薛 橋，高 磊，李 可，胡 鑫

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延長(zhǎng)壓迫時(shí)間可降低老年人股動(dòng)脈穿刺點(diǎn)出血風(fēng)險(xiǎn)

薛 橋*，高 磊，李 可，胡 鑫

（解放軍總醫(yī)院海南分院心內(nèi)科，三亞 572013）

評(píng)價(jià)以Angioseal動(dòng)脈閉合裝置封閉老年人股動(dòng)脈穿刺點(diǎn)后，延長(zhǎng)加壓包扎時(shí)間降低出血并發(fā)癥。連續(xù)入選接受冠狀動(dòng)脈造影（CAG）和經(jīng)皮冠狀動(dòng)脈介入治療（PCI）的老年患者728例，均以Angioseal封閉股動(dòng)脈穿刺點(diǎn)，上述患者隨機(jī)分為常規(guī)治療組（術(shù)后直腿平臥6h后可活動(dòng)，隨后于2h內(nèi)拆除加壓包扎用彈力繃帶）和延遲包扎組（直腿平臥6h后可活動(dòng)，但于術(shù)后20～24h拆除加壓包扎用彈力繃帶），觀察血管并發(fā)癥及其時(shí)機(jī)。兩組患者發(fā)生股動(dòng)脈穿刺點(diǎn)并發(fā)癥發(fā)生率相比，差異具有統(tǒng)計(jì)學(xué)意義。常規(guī)治療組的穿刺點(diǎn)出血、假性動(dòng)脈瘤等發(fā)生率明顯高于延遲包扎組（7.42%1.78%，＝0.001）。其中出血并發(fā)癥增高主要表現(xiàn)為拆除加壓包扎敷料后的出血并發(fā)癥增多（常規(guī)治療組6.14%，延遲包扎組0.59%，＝0.001）。而因出血形成的假性動(dòng)脈瘤發(fā)生率在常規(guī)治療組明顯增加（1.53%0.00%，＝0.033）；隨著出血后局部壓迫止血等措施的實(shí)施，靜脈血栓雖有增加（0.77%0.30%，＝0.628），但差異無(wú)統(tǒng)計(jì)學(xué)意義。股動(dòng)脈穿刺點(diǎn)在應(yīng)用Angioseal后的出血并發(fā)癥除與穿刺技術(shù)相關(guān)外，PCI術(shù)后的抗凝、抗血小板藥物治療也是重要原因。在這些強(qiáng)化抗凝、抗血小板藥物治療的患者中適當(dāng)延長(zhǎng)壓迫時(shí)間，減少早期活動(dòng)是減少股動(dòng)脈穿刺點(diǎn)出血并發(fā)癥的重要手段。

老年人；股動(dòng)脈穿刺點(diǎn)；出血風(fēng)險(xiǎn)

經(jīng)股動(dòng)脈冠狀動(dòng)脈造影（coronary arteriography，CAG）及經(jīng)皮冠狀動(dòng)脈介入治療（percutaneous coronary intervention，PCI）術(shù)后動(dòng)脈穿刺口的處理至關(guān)重要。封閉動(dòng)脈穿刺點(diǎn)的方法有人工壓迫止血和血管閉合裝置等。近年來(lái)，由于人工壓迫止血有諸多局限和弊端[1]，血管閉合裝置的應(yīng)用日趨廣泛[2]，較之手工壓迫，能明顯降低穿刺點(diǎn)并發(fā)癥發(fā)生概率，但出血發(fā)生率仍然維持在1.5%～9%[3]，老年患者的出血并發(fā)癥更多。如何進(jìn)一步降低經(jīng)股動(dòng)脈穿刺介入檢查治療患者的出血并發(fā)癥，仍然是介入醫(yī)師面臨的課題。

1 對(duì)象與方法

1.1 入選標(biāo)準(zhǔn)

