无保护左主干分叉部病变不同介入治疗策略的回顾性分析

发布时间：2018-04-23 03:17

本文选题：无保护左主干病变 + 左主干分叉病变　；参考：《郑州大学》2017年硕士论文

【摘要】：【背景】随着技术的发展以及检查设备的完善,人们对左主干病变的认识也在不断变化与成熟。冠状动脉造影(CAG)的出现以及血管内超声(IVUS)的应用等让我们能够更加直观准确的辨认左主干病变,评估左主干病变解剖特点,而有关左主干病变的研究也层出不穷。长期以来冠状动脉旁路移植术(CABG)是无保护左主干(ULMCA)病变治疗的标准方案,介入治疗曾经是ULMCA的禁忌。近年来随着药物涂层支架的出现,有关CABG与介入治疗的随机临床试验研究的开展,这种根深蒂固的观念逐渐动摇,临床指南也随之做出了重大更新,将无保护左主干病变的介入治疗由原来的禁忌症修改升级为IIa,B类适应症(SYNTAX≤32分),甚至对经过选择的左主干病变可作为介入治疗的I,B类适应症(SYNTAX≤22),指南的更新无疑为介入医生提供了强有力的证据。随着介入设备的发展、介入技术的成熟、新一代冠脉支架的问世,目前ULMCA病变的介入治疗已成为能与CABG术相媲美的血运重建方式。左主干病变中最为复杂多变的病变类型便是左主干分叉部病变,其介入治疗策略简单可概括为两种方式:单支架与双支架。此二者各有其优缺点:如单支架术式简单,符合“越简单越好”的介入原则,对原始血管改造较少,对于患者及术者更易接受,然而单支架置入有其弊端,例如Crossover技术对边支影响不确定;双支架能够获得较好的即刻效果,然而其术式相对复杂,改变了原始血管结构,远期预后可能受到影响。临床上有关此类病变的介入治疗策略选择仍存争议,相关研究结果也不尽相同。两种治疗策略对无保护左主干分叉部病变治疗孰优孰劣仍无定论,可用于临床参考的数据资料也相对缺乏。【目的】本文通过对无保护左主干分叉部病变患者临床基础资料及介入相关信息进行回顾性分析,探究无保护左主干分叉部病变不同的介入治疗策略对临床结果的影响,为介入医生临床治疗左主干病变提供更多文献参考与依据。【方法】入选2012年1月至2016年1月收入郑州大学第一附属医院心血管内科,冠脉造影示无保护左主干分叉部病变患者136例,并收集其详细的临床资料,包括病史、检查检验、介入手术相关资料、术后并发症发生情况、住院期间主要心血管事件(mace)发生情况以及1年随访资料,进行回顾性统计分析。mace事件包括心源性死亡、心肌梗死(mi)、靶病变血运重建(tlr)。纳入标准:1.冠脉造影示左主干分叉部病变(管腔狭窄50%);2.左主干不存在通畅的桥血管或者良好的的自身侧枝;3.均使用药物涂层支架(des)治疗。排除标准:1.急性或者慢性左主干闭塞;2.左主干严重钙化需旋磨者;3.左主干分叉部位原有支架置入者;4.因介入操作导致左主干遭受损伤行补救性支架置入者;5.恶性进展性疾病,预期寿命小于1年者;6.有cabg术病史者;7.严重心肺功能不全者;8.严重肝肾功能不全者;9.左主干合并其他严重瓣膜病、心肌病以及恶性心律失常者。纳入的136例患者,按照左主干分叉部位置入支架情况分为:单支架组(n=74)与双支架组(n=62)。记录所有入选患者临床资料、造影资料以及随访结果,应用统计学软件spss17.0对两组患者的相关资料进行统计分析,以p0.05为差异有统计学意义。【结果】(1)共入选136例左主干分叉部病变患者,置入单支架患者74例,置入双支架患者62例,所有患者均未出现严重的围手术期并发症(包括急性脑出血事件、急性消化道出血、造影剂肾病及脑病、急性支架内血栓形成、急性心包填塞等);且两组患者住院期间mace事件发生率为0。(2)单支架组患者syntax评分较双支架组高,其中轻度病变者(即syntax≤22分)单支架组较双支架组所占比例高,而中重度病变者(syntax≥23分)双支架组较单支架组所占比例高,差异有统计学意义;真性分叉(medina(3)1,1,1、1,0,1型)在单支架组较双支架组少,而假性分叉(Medina 1,1,0型)在单支架组较双支架组多,差异有统计学意义。(3)1年随访期间MACE事件发生率双支架组较单支架组高,差异有统计学意义(p0.05);双支架组TLR较单支架组高(p0.05),而两组心源性死亡率、MI发生率均无统计学差异(p0.05)。对两组患者SYNTAX评分、Medina分型进行分层分析结果显示:SYNTAX提示轻度病变患者中,单支架组MACE发生率较双支架组明显较小(p0.05),且主要体现在TLR上(p0.05);中重度病变患者中,两组MACE事件发生无显著差异;两组无论真性分叉(Medina1,1,1、1,0,1)还是假性分叉(Medina1,1,0)病变,其MACE发生率以及TLR等均无显著差异。【结论】1.准确评估左主干病变性质及解剖特点,对于选择介入策略至关重要。2.对于病变性质及解剖特点较为简单的左主干分叉部病变患者,单支架策略可能为更合适的选择;而对于病变性质及解剖特点较为复杂的左主干分叉部病变患者,单支架策略并不弱于双支架策略。
[Abstract]:[background] with the development of technology and the perfection of the inspection equipment, people's understanding of the left main disease is also changing and maturing. The appearance of CAG and the application of intravascular ultrasound (IVUS) make it more intuitive and accurate to identify the left main lesion and evaluate the anatomical characteristics of the left main disease, and the left The study of main stem lesions is also emerging. Coronary artery bypass grafting (CABG) has long been a standard scheme for the treatment of unprotected left main stem (ULMCA) lesions. Interventional therapy has been a taboo of ULMCA. In recent years, with the emergence of drug coated stents, a randomized clinical trial of CABG and interventional therapy has been carried out, which is deeply rooted The concept is gradually shaken, and the clinical guide has also made a major update. The intervention therapy of the unprotected left main lesion is upgraded from the original contraindication to IIa, B (SYNTAX < 32), even the selected left main lesion can be used as I for interventional therapy and B (SYNTAX < < 22). The update of the guide is undoubtedly involved in the intervention. Doctors provide strong evidence. With the development of the interventional equipment and the maturation of interventional techniques, the advent of a new generation of coronary stents, the interventional therapy of ULMCA lesions has become a way of revascularization comparable to that of CABG. The most complex and changeable pathological type of the left main disease is the left main bifurcation lesion and its interventional therapy The strategy can be summed up in two ways: single stents and double stents. Each of these two has its advantages and disadvantages. For example, single stent is simple and fits the principle of "simpler and better". It has less modification to the original blood vessels and more acceptable to patients and operators. However, single stent placement has its drawbacks, such as the uncertainty of Crossover technology on the side. The double stent has a better immediate effect, but its operation is relatively complex, the original vascular structure is changed and the long-term prognosis may be affected. The selection of intervention strategies for such lesions is still controversial and the results are not the same. The two treatment strategies are better for the treatment of the unprotected left main bifurcation lesion. It is still inconclusive and can