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目的探讨经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)术中并发冠状动脉穿孔(coronary artery perforation,CAP)的原因、临床表现、处理策略和院内转归。方法对上海交通大学附属第一人民医院2003年1月至2007年12月发生CAP的病例资料进行回顾性分析。结果 3312例PCI患者中有26例(0.8%)患者共发生27处CAP,其中指引导管引起的穿孔2例,导丝导致的穿孔15例(16处),支架术后的穿孔9例。16处导丝导致的CAP中,慢性完全闭塞病变12处,急性或近期闭塞病变3处,非闭塞病变1处。导丝导致的4例心脏压塞均为迟发性,最长者距离手术结束时间为46 h。9例支架术后的穿孔中,4例发生心脏压塞。本组资料共有9例发生心脏压塞,均进行心包穿刺引流,6例内科保守治疗治愈,3例行外科急诊修补术并冠状动脉旁路移植术,其中2例术后死亡。结论 CAP是PCI少见的并发症,导丝引起的CAP可导致迟发性心脏压塞甚至死亡。支架术后穿孔绝大部分在PCI术中即可发现,置入覆膜支架可能为首选措施。及时发现和正确处理是降低CAP死亡率的关键。
Objective To investigate the causes, clinical manifestations, treatment strategies and hospital outcomes of percutaneous coronary intervention (PCI) during coronary artery perforation (CAP). Methods A retrospective analysis was performed on the CAP data of the First People’s Hospital Affiliated to Shanghai Jiaotong University from January 2003 to December 2007. Results A total of 27 CAPs were observed in 26 out of 3312 PCI patients (0.8%). Among them, there were 27 cases of guiding catheter-induced perforation, 15 cases of perforation caused by guide wire and 16 cases of perforation after stenting. In 16 CAP-induced CAPs, there were 12 chronic occlusive lesions, 3 acute or recent occlusive lesions, and 1 non-occlusive lesion. 4 cases of cardiac tamponade caused by guide wire were delayed, the longest distance from the end of surgery was 46 h. In 9 cases of perforation of the stent, 4 cases of cardiac tamponade occurred. A total of 9 cases of this group of patients with cardiac tamponade were pericardial drainage, conservative treatment of 6 cases cured, 3 cases of emergency surgical repair and coronary artery bypass grafting, of which 2 patients died. Conclusions CAP is a rare complication of PCI. The guidewire-induced CAP can lead to delayed cardiac tamponade and even death. Perforation of the vast majority of stents in the PCI can be found, the placement of stent-graft may be the preferred measure. Timely detection and correct treatment is the key to reducing CAP mortality.