多层螺旋CT血管成像在主动脉夹层腔内支架隔绝术后内漏中的价值探讨
发布时间：2018-08-22 07:37
【摘要】：第一部分多层螺旋CT血管成像和彩色多普勒超声检查在主动脉夹层腔内支架隔绝术后内漏检测的对比研究目的:比较主动脉夹层腔内支架隔绝术后1月随访患者同时行多层螺旋CT血管成像和彩色多普勒超声检查对内漏的检测。材料与方法:收集四川省人民医院2014年1月1日至2016年10月31日共34例主动脉夹层腔内支架隔绝术后1月的随访患者进行回顾性分析,年龄范围38岁-81岁,平均年龄55.91±11.80岁,其中男性25例(73.5%),女性9例(26.5%)。所有患者在腔内支架隔绝术后1月(平均时间29±6天)同时行多层螺旋CT血管成像和彩色多普勒超声检查,两种检查间隔时间不超过1周。CT图像及超声检查图像各由2名经验丰富的高年资医师组成阅片小组进行评估,评估前互不知道另一种检查方法的结果。以多层螺旋CT血管成像检查结果作为术后内漏检测的金标准,获得彩色多普勒超声检测内漏的真阳性率、假阳性率、假阴性率、敏感性、特异性、准确性、阴性预测值、阳性预测值。数据分析采用配对χ2检验,p0.05为差异有统计学意义。Kappa指数进一步评估多层螺旋CT血管成像和彩色多普勒超声检测内漏的一致性。结果:多层螺旋CT检测出11例内漏,内漏发生率32.4%,其中I型内漏10例(29.4%),III型内漏1例(2.9%),无II型内漏。10例I型内漏中,5例出现在支架近端(Ia型),3例出现在支架远端(Ib型),2例在支架近、远端均可见(Ia、Ib型)。彩色多普勒超声检测出8例内漏,均为I型,其中5例内漏位于支架近端(Ia型),2例位于支架远端(Ib型),1例于支架近、远端均可查及(Ia、Ib型);8例内漏中,6例与多层螺旋CT血管成像检查结果一致,2例彩色多普勒超声显示阳性而多层螺旋CT为阴性。MS-CTA检出1例III型内漏而彩色多普勒超声显示为阴性。与多层螺旋CT血管成像相比,彩色多普勒超声对内漏检测的真阳性率54.5%(6/11),假阳性率8.7%(2/23),假阴性率为45.4%(5/11),敏感性54.5%(6/11),特异性91.3(21/23),准确性79.4%(27/34),阳性预测值和阴性预测值分别为75%(6/8)和80.8%(21/26)。两种检查方法的一致性中等(k=0.494)。34例主动脉夹层腔内支架隔绝术后1月随访患者植入支架均未发生断裂、解体、移位及变形,所有患者假腔内均有不同程度血栓形成,支架覆盖区真腔血流均通畅,34例患者支架内膜下均未见附壁血栓形成。因6例外院治疗患者术前影像资料缺乏,余28例术前影像资料完善患者,术后多层螺旋CT图像显示其夹层动脉瘤瘤体均未见继续扩大,真腔压迫减轻,形态得以不同程度恢复。结论:多层螺旋CT和彩色多普勒超声都能对主动脉夹层腔内支架隔绝术后内漏进行随访。考虑到放射累积剂量及花费,彩色多普勒超声可对内漏进行初步筛查,但其敏感性及阳性预测值较低。多层螺旋CT血管成像仍作为内漏随访主要的影像学检查方法。第二部分术前多层螺旋CT影像特征参数预测Standford B型主动脉夹层腔内隔绝术后1月I型内漏的研究目的:本研究旨在分析术前多层螺旋CT血管造影检查的影像特征参数,探讨不同特征参数对Standford B型主动脉夹层腔内隔绝术后I型内漏有无预测价值。材料与方法:收集四川省人民医院2014年1月1日至2016年10月31日共26例Standford B型主动脉夹层腔内支架隔绝术后1月行多层螺旋CT随访患者,对患者术前多层螺旋CT血管造影检查的影像参数进行回顾性分析。26例患者年龄范围40-81岁,平均年龄58.88±11.28岁,其中男性18例(69.23%),女性8例(30.77%)。术前首次行胸腹部MS-CTA检查的时间距离手术1-22天。所有患者术后1月行多层螺旋CT血管造影检查,根据检出有、无内漏,将患者分为内漏组(LG:术后1月MS-CTA检查发现内漏;n=10例)和无内漏组(NLG:术后1月MS-CTA检查未发现内漏;n=16例)。术前MS-CTA影像特征参数包括:初始破口宽度,近端破口层面、瘤体最大横径层面、左锁骨下动脉开口层面、气管隆突分叉层面、膈肌层面、膈肌至腹腔干区瘤体最大横径层面、腹腔干至肾动脉区瘤体最大横径层面、肾动脉至髂血管分叉区瘤体最大横径层面的真腔直径、假腔直径、主动脉直径及各层面真腔比(T/A:该层面真腔直径与主动脉直径的比值)、假腔比(F/A:该层面假腔直径与主动脉直径的比值)、真假腔比值(T/F:该层面真腔直径与假腔直径的比值),主动脉壁钙化,假腔血栓,支架近端主动脉壁钙化及该区假腔血栓,支架远端主动脉壁钙化及该区假腔血栓,腹腔干至肾动脉区主动脉壁钙化及该区假腔血栓情况。所有患者术前MS-CTA图像及腔内支架隔绝术后1月随访的MS-CTA图像均由2名经验丰富的高年资医师组成阅片小组分析影像特征及测量有关数据,且分析术前MS-CTA图像时并不知晓术后1月MS-CTA随访结果。数据分析采用独立样本t检验,Fisher确切概率法,使用受试工作者曲线(ROC曲线)下面积确定术前MS-CTA特征性参数的最佳临界值,并计算敏感度、特异度,以p0.05为差异有统计学意义。结果:26例Standford B型主动脉夹层EVGE术后1月行MS-CTA检查,检出无内漏患者16例,内漏患者10例,所有内漏均为I型,5例出现在支架近端(Ia型),3例出现在支架远端(Ib型),2例在支架近、远端均可见(Ia、Ib型),无II型内漏。术前MS-CTA特征性参数评估中:腹腔干至肾动脉瘤体区最大横径平面真假腔比值(T/F)在两组间有统计学差异(内漏组:1.11±0.50cm;无内漏组:0.67±0.41;p=0.04;ROC曲线下面积=0.77,最佳临界点cutoff值为0.68,敏感性75%,特异性83.3%)。内漏组和无内漏组在近端破口层面、瘤体最大横径层面、气管隆突分叉层面、膈肌层面、膈肌至腹腔干区瘤体最大横径层面、肾动脉至髂血管分叉区瘤体最大横径层面的真腔直径、假腔直径、主动脉直径及上述各层面真腔比(T/A)、假腔比(F/A)、真假腔比值(T/F)均无统计学差异;在左锁骨下动脉开口层面主动脉直径无统计学差异;在腹腔干至肾动脉区瘤体最大横径层面真腔直径、假腔直径、主动脉直径、真腔比(T/A)、假腔比(F/A)无统计学差异;两组间在初始破口宽度,主动脉壁钙化,假腔血栓,支架近端主动脉壁钙化及该区假腔血栓,支架远端主动脉壁钙化及该区假腔血栓,腹腔干至肾动脉区主动脉壁钙化及该区假腔血栓均无统计学差异。结论:术前多层螺旋CT血管成像检查图像上腹腔干至肾动脉区瘤体最大横径层面真腔与假腔的比值(T/F)可预测Standford B型主动脉夹层腔内支架隔绝术后1月I型内漏的发生。
[Abstract]:The first part is a comparative study of multi-slice spiral CT angiography and color Doppler ultrasonography in detecting endoleak after stent exclusion in aortic dissection. Methods: A retrospective analysis was made on 34 patients with dissecting aorta who were followed up for 1 month from January 1, 2014 to October 31, 2016 in Sichuan People's Hospital. The age ranged from 38 to 81 years, with an average age of 55.91 [11.80], including 25 males (73.5%) and 9 females (26.5%). The mean time was 29 As the gold standard of postoperative endoleak detection, the true positive rate, false positive rate, false negative rate, sensitivity, specificity, accuracy, negative predictive