng)計(jì)學(xué)意義。

表1 不同手術(shù)入路冠狀動(dòng)脈造影及介入術(shù)周圍血管并發(fā)癥的比較 n(%)

3 討 論

3.1 經(jīng)股動(dòng)脈途徑PCI并發(fā)癥

3.1.1 出血 穿刺部位出血是股動(dòng)脈徑路最常見的并發(fā)癥，本研究病例發(fā)生率為7.9%。文獻(xiàn)[1-4]報(bào)道PCI術(shù)后需要輸血的比例為1.8%～6.5%。出血的危險(xiǎn)因素包括：女性、高血壓、套鞘時(shí)間過長(zhǎng)(prolonged in-dwelling sheath time)、套管直徑大、老年人、低體質(zhì)量、肥胖、肝素劑量過大和使用血栓溶解劑[4]。有研究[5]認(rèn)為套管直徑6 Fr的出血并發(fā)癥少于7/8 Fr(13.8%vs23.5%，P<0.01)。但也有研究[6]認(rèn)為兩者并無差異。術(shù)后停用肝素有助于減少出血并發(fā)癥而對(duì)心臟無不利影響[7]。同樣，早期去除套鞘也能減少出血。

血腫表現(xiàn)為穿刺部位出現(xiàn)腫塊或飽滿。然而，肥胖患者血腫有時(shí)難以發(fā)現(xiàn)。出血的處理方式取決于出血嚴(yán)重性和出血后血液動(dòng)力學(xué)的改變。通常穿刺部位出血可以通過手工或機(jī)械壓迫、抗凝劑使用而被控制。如果上述步驟無效，則要考慮更積極的治療方法，如經(jīng)皮介入或外科手術(shù)。本組病例中有3例施行經(jīng)皮介入止血。

3.1.2 后腹膜血腫 文獻(xiàn)[8-9]報(bào)道介入操作引起后腹膜血腫的發(fā)生率為0.12%～0.44%。本研究病例發(fā)生率為0.4%。后腹膜血腫發(fā)生與穿刺部位過高(位于腹股溝韌帶以上)和刺破血管后壁有關(guān)[9]。熟悉股血管和腹股溝解剖有助于減少后腹膜血腫發(fā)生危險(xiǎn)。

后腹膜出血的癥狀和體征包括：血壓降低、腹脹和腹痛[9]。診斷需要依靠腹盆部CT或超聲。一旦懷疑后腹膜出血，抗凝劑必須停用。若有血容量不足癥狀，必須補(bǔ)充晶體溶液或血液制品以恢復(fù)血容量。若出血引起血流動(dòng)力學(xué)障礙，建議通過對(duì)側(cè)股動(dòng)脈的緊急血管造影明確出血部位。一旦出血點(diǎn)確定，可采用血管成形術(shù)球囊栓塞。若出血仍不能控制，可考慮放置血管覆膜支架或外科修補(bǔ)。

3.1.3 假性動(dòng)脈瘤 當(dāng)血腫持續(xù)并與動(dòng)脈壁溝通將形成假性動(dòng)脈瘤。PCI術(shù)后常規(guī)行超聲探測(cè)可發(fā)現(xiàn)假性動(dòng)脈瘤發(fā)生率高達(dá)6%，而出現(xiàn)癥狀后超聲探測(cè)發(fā)生率僅3%[10]。本研究病例發(fā)生率為 0.8%。假性動(dòng)脈瘤發(fā)生與進(jìn)針過低有關(guān)[11]。其余危險(xiǎn)因素包括女性、年齡大于70歲、糖尿病和肥胖[12]。

假性動(dòng)脈瘤表現(xiàn)為術(shù)后數(shù)天穿刺部位持續(xù)疼痛、伴有收縮期雜音的搏動(dòng)性血腫。股動(dòng)脈假性動(dòng)脈瘤的處理取決于其大小、癥狀嚴(yán)重程度及是否需要持續(xù)抗凝。直徑小于2 cm的假性動(dòng)脈瘤可以觀察隨訪，多數(shù)可自發(fā)吸收。較大假性動(dòng)脈瘤需要超聲引導(dǎo)下壓迫、經(jīng)皮凝血膠原注射、血管內(nèi)彈簧圈或覆膜支架放置。手術(shù)修補(bǔ)是最后手段。

3.1.4 動(dòng)靜脈瘺(arteriovenous fistulae, AVF) 當(dāng)穿刺針貫穿股動(dòng)脈和股靜脈，在套鞘撤出后形成AVF。導(dǎo)管介入術(shù)后AVF的發(fā)生率約為 0.4%[13]。本研究病例發(fā)生2例(0.4%)。AVF發(fā)生與穿刺過高或過低、多次穿刺和凝血時(shí)間延長(zhǎng)有關(guān)[12]。瘺道可以在手術(shù)后數(shù)天沒有臨床表現(xiàn)。臨床上，AVF表現(xiàn)為穿刺部位持續(xù)性往返性雜音。一些病例由于靜脈擴(kuò)張表現(xiàn)為下肢腫脹和觸痛，嚴(yán)重者可表現(xiàn)為動(dòng)脈血供不足(Steal綜合征)[14]。AVF確診依靠彩色多普勒超聲檢查。

