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近年,我国冠状动脉粥样硬化性心脏病(CHD)等心血管病的发病率不断攀升。目前,冠状动脉造影(CAG)和经皮冠状动脉介入治疗(PCI)是CHD的重要诊疗手段。与股动脉入径相比,经桡动脉入径的冠状动脉介入(TRI)具有损伤小、出血风险低、病人住院时间短等优势[1-3]。欧洲心脏病学会和美国心脏协会已建议将经桡动脉入径作为CHD病人CAG和PCI的优先选择入径[4-5]。然而,随着桡动脉入径被广泛地应用于CAG和介入手术,桡动脉闭塞(RAO)作为其常见的并发症越来越受到重视。尽管RAO在大多数情况下并未产生明显症状,但可能会导致下次无法在同侧进行经桡CAG,也会限制部分病人后续冠状动脉搭桥术的进行。此外,对需要血液透析的病人,RAO也会影响动静脉瘘管的构建。因此,探索RAO的危险因素、研究预防手段具有十分重要的临床意义。迄今为止,已经有一些研究探索了RAO的危险因素[6],初步探索了多种预防闭塞的方法,包括静脉给予大剂量肝素[7]、皮下注射硝酸甘油[8]、缩短压迫止血时间[9],以及非阻塞式止血[10]等。我们在临床实践中观测到,术后的手指运动有助于改善桡动脉血流速度,是一种经济有效地实现开放式止血的新策略。但目前尚缺乏充足可靠的临床数据揭示术后的指舞运动对于RAO的预防效果。本研究旨在动态监测病人CAG前后桡动脉血流动力学参数变化情况,分析术后指舞运动对于早期和晚期RAO的影响,为预防和治疗RAO提供新视角和重要临床证据。
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2组病人在吸烟情况、合并疾病(高血压、糖尿病、高脂血症)、血小板水平、是否长期服用抗血小板及他汀类药物、术中肝素用量、手术时间以及压迫止血时间等方面差异均无统计学意义(P>0.05)(见表 1),具有可比性。
项目 对照组(n=89) 观察组(n=82) zc P 年龄/岁 64(54,71) 64(55,70) 0.95 >0.05 体质量指数/(kg/m2) 26.2(23.3,27.5) 25.3(23.3,27.3) 0.94 >0.05 性别 55 46 0.58* >0.05 吸烟 27 17 1.93* >0.05 高血压 59 56 0.09* >0.05 糖尿病 25 16 1.72* >0.05 高脂血症 17 16 0.06* >0.05 血小板/(109/L) 176.0(145.5,207.5) 156.0(130.0,190.5) 1.52 >0.05 长期接受抗血小板治疗 66 66 1.04* >0.05 长期接受他汀类药物治疗 65 65 0.97* >0.05 术中肝素使用剂量/IU 2500(2500,7900) 2500(2500,7400) 0.88 >0.05 手术时间/min 28.0(15.0,62.5) 27.5(15.0,60.0) 0.41 >0.05 压迫止血时间/min 515.0(495.0,560.0) 530.0(500.0,579.0) 1.34 >0.05 *示χ2值 表 1 2组病人的临床基线资料[M(P25, P75)]
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桡动脉彩色多普勒超声动态检测结果提示:2组病人的桡动脉内膜术后3 d和术后1个月均比术前增厚(P<0.05),而术后3 d桡动脉内膜厚度与术后1个月相比差异无统计学意义(P>0.05)。2组病人各时期的桡动脉内膜厚度差异均无统计学意义(P>0.05) (见表 2)。
分组 n 术前 术后3d 术后1个月 桡动脉内膜厚度/mm 对照组 89 0.3(0.3,0.4) 0.4(0.3,0.4)* 0.4(0.4,0.4)* 观察组 82 0.3(0.3,0.4) 0.4(0.3,0.4)* 0.4(0.4,0.4)* zc — 0.81 0.49 0.77 P — >0.05 >0.05 >0.05 桡动脉直径/mm 对照组 89 2.1(1.9,2.4) 2.5(2.2,2.8)* 2.2(2.0,2.4) 观察组 82 2.2(2.0,2.4) 2.5(2.3,2.7)* 2.2(2.0,2.4) zc — 1.28 0.22 0.41 P — >0.05 >0.05 >0.05 桡动脉血流速度峰值/(m/s) 对照组 89 0.50(0.41,0.56) 0.41(0.21,0.51)* 0.50(0.36,0.62)△ 观察组 82 0.54(0.41,0.60) 0.42(0.33,0.52)* 0.54(0.44,0.62)△ zc — 1.13 1.99 2.06 P — >0.05 <0.05 <0.05 Wilcoxon符号秩检验:与术前比较*P<0.05;与术后3 d比较△P<0.05 表 2 2组病人的桡动脉内径、内膜厚度以及血流速度的动态变化[M(P25, P75)]
2组病人桡动脉直径在术后3 d均比术前增厚(P<0.05),而术后1个月与术前相比差异无统计学意义(P>0.05)。2组病人各时期桡动脉直径差异均无统计学意义(P>0.05)(见表 2)。
对照组病人桡动脉血流速度峰值术后3 d低于术前和术后1个月(P<0.05)且血流速度在术后1个月与术前相比差异无统计学意义(P>0.05)。2组病人的桡动脉血流速度峰值差异无统计学意义(P>0.05),但观察组桡动脉血流速度峰值在术后3 d及术后1个月均高于对照组(P<0.05)(见表 2)。
本研究共有132例病人同时接受术后3 d及术后1个月桡动脉超声检测。对照组术后3 d发生早期RAO 10例(14.5%),术后1个月发生晚期闭塞11例(15.9%),早期及晚期闭塞均发生的病人共7例(10.1%),观察组仅有发生早期闭塞2例(3.2%),无晚期闭塞发生。