（1）診斷冠心病，包括急性心肌梗死或不穩(wěn)定型心絞痛，擬行CAG和PCI者；（2）為明確冠心病診斷或外科手術(shù)前評(píng)估擬行CAG檢查者；（3）股動(dòng)脈造影局部無(wú)明顯狹窄、斑塊及嚴(yán)重扭曲，符合Angioseal動(dòng)脈閉合裝置條件者；（4）年齡＞65歲；（5）已簽署知情同意書(shū)者；（6）排除肝腎嚴(yán)重功能障礙、凝血功能障礙、合并感染、心源性休克和術(shù)中發(fā)生穿刺部位血腫等；排除股動(dòng)脈穿刺處明顯動(dòng)脈粥樣硬化斑塊，管腔顯著狹窄；排除股動(dòng)脈嚴(yán)重鈣化、紆曲，動(dòng)脈多次穿刺合并血腫和穿刺點(diǎn)位于股動(dòng)脈分叉處以遠(yuǎn)。

1.2 圍介入期用藥

（1）術(shù)前常規(guī)使用阿司匹林（aspirin）、氯吡格雷（clopidogrel）拮抗血小板功能，他汀類藥物抗動(dòng)脈硬化；（2）術(shù)中常規(guī)肝素抗凝（CAG，2500～3000IU，冠狀動(dòng)脈支架治療為100IU/kg）；（3）急診、多支架、復(fù)雜冠狀動(dòng)脈病變患者在支架植入術(shù)后，依病情使用低分子肝素鈣或注射用替羅非班（tirofiban；均按說(shuō)明書(shū)使用）防支架內(nèi)血栓[4,5]。

1.3 分組和操作方法

（1）采用隨機(jī)對(duì)照研究。符合入選標(biāo)準(zhǔn)的病例隨機(jī)分入常規(guī)治療組（＝391）和延遲包扎組（＝337）。使用Angioseal封閉動(dòng)脈穿刺點(diǎn)后，常規(guī)治療組患者術(shù)后直腿平臥6h后可活動(dòng)，隨后于2h內(nèi)拆除加壓包扎換用彈力繃帶，以無(wú)菌紗布無(wú)壓力包扎穿刺點(diǎn)繼續(xù)觀察；延遲包扎組患者術(shù)后直腿平臥6h后可活動(dòng)，但于術(shù)后20～24h拆除加壓包扎換用彈力繃帶，以無(wú)菌紗布無(wú)壓力包扎穿刺點(diǎn)繼續(xù)觀察。（2）Angioseal的應(yīng)用：股動(dòng)脈造影符合Angioseal使用條件，經(jīng)動(dòng)脈鞘管插入導(dǎo)絲，撤動(dòng)脈鞘，送入定位鞘至其出現(xiàn)噴血，前送定位鞘1～2cm后拔出鞘芯，送入內(nèi)芯直至輸送鞘完全插入，回撤內(nèi)芯釋放可吸收錨板，然后一起拔出內(nèi)芯和定位鞘，回送定位管使膠原海綿成型和錨板粘連，抓住定位管和定位線保持拉力10s。觀察穿刺點(diǎn)無(wú)出血，剪斷定位線后無(wú)菌加壓包扎。（3）加壓包扎方法：皮膚穿刺點(diǎn)用無(wú)菌紗布覆蓋，以4～6層無(wú)菌紗布和1個(gè)繃帶卷覆蓋股動(dòng)脈穿刺點(diǎn)，以彈力繃帶十字交叉加壓固定上述無(wú)菌敷料。（4）血腫處理方法：停用低分子肝素鈣或替羅非班，手工壓迫股動(dòng)脈穿刺點(diǎn)和血腫部位20～30min，按前述加壓包扎方式重新包扎穿刺點(diǎn)，患者直腿平臥24h后，拆除加壓包扎換用彈力繃帶。如有假性動(dòng)脈瘤形成，則在超聲引導(dǎo)下用內(nèi)注射凝血酶粉治療，必要時(shí)請(qǐng)血管外科行外科手術(shù)治療。（5）在加壓包扎期間，鼓勵(lì)患者在保持直腿平臥的同時(shí)收縮下肢肌肉、活動(dòng)踝關(guān)節(jié)，以預(yù)防下肢靜脈血栓形成。

1.4 主要觀察指標(biāo)

血管并發(fā)癥包括大血管并發(fā)癥（后腹膜出血、假性動(dòng)脈瘤、動(dòng)靜脈瘺、血紅蛋白下降＞3g/dl或需要輸血）及其時(shí)機(jī)（術(shù)后＜6h出血為早期出血，＞6h為晚期出血）、下肢血栓導(dǎo)致缺血和上述原因需要外科修補(bǔ)。