多數(shù)PCI操作術(shù)后AVF較小，沒有明顯血液動(dòng)力學(xué)改變，能自發(fā)閉合[15]。有癥狀的AVF需要及時(shí)閉合以免分流增加致遠(yuǎn)端肢體腫脹和觸痛。文獻(xiàn)[14-16]報(bào)道，一些患者通過超聲引導(dǎo)下壓迫和瘺口動(dòng)脈側(cè)覆膜支架置入治愈。覆膜支架的一個(gè)顯著不足是有12%～17%的支架內(nèi)血栓形成[16]。經(jīng)皮彈簧圈栓塞也治愈了少數(shù)患者，但經(jīng)驗(yàn)有限。手術(shù)閉合AVF是傳統(tǒng)方法，用于介入方法失敗時(shí)。

3.1.5 肢體缺血 與穿刺相關(guān)的股動(dòng)脈或下肢動(dòng)脈血栓形成并不常見，文獻(xiàn)[17]報(bào)道發(fā)生率低于1%，本研究病例發(fā)生率為1.3%。危險(xiǎn)因素包括：與相對(duì)較小的動(dòng)脈不匹配的較大型號(hào)導(dǎo)管或套鞘、周圍血管疾病、老年人、心肌病、高凝狀態(tài)。

急性下肢缺血的典型癥狀和特征即所謂的“5P”，包括：疼痛(pain)、蒼白(pallor)、感覺異常(paresthesia)、無脈(pulseless)和發(fā)冷(polar cold)。缺血的診斷依靠體檢，確診依靠多普勒超聲檢查。急性下肢缺血需行血管造影了解缺血的解剖情況。治療方法包括球囊擴(kuò)張血管成形術(shù)(可同時(shí)應(yīng)用溶栓治療)、支架置入或經(jīng)導(dǎo)管血栓切除。手術(shù)切除血栓和修補(bǔ)應(yīng)用于介入方法失敗時(shí)[17]。

3.1.6 動(dòng)脈夾層形成 PCI所致醫(yī)源性股動(dòng)脈或髂動(dòng)脈夾層發(fā)生率為0.01%～0.4%[18]，本研究病例發(fā)生率為0.4%。動(dòng)脈夾層會(huì)導(dǎo)致遠(yuǎn)端肢體缺血進(jìn)展、假性動(dòng)脈瘤或血栓形成。動(dòng)脈夾層的診斷需要?jiǎng)用}造影，同時(shí)明確夾層范圍。治療方法包括球囊擴(kuò)張血管成形術(shù)、血管內(nèi)支架放置或外科修補(bǔ)。

3.1.7 感染 穿刺部位局限性感染發(fā)生率低于1%[19]，本研究病例發(fā)生9例(1.9%)。最常見病原體是金黃色葡萄球菌和表皮葡萄球菌。感染表現(xiàn)為術(shù)后1 h內(nèi)出現(xiàn)發(fā)熱、寒戰(zhàn)和嗜睡等。

3.2 上肢徑路并發(fā)癥及其與經(jīng)股動(dòng)脈途徑的比較

3.2.1 橈動(dòng)脈途徑 由于橈動(dòng)脈表淺易于壓迫止血、患者術(shù)后即刻能下床活動(dòng)，經(jīng)橈動(dòng)脈PCI近年來廣受歡迎。Kiemeneij等[20]報(bào)道經(jīng)皮冠狀動(dòng)脈腔內(nèi)成形術(shù)(percutaneous transluminal coronary angioplasty, PTCA)經(jīng)橈動(dòng)脈、肱動(dòng)脈和股動(dòng)脈的成功率分別為93%、95.7%和99.7%。一項(xiàng)研究[20]表明：經(jīng)肱動(dòng)脈和股動(dòng)脈PTCA的穿刺部位重大并發(fā)癥發(fā)生率相仿(2.3%和2.0%)，而經(jīng)橈動(dòng)脈PTCA幾乎沒有穿刺部位重大并發(fā)癥發(fā)生。盡管橈動(dòng)脈較細(xì)，使用6/7 Fr的套鞘經(jīng)橈動(dòng)脈行PTCA仍是可行的。一項(xiàng)比較研究[21]表明：經(jīng)橈動(dòng)脈PTCA無明顯穿刺部位出血，而經(jīng)股動(dòng)脈PTCA的發(fā)生率為 7.4%(P<0.04)。

