急诊pci的特殊问题罪犯血管的罪犯病变和非罪犯病变

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1、急诊PCI的特殊问题——罪犯血管的罪犯病变和非罪犯病变信栓力博士主任医师15630050688http://www.hdxzw.comxinkexuan@163.comCasebaselinedataMV-PCI:罪犯血管和非罪犯血管—因支施救：除非有血流动力学紊乱并且非罪犯病变狭窄大于90%时，一般只处理罪犯病变。韩雅玲教授的观点：在有缺血证据的前提下，在同次住院期内处理非罪犯血管。关注支中重点：罪犯血管的罪犯病变和非罪犯病变：tandem病变、多处病变急性心肌梗塞时血管容易痉挛、机体处于高凝状态Tandem病变或弥漫性长病变一个支架不能完全覆盖时，怎么办？一个和多个支架植入对预

2、后的影响是什么？瑞金医院张奇做了初步研究。当罪犯血管存在tandem病变或弥漫性长病变时，如果一个支架不能完全覆盖，建议只处理罪犯病变。且看我院的三个病例Ourhospitalcase01Overallviewsofthispuzzlepatientimage01EmergencyPCIIndicatesaostialtotalocclusionofLAD---2012.3.26Thepatient’sRCAInitialdilationoftheculpritlesionShowstheresultpostinitialdilationCranialprojectionofLAD

3、Findings:Therightproximallesionis85%stenosisThereis“normalsegment”of>5mminlengthbutmaybenotatandemlesiononthisviewTIMIflowogradedistaltoDiago1Afterdilationwecanseeasecondlesion----whoistheculprit?SomeonesuspectedthrombusinthedistallesionandthinktheculpritisrighthereWhataboutyouropinion?Forthep

4、roximallesion,whyitisnottheculpritlesion?InitialcineshowstotalocclusionSeriouslystenosisafterdilationTwoculpritlesion?Whytheproximallesionistotaloccluded?Thrombosis?Spasm?Both?Whythedistallesionalsototaloccluded?ArealCTOorsub-acutetotalocclusion?Totaloccludedbythrombusfromtheupstreamlesiononba

5、seofstenosis?Whichistheprimary?whichisthesecondary?Why?Howtocopewiththem?Whatshouldwedofornextstep?MerelyImplantedpartnerstentinthedistallesion!Right?2012.4.8selectivepci….Finalresultsafterstentimplantationon8April2012case02罪犯血管的长病变的处理PostDilatation……AvoidinglongstentimplantationFinalresultcas

6、e03InvestigationafterdilationMorecarefullyinvestigation1、Predilate2、stentposition3、implantationCopewithproximalsegmentImplantationandpostdilationFinalcineButsymptomdeveloped…Dissection?Finished思考诸如此类的病例和病变到底如何处理？是理性的考虑？医生个体经验基于患者个体的判断？还是基于循证医学的证据？如何才能兼顾医疗安全和患者安全？谢谢关注！