1.5 統(tǒng)計(jì)學(xué)處理

2 結(jié) 果

2.1 入選患者一般資料

2011年1月至2012年12月共入組解放軍總醫(yī)院海南分院心內(nèi)科監(jiān)護(hù)室，符合要求病例728例，年齡（73.8±7.2）歲，男性460例，女性268例。其中常規(guī)治療組平均年齡73.6歲，延遲包扎組平均年齡73.9歲。兩組患者臨床基線特征（如性別、年齡、血壓等）、罹患冠心病類型/程度、CAG及PCI比例、合并高血壓、糖尿病等差異無(wú)統(tǒng)計(jì)學(xué)意義（＞0.05；表1）。

表1 兩組患者一般資料比較

STEMI: ST-segment elevation myocardial infarction; NSTEMI: non-ST segment elevation myocardial infarction; OMI: old myocardial infarction; SAP: stable angina pectoris; UAP: unstable angina pectoris; CAG: coronary angiography; PCI: percutaneous coronary intervention

2.2 穿刺點(diǎn)并發(fā)癥發(fā)生率

兩組患者的股動(dòng)脈穿刺點(diǎn)并發(fā)癥發(fā)生率有明顯差異。常規(guī)治療組的穿刺點(diǎn)出血、假性動(dòng)脈瘤等發(fā)生率明顯高于延遲包扎組（＝0.001）。其中出血并發(fā)癥增高主要表現(xiàn)為晚期出血增加，即PCI術(shù)后6h以后，拆除加壓包扎敷料后的出血并發(fā)癥增多（＝0.001）。而因出血形成的假性動(dòng)脈瘤發(fā)生率在常規(guī)治療組明顯增加（＝0.033）；隨著出血后局部壓迫止血等措施的實(shí)施，常規(guī)治療組靜脈血栓雖有增加，但差異無(wú)統(tǒng)計(jì)學(xué)意義（＝0.628；表2）。

2.3 抗凝/抗血小板治療的影響

抗凝、抗血小板聚集治療組出血率事件明顯增多（＝0.003），尤其以晚期出血增多明顯（＝0.001）。延遲包扎可以降低晚期出血的發(fā)生率（表3）。

3 討 論

冠心病PCI術(shù)后穿刺部位處理是圍術(shù)期管理的重要組成部分，是影響患者住院時(shí)間和住院滿意度的重要因素。隨著各種股動(dòng)脈穿刺點(diǎn)封堵器械的引入，傳統(tǒng)的人工壓迫止血并發(fā)癥多發(fā)的特點(diǎn)有所改善[6,7]。

表2 兩組患者穿刺血管并發(fā)癥比較

CAG: coronary angiography; PCI: percutaneous coronary intervention

表3 抗凝/抗血小板治療的影響

部分醫(yī)療機(jī)構(gòu)在PCI患者使用血管閉合器后6h或次日可以安排出院，說(shuō)明血管閉合裝置可有效替代人工壓迫止血，療效可靠。有臨床試驗(yàn)結(jié)果表明，Angioseal與人工壓迫相比不但可縮短止血時(shí)間，而且可顯著降低局部血腫并發(fā)癥的發(fā)生率。但也有相反資料提示，使用Angioseal的患者腹股溝血腫、出血、動(dòng)靜脈瘺、假性動(dòng)脈瘤、下肢動(dòng)脈血栓形成等的發(fā)生率并不低于手工壓迫組[8,9]。在老年患者中，由于動(dòng)脈硬化等因素，穿刺點(diǎn)出血、血腫等并發(fā)癥的發(fā)生率明顯高于普通成年人[10?13]。

本研究結(jié)果顯示，Angioseal在PCI患者中，穿刺點(diǎn)并發(fā)癥可發(fā)生于術(shù)后即刻的早期，也可發(fā)生于解除壓迫和制動(dòng)后的晚期。但更多發(fā)生于冠狀動(dòng)脈支架植入術(shù)后使用強(qiáng)化抗凝或抗血小板活性藥物的患者。

