糖尿病下肢血管病变介入治疗长期随访及相关危险因素研究

发布时间：2018-03-11 10:26

  本文选题：2型糖尿病　切入点：介入治疗　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究目的糖尿病下肢血管病变是糖尿病常见的一种并发症,现已成为糖尿病患者截肢的主要原因。临床上干预措施主要包括内科药物、外科手术和导管介入等。介入治疗现已在临床上开展,但介入后的疗效尤其是远期效果仍存争议。本研究旨在探讨糖尿病下肢血管病变介入治疗的效果及影响血管再狭窄的危险因素,期以给予临床指导。研究方法选取自2006年1月至2015年12月在齐鲁医院内分泌科及血管外科住院的2型糖尿病下肢血管病变患者71例,采集患者的病历资料并进行随访,包括一般资料:性别,年龄,体重质量指数(BMI),踝肱指数(ABI);病史:糖尿病病程,高血压病程,脑梗塞病程,冠状动脉粥样硬化病程,吸烟史;实验室指标:低密度脂蛋白,高密度脂蛋白,甘油三脂,总胆固醇,肌酐,尿素氮,尿酸,糖化血红蛋白,尿微量白蛋白、C反应蛋白、同型半胱氨酸等,召集患者来齐鲁医院行下肢动静脉超声检查,分析糖尿病下肢血管病变患者行介入治疗后1年、2年、3年、5年、8年下肢血管通畅率,分析截肢率、全因死亡率,并探讨影响患者行下肢血管介入治疗后再狭窄的可能相关危险因素。结果本研究共随访71例行下肢血管介入治疗的糖尿病患者,随访时间最长8年,最短1年,平均随访时间2.80年。其中失访10例,失访率为14.08%,最终纳入该研究的为61例。其中男性41例,女性20例,男:女=2:1;平均年龄(68.11±8.88)岁,年龄最大84岁,最小49岁;年龄小于50岁的为3人,占4.90%;51-60岁的为12人,占19.700%;61-70岁的为21人,占34.40%;71-80岁的为21人,占34.40%;80岁以上的为4人,占6.60%。详见表1,图1。1.根据Fontaine分级,Ⅰ级有10例,Ⅱ级有13例,Ⅲ级有18例,Ⅳ级有20例。各组资料行统计学分析显示,年龄、性别、高血压病程等未见明显统计学差异(P0.05),吸烟史、FPG、LDL-C、CRP、尿Alb、Hcy之间差异具有统计学意义(P0.05)。详见表2。2.按泛大西洋协作组织(TASC)对下肢动脉硬化病变程度分级方法,将61例糖尿病下肢血管病变患者为A、B、C、D四型。四组经统计学分析显示,年龄、性别构成比相当,糖尿病病程、肌酐、尿素氮等代谢指标组间无明显差异(P0.05);四组间比较,吸烟史、LDL-C、CRP、尿Alb、Hcy之间有统计学差异(P0.05)。详见图2,图3,表3。3.随访期间截肢共11人,男性7人,女性4人,截肢率为18.03%。按照TASC对糖尿病下肢血管病变患者进行分组,在随访过程中A组患者截肢1例,B组患者截肢2例,C组患者截肢4例,D组患者截肢4例,分别占各组的4.34%,11.76%,36.36%,40.00%,经统计学分析显示A组与B组之间截肢率差异无统计学意义(P0.05),C组、D组与A组、B组之间截肢率差异具有统计学意义(P0.05)。详见表4,图4。4.随访期间死亡共9例,全因死亡率为14.70%,男性5例,女性4例,其中因心肌梗死去世的有2例,因肺癌去世的有1例,因肺部感染去世的有1例,因多脏器功能衰竭去世的有1例,因过敏性休克抢救无效去世的有1例,不明原因去世的有3例。死亡病例中从实施介入后生存5年的有6例,占67.67%;生存5年以上的有3例,占33.33%。5.61例糖尿病下肢血管病变患者当中,其中髂动脉闭塞5例,占所有闭塞的8.20%;股总动脉闭塞为8例,占13.11%;股深动脉闭塞为13例,占21.31%;股浅动脉闭塞为14例,占22.92%;乆动脉闭塞为10例,占16.39%;胫前动脉闭塞为5例,占8.20%;胫后动脉闭塞为6例,占9.83%。随访一年原闭塞部位保持通畅的为30例,通畅率为49.18%;随访2年通畅的有22例,通畅率为36.07%;三年通畅的有21例,通畅率为34.43%;5年通畅的有11例,通畅率为18.03%;8年通畅的有6例,通畅率为9.83%。随着介入时间的延长,血管发生再狭窄的概率增大。详见图5,图6。6.根据患者行介入治疗后1年是否发生再狭窄情况,分为再狭窄组(n=31),无狭窄组(n=30),对两组患者年龄,性别,HbA1c,尿A1b,糖尿病病程,高血压,吸烟史,脑梗,冠心病,血脂,Hcy,CRP行二元Logistic回归分析,采用向前选择法变量筛选方法,选入水准为0.05,剔除水准为0.10,分析显示尿A1b、Hcy、CRP是影响介入术后发生再狭窄的独立影响因素。详见表5,表6,表7,表8。结论1.吸烟史,血糖,血脂等在一定程度上影响着糖尿病下肢血管病变的发生发展,糖尿病下肢血管病变越重,CRP与Hcy水平越高。2.随着介入治疗时间的延长,下肢血管发生再狭窄的可能性增大,尿A1b、CRP、Hcy是血管发生再狭窄的独立影响因素,减少尿A1b的排泄,维持CRP与Hcy的较低水平可以在一定程度上减少再狭窄,关于介入后发生再狭窄的具体机制还有待进一步探索。3.介入治疗能较好改善患者下肢血管闭塞情况,防止血管远期发生再狭窄将是临床上的重中之重。
[Abstract]:Objective to study diabetic lower extremity arterial disease is a common complication of diabetes, has become the main reason for amputation in diabetes mellitus. Clinical interventions include medical, surgical and interventional. Interventional therapy is now in clinical development, but the effect after the intervention especially long-term effect is still controversial. And the effects of risk the purpose of this study is to investigate the vascular interventional treatment of diabetic lower extremity vascular disease factors of restenosis, to give clinical guidance. The research methods from January 2006 to December 2015 in 71 cases of type 2 diabetic patients with lower extremity vascular disease and vascular surgery in Department of endocrinology of Qilu Hospital, collecting medical records of the patients were followed up, including general information: gender, age and the body mass index (BMI), ankle brachial index (ABI); History: the duration of diabetes, hypertension, cerebral infarction, coronary disease. The course of atherosclerosis, smoking history; laboratory index: low density lipoprotein, high density lipoprotein, glycerin three fat, total cholesterol, creatinine, urea nitrogen, uric acid, glycosylated hemoglobin, urinary albumin, C reactive protein, homocysteine, called patients to Qilu Hospital of lower extremity venous ultrasonography of diabetic lower limb vascular patients with lesions of 1 years, after the intervention of 2 years, 3 years, 5 years, 8 years of lower extremity vascular patency rate analysis, amputation rate, all-cause mortality, and to explore the effect of patients with lower extremity vascular restenosis after interventional therapy may be related risk factors. The results of this study were followed up 71 cases of lower extremity vascular intervention in patients with diabetes mellitus for the longest follow-up period of 8 years, the shortest 1 years, the average follow-up time of 2.80 years. Among them 10 cases were lost, the lost rate was 14.08%, finally enrolled in this study were 61 cases. 41 patients were male, 20 were female, male: female =2:1; average 骞撮緞(68.11卤8.88)宀，

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