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术后3 d和术后1个月,观察组闭塞率均低于对照组(P<0.05和P<0.01)。对照组在术后3 d与术后1个月的RAO率差异无统计学意义(P>0.05),而观察组在术后1个月的RAO率低于术后3 d(P<0.05)(见表 3)。
分组 术后3d 术后1个月 χ2 P 对照组 13(16.3) 11(14.9) 0.06 >0.05 观察组 4(5.7) 0(0.0) 4.00 <0.05 χ2 4.12 10.90 — — P <0.05 <0.01 — — 表 3 2组病人术后3 d和1个月的桡动脉闭塞率[n; 百分率(%)]
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观察组前臂肿胀及穿刺点渗血等不良反应发生率与对照组相比差异无统计学意义(P>0.05)(见表 4)。
分组 前臂肿胀 穿刺点渗血 合计 对照组 1(1.1) 1(1.1) 2(2.2) 观察组 2(2.4) 3(3.7) 5(6.1) χ2 0.43 1.20 1.61 P >0.05 >0.05 >0.05 表 4 术后3 d 2组病人不良反应发生情况[n; 百分率(%)]
指舞运动在经桡冠状动脉介入术后预防桡动脉闭塞的效果评价
Effect evaluation of finger movements on preventing radial artery occlusion after transradial coronary intervention
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摘要:
目的探索经桡介入术后的指舞运动对于桡动脉闭塞(RAO)的预防效果。动态观测病人术后桡动脉血流动力学参数变化情况,分析指舞运动对于早期和晚期RAO的影响。 方法纳入择期行冠状动脉造影及介入治疗的171例病人,随机分为对照组89例和观察组82例。观察组在术后开展3 h的指舞运动,对照组无上述操作。分别在穿刺前、术后第3天和术后1个月检测2组病人桡动脉内膜厚度、直径以及血流速度峰值等指标,动态观测上述指标的变化,分析早期和晚期RAO情况。 结果2组病人的年龄、性别、吸烟、合并疾病等临床特征差异均无统计学意义(P>0.05)。观察组桡动脉直径以及内膜厚度在术前、术后3 d及术后1个月与同时期对照组相比差异均无统计学意义(P>0.05),观察组病人的桡动脉血流速度峰值在术前与对照组病人相比差异无统计学意义(P>0.05),但观察组桡动脉血流速度峰值在术后3 d及术后1个月均高于对照组(P < 0.05)。术后3 d,观察组早期RAO率为5.7% (4/70),低于对照组的16.3%(13/80)(P < 0.05)。术后1个月,观察组未发生RAO,闭塞率为0%(0/68),低于对照组的14.9%(11/74)(P < 0.01)。观察组前臂肿胀及穿刺点渗血等不良反应发生率与对照组相比差异无统计学意义(P>0.05)。 结论指舞运动有助于提升早期桡动脉血流速度,能显著降低冠状动脉造影术后早期和晚期RAO的发生,且未明显影响不良反应发生率。术后指舞运动是一种简便、安全有效的RAO防治策略。 Abstract:ObjectiveTo explore the effect of finger movements on preventing radial artery occlusion (RAO), the changes of the postoperative hemodynamic parameters of the radial artery in patients were observed dynamically, and the effects of the finger dance exercise on the early and late RAO occurrence were analyzed. MethodsA total of 171 patients undergoing elective coronary angiography and interventional therapy were randomly divided into control group (89 patients) and observation group (82 patients).The observation group carried out finger movements for 3 h after surgery, and none was performed in the control group.The thickness, diameter and peak flow velocity of the radial artery were measured before puncture, 3 days and 1 month after surgery.The changes of the above indicators were dynamically observed, and the early and late RAO occurrence were analyzed. ResultsThe age, gender, smoking, combined disease and other clinical characteristics of patients in the two groups were not significantly different (P>0.05).The radial artery diameter and intimal thickness in the observation group had no statistical significance compared with the control group in the same period before surgery, 3 days and 1 month after surgery (P>0.05).The