早期出血的發(fā)生與穿刺的一次成功率、是否穿透血管后壁、血管閉合器操作是否規(guī)范、加壓包扎方法是否正確等因素有關(guān)。股動(dòng)脈穿刺一次成功，避免多次試穿及透壁損傷，否則血管閉合裝置只能封閉主要穿刺點(diǎn)，而遺留其他動(dòng)脈壁損傷，造成術(shù)后出血。不管是血管閉合器的適應(yīng)證選擇不當(dāng)，還是操作不規(guī)范（如線沒(méi)拉緊、明膠海綿推送不到位等），都是潛在的導(dǎo)致出血的因素。加壓包扎操作不當(dāng)（如壓迫點(diǎn)選擇不當(dāng)、壓迫強(qiáng)度不夠等）也可以造成出血。

晚期出血?jiǎng)t更多與PCI術(shù)后使用強(qiáng)化抗凝、抗血小板活性藥物治療有關(guān)。多次穿刺、穿透動(dòng)脈后壁等因素，也可能參與影響股動(dòng)脈穿刺點(diǎn)晚期出血。隨著常規(guī)加壓包扎時(shí)間的延長(zhǎng)，局部血管外血栓的形成，按常規(guī)解除加壓包扎后，局部不會(huì)出血。PCI后強(qiáng)化抗凝治療，則抑制局部凝血功能。早期解除加壓包扎，可能導(dǎo)致局部出血事件發(fā)生。術(shù)后適當(dāng)延長(zhǎng)壓迫時(shí)間、減少過(guò)度活動(dòng)，是減少此類并發(fā)癥的重要手段。

當(dāng)然，壓迫過(guò)度或時(shí)間過(guò)長(zhǎng)，也可能增加下肢靜脈血栓等事件發(fā)生。在本組病例中，靜脈血栓多發(fā)生于穿刺點(diǎn)出血并發(fā)癥后再次加壓包扎止血的患者。這與第二次加壓包扎，不敢使用抗凝治療有關(guān)。

通過(guò)本組病例研究表明，股動(dòng)脈穿刺點(diǎn)在應(yīng)用Angioseal后的出血并發(fā)癥，除與穿刺技術(shù)相關(guān)外，PCI術(shù)后使用抗凝、抗血小板藥物治療也是重要原因。在這些強(qiáng)化抗凝、抗血小板藥物治療的患者中適當(dāng)延長(zhǎng)壓迫時(shí)間，減少早期活動(dòng)是降低股動(dòng)脈穿刺點(diǎn)出血并發(fā)癥發(fā)生率的重要手段。

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（編輯: 李菁竹）

Extending compression time reduces bleeding risk of femoral artery puncture point in elderly

XUE Qiao*, GAO Lei, LI Ke, HU Xin

(Department of Cardiology, Hainan Branch of Chinese PLA General Hospital, San’ya 572013, China)

To evaluate the effect of prolonged compression bandaging time on bleeding Atotol of complications after closing the femoral artery puncture point with the Angioseal artery occluders in the elderly.Totally 728 elderly patients were selected for coronary angiography and interventional treatment, whose femoral artery puncture points were closed with Angioseal. These patients were randomly divided into the conventional treatment group (keeping postoperative straight leg lie for 6 hours, and then elastic pressure bandage was removed within 2h) and delayed bandaging group (keeping postoperative straight leg lie for 6 hours, and then elastic pressure bandage was not removed until 20?24h). The vascular complications and occurrent time were observed.There was significant difference in femoral artery puncture site complications between two groups. The incidence of puncture site bleeding and pseudoaneurysm from conventional treatment group was significantly higher than that from delayed bandaging one (7.42%1.78%,＝0.001). And bleeding complications were manifested as increased hemorrhagic complications after removement of compression bandage (conventional treatment group, 6.14%, and delayed bandaging group, 0.59%,＝0.001). The formation incidence of pseudoaneurysm due to hemorrhage increased significantly in the conventional treatment group (1.53%0.00%,＝0.033). Although incidence of venous thrombosis due to local pressed hemostasis after bleeding increased (0.77%0.30%,＝0.628), there was no statistical difference.Bleeding complication of femoral artery puncture site with Angioseal not only related with the puncture technique, but also with PCI postoperative anticoagulation and antiplatelet treatment. Extending compression time and reducing the early activities appropriately are very important means of reducing femoral artery puncture site bleeding complications.

aged; femoral artery puncture point; bleeding risk

R592; R446.8

A

10.11915/j.issn.1671-5403.2015.02.026

(CWS12J122).

2014?11?06;

2014?12?31

全軍后勤科研計(jì)劃（CWS12J122）

薛 橋, E-mail: xueqiao301@sina.com