冠脉腔内影像学指导冠脉重度钙化病变介入治疗中影响支架膨胀不良的相关因素分析

发布时间：2018-04-24 14:52

本文选题：经皮冠状动脉介入治疗 + 冠状动脉钙化　；参考：《中国人民解放军医学院》2017年博士论文

【摘要】：研究背景:冠脉重度钙化病变经皮冠脉介入治疗术(Percutaneous coronary intervention, PCI)中,支架膨胀不良发生率高,从而增加了心血管不良事件(Major adverse cardiac event, MACE)的发生率。经冠脉旋磨术(Rotational atherectomy,RA)联合切割球囊成形术(Cutting balloon angioplasty, CB)充分预处理重度钙化病变,可能有利于支架良好膨胀,改善近远期预后,但是相关研究数据较少。此外,重度钙化病变PCI治疗中,相关钙化参数如何影响支架膨胀不良,研究甚少。研究目的:1、评价旋磨术联合切割球囊成形术,充分预处理重度冠脉钙化狭窄病变,支架置入的膨胀效果及MACE事件。利用冠脉造影定量分析(Quantitation coronary analyze, QCA),以及冠状动脉血管内超声(Intra-Vascular ultrasound, IVUS)评价支架膨胀不良的相关影响因素,探讨重度钙化病变中预处理的标准。2、利用冠脉光学相干断层成像(Optical coherence tomography, OCT)评价,经过旋磨联合切割球囊处理后的重度冠脉钙化病变中,支架膨胀不良的相关影响因素。研究方法:1、回顾性分析2013年1月至2015年12月,在中国人民解放军总医院,行冠状动脉造影(Coronary artery angioplasty,CAG)及IVUS检查的,92例冠脉高度钙化伴狭窄的冠心病患者。其相关缺血病变均经RA处理,根据是否联合切割球囊分为RA联合CB (RACB)组46例,以及单纯旋磨(ROTA)组46例。根据钙化程度,年龄,性别等因素,匹配了 40例仅经普通球囊处理的冠脉高度钙化患者,为普通球囊处理(POBA)组。所有患者均在病变预处理后,置入第二代药物洗脱支架。在病变处理前,旋磨后,切割/普通球囊扩张后,以及支架置入后,均使用QCA测量管腔直径,和管腔直径狭窄率。使用IVUS观察病变钙化相关参数,以及预处理后钙化环断裂。分析支架膨胀不良的影响因素。2、前瞻性分析在我中心行冠脉旋磨术联合切割球囊成形术,并于术中行OCT检查的重度钙化病变的患者9例。在旋磨联合切割预处理后,和支架置入后,使用OCT自动回撤记录病变相关血管段,记录最小管腔面积,钙化弧度,钙化长度,钙化厚度,钙化组织表面组织厚度,钙化环断裂,钙化小结,支架置入后支架面积,支架贴壁情况,以及组织脱垂情况。按2mm为一病变节段,共收集148个病变节段,其中105个钙化节段。分析影响支架膨胀不良,贴壁不良的因素,以及影响钙化环断裂的因素。研究结果:1、在ROTA和RACB两组中,病变处理前,以及旋磨后,管腔直径和直径狭窄率均未见统计学差异。但是在经过不同球囊预处理后,RACB组的管腔直径狭窄率明显减低(从54.5%±8.9%降至36.1%±7.1%),而ROTA组的管腔直径狭窄率仅轻度减低(从55.7%±7.8%到46.9%±9.4%),P0.001。支架置入后,RACB组的良好支架膨胀比例(71.7%)明显高于ROTA组(54.5%),和POBA组(15%),P0.001。并且支架置入后的残余管腔狭窄率在RACB组(6.0%±23%),明显低于另两组(RA 组 10.8%±3.3%,POBA 组 12.7%±2.1%), P0.001。2、病变预处理后管腔直径狭窄率≤40%,与支架良好膨胀相关(OR=2994, 95%CI:1.297-6.911)。IVUS下观察到的钙化环断裂,与病变预处理后管腔狭窄率≤40%呈正相关(r=0.581,P0.001)。3、OCT观察的105段钙化病变节段中,平均最小管腔面积2.4±0.76mm2,钙化弧度164.3±86.4°,钙化长度1.72±0.39mm,钙化厚度0.47±0.18mm,钙化表层组织厚度0.15 ±0.14mm, 42个钙化节段出现钙化环断裂(40%)。支架置入后,平均支架面积为5.26±1.11mm2,29个节段出现支架膨胀不良(27.6%), 29个节段出现支架贴壁不良,24个节段出现组织脱垂(22.9%)。4、OCT观察下,支架膨胀不良的主要影响因素为钙化环断裂(OR=0.160,95%CI:0.050,0.516),以及预处理后的最小管腔面积(OR=1.87,95%CI:1.021, 3.425)。支架贴壁不良的主要影响因素为钙化弧度(OR=1.006,95%CI:1.001,1.011)。钙化环断裂的主要影响因素为,钙化弧度(OR=1.008,95%CI:1.002,1.015),以及钙化表面组织厚度(OR=0.000,95%CI: 0.000,0.001)。研究结论:1、旋磨联合切割球囊成形术预处理重度钙化病变,可以增加钙化环断裂比例,减少管腔残余狭窄率,有利于支架良好膨胀。2、预处理后管腔直径狭窄≤40%,是支架膨胀良好的预测因素。而预处理后出现钙化环断裂,与预处理后管腔直径狭窄≤40%相关。3、经旋磨联合切割球囊充分预处理钙化病变后,OCT下观察的支架膨胀不良以及贴壁不良的发生率较低。4、重度钙化病变预处理后,钙化环断裂,以及管腔面积的增加,可能有助于支架良好膨胀。而旋磨联合切割处理钙化病变后,钙化环断裂的发生与OCT下观察到的广泛的钙化弧度,以及钙化表面组织厚度0.1mm相关。
[Abstract]:Background: the incidence of stent dilatation is high in Percutaneous coronary intervention (PCI), which increases the incidence of adverse cardiovascular events (Major adverse cardiac event, MACE). Coronary artery rotation (Rotational atherectomy, RA) combined balloon angioplasty (Rotational atherectomy, RA) Tting balloon angioplasty, CB) fully preconditioning severe calcification, may be beneficial to the good expansion of the stent, improve the near and long term prognosis, but the related research data are few. In addition, in the PCI treatment of severe calcification, how