冠状动脉CT血管造影在慢性完全闭塞病变中应用价值
发布时间：2018-11-29 12:57
【摘要】：第一部分冠状动脉CT血管造影对慢性完全闭塞病变的诊断价值目的以冠状动脉造影(coronary artery angiography,CAG)确诊冠状动脉慢性完全闭塞病变(chronic total occlusion,CTO)为金标准,探讨冠状动脉CT血管造影(coronary computed tomography angiography,CCTA)对CTO病变的诊断价值。材料与方法回顾性分析2013年6月至2016年8月就诊于首都医科大学附属北京安贞医院心内科一病房经CAG确诊至少1支冠状动脉完全闭塞,闭塞时间超过3个月以上患者2089例,且冠状动脉造影前60天内接受CCTA检查患者231例。根据入选及排除标准,最终入选患者198例。由经验丰富的影像科医师通过CCTA评价594支主要心外膜冠状动脉血管是否完全闭塞。以CAG为金标准,判断CCTA诊断CTO病变的敏感性、特异性、准确性、阴性预测价值、阳性预测价值,计算Kappa系数衡量CAG及CCTA诊断CTO病变的一致性。结果共纳入分析198例患者共594支主要冠状动脉血管,男性74.2%,平均年龄(57.5±10.2)岁。CAG共确诊221处病变完全闭塞,CCTA诊断CTO的敏感性为88%,特异性为99%,准确性95%,阳性预测价值98.0%,阴性预测价值93.2%。以CAG诊断CTO病变为金标准,CCTA与CAG具有较好的诊断一致性,Kappa值为0.89,P0.05。结论CCTA确诊CTO病变方面具有较好的诊断价值,敏感性为88%,特异性为99%,准确性95%。与CAG诊断CTO病变有较高的一致性。钙化病变、支架内闭塞(支架类型)及病变血管本身细小等方面存在一定局限性。第二部分冠状动脉CT腔内衰减梯度评价慢性完全闭塞病变侧支循环及探讨其影响因素目的探讨冠状动脉腔内衰减梯度(transluminal attenuation gradient,TAG)对冠状动脉慢性完全闭塞病变(chronic total occlusion,CTO)侧支循环形成的预测价值,以及影响CTO病变侧支循环建立的因素。材料与方法回顾性分析2013年6月至2016年8月就诊于首都医科大学附属北京安贞医院心内科一病房经CAG确诊至少1支冠状动脉完全闭塞,闭塞时间超过3个月以上患者2089例,且冠状动脉造影前60天内接受CCTA检查患者231例。根据入选及排除标准,最终入选患者82例,85支主要心外膜冠状动脉血管。采用冠状动脉造影Rentrop分级评价侧支循环,定义Rentrop3级为侧支循环良好组。比较不同侧支循环等级时TAG差别,采用单因素及多因素Logistic回归分析影响CTO病变侧支循环建立的因素。结果随着Rentrop分级增加,TAG呈升高趋势,当TAG≥-15.6HU/10mm提示良好侧支循环,ROC曲线下面积0.63(95%CI=0.49-0.77,P=0.04),TAG诊断侧支循环的敏感性67.9%,特异性69%,准确性67.4%。侧支循环良好组与侧支循环不良组在既往糖尿病病史、心梗病史及TAG方面存在差异,差异有统计学意义。经多因素Logistic回归分析,糖尿病病史及心肌梗死病史是CTO病变影响侧支循环形成的独立预测因素。结论TAG在评价侧支循环方面具有一定预测价值。糖尿病病史是CTO病变侧支循环形成不良的影响因素,心肌梗死病史有助于预测良好侧支循环的形成。第三部分评价冠状动脉CT血管造影对CTO介入治疗的影响目的通过术前冠状动脉CT血管造影(coronary computed tomography angiography,CCTA)评估慢性完全闭塞病变(chronic total occlusion,CTO)特征,分析影响CTO病变介入治疗的因素。材料与方法回顾性分析2013年6月至2016年8月就诊于首都医科大学附属北京安贞医院心内科一病房经冠状动脉造影(coronary artery angiography,CAG)确诊至少1支冠状动脉完全闭塞,闭塞时间超过3个月以上患者2089例,且冠状动脉造影前60天内接受CCTA检查患者231例。根据入选及排除标准,最终入选82例患者,85支主要心外膜冠状动脉。将30分钟内导丝通过闭塞段定义为PCI成功,反之为PCI失败。采集CCTA分析两组患者的病变特征及临床资料,利用单因素及多因素Logistic回归分析影响CTO病变介入手术成功的因素,利用ROC曲线对比CT-CTO评分和J-CTO评分的诊断效能。结果共纳入82例患者(85支CTO病变血管),男性66例(80.5%),平均年龄57.3±10.4岁,CCTA与CAG检查时间平均间隔为9.5±12.5天。30分钟内导丝通过闭塞病变47处,PCI成功率为55.3%,最终有61支病变血管成功开通,成功率达71.8%。闭塞段远端纤维帽形态不清晰,闭塞近段分叉、闭塞长度≥20mm是影响CTO病变介入治疗独立危险因素。随着CT-CTO评分升高,CTO病变介入治疗的手术成功率逐渐减低(85.7%、65.8%、33.3%、0%)。CT-CTO评分预测30分钟内导丝通过闭塞病变成功率高于J-CTO评分,差异有统计学意义(0.734vs 0.726,P0.001)。结论闭塞段远端形态纤维帽形态不清晰、闭塞段头端分叉、闭塞段长度≥20mm是影响CTO病变手术成功的独立危险因素。与J-CTO评分相比,CT-CTO评分可以较好的预测30分钟内导丝通过闭塞病变。
[Abstract]:The first part of the study on the diagnostic value of the first part of the coronary artery computed tomography (CT) on the diagnosis of the chronic total occlusion (CAG) was the diagnosis of the coronary chronic total occlusion (CTO) as the gold standard, and the coronary computed tomography (CT) was also discussed. The value of CCTA in the diagnosis of CTO lesions. Materials and Methods From June 2013 to August 2016, at least one coronary artery was completely occluded by CAG, and the total occlusion time was over 3 months. In the first 60 days of coronary angiography, 231 patients were examined with CCTA. A total of 198 patients were selected according to the inclusion and exclusion criteria. A total of 594 primary epicardial coronary vessels were completely occluded by an experienced Image Section through the CCTA. The sensitivity, specificity, accuracy, negative predictive value and positive predictive value of CCTA in the diagnosis of CTO were determined by CAG as the gold standard. Results A total of 594 main coronary vessels were included in 198 patients. The average age was 72.5%. The sensitivity of CCTA to the diagnosis of CTO was 88%, the specificity was 99%, the accuracy was 95%, the positive predictive value was 98. 