我看美国DAPT指南

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1 抽吸导管的应用 : Why?When?How? 颜红兵, MD,PhD,FACC,FESC 国家心血管病中心中国医学科学院阜外医院

2 Why? Proximal Guiding Catheter: inexpensive less selective systemic effects 抽吸导管的应用 Intralesional ClearWay Catheter: additional costs controlled and targeted drug delivery Distal Microcatheters: thrombectomy devices high availability Infusion in microcirculatory

3 Title Citation Class LOE 2012 ESC Guidelines STsegment elevation myocardial infarction ESC/EACTS guidelines on myocardial revascularization 2015 ACC/AHA focused update PPCI 2015 ACC/AHA focused update PPCI 2017 ESC Guidelines STsegment elevation myocardial infarction 抽吸导管 : 指南建议 European Heart Journal 2012 Oct;33(20): Eur Heart J Oct 1;35(37): JACC JACC European Heart Journal 2017 Routine aspiration should be considered May be considered in selected patients Routine thrombectomy not useful Selective and bailout Thrombectomy not well established Routine use of thrombus aspiration is not recommended. IIa IIb III IIb III B A A C A

4 单纯抽吸就能降低死亡率吗?

5 3T 研究说明了什么? TAPAS(2008) TASTE(2013) TOTAL(2015)

6 指南与实践

burden No reflow phenomenon Reperfusion injury 面临的主要挑战 STEMI

7 Shorten time to reperfusion Reduce access site related complications Choosing the correct stent High thrombotic burden No reflow phenomenon Reperfusion injury 面临的主要挑战 STEMI with multivessel disease STEMI with cardiogenic shock Long-term DAPT management

8 1. Distal embolization 无复流发生机制 2. Ischemia-related injury 4. Individual susceptibility 3. Reperfusion-related injury Genetic variability Diabetes Acute Hyperglycemia Dislipidemia Lack of preconditioning adpted from Niccoli et al. J Am Coll Cardiol 2009;54:281-92

9 ACS 患者的特征高炎症状态高致血栓状态和血栓成分的复杂性合并多支病变率高 (60.9%) 合并性疾病率高 ( 糖尿病肾功能不全和房颤等 )

11 抽吸物的组成血小板新鲜血栓机化的组织斑块动脉粥样硬化斑块组成胆固醇结晶泡沫细胞坏死的核心血管活性物质 5 羟色胺 ADP 血栓素 A2 炎性介质

12 Culprit Vessel Aspirin Ticagrelor Clopidogrel Bivalirudin Abciximab 血栓的动态性质 Fresh, Friable Platelet rich Thrombus DURATION OF CHEST PAIN (Hrs) Thrombo Aspiration Angiojet (Large Vessel) Stenting Dense Organized Thrombus with RBC, Fibrin Angiojet Clearway Laser Staged procedure with prolonged anticoagulation AMI presentation in developing countries

0 1 2 3 4 STEMI 患者血栓分层处理策略分级血栓定义血管造影举例 Mehta 分类技术要点 No cine angiographic characteristics of thrombus present Possible thrombus present.

of thrombus Thrombus present-small size: Definite thrombus with greatest dimensions less than or equal to ½ vessel diameter Thrombus present- moderate size: Definite thrombus

equal to 2 vessel diameters 5 Total occlusion Direct Stent+/- Pre dilatation Aspiration thrombectomy Angio Jet Aspiration Catheter Most effective with fresh clot; organized

All are 6F-compatable It is useful to stock and be familiar with the use of at least one. Flush catheter lumen well before use as it facilitates better tracking over the wire.

Monitor distal tip of the guide wire as the aspiration catheter is advanced it is not uncommon for the guide wire to advance during this maneuver Advance the aspiration

Although LAD and some LCX may not need a TPM, I place TPM s in all Angiojet procedures. Often, multiple passes will be required.

13 STEMI 患者血栓分层处理策略分级血栓定义血管造影举例 Mehta 分类技术要点 No cine angiographic characteristics of thrombus present Possible thrombus present. Angiography demonstrates reduced contrast density, haziness, irregular lesion contour or a smooth convex "meniscus" at the site of total occlusion suggestive but not diagnostic of thrombus Thrombus present-small size: Definite thrombus with greatest dimensions less than or equal to ½ vessel diameter Thrombus present- moderate size: Definite thrombus but with greatest linear dimension greater than ½ but less than 2 vessel diameters Thrombus present- large size: As in Grade 3 but with the largest dimension greater than or equal to 2 vessel diameters 5 Total occlusion Direct Stent+/- Pre dilatation Aspiration thrombectomy Angio Jet Aspiration Catheter Most effective with fresh clot; organized thrombus is more resistant to debulking. Have different profiles, different push- ability, tractability and aspiration rates. All are 6F-compatable It is useful to stock and be familiar with the use of at least one. Flush catheter lumen well before use as it facilitates better tracking over the wire. Avoid kinking the catheter advance slowly over the initial, softer portion of the catheter. Monitor distal tip of the guide wire as the aspiration catheter is advanced it is not uncommon for the guide wire to advance during this maneuver Advance the aspiration catheter through the entire length of occlusive disease. Angio Jet Can be used from the radial route. Although LAD and some LCX may not need a TPM, I place TPM s in all Angiojet procedures. Often, multiple passes will be required. Try to pause after every 2-3 pases to enable hemodynamics to be restored, to optimize guide wire and guiding catheter support and to evaluate the results. Often, just the first passage will restore adequate flow Resistant and stubborn thrombus will require more distal advancement that must be done more carefully. Avoid advancing in severe tortuousity and in vessels<2mm Since the Angiojet is used for large thrombus burden and high thrombus grade, consider Abciximab as adjunctive therapy

14 为何使用抽吸导管? Restore flow in the culprit artery. Optimize myocardial perfusion.

15 抽吸导管只是一个平台可以抽吸可以超选择给药各种性质的血栓斑块物质可以超选择造影降低局部炎性介质

16 When? Proximal Guiding Catheter: inexpensive less selective systemic effects 抽吸导管的应用 Intralesional ClearWay Catheter: additional costs controlled and targeted drug delivery Distal Microcatheters: thrombectomy devices high availability Infusion in microcirculatory

17 抽吸? 超选择给药? 超选择造影? 你的目的?

18 How? Proximal Guiding Catheter: inexpensive less selective systemic effects 抽吸导管的应用 Intralesional ClearWay Catheter: additional costs controlled and targeted drug delivery Distal Microcatheters: thrombectomy devices high availability Infusion in microcirculatory

19 抽吸导管的应用抽吸导管具有 3 大功能 : 抽吸输送支撑抽吸导管只是提供了一个平台终点是要改善血流与灌注应当强调综合处理

20 请提问题抽吸导管的应用

21 不忘初心改善血流与灌注牢记使命各种性质的血栓斑块物质抽吸导管的应用降低局部炎性介质

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<443A5CD0D8CDB CD0D8CDB C C43315C D D49D6B8C4CFB8FCD0C2C4DAC8DDD3EBD6D0B9FACAB5BCF92E > 欧洲新版 STEMI 指南与临床实践 : 面临的 3 大挑战颜红兵, MD,PhD,FACC,FESC 国家心血管病中心中国医学科学院阜外医院直接 PCI 的目的 Restore flow in the culprit artery. Optimize myocardial perfusion. Preserve LV function. Diminish mechanical & electrical