the related calcification parameters affect the stent dilatation is very rare. 1. Plasty, fully preprocessing of severe coronary artery calcification, the expansion effect of stent implantation and MACE events. Using Quantitation coronary analyze (QCA), and coronary artery intravascular ultrasound (Intra-Vascular ultrasound, IVUS) to evaluate the related factors of stent dilatation, and to explore the severe calcification disease. The standard.2, Optical coherence tomography (OCT), was used to evaluate the related factors of poor stent dilatation in severe coronary artery calcification after a combined balloon treatment. 1. A retrospective analysis from January 2013 to December 2015 in the Chinese people's Liberation Army. Hospital, Coronary artery angioplasty (CAG) and IVUS examination, 92 patients with coronary artery height calcification with stenosis of coronary heart disease. The related ischemic lesions were treated by RA, according to whether the joint sacs were divided into RA combined with CB (RACB) in 46 cases, and 46 cases of single pure rotation (ROTA) group. 40 patients with coronary artery height calcification only treated with common balloon treatment were matched for the common balloon treatment (POBA) group. All patients were treated with second generation drug eluting stents after the lesion preconditioning. After the lesion, the diameter of the lumen and the diameter of the lumen were measured and the diameter of the lumen and the diameter of the lumen were measured with QCA after the rotation, the dilation of the common balloon and the support. Stenosis rate. IVUS observation of calcification related parameters and pre treated calcified ring fracture. Analysis of the influence factors of stent dilatation.2. Prospective analysis of 9 patients with severe calcification with OCT examination in the center of coronary artery grinding combined with cutting balloon angioplasty and in the operation, after the combined rotation of grinding, and the branch. After the stent was placed, OCT was automatically retracted to record the vascular segments of the lesion, recording the minimum lumen area, calcification arc, calcification length, calcification thickness, calcified tissue thickness, calcified ring fracture, calcified nodule, stent area, stent placement, and tissue prolapse. A total of 148 segments were collected by 2mm. Diseased segments, 105 calcified segments. Analysis of factors affecting poor stent dilatation, poor adherence to the wall, and factors affecting the calcification ring fracture. 