![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/1fb33c28399d448da1fd38e2d76d2ecd.jpg)
本期分享病例:以柔克刚,步步为营,急性心梗遇支架内闭塞合并严重钙化病变一例
分享嘉宾:同济大学附属东方医院金济福博士
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/e5e320b5d7e4404a83320c6a749bfcdf.png)
急性心肌梗死 手术刻不容缓
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患者基本情况
61岁,男性。
既往病史
主诉:“突发胸痛2小时”。
既往史:冠心病PCI术10年余;高血压、糖尿病病史。
术前检查
1.心电图示窦性心律、前壁导联ST段抬高,考虑急性心肌梗死。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/3662f53f7872499b8a77aaf5c42d6d84.png)
2.急诊冠脉造影提示前降支支架内完全闭塞伴血栓影,回旋支支架内重度狭窄,右冠重度狭窄。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/2b9c2b6eae6c409a85519256a786f3a0.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/1403205f6bef4e478ac824179761b83b.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/fb2f1c382a4c42cdbb110a7106e6d686.gif)
多支血管狭窄闭塞 风险持续升级
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病情诊断
急性心肌梗死,多支血管病变伴钙化,LAD支架内完全闭塞,LCX支架内重度狭窄,RCA重度狭窄。
手术难点
急性心肌梗死起病;
支架内急性闭塞;
多支血管严重狭窄伴钙化病变;
手术策略
1.急诊手术优先开通LAD罪犯血管;
2.择期处理LCX支架内狭窄,腔内影像学评估RCA病变情况。
步步为营 联合震波球囊稳扎稳打
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急诊手术
急诊行血栓抽吸术。首先经桡动脉置入6F EBU3.5指引导管至左冠, Runthrough NS导丝顺利通过LAD闭塞段达远段,冠脉内选择性注入铭复乐3mg,再送入Exportap抽吸导管至LAD近段处进行抽吸,抽吸出呈现条状红色血栓影,实现LAD血流再通。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/3202cba4e477407da7853d2dc657d0f3.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/ba8d6cb60fd8416194191a77ecd97eba.gif)
然后送入Sionblue导丝至LCX达远段,选择2.5×15mm NC Trek球囊于LAD近中段至近段以8-10atm×5s扩张,再送入3.0×10mm Wolverine切割球囊于支架内以8-10-12atm×5s扩张,复查造影提示LAD出现无复流。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/48b9d6b56f8d485eb54ffeadd062c52b.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/3f1b4c9ef1bb48568db8e21a9b46556f.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/f8a3985890944abdbe03ef5599829aa7.gif)
再次送入原抽吸导管于前降支近段处,冠脉内选择性注射铭复乐3mg,并反复进行血栓抽吸,然后送入Finecross微导管至LAD近中段处,通过微导管注入腺苷注射液180ug×4次,替罗非班400ug,复造影,LAD血流恢复TIMI3-级。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/a4ca7bf52a834259bc07c8c20783ca88.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/395dd4534c6b42458c3c3f0bcf2acb28.gif)
一周后复查冠脉造影发现LAD支架内见白色模糊影,经IVUS证实LAD近段支架内严重钙化斑块(钙化环>180°,钙化长度>10mm)伴内膜撕裂致假腔形成,因此决定在IVUS指导下使用震波球囊修饰钙化病变。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/8ac182564099456db384beffa8d4e9e7.jpg)
脉冲分配
根据IVUS参考血管直径,选择3.5×12mm冲击波球囊,压力泵反复负压3次,球囊充分排气后,先4atm扩张球囊,释放10次脉冲后,增加至6atm持续原位扩张10s作为一个周期,每完成2周期治疗后,再次进行负压抽吸排气。由远及近,重叠2mm,于LAD近段支架内钙化病变处进行3周期脉冲震波,共完成7个周期。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/b45297be9644455980024c61d86de701.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/a06b4854d8f74b54ab7c743ec8458622.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/95246ce8f9f644788fc25c0e8e61b55e.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/edee47801c9146ab95855f60ca07c654.gif)
复查IVUS提示血管内有碎裂钙化斑块,撕裂的钙化斑块与假腔完全贴合,管腔有效面积明显增加,达到了理想的预处理效果。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/157002780d894aa1a35ecf960b2ef8ea.png)
最终在LAD原支架的远端串联植入一枚3.0×15mm的支架,近段支架内使用3.5×30mm 的药物涂层球囊进行扩张,获得了满意的效果,准备择期(1-2个月后)再处理LCX支架内狭窄病变。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/343961e25ab7453ba86af1449d641bf8.gif)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/7fab6e8415094e5a8a57b4c3d1485067.gif)
术后影像
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/883b927195344bde9fb8ce3dd89a10f8.png)
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/f40a424089014a5e85b69a6ce422456a.gif)
化繁为简 IVL冲击严重钙化势不可挡
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金济福博士总结此病例难点为急性心肌梗死支架内完全闭塞起病,且急诊PTCA术后出现一过性无复流,经血栓抽吸、微导管给药等处理后,血流恢复。急诊造影经非顺应性球囊和切割球囊扩张后,支架内残余狭窄仍然明显,后经IVUS证实为严重钙化伴内膜撕裂致假腔形成,但使用Shockwave IVL处理后撕裂的钙化斑块与假腔完全贴合,达到了理想的处理效果。
现场评审团点评首先给出建议在急诊冠脉造影预处理效果不佳时,尽量不要直接启动震波球囊进行治疗,仍需要全面评估心脏及血管情况后谨慎使用震波球囊择期进行处理。术者在急诊手术初步进行血栓抽吸和球囊扩张的处理后,配合术后规范化药物治疗和管理,择期手术中腔内影像学指导下使用了震波球囊处理了支架内狭窄钙化斑块,取得了良好的治疗效果。
![](https://drvoicedev.oss-cn-beijing.aliyuncs.com/drvoice/server/uploadfile/2024/07/10/8ce777157d074c048590f78b50845763.jpg)
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