value and positive predictive value of color Doppler ultrasound were obtained. Results: 11 cases of endoleak were detected by multi-slice spiral CT, and the rate of endoleak was 32.4%. Among them, 10 cases (29.4%) were type I, 1 case (2.9%) was type III and 1 case (2.9%) had no type II endoleak. Color Doppler ultrasonography detected 8 cases of endoleaks, all type I, including 5 cases in the proximal end of the stent (type Ia), 2 cases in the distal end of the stent (type Ib), 1 case in the proximal end of the stent (type Ia, type Ib), and 1 case in the distal end of the stent (type Ia, type Ib). Compared with multi-slice spiral CT angiography, the true positive rate, false positive rate, false negative rate, sensitivity, specificity and accuracy of color Doppler ultrasonography were 54.5% (6/11), 8.7% (2/23), 45.4% (5/11), 54.5% (6/11), 91.3 (21/23), respectively. Sex 79.4% (27/34), positive predictive value and negative predictive value were 75% (6/8) and 80.8% (21/26), respectively. The consistency of the two methods was moderate (k = 0.494). 34 patients with aortic dissection were followed up for 1 month without stent rupture, disintegration, displacement and deformation. All patients had different degrees of thrombosis and branches in the false lumen. True lumen blood flow was smooth in the covered area of the stent, and no mural thrombosis was found in 34 patients under the stent. Because of the lack of preoperative imaging data in 6 patients and the improvement of preoperative imaging data in the remaining 28 patients, multislice spiral CT images showed that the dissecting aneurysms were not enlarged, the true lumen compression was relieved, and the shape of the dissecting aneurysms to varying degrees. Conclusion: Multislice spiral CT and color Doppler ultrasonography can be used for follow-up of endoleak after endovascular stent exclusion in aortic dissection. Considering the cumulative dose and cost of radiation, color Doppler ultrasonography can be used for preliminary screening of endoleak, but its sensitivity and positive predictive value are low. The second part is the study of predicting type I leak in patients with Standford type B aortic dissection after endovascular graft exclusion by preoperative multi-slice spiral CT imaging characteristic parameters. The purpose of this study was to analyze the imaging characteristic parameters of preoperative multi-slice spiral CT angiography and to explore the effect of different characteristic parameters on Standford type B aortic dissection. Materials and Methods: From January 1, 2014 to October 31, 2016, 26 patients with Standford B type aortic dissection underwent multislice spiral CT follow-up one month after endovascular stent exclusion in Sichuan Provincial People's Hospital. The imaging parameters of preoperative multislice spiral CT angiography were retrospectively analyzed. The mean age of 26 patients ranged from 40 to 81 years, with an average age of 58.88 (+ 11.28 years). 18 males (69.23%) and 8 females (30.77%). The first time of MS-CTA examination was 1-22 days after operation. All patients underwent multi-slice spiral CT angiography one month after operation. According to the presence or absence of endorrhea, the patients were divided into endorrhea group (LG: 1 month after operation). MS-CTA revealed endoleak; n = 10 cases) and no endoleak (NLG: No endoleak was found in MS-CTA at 1 month postoperatively; n = 16 cases). The preoperative imaging features of MS-CTA included: initial rupture width, proximal rupture level, maximum