[ppt]-冠狀動(dòng)脈瘺介入治療

1、冠狀動(dòng)脈瘺介入治療,第二軍醫(yī)大學(xué)長(zhǎng)海醫(yī)院心內(nèi)科 趙仙先,,定 義,冠狀動(dòng)脈瘺是指冠狀動(dòng)脈未經(jīng)過(guò)毛細(xì)血管網(wǎng),而與心腔或大血管（體循環(huán)或肺循環(huán)）任一節(jié)段之間直接相相通（coronary artery fistula，CAF）,病因及發(fā)病率,先天性占先天性心臟病的0.27%～0.40%占冠狀動(dòng)脈造影患者的0.2%。其它原因心臟外科術(shù)后：瓣膜置換、CABG反復(fù)心肌活檢,病理解剖,右冠狀動(dòng)脈瘺多見(jiàn)，約為56%左冠狀動(dòng)脈瘺約為

2、35%雙冠狀動(dòng)脈瘺約為5%90%的冠脈瘺匯入靜脈系統(tǒng)中肺動(dòng)脈占17%右心室占41%右心房占26%，左室占3%上腔靜脈占1%,分 類(lèi),Sakarllbara分型I型引流入右心房Ⅱ型引流入右心室Ⅲ型引流入肺動(dòng)脈Ⅳ型引流入左心房Ⅴ型引流入左心室,病理生理,心肌缺血：冠狀動(dòng)脈舒張期灌注壓減低，瘺口遠(yuǎn)端的冠狀動(dòng)脈血流量減少（冠狀動(dòng)脈“竊血”）肺動(dòng)脈高壓心力衰竭,臨床表現(xiàn),癥狀：絕大多數(shù)患者臨床上無(wú)明顯癥狀典型或

3、不典型的心絞痛（冠狀動(dòng)脈“竊血”）充血性心力衰竭暈厥、甚至猝死（血栓形成、AMI、破裂）體征：連續(xù)性雜音或收縮期和舒張期雙期雜音肺動(dòng)脈瓣第2心音亢進(jìn)、分裂心力衰竭體 征,診斷方法,ECG：多數(shù)無(wú)特異性表現(xiàn)X-Ray：心臟擴(kuò)大、肺血增多,診斷方法,超聲心動(dòng)圖(1)累及冠狀動(dòng)脈起始段有不同程度的擴(kuò)張(2)瘺口入口所在的房室壁連續(xù)性中斷，局部呈圓形或不規(guī)則形無(wú)回聲區(qū)(3) 心腔或肺動(dòng)脈內(nèi)可見(jiàn)異常血流(4)連續(xù)多普勒所探及

4、的是以舒張期為主的連續(xù)性血流頻譜，且流速比較低。(5)心腔負(fù)荷過(guò)重的表現(xiàn),,診斷方法,多排螺旋CT,Clin Res Cardiol, 2007,96:120–121,診斷方法,Fig. 9a,b Abnormal termination. Coronary fistula from the left anterior descending artery to right ventricle with volume rendering

5、 (a)and maximum intensity projection images(b). This anomaly causes right ventriclevolume overload.,Radiol med,2007,112:1117–1131,,Fig 3. Operative photograph clearly demonstrating the bilateral coronary-to-pulmonary

6、artery fistulas and vascular malformation.(LCPAF left coronary-to-pulmonary artery fistula; RCPAF rightcoronary-to-pulmonary artery fistula; VM vascularmalformation,Fig 2. Multi-detector computed tomographic scan w

7、ith three-imensional reconstruction.The left coronary-to-pulmonary artery fistula (arrow) and (B) the right coronary-topulmonary artery fistula are comparable with the selective coronary angiography. (LAD left anterior

8、 descending coronary artery;LCPAF left coronary-to-pulmonary arteryfistula; RCPAF right coronary-to-pulmonaryartery fistula; VM vascular malformation[arrow].),Ann Thorac Surg 2006;82:1886–8),,冠狀動(dòng)脈造影,觀察冠狀動(dòng)脈分支分布和心臟結(jié)

9、構(gòu)的關(guān)系冠狀動(dòng)脈瘺的位置、最大和最小冠狀動(dòng)脈直徑瘺口的形態(tài)和位置及其累及的冠狀動(dòng)脈分支,,Fig 1. Selective coronary angiography. (A)The left coronary-to pulmonary artery fistula originates from the proximal left descendingartery and drains into the main pulmona

10、ry trunk. (B) The right coronary-to-pulmonary artery fistula travels across the right ventricular outlet tract and drains into the main pulmonary artery. (LAD left anterior descending coronary artery; LCPAF left coron

