改良桡动脉路径颈动脉支架成形术的临床研究
本文选题：颈动脉 + 支架 ； 参考：《郑州大学》2016年博士论文
【摘要】：第一部分:改良桡动脉路径颈动脉支架成形术的临床研究研究背景及目的股动脉是CAS的常规路径,但是股动脉穿刺并发症高,舒适度差,且部分患者经股动脉手术困难或手术失败;传统经桡动脉路径CAS手术操作繁琐,成功率低,并发症高;本研究通过探讨改良经桡动脉路径CAS的可行性及安全性,总结改良经桡动脉路径CAS的注意事项、技术要点,器械及技术改进,为CAS开拓一个新的手术路径。材料与方法回顾性分析2015年9月至2016年6月郑州大学人民医院脑血管病介入治疗中心46例患者经桡动脉路径行CAS临床资料,分析技术成功率及围手术其心脑血管及穿刺并发症。回顾性分析2015年1月至2015年12月郑州大学人民医院脑血管病介入治疗中心46例经股动脉行CAS患者临床及手术资料,对比分析其与经桡动脉行CAS射线投射时间差异。回顾性分析2014年1月至2015年12月郑州大学人民医院脑血管病介入治疗中心20例经股动脉路径CAS治疗Ⅲ型主动脉弓合并右侧颈动脉狭窄及牛角型主动脉弓合并左侧颈动脉狭窄患者的临床及手术资料,对比分析其与经桡动脉CAS射线投射时间差异。结果所有患者均经右侧桡动脉入路,均经桡动脉进行脑血管造影,成功率100%,指引导管到位成功率98%,手术成功率98%。无严重心脑血管事件发生。1例患者出现桡动脉无症状性闭塞。经桡动脉路径CAS射线投照时间与经股动脉路径CAS射线投照时间对比分析差异无统计学意义(P=0.376)。Ⅲ型主动脉弓合并右侧颈动脉狭窄及牛角型主动脉弓合并左侧颈动脉狭窄患者经桡动脉路径CAS术中射线投射时间[(9.23±1.02)min]较经股动脉入路患者[(11.51±1.39)min]射线投照时间明显减少,差异有统计学意义(P=0.001)。结论改良经桡动脉路径CAS手术成功率高,并发症低是安全、可行的。经桡动脉路径CAS不增加手术难度;且克服了因股动脉、髂动脉、主动脉闭塞或严重迂曲等原因对CAS的限制,大大扩展了CAS的适应症;对于Ⅲ型主动脉弓合并右侧颈动脉狭窄及牛角型主动脉弓合并左侧颈动脉狭窄患者经桡动脉行CAS可减低手术难度,缩短手术时间及降低手术风险。第二部分:主动脉弓形态对颈动脉支架成形术入路选择的影响一530例主动脉弓DSA影像分析背景及目的主动脉弓及其分支血管是颈动脉支架成形的必经之路,被称为“脑前血管”,其分型及分支变异对颈动脉支架成形术有重大影响,本研究通过数字减影造影(DSA)对成人主动脉弓及其分支血管进行分析,观察主动脉弓分型及其分支的相关变异,并分析主动脉弓分型与性别、年龄、高血压、糖尿病、高脂血症等因素之间的相关性。旨在为颈动脉支架成形术的开展提供帮助。材料与方法分析本中心2015年1月-2016年12月的530例主动脉弓数字剪影血管造影(DSA)患者的影像资料及临床资料。男性347例(65.5%),女性183例(34.5%);年龄18~83岁,平均年龄58.3±11.7岁。主动脉弓分支变异进行分类方法采取:以De Garis的分型法与Mc Donald、Anson的分型法相结合的方法进行分型。主动脉弓分型采取:测量主动脉弓顶到头臂干的垂直距离,以优势侧颈总动脉直径为参照标准(多以左侧颈总动脉为标准),1倍以内的是Ⅰ型,大于2倍者为Ⅲ型,距离介于1~2倍之间为Ⅱ型主动脉弓。并统计分析主动脉弓分型情况。采用SPSS 18.0软件,所有患者的人群基本特征、临床特点及主动脉弓型经采集后进入数据库,统计方法采用采用单变量分析方法,有统计学意义的指标进行Logistic检验,差异具有统计学意义为P0.05。结果主动脉弓分型:530例患者中Ⅰ型231例43.6%(男143例,女88例),Ⅱ型167例31.5%(男105例,女62例),Ⅲ型132例24.9%(男99例,女33例)。青年组(≤44岁)95例,Ⅰ型69例,Ⅱ型19例,Ⅲ型7例,其中30岁以下患者9例均为Ⅰ型;中年组(45~59岁)184例,Ⅰ型99例,Ⅱ型54例,Ⅲ型31例;老年组(≥60岁)251例,Ⅰ型63例,Ⅱ型94例,Ⅲ型94例。单因素分析有统计学意义的年龄、冠心病、甘油三酯、高密度脂蛋白胆固醇4项指标进行多因素Logistic回归分析,结果显示:年龄是Ⅲ型主动脉弓的独立危险因素。主动脉弓上分支变异:530例患者中正常3干440例(81.1%),主动脉弓及其分支变异LCCA与BCT共干、LSCA:37例;LCCA发自BCT、LSCA:29例;BCT、LCCA、LVA、LSCA:18例;LCCA与RCCA共干、RSCA、LSCA:2例;无BCT、RCCA、LCCA、LVA、LSCA、迷走RSCA最后发出:2例;LCCA与RCC共干发自BCT、LSCA:1例,主动脉弓分支变异发生率男女组间差异无统计学意义(P㧐0.05)。结论老年人群中Ⅲ型主动脉弓比例显著升高;主动脉弓及其分支变异发生率相对较高,最常见的是左侧颈总动脉与头臂干共干/共同开口;Ⅲ型主动脉弓及主动脉弓分支变异患者经股动脉行颈动脉支架成形手术难度及风险均明显增大,而经桡动脉路径则相对简易,需引起神经介入医生术前高度关注。
[Abstract]:The first part: the clinical research background and objective femoral artery of modified radial artery pathway carotid artery stenting is the routine route of CAS, but the femoral artery puncture complications are high, the comfort is poor, and some patients are difficult to operate through the femoral artery or the operation failure. The traditional radial artery route CAS operation is tedious, the success rate is low, and the complications are high. In this study, the feasibility and safety of the modified transradial artery pathway CAS were discussed, and the improvement of CAS by radial artery pathway was summarized, and the technical points, instruments and techniques were improved to open up a new surgical path for CAS. The materials and methods were reviewed for the interventional treatment of cerebrovascular disease in the people's Hospital of Zhengzhou University from September 2015 to June 2016. The clinical data of 46 patients with