peak flow velocity of radial artery in the observation group had no statistical significance compared with the control group before surgery (P>0.05), but the peak flow velocity of radial artery in the observation group was higher than that in the control group 3 days and 1 month after surgery (P < 0.05).On the third day after surgery, the early RAO rate in the observation group was 5.7% (4/70), lower than the 16.3% (13/80) in the control group (P < 0.05).At 1 month after surgery, no RAO occurred in the observation group, and the occlusion rate was 0% (0/68), which was lower than 14.9% (11/74) in the control group (P < 0.01).The incidence of adverse reactions such as forearm swelling and puncture point blood infiltration was not significantly different between the two groups (P>0.05). ConclusionsFinger movements helps to improve the early radial artery blood flow velocity, can significantly reduce the occurrence of early and late RAO after coronary angiography, and does not significantly affect the incidence of adverse reactions.Postoperative finger dance exercise is a simple, safe and effective prevention strategy for RAO. -
表 1 2组病人的临床基线资料[M(P25, P75)]
项目 对照组(n=89) 观察组(n=82) zc P 年龄/岁 64(54,71) 64(55,70) 0.95 >0.05 体质量指数/(kg/m2) 26.2(23.3,27.5) 25.3(23.3,27.3) 0.94 >0.05 性别 55 46 0.58* >0.05 吸烟 27 17 1.93* >0.05 高血压 59 56 0.09* >0.05 糖尿病 25 16 1.72* >0.05 高脂血症 17 16 0.06* >0.05 血小板/(109/L) 176.0(145.5,207.5) 156.0(130.0,190.5) 1.52 >0.05 长期接受抗血小板治疗 66 66 1.04* >0.05 长期接受他汀类药物治疗 65 65 0.97* >0.05 术中肝素使用剂量/IU 2500(2500,7900) 2500(2500,7400) 0.88 >0.05 手术时间/min 28.0(15.0,62.5) 27.5(15.0,60.0) 0.41 >0.05 压迫止血时间/min 515.0(495.0,560.0) 530.0(500.0,579.0) 1.34 >0.05 *示χ2值 表 2 2组病人的桡动脉内径、内膜厚度以及血流速度的动态变化[M(P25, P75)]
分组 n 术前 术后3d 术后1个月 桡动脉内膜厚度/mm 对照组 89 0.3(0.3,0.4) 0.4(0.3,0.4)* 0.4(0.4,0.4)* 观察组 82 0.3(0.3,0.4) 0.4(0.3,0.4)* 0.4(0.4,0.4)* zc — 0.81 0.49 0.77 P — >0.05 >0.05 >0.05 桡动脉直径/mm 对照组 89 2.1(1.9,2.4) 2.5(2.2,2.8)* 2.2(2.0,2.4) 观察组 82 2.2(2.0,2.4) 2.5(2.3,2.7)* 2.2(2.0,2.4) zc — 1.28 0.22 0.41 P — >0.05 >0.05 >0.05 桡动脉血流速度峰值/(m/s) 对照组 89 0.50(0.41,0.56) 0.41(0.21,0.51)* 0.50(0.36,0.62)△ 观察组 82 0.54(0.41,0.60) 0.42(0.33,0.52)* 0.54(0.44,0.62)△ zc — 1.13 1.99 2.06 P — >0.05 <0.05 <0.05 Wilcoxon符号秩检验:与术前比较*P<0.05;与术后3 d比较△P<0.05 表 3 2组病人术后3 d和1个月的桡动脉闭塞率[n; 百分率(%)]
分组 术后3d 术后1个月 χ2 P 对照组 13(16.3) 11(14.9) 0.06 >0.05 观察组 4(5.7) 0(0.0) 4.00 <0.05 χ2 4.12 10.90 — — P <0.05 <0.01 — — 表 4 术后3 d 2组病人不良反应发生情况[n; 百分率(%)]
分组 前臂肿胀 穿刺点渗血 合计 对照组 1(1.1) 1(1.1) 2(2.2) 观察组 2(2.4) 3(3.7) 5(6.1) χ2 0.43 1.20 1.61 P >0.05 >0.05 >0.05 -