11、ary to-pulmonary artery fistula;,Ann Thorac Surg 2006;82:1886–8,治療,冠狀動(dòng)脈瘺自然閉合的機(jī)會(huì)少。由于隨著年齡的增長(zhǎng)，會(huì)出現(xiàn)多種嚴(yán)重的并發(fā)癥，所以，一旦確診，現(xiàn)在多主張?jiān)缙谥委煛Ｍ饪剖中g(shù)介入治療,治 療,外科手術(shù)適應(yīng)癥 冠狀動(dòng)脈瘺合并其它心血管畸形 冠狀動(dòng)脈瘺粗大而不適于經(jīng)導(dǎo)管堵塞者 多發(fā)性冠狀動(dòng)脈瘺開(kāi)口者 合并感染性心內(nèi)膜炎

12、 冠狀動(dòng)脈瘺擴(kuò)張明顯或伴有大的血管瘤,介入治療,介入治療適應(yīng)癥,大量左向右分流心肌缺血、心絞痛肺動(dòng)脈高壓充血性心力衰竭預(yù)防感染性心內(nèi)膜炎,介入治療禁忌癥,要栓塞的冠狀動(dòng)脈分支遠(yuǎn)端有側(cè)支發(fā)出 受累的冠狀動(dòng)脈血管極度迂曲右心導(dǎo)管提示右向左分流，重度肺動(dòng)脈高壓術(shù)前1個(gè)月內(nèi)患有嚴(yán)重感染,介入封堵器械,1. 彈簧圈： 可控彈簧圈 不可控彈簧圈2. Amplatzer Plug 或 PDA 封堵器3.可脫卸球囊（Detacha

13、ble balloons)4.帶膜支架,介入治療方法,操作步驟：右心導(dǎo)管檢查：計(jì)算分流量(QP/Qs)、全肺阻力。心血管造影升主動(dòng)脈造影左、右冠狀動(dòng)脈造影冠狀動(dòng)脈栓塞試驗(yàn),心血管造影,彈簧法適應(yīng)證,易于安全到達(dá)需栓塞的瘺管、單發(fā)的冠狀動(dòng)脈瘺開(kāi)口冠狀動(dòng)脈瘺口狹窄、瘺口附近無(wú)正常的冠狀動(dòng)脈分支瘺道呈瘤樣擴(kuò)張、引流瘺口有明確的狹窄直徑較小,彈簧圈法,器 械 1. PTCA 指引導(dǎo)管 2. 0.014PTCA 導(dǎo)絲

14、 3. 2.0~2.4F 微導(dǎo)管 4.彈簧圈：比栓塞血管的直徑大20%~40% 電解彈簧圈（GDC）,,,,,注意事項(xiàng),明確靶血管開(kāi)口部位：多體位造影導(dǎo)絲插入困難強(qiáng)支撐力GC彈性合適的PCI 導(dǎo)絲：BMW， Runthrogh冠心介入治療經(jīng)驗(yàn)選擇可控彈簧圈GDC EV3微導(dǎo)管盡量接近瘺口處彈簧圈近端不能位于冠脈主支內(nèi),Amplatzer 封堵器,適合于瘺口較大的患者PDA 封堵器血管塞子（A

15、mplatzer Plug)方法：經(jīng)動(dòng)脈途徑（順行法）經(jīng)靜脈途徑（逆行 法）,,,注意事項(xiàng),對(duì)瘺道較短的冠狀動(dòng)脈瘺可直接將導(dǎo)管送至瘺管最窄處的最末端，用封堵器進(jìn)行封堵對(duì)于冠狀動(dòng)脈瘺的異常曲折盤(pán)繞血管，管道途徑較長(zhǎng)，從動(dòng)脈側(cè)難以封堵或瘺口開(kāi)口于右心房者，采用建立動(dòng)靜脈軌道法逆行封堵。封堵器宜大不宜小，需比最窄徑大50%~100%,其它方法,可脫缷球囊,其它方法,帶膜支架？射頻消融？經(jīng)導(dǎo)管誘導(dǎo)血栓形成封堵法,中遠(yuǎn)期療效,Fig

16、. 2 (A) Left coronary angiogram shows a large feeding artery from the left anterior descending coronary artery complicated with a giant aneurysm (arrows) before entering the apex of the right ventricle. The distal anteri

17、or descending and circumflex coronary arteriesare poorly visualized. (B) Angiogram following two-coil deployment demonstrates fistula occlusion and good coronary artery sidebranches. (C) One-year follow-up coronary ang

18、iogram shows complete aneurysm obliteration,Pediatr Cardiol ,2006, 27:557–563,Gianturco coil occlusion,并發(fā)癥,心律失常冠狀動(dòng)脈痙攣、夾層術(shù)后殘余分流和溶血封堵器脫落及異位栓塞瓣膜的損傷感染性心內(nèi)膜炎外周血管并發(fā)癥,小 結(jié),經(jīng)導(dǎo)管封堵治療冠狀動(dòng)脈瘺是一種有效的方法創(chuàng)傷小、術(shù)后恢復(fù)快、療效可靠經(jīng)過(guò)嚴(yán)格選擇的病例，可基本取