CTA确定的支架gap的预测因子和临床预后及相关基础研究
发布时间：2018-12-29 15:13
【摘要】：本研究由基础和临床研究两部分组成。基础研究中，我们首先评价我们新开发的基于冠脉计算机断层成像（CTA）的支架三维角度测量方法的可靠性，然后进行支架弯曲后应力变化的有限元分析，并与临床结果进行对照，最后明确冠脉支架gap诊断中gap处CT值300Hu的合理性。临床研究则为观察冠脉支架gap组的临床预后和分析支架gap的预测因素。藉此为CTA研究冠脉支架断裂（CSF）提供理论依据和有力工具。 第一部分基础研究中，使用我们新开发设计的基于CTA的支架三维角度测量方法，分别测量体外模型和患者体内支架的角度。发现使用冠脉造影法（CA）测定的支架角度存在较大偏差。而我们设计的CTA中心线法有很好的准确性和重复性，与常规的旋转血管树法在临床和基础研究中可以相互代替，但明显可以减少测量时间。西莫罗斯药物涂层支架（SES）弯曲后的有限元分析显示，支架弯曲至140-145°时出现了明显的应力和应变变化，这一结果同临床资料的分析结果非常吻合。不同类型支架的CTA影像学上存在差异，CT值也不同，，但各支架支架梁完整时，未见支架CT值300Hu，提示将冠脉支架gap的界定值设为300Hu是合理的。另外，支架CT值与支架种类、直径、血管内造影剂CT值、支架金属梁厚度、支架形态等因素有关。 第二部分为临床资料的分析。我们对226名患者共植入的491个支架的CTA随访资料（其中83名患者共208枚支架，同时进行了CA随访）进行了回顾性分析，并重新严格定义了支架重叠、支架钙化、准确测量支架角度后，发现支架gap组的支架内再狭窄（ISR）、靶病变血运重建（TLR）的发生率较对照组均明显升高（55.8%vs13.9%，P=0.000;32.6%vs10.3%, P=0.0003），支架内血栓也有升高的趋势（4.7%vs0.6%, P=0.1091）。支架长度、成角、重叠、钙化、植入时间和室壁运动障碍是支架gap的独立危险因素（P=0.016；P=0.000; P=0.018; P=0.016; P=0.015; P=0.035）。 结论：1.整合了我们新开发的支架血管三维角度测量方法的CTA后处理工作站，可以准确快速地测量体内支架的成角，为冠脉支架的离体试验提供第一手准确的临床数据。并且初步试验显示，支架角度-应力的有限元分析的结果与我们的临床数据基本吻合。 2. CTA影像学上将支架gap的CT界定值设为300Hu是合理的，为以支架gap的概念分析CSF提供了进一步的理论依据。 3.在尽可能获得了详尽的临床资料，重新明确支架重叠、钙化和准确测量支架成角后，发现新定义的支架gap发生后ISR和TLR率升高，支架gap与支架长度、成角、重叠、钙化、植入时间和节段性室壁运动障碍有关，从支架gap的影像学特点、临床预后和其预测因素分析，进一步明确了新定义的支架gap就是CSF。 4.新的支架gap概念的使用，将进一步提高CSF的临床检出率，CTA将在临床预后观察、支架力学的基础研究中发挥重要的作用。
[Abstract]:This study consists of two parts: basic and clinical. In basic research, we first evaluate the reliability of our newly developed three-dimensional angle measurement method based on coronary computed tomography (CTA), and then do finite element analysis of the stress changes after the stent bending. Compared with the clinical results, the rationality of CT value 300Hu at gap in gap diagnosis of coronary stents was determined. The clinical study was used to observe the clinical prognosis of coronary stent gap group and to analyze the predictive factors of stent gap. It provides a theoretical basis and a powerful tool for the study of coronary stent rupture (CSF) by CTA. In the first part of the basic research, we use our newly developed three-dimensional angle measurement method based on CTA to measure the angle of the stent in vitro and in vivo, respectively. It was found that the angle of stent measured by coronary angiography (CA) was significantly different. The CTA centerline method designed by us has good accuracy and repeatability. It can be replaced by the conventional rotating vascular tree method in clinical and basic research, but it can obviously reduce the measuring time. Finite element analysis after (SES) bending of Simulos drug-coated stent showed that obvious stress and strain changes occurred at 140-145 掳bending of the stent, which was in good agreement with the clinical data. There were differences in CTA imaging and CT values among different stents, but no stent CT value 300 Hu. when each beam was intact, it suggested that it was reasonable to set the gap value of coronary stent to 300Hu. In addition, stent CT value was related to stent type, diameter, intravascular contrast agent CT value, stent metal beam thickness, stent shape and so on. The second part is the analysis of clinical data. We retrospectively analyzed the CTA data of 491 stents implanted in 226 patients (of which 83 patients had 208 stents and followed up with CA), and redefined stents overlapping and stent calcification. After accurate measurement of stent angle, it was found that the incidence of revascularization (TLR) in stent restenosis (ISR), target in stent gap group was significantly higher than that in control group (55.8 vs 13.9). 32.6 vs 10.3, P0. 0003), the thrombus in the stent also increased (4. 7 vs 0. 6, P0. 1091). Stent length, angulation, overlap, calcification, implantation time and ventricular wall motion disorder were independent risk factors for stent gap (P0. 016, P0. 018, P0. 016, P0. 015, P0. 035). Conclusion: 1. The CTA post processing workstation which integrates our newly developed three-dimensional angle measurement method of stent vessel can accurately and quickly measure the angle of stent in vivo and provide the first hand and accurate clinical data for the in vitro test of coronary stent. The preliminary results show that the results of the finite element analysis of angle-stress are in good agreement with our clinical data. 2. It is reasonable for CTA imaging to set the CT threshold of stent gap to 300Hu, which provides a further theoretical basis for the analysis of CSF with the concept of stent gap. 3. After obtaining as detailed clinical data as possible, redefining stent overlap, calcification and accurate measurement of stent angle, it was found that ISR and TLR rates increased after the occurrence of newly defined stent gap, and stent gap and stent length, angle, overlap, calcification. The implantation time is related to segmental ventricular wall motion disorder. From the analysis of imaging features, clinical prognosis and predictive factors of stent gap, it is further clear that the newly defined stent gap is CSF.. 4. The application of the new concept of stent gap will further improve the clinical detection rate of CSF. CTA will play an important role in clinical prognosis observation and basic research of stenting mechanics.