[1] VALGIMIGLI M, FRIGOLI E, LEONARDI S, et al. Radial versus femoral access and bivalirudin versus unfractionated heparin in invasively managed patients with acute coronary syndrome (MATRIX): final 1-year results of a multicentre, randomised controlled trial[J]. Lancet (London, England), 2018, 392(10150): 835. doi: 10.1016/S0140-6736(18)31714-8 [2] FERRANTE G, RAO SV, JVNI P, et al. Radial versus femoral access for coronary interventions across the entire spectrum of patients with coronary artery disease: a meta-analysis of randomized trials[J]. JACC Cardiovasc Interv, 2016, 9(14): 1419. doi: 10.1016/j.jcin.2016.04.014 [3] 桑更生, 石增刚, 石世强, 等. 经桡动脉和股动脉途径行冠状动脉介入术的临床比较[J]. 蚌埠医学院学报, 2009, 34(8): 688. [4] IBANEZ B, JAMES S, AGEWALL S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)[J]. Eur Heart J, 2018, 39(2): 119. doi: 10.1093/eurheartj/ehx393 [5] MASON PJ, SHAH B, TAMIS-HOLLAND JE, et al. An update on radial artery access and best practices for transradial coronary angiography and intervention in acute coronary syndrome: a scientific statement from the american heart association[J]. Circ Cardiovasc Interv, 2018, 11(9): e35. [6] RASHID M, KWOK CS, PANCHOLY S, et al. Radial artery occlusion after transradial interventions: a systematic review and meta-analysis[J]. J Am Heart Assoc, 2016, 5(1): e002686. doi: 10.1161/JAHA.115.002686 [7] HAHALIS GN, LEOPOULOU M, TSIGKAS G, et al. Multicenter randomized evaluation of high versus standard heparin dose on incident radial arterial occlusion after transradial coronary angiography: the spirit of artemis study[J]. JACC Cardiovasc Interv, 2018, 11(22): 2241. doi: 10.1016/j.jcin.2018.08.009 [8] KWOK CS, RASHID M, FRASER D, et al. Intra-arterial vasodilators to prevent radial artery spasm: a systematic review and pooled analysis of clinical studies[J]. Cardiovasc Revasc Med, 2015, 16(8): 484. doi: 10.1016/j.carrev.2015.08.008 [9] EDRIS A, GORDIN J, SALLAM T, et al. Facilitated patent haemostasis after transradial catheterisation to reduce radial artery occlusion[J]. EuroIntervention, 2015, 11(7): 765. [10] CUBERO JM, LOMBARDO J, PEDROSA C, et al. Radial compression guided by mean artery pressure versus standard compression with a pneumatic device (RACOMAP)[J]. Catheter Cardiovasc Interv, 2009, 73(4): 467. doi: 10.1002/ccd.21900 [11] PLANTE S, CANTOR WJ, GOLDMAN L, et al. Comparison of bivalirudin versus heparin on radial artery occlusion after transradial catheterization[J]. Catheter Cardiovasc Interv, 2010, 76(5): 654. doi: 10.1002/ccd.22610 [12] SHROFF AR, FERNANDEZ C, VIDOVICH MI, et al. Contemporary transradial access practices: results