transverse diameter level, left subclavian artery opening level, tracheal eminence bifurcation level, diaphragm level, diaphragm to abdominal trunk area, the most common tumor. On the large transverse plane, from the abdominal trunk to the largest transverse plane of the aneurysm, from the renal artery to the bifurcation of the iliac artery, the true lumen diameter, the false lumen diameter, the aortic diameter and the true lumen ratio (T/A: the ratio of the true lumen diameter to the aortic diameter) and the false lumen ratio (F/A: the ratio of the false lumen diameter to the aortic diameter in this plane) Value, true to false lumen ratio (T/F: ratio of true to false lumen diameter at this level), aortic wall calcification, false lumen thrombosis, proximal aortic wall calcification of stent and false lumen thrombosis in this area, distal aortic wall calcification of stent and false lumen thrombosis in this area, abdominal trunk to renal artery wall calcification and false lumen thrombosis in this area. Both CTA images and MS-CTA images of 1-month follow-up after endovascular stent exclusion were analyzed by a group of two experienced senior physicians. The preoperative MS-CTA images were analyzed without knowing the results of 1-month follow-up. Data were analyzed by independent sample t test, Fisher exact probability method, and received. Results: Twenty-six patients with Standford B type aortic dissection underwent MS-CTA examination one month after EVGE. There were 16 patients without endoleak, 10 patients with endoleak, all of which were type I and 5 patients with endoleak. In the preoperative evaluation of MS-CTA characteristic parameters, the ratio of true to false lumen (T/F) from abdominal trunk to renal artery aneurysm was significantly different between the two groups (endoleak group: 1.11 + 0.50 cm; no endoleak group: 0.67 + 0.50 cm). The cutoff value of the best critical point was 0.68, sensitivity 75%, specificity 83.3%. There was no significant difference in the true lumen diameter, false lumen diameter, aortic diameter, true lumen ratio (T/A), false lumen ratio (F/A) and true to false lumen ratio (T/F) between the two layers; there was no significant difference in the aortic diameter at the left subclavian artery opening level; there was no significant difference in the true lumen diameter, false lumen diameter, aortic diameter at the maximum transverse dimension from the celiac trunk to the renal artery region. There was no significant difference between the two groups in the initial rupture width, aortic wall calcification, false lumen thrombosis, proximal aortic wall calcification and false lumen thrombosis, distal aortic wall calcification and false lumen thrombosis, abdominal trunk to renal artery calcification and false lumen thrombosis. Conclusion: The ratio of true to false lumen (T/F) at the maximum transverse dimension from the celiac trunk to the renal artery on preoperative multi-slice spiral CT angiography can predict the occurrence of type I endoleak after endovascular stent exclusion for Standford type B aortic dissection.
【学位授予单位】：遵义医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.3;R816.2
本文编号：2196431