CAS from the radial artery were carried out to analyze the success rate and the peri operative cardiovascular and puncture complications. The clinical and surgical data of 46 patients with CAS in the interventional therapy center of the cerebral vascular disease, Zhengzhou University, from January 2015 to December 2015, were retrospectively analyzed and compared with the radial artery. The differences in the time of CAS ray projection. A retrospective analysis of the clinical and surgical data of 20 cases of cerebral vascular disease interventional therapy center in the people's Hospital of Zhengzhou University from January 2014 to December 2015 with the treatment of the femoral artery pathway CAS in the treatment of type III aortic arch with right carotid artery stenosis and angular aortic arch with left carotid artery stenosis. The CAS ray projection time of the radial artery was different from that of the radial artery. All the patients underwent cerebral angiography through the radial artery through the right radial artery. The success rate was 100%, the success rate of the catheter was 98%, the success rate of the operation was 98%. without serious cardio cerebral vascular events and the asymptomatic occlusion of the radial artery occurred in the.1 patients. The CAS ray through the radial artery pathway There was no significant difference between the time of exposure and the time of CAS ray exposure through the femoral artery (P=0.376). Type III aortic arch combined with right carotid artery stenosis and the radiographic projection time of the left carotid artery stenosis in patients with left carotid artery stenosis via the radial artery path CAS [(9.23 + 1.02) min] compared with the femoral artery approach patients [11.51] The time of min] ray exposure decreased significantly (P=0.001), and the difference was statistically significant (P=0.001). Conclusion it is safe and feasible to improve the successful rate of CAS operation through the radial artery path, and it is feasible. The route of the radial artery path does not increase the difficulty of operation; and it overcomes the limitation of the CAS because of the femoral and iliac arteries, the aorta occlusion or severe tortuosity. Extension of the indications of CAS; for the type III aortic arch with right carotid artery stenosis and the angular aortic arch with left carotid artery stenosis patients with left carotid artery stenosis, CAS can reduce the difficulty of operation, shorten the operation time and reduce the risk of operation. Second part: the effect of the aortic arch shape on the choice of carotid artery stenting approach is 530 The aortic arch DSA image analysis background and objective aortic arch and its branch vessel is the only way of carotid artery stenting. It is called "anterior cerebral vascular". Its classification and branch variation have great influence on carotid artery stenting. This study analyzed adult aortic arch and its branch vessels by digital subtraction angiography (DSA). To observe the correlation between aortic arch classification and its branches, and analyze the correlation between aortic arch