1. In the ROTA and RACB two groups, there were no statistically significant differences in the diameter and diameter of the lumen before and after the treatment of the lesions, but after a different balloon preconditioning, RACB The stenosis rate of the lumen diameter of the group decreased significantly (from 54.5% + 8.9% to 36.1% + 7.1%), and the stenosis rate of the lumen diameter in the ROTA group was only slightly lower (from 55.7% + 7.8% to 46.9% + 9.4%). After the P0.001. stent implantation, the good expansion ratio of the RACB group (71.7%) was significantly higher than that of the ROTA group (54.5%), and the POBA group (15%), P0.001. and the remnants of the stent implantation. The stenosis rate of the lumen in the RACB group (6% + 23%) was significantly lower than that in the other two groups (group RA, 10.8% + 3.3%, group POBA 12.7% + 2.1%), P0.001.2. The stenosis rate of the lumen diameter was less than 40% after the lesion preconditioning. The calcium ring fracture was observed under OR=2994, 95%CI:1.297-6.911.IVUS, and the stenosis rate of the lumen was less than 40% Cheng Zhengxiang after the lesion pretreated. In the 105 segment calcification segment observed by r=0.581, P0.001.3 and OCT, the average minimum lumen area was 2.4 + 0.76mm2, calcified radians were 164.3 + 86.4 degrees, calcification was 1.72 + 0.39mm, calcification was 0.47 + 0.18mm, calcified surface tissue thickness was 0.15 + 0.14mm, and 42 calcified segments appeared calcified ring fracture (40%). The average stent area was 5.26 The stent dilatation (27.6%) was found in the 1.11mm2,29 segment, and the stent was poor in the 29 segment, and the 24 segment appeared tissue prolapse (22.9%).4. Under the OCT observation, the main influence factor of the stent dilatation was the calcified ring fracture (OR=0.160,95%CI:0.050,0.516), and the minimum lumen area after the pretreatment (OR=1.87,95%CI:1.021, 3.425). The main influencing factors of poor adherence were calcified arc degree (OR=1.006,95%CI:1.001,1.011). The main factors affecting calcification ring fracture were calcified radian (OR=1.008,95%CI:1.002,1.015) and calcified surface tissue thickness (OR=0.000,95%CI: 0.000,0.001). 1. The results of the study were as follows: the combined resection of ball sacculoplasty for severe calcification, It can increase the fracture ratio of the calcification ring, reduce the residual stenosis rate of the lumen, and be beneficial to the good expansion of the stent.2. The stenosis of the diameter of the cavity is less than 40% after pretreatment, and it is a predictor of the good expansion of the stent. The calcification ring fracture after pretreatment and the stenosis of the diameter of the lumen after the pretreatment are less than.3, and the calcification is fully pretreated by the milling combined with the balloon. After the lesions, the stent expansion under OCT and the incidence of poor adherence were lower.4. The calcification ring fracture and the increase of the lumen area may contribute to the good expansion of the stent after severe calcification, and the occurrence of calcified ring fracture and the extensive calcification arc observed under OCT Degree, as well as calcified surface tissue thickness 0.1mm related.

【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R541.4

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