本研究病例顯示，經(jīng)橈動(dòng)脈途徑的重大并發(fā)癥(后腹膜血腫、假性動(dòng)脈瘤、動(dòng)靜脈瘺、動(dòng)脈夾層)發(fā)生率為0%；而且經(jīng)橈動(dòng)脈的總體并發(fā)癥和出血的發(fā)生率均低于經(jīng)股動(dòng)脈途徑(P<0.05)。這也是本院近年來經(jīng)橈動(dòng)脈操作逐漸多于經(jīng)股動(dòng)脈操作的重要原因之一。但是，橈動(dòng)脈為冠狀動(dòng)脈旁路移植血管和慢性腎功能不全透析備用血管、患有血栓閉塞性動(dòng)脈炎(Buerger’s病)或嚴(yán)重雷諾綜合征的患者不宜進(jìn)行橈動(dòng)脈穿刺術(shù)；對(duì)于PCI中的復(fù)雜病變、需要7 Fr以上動(dòng)脈鞘管、多次更換導(dǎo)管、對(duì)吻球囊技術(shù)、旋磨、旋切術(shù)等的使用可能受到限制。此外，Allen試驗(yàn)陰性是絕對(duì)禁忌證[4]。經(jīng)橈動(dòng)脈入路的不利之處在于較高的穿刺失敗率和不能使用較大直徑的套鞘操作。

3.2.2 經(jīng)肱動(dòng)脈途徑 經(jīng)肱動(dòng)脈途徑與穿刺部位相關(guān)的血栓形成發(fā)生率較高，約為經(jīng)股動(dòng)脈途徑的4倍(0.96%vs0.22%，P<0.001)[17]。經(jīng)肱動(dòng)脈途徑最常見的并發(fā)癥為出血、血栓形成、假性動(dòng)脈瘤和臂叢神經(jīng)壓迫。相對(duì)于經(jīng)股動(dòng)脈途徑，經(jīng)肱動(dòng)脈途徑的血栓形成發(fā)生率高于出血。若經(jīng)肱動(dòng)脈套管插入術(shù)后發(fā)生無脈或其他缺血癥狀提示血栓形成時(shí)，建議行局部溶栓或?qū)Ч軆?nèi)血栓切除術(shù)。若為內(nèi)膜移位或夾層，建議行血管成形術(shù)或支架放置。手術(shù)修補(bǔ)應(yīng)用于介入方法無效時(shí)。本院未采用經(jīng)肱動(dòng)脈途徑。

綜上所述，經(jīng)股動(dòng)脈和橈動(dòng)脈途徑冠狀動(dòng)脈介入治療的周圍血管并發(fā)癥發(fā)生率有差異，選擇時(shí)應(yīng)結(jié)合病情慎重考慮。

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Comparison of peripheral vascular complication rates during percutaneous coronary intervention through different approaches

ZHANG Shu-qing1, CUI Lei2*, QI Rong-xing2, SANJEEV KUMAR P S3, HUANG Sheng2, GE Li4, QIAN Cheng4

1. Cardiac Catheterization Laboratory, the Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu, China 2. Department of Radiology, the Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu, China 3. Medical Imaging Service of PAREXEL International Corporation, Waltham, MA 02451, USA 4. Library of the Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu, China

Objective： To compare the incidence of peripheral vascular complications during percutaneous coronary intervention (PCI) through femoral artery and radial artery, and to provide reference for clinical diagnosis and treatment.MethodsThe clinical data of 780 patients who underwent coronary angiography and interventional therapy in Cardiovascular Center of Nantong First People’s Hospital from July 2014 to December 2016 were analyzed, and the incidence of peripheral vascular complications was compared.ResultsThere were 471 cases through femoral artery and 309 through radial artery. The overall complication rate of femoral artery approach was 13.2%, which was higher than that of radial artery approach (4.5%), and the difference was statistically significant (P<0.001). The bleeding rate of femoral artery approach was 7.9%, which was higher than that of radial artery approach (2.6%), and the difference was statistically significant (P=0.002). The incidence of major complications (retroperitoneal hematoma, pseudoaneurysm, arteriovenous fistula, and artery dissection) of femoral artery approach was higher than those of radial artery approach (2.1%vs0%), but the difference was not statistically significant.ConclusionsThe incidence of peripheral vascular complications during PCI of femoral artery approach is higher than those of radial artery approach, and the approach should be considered comprehensively in clinical practice.

percutaneous coronary intervention; complication; surgical approach

2017-07-13接受日期2017-09-01

南通市社會(huì)事業(yè)科技創(chuàng)新與示范計(jì)劃(HS2014066). Supported by Science and Technology Innovation and Demonstration Project of Nantong Social Programs in 2014 (HS2014066).

張樹清，副主任技師. E-mail: ntyyzsq@163.com

*通信作者(Corresponding author). Tel: 0513-85061070, E-mail: cuigeleili@126.com

10.12025/j.issn.1008-6358.2017.20170584

R 815

A

[本文編輯] 廖曉瑜， 賈澤軍