classification and sex, age, hypertension, diabetes, hyperlipidemia and other factors. The purpose is to provide help for the development of carotid artery stenting. Materials and methods were analyzed in 530 cases of aortic arch digital silhouette in December -2016 January 2015. Angiography (DSA) patients' imaging data and clinical data. Male 347 (65.5%), female 183 cases (34.5%); age 18~83 years, average age 58.3 + 11.7 years old. Aortic arch branch variation was classified by classification of De Garis typing with Mc Donald, Anson typing method. Aortic arch classification was taken: Measurement The vertical distance from the top of the aortic arch to the head of the brachial trunk, with the diameter of the dominant common carotid artery as the reference standard (more than the left common carotid artery as the standard), was type I within 1 times, the type of type I was type III more than 2 times, and the distance between 1~2 times was type II aortic arch. The aortic arch classification was statistically analyzed. SPSS 18 software was used in all patients. The basic features, clinical characteristics and the aortic arch type were collected into the database. Statistical methods were used for Logistic test with statistically significant indexes. The difference was statistically significant for the P0.05. result of aortic arch typing: 530 cases were type I 231 cases 43.6% (male 143, female 88), and type II 167 cases 31.5% (3 cases). Male 105, female 62 cases, type III 132 cases 24.9% (men 99 cases, 33 cases). Young group (< < 44 years old) 95 cases, type I 69 cases, 19 cases, 19, 7 cases, among them 30 years, 9 cases are all type I; middle age group (45~59 years) of 184 cases, type I cases, type III cases, type III cases, type I cases, type I cases, type III cases, type III cases. The statistically significant age, coronary heart disease, triglyceride, and high density lipoprotein cholesterol were analyzed by multiple factor Logistic regression analysis. The results showed that age was an independent risk factor for the type III aortic arch. The branch variation in the aortic arch: 440 cases of normal 3 dry (81.1%) in 530 cases, the aortic arch and its branch variation LCCA and BCT, LS CA:37 cases; LCCA from BCT, LSCA:29 cases; BCT, LCCA, LVA, LSCA:18 cases; LCCA and RCCA co dry, RSCA, LSCA:2 examples; there are 2 cases; there is no statistical difference between male and female group of aortic arch branch variation (0.05). Conclusion the type III aortic arch in the elderly population The incidence of the aortic arch and its branch variation is relatively high, the most common is the common trunk / joint opening of the left common carotid artery and the head arm, and the degree of difficulty and risk of the carotid artery stenting in the patients with the type III aortic arch and the aortic arch branch is significantly increased, while the radial artery path is relatively simple. It is necessary to arouse the attention of the doctor before the operation of the nerve.
【学位授予单位】：郑州大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R743.3
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