of the second international survey[J]. Catheter Cardiovasc Interv, 2019, 93(7): 1276. doi: 10.1002/ccd.27989 [13] HAHALIS G, AZNAOURIDIS K, TSIGKAS G, et al. Radial artery and ulnar artery occlusions following coronary procedures and the impact of anticoagulation: ARTEMIS (Radial and Ulnar ARTEry Occlusion Meta-AnalysIs) systematic review and meta-analysis[J]. J Am Heart Assoc, 2017, 6(8): e005430. doi: 10.1161/JAHA.116.005430 [14] BERNAT I, AMINIAN A, PANCHOLY S, et al. Best practices for the prevention of radial artery occlusion after transradial diagnostic angiography and intervention: an international consensus paper[J]. JACC Cardiovasc Interv, 2019, 12(22): 2235. doi: 10.1016/j.jcin.2019.07.043 [15] MAMAS MA, FRASER DG, RATIB K, et al. Minimising radial injury: prevention is better than cure[J]. EuroIntervention, 2014, 10(7): 824. doi: 10.4244/EIJV10I7A142 [16] YONETSU T, KAKUTA T, LEE T, et al. Assessment of acute injuries and chronic intimal thickening of the radial artery after transradial coronary intervention by optical coherence tomography[J]. Eur Heart J, 2010, 31(13): 1608. doi: 10.1093/eurheartj/ehq102 [17] ABDELAAL E, MOLIN P, PLOURDE G, et al. Successive transradial access for coronary procedures: experience of Quebec Heart-Lung Institute[J]. Am Heart J, 2013, 165(3): 325. doi: 10.1016/j.ahj.2012.10.016 [18] KOTOWYCZ MA, JOHNSTON KW, IVANOV J, et al. Predictors of radial artery size in patients undergoing cardiac catheterization: insights from the Good Radial Artery Size Prediction (GRASP) study[J]. Can J Cardiol, 2014, 30(2): 211. doi: 10.1016/j.cjca.2013.11.021 [19] AMINIAN A, SAITO S, TAKAHASHI A, et al. Comparison of a new slender 6 Fr sheath with a standard 5 Fr sheath for transradial coronary angiography and intervention: RAP and BEAT (Radial Artery Patency and Bleeding, Efficacy, Adverse evenT), a randomised multicentre trial[J]. EuroIntervention, 2017, 13(5): e549. doi: 10.4244/EIJ-D-16-00816 [20] PANCHOLY S, COPPOLA J, PATEL T, et al. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization[J]. Catheter Cardiovasc Interv, 2008, 72(3): 335. doi: 10.1002/ccd.21639 [21] COSTA F, VAN LEEUWEN MA, DAEMEN J, et al. The rotterdam radial access research: ultrasound-based radial artery evaluation for diagnostic and therapeutic coronary procedures[J]. Circ Cardiovasc Interv, 2016, 9(2): e3129. [22] DAHM J B, VOGELGESANG D, HUMMEL A, et al. A randomized trial of 5 vs. 6 French transradial percutaneous coronary interventions[J]. Catheter Cardiovasc Interv, 2002, 57(2): 172. doi: 10.1002/ccd.10321 [23] DANGOISSE V, GUÉDÈS A, CHENU