[Abstract]:The first part is a comparative study of multi-slice spiral CT angiography and color Doppler ultrasonography in detecting endoleak after stent exclusion in aortic dissection. Methods: A retrospective analysis was made on 34 patients with dissecting aorta who were followed up for 1 month from January 1, 2014 to October 31, 2016 in Sichuan People's Hospital. The age ranged from 38 to 81 years, with an average age of 55.91 [11.80], including 25 males (73.5%) and 9 females (26.5%). The mean time was 29 As the gold standard of postoperative endoleak detection, the true positive rate, false positive rate, false negative rate, sensitivity, specificity, accuracy, negative predictive value and positive predictive value of color Doppler ultrasound were obtained. Results: 11 cases of endoleak were detected by multi-slice spiral CT, and the rate of endoleak was 32.4%. Among them, 10 cases (29.4%) were type I, 1 case (2.9%) was type III and 1 case (2.9%) had no type II endoleak. Color Doppler ultrasonography detected 8 cases of endoleaks, all type I, including 5 cases in the proximal end of the stent (type Ia), 2 cases in the distal end of the stent (type Ib), 1 case in the proximal end of the stent (type Ia, type Ib), and 1 case in the distal end of the stent (type Ia, type Ib). Compared with multi-slice spiral CT angiography, the true positive rate, false positive rate, false negative rate, sensitivity, specificity and accuracy of color Doppler ultrasonography were 54.5% (6/11), 8.7% (2/23), 45.4% (5/11), 54.5% (6/11), 91.3 (21/23), respectively. Sex 79.4% (27/34), positive predictive value and negative predictive value were 75% (6/8) and 80.8% (21/26), respectively. The consistency of the two methods was moderate (k = 0.494). 34 patients with aortic dissection were followed up for 1 month without stent rupture, disintegration, displacement and deformation. All patients had different degrees of thrombosis and branches in the false lumen. True lumen blood flow was smooth in the covered area of the stent, and no mural thrombosis was found in 34 patients under the stent. Because of the lack of preoperative imaging data in 6 patients and the improvement of preoperative imaging data in the remaining 28 patients, multislice spiral CT images showed that the dissecting aneurysms were not enlarged, the true lumen compression was relieved, and the shape of the dissecting aneurysms to varying degrees. Conclusion: Multislice spiral CT and color Doppler ultrasonography can be used for follow-up of endoleak after endovascular stent exclusion in aortic dissection. Considering the cumulative dose and cost of radiation, color Doppler ultrasonography can be used for preliminary screening of endoleak, but its sensitivity and positive predictive value are low. The second part is the study of predicting type I leak in patients with Standford type B aortic dissection after endovascular graft exclusion by preoperative multi-slice spiral CT imaging characteristic parameters. The purpose of this study was to analyze the imaging characteristic parameters of preoperative multi-slice spiral CT angiography and to explore the effect of different characteristic parameters on Standford type B aortic dissection. Materials and Methods: From January 1, 2014 to October 31, 2016, 26 patients with Standford B type aortic dissection underwent multislice spiral CT follow-up one month after endovascular stent exclusion in Sichuan Provincial People's Hospital. The imaging parameters of preoperative multislice spiral CT angiography were retrospectively analyzed. The mean age of 26 patients ranged from 40 to 81 years, with an average age of 58.88 (+ 11.28 years). 