0%, and the negative predictive value was 93.2%. The results showed that the value of Kappa was 0.89, P <0.05, and the value of Kappa was 0.89, P <0.05. Conclusion CCTA has good diagnostic value in the diagnosis of CTO, the sensitivity is 88%, the specificity is 99%, and the accuracy is 95%. There was a higher consistency with the CAG in the diagnosis of CTO. There are some limitations in calcified lesion, stent-in-stent occlusion (type of stent), and small lesion vessel. In the second part, the internal attenuation gradient of the coronary artery was evaluated to evaluate the side branch circulation of the chronic total occlusion and to explore the predictive value of the internal attenuation gradient (TAG) of the coronary artery on the collateral circulation of the chronic total occlusion (CTO) of the coronary artery. and the factors that affect the establishment of the side branch of the CTO lesion. Materials and Methods From June 2013 to August 2016, at least one coronary artery was completely occluded by CAG, and the total occlusion time was over 3 months. In the first 60 days of coronary angiography, 231 patients were examined with CCTA. According to the inclusion and exclusion criteria, 82 patients and 85 main epicardial coronary vessels were selected. The side branch circulation was evaluated by using the Renta grade of the coronary angiography, and the Rentrop3 stage was defined as a good group of the lateral branch. A single factor and a multi-factor logistic regression were used to analyze the factors affecting the establishment of the side branch of CTO. The results showed that with the increasing of Renta, TAG showed a tendency to increase, and the area was 0.63 (95% CI = 0.49-0.77, P = 0.04) under the ROC curve, the sensitivity of the TAG diagnosis side branch was 60.9%, the specificity was 69% and the accuracy was 64.4%. There was a significant difference in the history of previous diabetes, the history of myocardial infarction and the TAG, and there was a significant difference in the history of previous diabetes, the history of myocardial infarction and the TAG. Logistic regression analysis of multiple factors, the history of diabetes and the history of myocardial infarction were independent predictors of the formation of the lateral branch of CTO. Conclusion TAG has a certain predictive value in the evaluation of collateral circulation. The history of diabetes is an adverse factor in the formation of the side branch of the CTO. The medical history of the myocardial infarction can be used to predict the formation of the good collateral circulation. In the third part, the effect of coronary artery CT angiography on the treatment of CTO was evaluated, and the characteristics of chronic total occlusion (CTO) were assessed by coronary computed tomography (CCTA) before and after operation, and the factors influencing the interventional treatment of CTO were analyzed. Materials and Methods From June 2013 to August 2016, at least one coronary artery was completely occluded by coronary angiography (CAG), and 2089 patients with more than 3 months of occlusion were diagnosed by coronary angiography (CAG). In the first 60 days of coronary angiography, 231 patients were examined with CCTA. According to the inclusion and exclusion criteria, 82 patients and 85 primary epicardial coronary arteries were included. The 30-minute guide wire is defined as PCI success through the block segment, and vice versa. CT-CTO score and J-CTO score were compared by ROC curve. Results There were 82 patients (85 CTO lesions), 66 male (80.5%), mean age of 57. 3 and 10. 