P, et al. Usefulness of a gentle and short hemostasis using the transradial band device after transradial access for percutaneous coronary angiography and interventions to reduce the radial artery occlusion rate (from the prospective and randomized crasoc I, II, and III studies)[J]. Am J Cardiol, 2017, 120(3): 374. doi: 10.1016/j.amjcard.2017.04.037 [24] DHARMA S, KEDEV S, PATEL T, et al. A novel approach to reduceradial artery occlusion after transradial catheterization: postprocedural/prehemostasis intra-arterial nitroglycerin[J]. Catheter Cardiovasc Interv, 2015, 85(5): 818. doi: 10.1002/ccd.25661 [25] AMINIAN A, SAITO S, TAKAHASHI A, et al. Impact of sheath size and hemostasis time on radial artery patency after transradial coronary angiography and intervention in Japanese and non-Japanese patients: a substudy from RAP and BEAT (Radial Artery Patency and Bleeding, Efficacy, Adverse evenT) randomized multicenter trial[J]. Catheter Cardiovasc Interv, 2018, 92(5): 844. doi: 10.1002/ccd.27526 [26] SANMARTIN M, GOMEZ M, RUMOROSO JR, et al. Interruption of blood flow during compression and radial artery occlusion after transradial catheterization[J]. Catheter Cardiovasc Interv, 2007, 70(2): 185. doi: 10.1002/ccd.21058 [27] AMINIAN A, DOLATABADI D, LEFEBVRE P, et al. Initial experience with the Glidesheath Slender for transradial coronary angiography and intervention: a feasibility study with prospective radial ultrasound follow-up[J]. Catheter Cardiovasc Interv, 2014, 84(3): 436. doi: 10.1002/ccd.25232 [28] MAMAS M, D'SOUZA S, HENDRY C, et al. Use of the sheathless guide catheter during routine transradial percutaneous coronary intervention: a feasibility study[J]. Catheter Cardiovasc Interv, 2010, 75(4): 596. doi: 10.1002/ccd.22246 [29] KWAN TW, CHERUKURI S, HUANG Y, et al. Feasibility and safety of 7F sheathless guiding catheter during transradial coronary intervention[J]. Catheter Cardiovasc Interv, 2012, 80(2): 274. doi: 10.1002/ccd.24310 [30] PANCHOLY SB. Comparison of the effect of intra-arterial versus intravenous heparin on radial artery occlusion after transradial catheterization[J]. Am J Cardiol, 2009, 104(8): 1083. doi: 10.1016/j.amjcard.2009.05.057 [31] PANCHOLY SB, AHMED I, BERTRAND OF, et al. Frequency of radial artery occlusion after transradial access in patients receiving warfarin therapy and undergoing coronary angiography[J]. Am J Cardiol, 2014, 113(2): 211. doi: 10.1016/j.amjcard.2013.09.043 [32] 冯伟, 荣向霞, 刘利军, 等. 旋压式桡动脉止血器改良加压包扎对冠状动脉介入术后止血效果和舒适度的影响[J]. 蚌埠医学院学报, 2019, 44(5): 677. doi: 10.13898/j.cnki.issn.1000-2200.2019.05.034