be used for clinical reference data. Doctors provide more reference and basis for clinical treatment of left main disease. [Methods] 136 patients were enrolled in the Department of cardiovascular medicine, the First Affiliated Hospital of Zhengzhou University from January 2012 to January 2016. Coronary angiography showed no protection of left main branches of the left main lesion, and collected the detailed clinical data, including medical history, examination and intervention. Data, postoperative complications, the incidence of major cardiovascular events (MACE) and 1 years of follow-up during hospitalization, and a retrospective statistical analysis of.Mace events included cardiac death, myocardial infarction (MI) and target lesion revascularization (TLR). 1. coronary angiography showed the left main bifurcation lesion (50%); 2. left main trunk There were no smooth bridge vessels or good lateral branches; 3. were treated with drug coated stents (DES). Exclusion criteria: 1. acute or chronic left main stem occlusion; 2. left main trunk calcification for severe calcification; 3. left main stem bifurcations in the original stents; 4. the left main trunk was damaged by interventional operation for remedial stent placement. Patients with 5. malignant progressive diseases, life expectancy less than 1 years; 6. patients with CABG history; 7. patients with severe cardiopulmonary insufficiency; 8. severe liver and kidney insufficiency; 9. left main trunk with other severe valvular disease, cardiomyopathy and malignant arrhythmia. 136 patients were divided into single stents according to the position of the left main trunk. N=74) and the double stent group (n=62). Record all the selected patients' clinical data, imaging data and follow-up results. Statistical software SPSS17.0 was used to analyze the related data of two groups of patients with statistical significance. [results] (1) a total of 136 patients with left main bifurcation lesions were selected and 74 cases were placed in single stents. There were 62 patients with double stents. All patients had no serious perioperative complications (including acute cerebral hemorrhage, acute gastrointestinal bleeding, contrast nephropathy and encephalopathy, acute stent thrombosis, acute pericardial tamponade, etc.); and the incidence of mace events in the two groups was 0. (2) in the single stenting group, with a higher SYNTAX score. The proportion of stent group was higher, and the proportion of mild lesion (syntax < 22) single stent group was higher than that of double stenting group, while the proportion of middle and severe lesion (syntax > 23) double stent group was higher than that of single stents group, and the difference was statistically significant. The true bifurcation (Medina (3) 1,1,1,1,0,1 type) was less in the single stents group than in the double stents group, and the false branching (Medina 1,1, Medina). The difference was statistically significant in the single stenting group compared with the double stenting group. (3) the incidence of MACE events during the 1 year follow-up was higher than that in the single stents group (P0.05), and the TLR in the two stents group was higher than that of the single stents group (P0.05), but there was no statistical difference between the two groups of cardiac mortality and the incidence of MI (P0.05). The SYNTAX evaluation of the two groups of patients was not statistically significant (P0.05). The results of stratified analysis of Medina typing showed that the incidence of MACE in the single stent group was significantly smaller than that in the double stenting group (P0.05) in the patients with mild lesions (P0.05), and mainly on TLR (P0.05). There were no significant differences in the two groups of MACE events in the patients with moderate and severe lesions, and the two groups were either genuine bifurcation (Medina1,1,1,1,0,1) or false bifurcation (M). Edina1,1,0) there were no significant differences in the incidence of MACE and TLR. [Conclusion] 1. the accurate assessment of the nature and anatomical characteristics of the left main artery disease is critical to the choice of the intervention strategy for the patients with the left main branch of the left main lesion, which is very simple for the nature of the lesion and the anatomical characteristics of the left trunk, and the single stent strategy may be a more appropriate choice. Single stent strategy is not less effective than dual stent strategy in patients with complex left main bifurcation lesions.

【学位授予单位】：郑州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R54

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