18 males (69.23%) and 8 females (30.77%). The first time of MS-CTA examination was 1-22 days after operation. All patients underwent multi-slice spiral CT angiography one month after operation. According to the presence or absence of endorrhea, the patients were divided into endorrhea group (LG: 1 month after operation). MS-CTA revealed endoleak; n = 10 cases) and no endoleak (NLG: No endoleak was found in MS-CTA at 1 month postoperatively; n = 16 cases). The preoperative imaging features of MS-CTA included: initial rupture width, proximal rupture level, maximum transverse diameter level, left subclavian artery opening level, tracheal eminence bifurcation level, diaphragm level, diaphragm to abdominal trunk area, the most common tumor. On the large transverse plane, from the abdominal trunk to the largest transverse plane of the aneurysm, from the renal artery to the bifurcation of the iliac artery, the true lumen diameter, the false lumen diameter, the aortic diameter and the true lumen ratio (T/A: the ratio of the true lumen diameter to the aortic diameter) and the false lumen ratio (F/A: the ratio of the false lumen diameter to the aortic diameter in this plane) Value, true to false lumen ratio (T/F: ratio of true to false lumen diameter at this level), aortic wall calcification, false lumen thrombosis, proximal aortic wall calcification of stent and false lumen thrombosis in this area, distal aortic wall calcification of stent and false lumen thrombosis in this area, abdominal trunk to renal artery wall calcification and false lumen thrombosis in this area. Both CTA images and MS-CTA images of 1-month follow-up after endovascular stent exclusion were analyzed by a group of two experienced senior physicians. The preoperative MS-CTA images were analyzed without knowing the results of 1-month follow-up. Data were analyzed by independent sample t test, Fisher exact probability method, and received. Results: Twenty-six patients with Standford B type aortic dissection underwent MS-CTA examination one month after EVGE. There were 16 patients without endoleak, 10 patients with endoleak, all of which were type I and 5 patients with endoleak. In the preoperative evaluation of MS-CTA characteristic parameters, the ratio of true to false lumen (T/F) from abdominal trunk to renal artery aneurysm was significantly different between the two groups (endoleak group: 1.11 + 0.50 cm; no endoleak group: 0.67 + 0.50 cm). The cutoff value of the best critical point was 0.68, sensitivity 75%, specificity 83.3%. There was no significant difference in the true lumen diameter, false lumen diameter, aortic diameter, true lumen ratio (T/A), false lumen ratio (F/A) and true to false lumen ratio (T/F) between the two layers; there was no significant difference in the aortic diameter at the left subclavian artery opening level; there was no significant difference in the true lumen diameter, false lumen diameter, aortic diameter at the maximum transverse dimension from the celiac trunk to the renal artery region. There was no significant difference between the two groups in the initial rupture width, aortic wall calcification, false lumen thrombosis, proximal aortic wall calcification and false lumen thrombosis, distal aortic wall calcification and false lumen thrombosis, abdominal trunk to renal artery calcification and false lumen thrombosis. Conclusion: The ratio of true to false lumen (T/F) at the maximum transverse dimension from the celiac trunk to the renal artery on preoperative multi-slice spiral CT angiography can predict the occurrence of type I endoleak after endovascular stent exclusion for Standford type B aortic dissection.
【学位授予单位】：遵义医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.3;R816.2
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