Lincoff A M, Popma J J, Ellis S G, Vogel R A, Topol E J
Department of Internal Medicine (Cardiology Division), University of Michigan Medical Center, Ann Arbor 48109-0022.
J Am Coll Cardiol. 1991 Mar 1;17(3):770-80. doi: 10.1016/s0735-1097(10)80197-4.
Indications for coronary angioplasty have expanded to include patients with unstable acute ischemic syndromes, severe multivessel coronary artery disease and impaired left ventricular function. Several mechanical approaches have been developed as adjuncts to high risk coronary angioplasty to improve patient tolerance of coronary balloon occlusion and maintain hemodynamic stability in the event of complications. These percutaneous techniques include intraaortic balloon counterpulsation, anterograde transcatheter coronary perfusion, coronary sinus retroperfusion, cardiopulmonary bypass, Hemopump left ventricular assistance and partial left heart bypass. The intraaortic balloon pump provides hemodynamic support and ameliorates ischemia by decreasing myocardial work; it may be inserted for periprocedural complications or before angioplasty in patients with ischemia or hypotension. Anterograde distal coronary artery perfusion may be accomplished passively through an autoperfusion catheter or by active pumping of oxygenated blood or fluorocarbons through the central lumen of an angioplasty catheter. Synchronized coronary sinus retroperfusion produces pulsatile blood flow via the cardiac veins to the coronary bed distal to a stenosis. Both perfusion techniques limit development of ischemic chest pain and myocardial dysfunction in patients undergoing prolonged balloon inflations. Percutaneous cardiopulmonary bypass provides complete systemic hemodynamic support which is independent of intrinsic cardiac function or rhythm and has been employed prophylactically in very high risk patients before coronary angioplasty or emergently for abrupt closure. These and newer support devices, while associated with significant complications, may ultimately improve the safety of coronary angioplasty and allow its application to those who would otherwise not be candidates for revascularization.
冠状动脉血管成形术的适应证已扩大到包括不稳定型急性缺血综合征、严重多支冠状动脉疾病和左心室功能受损的患者。已经开发了几种机械方法作为高危冠状动脉血管成形术的辅助手段，以提高患者对冠状动脉球囊闭塞的耐受性，并在出现并发症时维持血流动力学稳定。这些经皮技术包括主动脉内球囊反搏、顺行性经导管冠状动脉灌注、冠状静脉窦逆行灌注、体外循环、Hemopump左心室辅助和部分左心旁路。主动脉内球囊泵通过减少心肌做功提供血流动力学支持并改善缺血；它可在围手术期并发症时插入，或在有缺血或低血压的患者进行血管成形术前插入。顺行性冠状动脉远端灌注可通过自动灌注导管被动完成，或通过将含氧血液或氟碳化合物主动泵入血管成形术导管的中心腔来完成。同步冠状静脉窦逆行灌注通过心脏静脉产生搏动性血流至狭窄远端的冠状动脉床。两种灌注技术都可限制接受长时间球囊扩张的患者出现缺血性胸痛和心肌功能障碍。经皮体外循环提供完全独立于心脏固有功能或节律的全身血流动力学支持，已在冠状动脉血管成形术前预防性用于极高风险患者，或在紧急情况下用于急性血管闭塞。这些及更新的支持装置虽然伴有严重并发症，但最终可能提高冠状动脉血管成形术的安全性，并使其能够应用于那些否则不适合进行血运重建的患者。