4 years. The average time interval between CCTA and CAG was 9.5 to 12.5 days. The success rate of PCI was 53.3% in 30 minutes, and the success of 61 diseased vessels was successful. The success rate was 71.8%. The shape of the distal fiber cap in the occluded segment is not clear, the proximal segment of the occlusion is bifurcated, and the occlusion length is equal to 20mm, which is an independent risk factor affecting the intervention of the CTO lesion. As the CT-CTO score increased, the success rate of the operation of the CTO lesion was gradually decreased (85.7%, 65.8%, 33.3%, 0%). The success rate of CT-CTO score was higher than that of J-CTO in 30 minutes, and the difference was statistically significant (0.734vs. 0.726, P0.001). Conclusion The shape of the distal end of the occlusion segment is not clear, the tip of the occlusion segment is bifurcated, and the length of the occlusion segment is equal to 20mm, which is an independent risk factor affecting the success of the operation of the CTO lesion. Compared with the J-CTO score, the CT-CTO score can be well predicted for 30-minute lead wire passing through the occlusion lesion.
【学位授予单位】：首都医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.4
本文编号：2365056
[Abstract]:The first part of the study on the diagnostic value of the first part of the coronary artery computed tomography (CT) on the diagnosis of the chronic total occlusion (CAG) was the diagnosis of the coronary chronic total occlusion (CTO) as the gold standard, and the coronary computed tomography (CT) was also discussed. The value of CCTA in the diagnosis of CTO lesions. Materials and Methods From June 2013 to August 2016, at least one coronary artery was completely occluded by CAG, and the total occlusion time was over 3 months. In the first 60 days of coronary angiography, 231 patients were examined with CCTA. A total of 198 patients were selected according to the inclusion and exclusion criteria. A total of 594 primary epicardial coronary vessels were completely occluded by an experienced Image Section through the CCTA. The sensitivity, specificity, accuracy, negative predictive value and positive predictive value of CCTA in the diagnosis of CTO were determined by CAG as the gold standard. Results A total of 594 main coronary vessels were included in 198 patients. The average age was 72.5%. The sensitivity of CCTA to the diagnosis of CTO was 88%, the specificity was 99%, the accuracy was 95%, the positive predictive value was 98. 0%, and the negative predictive value was 93.2%. The results showed that the value of Kappa was 0.89, P <0.05, and the value of Kappa was 0.89, P <0.05. Conclusion CCTA has good diagnostic value in the diagnosis of CTO, the sensitivity is 88%, the specificity is 99%, and the accuracy is 95%. There was a higher consistency with the CAG in the diagnosis of CTO. There are some limitations in calcified lesion, stent-in-stent occlusion (type of stent), and small lesion vessel. In the second part, the internal attenuation gradient of the coronary artery was evaluated to evaluate the side branch circulation of the chronic total occlusion and to explore the predictive value of the internal attenuation gradient (TAG) of the coronary artery on the collateral circulation of the chronic total occlusion (CTO) of the coronary artery. and the factors that affect the establishment of the side branch of the CTO lesion. Materials and Methods From June 2013 to August 2016, at least one coronary artery was completely occluded by CAG, and the total occlusion time was over 3 months. In the first 60 days of coronary angiography, 231 patients were examined with CCTA. According to the inclusion and exclusion criteria, 82 patients and 85 main epicardial