应用血栓抽吸导管的循证学依据.ppt

应用血栓抽吸导管的 循证学依据 赵汉军 颜红兵 首都医科大学附属北京安贞医院 北京市心肺血管疾病研究所 陈某，男、51yr No-Reflow Doubles Mortality Risk in STEMI Pts Out to 5 Yrs  Almost 30% of STEMI pts found to have no reflow after primary PCI No reflow raises risk of all-cause, cardiovascular mortality out to 5 yrs Clinicians lack effective treatment for condition ? No Reflow(n = 410) Reflow(n = 996) OR(95% CI) P Value Death 18.2% 9.5% 2.02(1.44-2.82) 0.001 Cardiovascular Death 12.4% 6.3% 2.18(1.46-3.27) 0.001 Ndrepepa G. J Am Coll Cardiol. 2010;55:2383-2389. ? 抽吸导管(Diver CE) 近端阻塞保护装置 Proxis 远端阻塞保护装置 PercuSurge GuardWire 远端滤过保护装置 FilterWire 机械抽吸装置 (X-Sizer) 血栓抽吸与远端保护装置的分类 Meta-analysis of the Impact of Thrombectomy DPD on Mortality Mortality (%) Bavry AA et al, Eur Heart J 2008; 29: 2989-3001 p =0.018 p = 0.05 p = 0.89 30 Studies, 6415 patients, weighted mean FU of 5 months 2.7 5.3 3.1 4.4 2.8 3.4 0 2 4 6 Aspiration Mechanical Thrombectomy Embolic Protection Device PCI Alone 建议IIa：益处危险。需要对相关问题进一步研究；有理由完成或实施治疗 证据B：有限人群评估。数据来自单个随机试验或非随机试验 ACC/AHA指南的依据： -2项临床随机试验：TAPAS和EXPIRA -1项荟萃分析（Bavry et al） -1项对随机试验的荟萃分析（ ATTEMPT） 限于手工抽吸导管 不适合机械性装置 (例如 Angiojet) Thrombus Aspiration During PCI for STEMI AMI血栓病理研究支持血栓抽吸 几点结论 血栓负荷是直接PCI再灌注不良的独立预测因素 陈旧血栓是影响预后的独立因素 血栓抽吸清除斑块物质是血栓抽吸获益的主要机制 血栓负荷是直接PCI再灌注不良的独立预测因素 RLD: reference lumen diameter Type II lesion: thrombus linear length ≧3RLD High-burden thrombus CHEST 2002;122:1322-1332 Impact of Thrombus Burden on Stent Thrombosis after DES for AMI (2yr FU) Sianos G et al, J Am Coll Cardiol 2007; 50:573-83 Smaller Thrombus Burden is Associated with Reduced DES Thrombosis Cumulative IRA DES Thrombosis (%) (n=792 patients) Follow-Up (months) p 0.001 Large Thrombus Burden Small Thrombus Burden Total Population 12 5.8% 8.2% 3.2% 1.3% 3.2% 2.7% 1.1% 2.1% 0.7% 0.5% 19 6 3 0 0 1 3 6 9 12 15 18 21 24 1.4% Large thrombus burden: ≧2 vessel diameters 51% of thrombi several days to several weeks old Acute STEMI ? Thrombus Age Saskia ZH. Circulation 2005;111:1160-1165.