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1、Emergent PCI in AMI Patients with transradial approach Strategy and Skills,Weimin Li, MD,The First Affiliated Hospital Harbin Medical University, Harbin, China,Introduction,At the beginning,TRA tended to be avoided in AMI patients. Major concern was anexpected longer time for arterial cannulation .
2、Many studies have now demonstrated the safety, feasibility and good outcomes of primary PCI performed with TRA,and with a drastic reduction in vascular complications and length of in-hospital stays.,According to the most recent guidelines, patients with TFA undergo aggressive anticoagulation, which
3、leads eventually to an increased incidence of bleeding(up to 7%). However, the combination of GP IIb/IIIa inhibitors and catheterisation withTRA is virtually avoid from serious bleeding.,Introduction,Louvard et al. in the first 50 cases, demonstrated that any operator will have a failure of about 10
4、%, which will drop to 3-4% after other 500 cases, however procedural failure will stabilise after 1000 procedures at less than 1%. A operator who performed 500 cases may be regarded as the experienced operator for emergent TRA PCI. Indeed,TRA may find its most suitable application in patients with A
5、CS/ STEMI.,Introduction,A 47-year-old male Severe chest pain for 3 hours A history of hypertension, hyperlipidemia ECG: precordial leads showing up to 3 mm ST elevation in leads V1V4,Case 1,The incidence of slow flow and no-reflow after Primary PCI is up to 10%-20%, especially high in lesions with l
6、arge thrombus burden,Case 1,Case 1,Ryujin 2.5 x 20,Case 1,Case 1,Case 1,DIVER CE,Case 1,Case 1,Case 1,Case 1,Case 1,OM thrombus aspiration,Case 1,If aspirate the thrombus first, the result maybe better.,A 72-year-old male Severe chest pain for 3 hours Tri-chamber pacemaker implantation two years ago
7、 ECG: ST-segment elevation in leads II, III, aVF,Direct stenting strategy is feasible in most of emergent PCI cases after thrombus aspiration.,Case 2,Case 2,Case 2,DIVER CE,Case 2,Nitroglycerin 200g,Case 2,Direct stenting,TAPAS In the thrombus-aspiration group, direct stent implantation were perform
8、ed in 55.1% cases. In the conventional- PCI group, 98.8% cases need balloon predilation.,PCR 2008,It has been reported that more than half of the culprit lesions(66%) in AMI patients with stenosis 50% and in majority patients(97%) the stenosis were less than 70%.,WC Little,et al. Circulation 1988;78
9、;1157-1166,Diver CE aspiration catheter,Distal radiopaque marker band:1 mm proximal to the tip,Oblique aspiration tip: lumen ID=0.9mm,Side hole diameter: 1.5mm,The proximal segment(20cm) has a hydrophilia coating .,Prevention is better than cure. Risk features. (clinical and angiographic features),L
10、arge IRA (3.5mm) Cut-off pattern Accumulated thrombus 5mm Non-occluded thrombus with linear dimension 3 RVD Floating thrombus (proximal to the occlusion); Persistent dye stasis (distal to the obstruction).,Wall motion integration TIMI grade of IRA Lack angina before AMI Number of leads with patholog
11、ical Q wave,Case 3,A 62-year-old male Severe chest pain for 5 hours A history of diabetes , hypercholesterolemia,smoking ECG:sinus brandycardia, ST-segment elevation in leads V1-V5 BP:75/55mmHg,Some complex lesions can be performed with transradial approach in STEMI patients.,Case 3,Case 3,2.0 15mm
12、Ryujin (6atm),Case 3,Case 3,Case 3,3.0 20mm Ryujin,Case 3,3.5 33mm Firebird II,Case 3,Case 3,Kissing Dilation,Case 3,A: The stent is advanced to the ostial branch lesion and a second balloon is placed in the main branch,B: The main branch balloon is inflated at low atmospheres and the stent gently p
13、ulled back,Stent pull back technique,C: The stent is deployment at high pressures,D: The main branch balloon and the stent balloon are removed,Stent pull back technique,When needed, and in selected patients,such as males with good pulsation,the radial artery can acommodate also 7F or 8F catheters.,C
14、ase 4,A 72-year-old male substernal squeezing pain for 3 hours A history of diabetes, renal failure for 2 years ECG:sinus bradycardia, ST-segment elevation in leads II, III, and aVF,Prevention is better than cure with CIN patients in emergent PCI,Case 4,Voyger 2.520mm,Cypher selected plus 3.033mm,Cy
15、pher selected plus 3.518mm,Case 4,Case 4,Ryujin 1.515mm,Case 4,Voyger 2.520mm,Case 4,Partner 2.7536mm,Case 4,Def. Of CIN: 44.3mol/ L or 25% increase Cr at 48 hours,CIN,Lodixanol 100ml,Risk Factors for CIN,Patient-related Risk Factors Renal insufficiency Diabetes mellitus Age (70) Volume depletion /
16、Low cardiac output / Hypotension Class IV CHF Other nephrotoxins Renal transplant Anemia,Procedure-related Risk Factors Multiple CM injection (72h) Intra-arterial injection High volume of CM High osmolality of CM High VISCOSITY,Contrast medium (Selection),IOCM & LOCM OSMOLALITY & VISCOSITY,?,Screeni
17、ng high-risk patients. Adequate hydration during contrast medium exposure and after the procedure. Selecting low osmolar and less Viscosity contrast. Use lower doses of contrast.,Case 5,A 72-year-old female substernal squeezing pain for 3 hours A history of diabetes ECG:sinus bradycardia, ST-segment
18、 elevation in leads II, III, and aVF,Q waves,Sometimes the regular projections can not give you the true angiograghic imagine, taking pictrues with multi- projections may reduce missed diagnosis.,Case 5,Case 5,CAU,Case 5,Ryujin 2.520mm,Case 5,Case 5,Case 5,Nitrate 200ug,Tirofiban 5ml,I.C,Case 5,Intr
19、acoronary administration of tirofiban followed by intravenous infusion is associated with an improved TIMI flow and TMPG, and reduced thrombus scores following primary PCI.,Circ J2008; 72:16051609,Nowadays there is virtually no anatomical limitation for performing complex PCI procedures using the TR
20、A. Six-French-widelumen guiding catheters,low-profile balloons and stents,and high- performance wires are available ,even the advanced devices(such as DPD,Diver catheter and IVUS ,etc.) are at present 6F compatible. The transradial approach for emergent PCI is as safety and feasible as the transfemoral approach in AMI patients .,Conclusion,Knowing is not enough, we must apply. Willing is not enough, we must do！,Goethe,