coronary vessels were selected. The side branch circulation was evaluated by using the Renta grade of the coronary angiography, and the Rentrop3 stage was defined as a good group of the lateral branch. A single factor and a multi-factor logistic regression were used to analyze the factors affecting the establishment of the side branch of CTO. The results showed that with the increasing of Renta, TAG showed a tendency to increase, and the area was 0.63 (95% CI = 0.49-0.77, P = 0.04) under the ROC curve, the sensitivity of the TAG diagnosis side branch was 60.9%, the specificity was 69% and the accuracy was 64.4%. There was a significant difference in the history of previous diabetes, the history of myocardial infarction and the TAG, and there was a significant difference in the history of previous diabetes, the history of myocardial infarction and the TAG. Logistic regression analysis of multiple factors, the history of diabetes and the history of myocardial infarction were independent predictors of the formation of the lateral branch of CTO. Conclusion TAG has a certain predictive value in the evaluation of collateral circulation. The history of diabetes is an adverse factor in the formation of the side branch of the CTO. The medical history of the myocardial infarction can be used to predict the formation of the good collateral circulation. In the third part, the effect of coronary artery CT angiography on the treatment of CTO was evaluated, and the characteristics of chronic total occlusion (CTO) were assessed by coronary computed tomography (CCTA) before and after operation, and the factors influencing the interventional treatment of CTO were analyzed. Materials and Methods From June 2013 to August 2016, at least one coronary artery was completely occluded by coronary angiography (CAG), and 2089 patients with more than 3 months of occlusion were diagnosed by coronary angiography (CAG). In the first 60 days of coronary angiography, 231 patients were examined with CCTA. According to the inclusion and exclusion criteria, 82 patients and 85 primary epicardial coronary arteries were included. The 30-minute guide wire is defined as PCI success through the block segment, and vice versa. CT-CTO score and J-CTO score were compared by ROC curve. Results There were 82 patients (85 CTO lesions), 66 male (80.5%), mean age of 57. 3 and 10. 4 years. The average time interval between CCTA and CAG was 9.5 to 12.5 days. The success rate of PCI was 53.3% in 30 minutes, and the success of 61 diseased vessels was successful. The success rate was 71.8%. The shape of the distal fiber cap in the occluded segment is not clear, the proximal segment of the occlusion is bifurcated, and the occlusion length is equal to 20mm, which is an independent risk factor affecting the intervention of the CTO lesion. As the CT-CTO score increased, the success rate of the operation of the CTO lesion was gradually decreased (85.7%, 65.8%, 33.3%, 0%). The success rate of CT-CTO score was higher than that of J-CTO in 30 minutes, and the difference was statistically significant (0.734vs. 0.726, P0.001). Conclusion The shape of the distal end of the occlusion segment is not clear, the tip of the occlusion segment is bifurcated, and the length of the occlusion segment is equal to 20mm, which is an independent risk factor affecting the success of the operation of the CTO lesion. Compared with the J-CTO score, the CT-CTO score can be well predicted for 30-minute lead wire passing through the occlusion lesion.
【学位授予单位】：首都医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.4
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