八、心外并发症
1.造影剂肾病 CTO介入时造影剂用量较大，造影剂肾病的风险也随之增加。造影剂肾病的定义为血管内注射碘造影剂后3天内，在排除其他病因的前提下，肾功能发生损害，血清肌酐水平升高0.5 mg/dl（44.2 μmol/L）或比基础值升高25%。一项18 061例患者的荟萃分析显示，造影剂肾病的发生率为3.8%。
图22—0—15 双向弹簧圈封堵侧支穿孔
62岁女性，陈旧性前壁心肌梗死，造影见前降支中段完全闭塞，钝缘支向前降支中远段提供侧支循环（A）。采用逆向技术，Corsair微导管在Sion导丝引导下成功送至前降支远端，微导管造影见侧支穿孔（B），指引导管造影见穿孔点双向供血（C）。穿孔外渗不多，无症状，决定继续逆向干预。更换GAIA First导丝成功逆向通过闭塞段，送入RG3导丝体外化（D～E），正向送入130cm Finecross微导管至前降支远端（F），撤出RG3导丝（G），经逆向Finecross微导管送入弹簧圈一枚封堵穿孔部位（H）。正向送入Sion导丝，球囊预扩张后植入2.25mm×18mm DES（I）。复查造影远端侧支仍有造影剂外渗（J），正向送入Finecross微导管送入弹簧圈一枚封堵穿孔部位（K）。床旁心超见中等量心包积液，行心包穿刺引流术，引出新鲜血液240 ml。最后造影未见造影剂外渗（L）。观察6天后患者顺利出院
预防造影剂肾病需要记住6字方针：分层、水化、限量。①分层：术前甄别造影剂肾病的高危患者，包括高龄、糖尿病、基础状态肾功能不全、心力衰竭、贫血及血流动力学不稳定等；②水化：对高危人群术前进行水化，术前12 h采用等渗生理盐水1 ml/（kg·h），维持到术后12～24 h；③限量：术中尽量减少造影剂用量，避免短时间内重复使用造影剂。
2.放射性损伤 放射性损伤包括皮肤灼伤、肿瘤发生风险增加、脱发、白内障等。放射性皮肤灼伤往往是同一体位长时间曝光所致，在CTO介入中发生率大约为1.5%。放射性皮肤损伤具有以下几个特点：不易感知；常在手术后数天发生，个别患者甚至在数月后发生；常发生在背部；最常见的症状是轻度红斑。放射性皮肤坏死是一种无菌性坏死，伤口难自愈，有时需要外科手术植皮治疗。
减少放射损伤的基本原则如下：防护设备要充分利用；导管床要升高（离机头最少80cm），平板或影像增强器要尽可能贴近患者，减少透视和电影时间；影像不要过度放大；采用最小帧频；避免长时间同一体位曝光；曝光角度不要过小；一次性操作时间不要过长；第二次介入手术与第一次相距1个月以上等。
总之，CTO介入治疗的宗旨是并发症最小化、获益最大化。全力开通是目标，及时收手是底线。CTO介入术者要胆大心细，料敌于先，出现并发症后要冷静合理地选择处置对策，最大限度降低并发症造成的损害。目前，我国CTO术者的介入治疗技术水平差异较大，为减少术中并发症风险，介入医师应敬畏生命，熟练掌握CTO PCI的适应证，尽量做到规范化处理CTO病变，避免并发症的发生。
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