Gorog Diana A
Imperial College, London, and East and North Hertfordshire NHS Trust, Queen Elizabeth II Hospital, Howlands, Welwyn Garden City, Herts AL7 4HQ, UK.
Curr Treat Options Cardiovasc Med. 2007 Feb;9(1):52-9. doi: 10.1007/s11936-007-0051-0.
The success of intervention and clinical outcome is markedly reduced in patients who sustain distal embolization during percutaneous coronary intervention (PCI). Such embolization occurs in up to 15% of patients with acute myocardial infarction (AMI) undergoing PCI, and angiographic indicators of embolization are highly predictive of clinical and functional outcome. Saphenous vein graft (SVG) interventions carry a 20% risk of major adverse cardiac events (MACE), predominantly AMI, and significant risk of no-reflow. There are four types of embolic protection: distal occlusion/aspiration systems, filters, proximal occlusion/aspiration devices, and thrombectomy catheters. There seem to be no data to suggest that routine use of any embolic protection system is beneficial in patients with ST-elevation myocardial infarction (STEMI) undergoing PCI. The message from both the EMERALD and PROMISE trials is that embolic protection does not improve perfusion in the setting of AMI. Although pretreatment with thrombus aspiration before PCI improves angiographic reperfusion rates compared with standard PCI, enzymatic release and early clinical outcomes are not improved. Although the clinical implications of routine thrombus aspiration have yet to be established, selective use may be justified in patients with the highest thrombus burden. In addition, it should be considered in those with acute stent thrombosis and elective use of filter-based protection considered in very high risk vessel PCI (eg, last remaining conduit). There is no easy way to anticipate which SVG intervention will result in embolization. In SVG intervention, both balloon occlusion/aspiration and filter-based distal protection devices have significantly reduced the incidence of 30-day MACE, driven by AMI and should, I believe, be used routinely. Risk of complications is low with all the established devices. The profile and deliverability are continuing to improve with newer devices. Cost-effectiveness of selective use in high-risk graft cases has only recently been demonstrated.
在经皮冠状动脉介入治疗（PCI）期间发生远端栓塞的患者中，干预措施的成功率和临床结局会显著降低。这种栓塞在接受PCI的急性心肌梗死（AMI）患者中发生率高达15%，栓塞的血管造影指标对临床和功能结局具有高度预测性。隐静脉移植血管（SVG）介入治疗有20%的主要不良心脏事件（MACE）风险，主要是AMI，且无复流风险显著。有四种类型的栓子保护装置：远端闭塞/抽吸系统、过滤器、近端闭塞/抽吸装置和血栓切除术导管。似乎没有数据表明在接受PCI的ST段抬高型心肌梗死（STEMI）患者中常规使用任何栓子保护系统有益。EMERALD和PROMISE试验传达的信息是，栓子保护并不能改善AMI情况下的灌注。尽管与标准PCI相比，PCI前进行血栓抽吸预处理可提高血管造影再灌注率，但酶释放和早期临床结局并未得到改善。尽管常规血栓抽吸的临床意义尚未确立，但在血栓负荷最高的患者中选择性使用可能是合理的。此外，对于急性支架血栓形成的患者以及在极高风险血管PCI（如最后剩余的血管）中考虑选择性使用基于过滤器的保护措施时，也应予以考虑。没有简单的方法可以预测哪种SVG介入治疗会导致栓塞。在SVG介入治疗中，球囊闭塞/抽吸和基于过滤器的远端保护装置均显著降低了由AMI导致的30天MACE发生率，我认为应该常规使用。所有已确立的装置并发症风险都很低。随着新型装置的出现，其外形和可操作性正在不断改善。高风险移植病例中选择性使用的成本效益最近才得到证实。
