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:/Case baseline data1.MV-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。2.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。1.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2.急性心肌梗塞时血管容易痉挛、机体处于高凝状态3.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后的影响是什么？瑞金医院张奇做了初步研究。当罪犯血管
2、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Our hospital case01Overall views of this puzzle patientimage01Emergency PCI Indicates a ostial total occlusion of LAD-2012.3.26The patients RCAInitial dilation of the culprit lesionShows the result post initial dilationCranial projection of LADFindi
3、ngs:The right proximal lesion is 85% stenosisThere is “normal segment” of 5mm in length but may be not a tandem lesion on this viewTIMI flow o grade distal to Diago1 After dilation we can see a second lesion-who is the culprit?Someone suspected thrombus in the distal lesion and think the culprit is
4、right hereWhat about your opinion ? For the proximal lesion, why it is not the culprit lesion ?Initial cine shows total occlusionSeriously stenosis after dilationTwo culprit lesion?Why the proximal lesion is total occluded? Thrombosis ? Spasm? Both?Why the distal lesion also total occluded? A real C
5、TO or sub-acute total occlusion? Total occluded by thrombus from the upstream lesion on base of stenosis?Which is the primary? which is the secondary? Why?How to cope with them?What should we do for next step?Merely Implanted partner stent in the distal lesion! Right?2012.4.8 selective pci .Final re
6、sults after stent implantation on 8 April 2012case02罪犯血管的长病变的处理Post Dilatation Avoiding long stent implantationFinal resultcase03Investigation after dilationMore carefully investigation1、Predilate 2、stent position 3、implantationCope with proximal segmentImplantation and postdilationFinal cineBut symptom developedDissection?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！