【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】：2013
【分类号】：R541.4;R816.2
本文编号：2394980
[Abstract]:This study consists of two parts: basic and clinical. In basic research, we first evaluate the reliability of our newly developed three-dimensional angle measurement method based on coronary computed tomography (CTA), and then do finite element analysis of the stress changes after the stent bending. Compared with the clinical results, the rationality of CT value 300Hu at gap in gap diagnosis of coronary stents was determined. The clinical study was used to observe the clinical prognosis of coronary stent gap group and to analyze the predictive factors of stent gap. It provides a theoretical basis and a powerful tool for the study of coronary stent rupture (CSF) by CTA. In the first part of the basic research, we use our newly developed three-dimensional angle measurement method based on CTA to measure the angle of the stent in vitro and in vivo, respectively. It was found that the angle of stent measured by coronary angiography (CA) was significantly different. The CTA centerline method designed by us has good accuracy and repeatability. It can be replaced by the conventional rotating vascular tree method in clinical and basic research, but it can obviously reduce the measuring time. Finite element analysis after (SES) bending of Simulos drug-coated stent showed that obvious stress and strain changes occurred at 140-145 掳bending of the stent, which was in good agreement with the clinical data. There were differences in CTA imaging and CT values among different stents, but no stent CT value 300 Hu. when each beam was intact, it suggested that it was reasonable to set the gap value of coronary stent to 300Hu. In addition, stent CT value was related to stent type, diameter, intravascular contrast agent CT value, stent metal beam thickness, stent shape and so on. The second part is the analysis of clinical data. We retrospectively analyzed the CTA data of 491 stents implanted in 226 patients (of which 83 patients had 208 stents and followed up with CA), and redefined stents overlapping and stent calcification. After accurate measurement of stent angle, it was found that the incidence of revascularization (TLR) in stent restenosis (ISR), target in stent gap group was significantly higher than that in control group (55.8 vs 13.9). 32.6 vs 10.3, P0. 0003), the thrombus in the stent also increased (4. 7 vs 0. 6, P0. 1091). Stent length, angulation, overlap, calcification, implantation time and ventricular wall motion disorder were independent risk factors for stent gap (P0. 016, P0. 018, P0. 016, P0. 015, P0. 035). Conclusion: 1. The CTA post processing workstation which integrates our newly developed three-dimensional angle measurement method of stent vessel can accurately and quickly measure the angle of stent in vivo and provide the first hand and accurate clinical data for the in vitro test of coronary stent. The preliminary results show that the results of the finite element analysis of angle-stress are in good agreement with our clinical data. 2. It is reasonable for CTA imaging to set the CT threshold of stent gap to 300Hu, which provides a further theoretical basis for the analysis of CSF with the concept of stent gap. 3. After obtaining as detailed clinical data as possible, redefining stent overlap, calcification and accurate measurement of stent angle, it was found that ISR and TLR rates increased after the occurrence of newly defined stent gap, and stent gap and stent length, angle, overlap, calcification. The implantation time is related to segmental ventricular wall motion disorder. From the analysis of imaging features, clinical prognosis and predictive factors of stent gap, it is further clear that the newly defined stent gap is CSF.. 4. The application of the new concept of stent gap will further improve the clinical detection rate of CSF. CTA will play an important role in clinical prognosis observation and basic research of stenting mechanics.
【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】：2013
【分类号】：R541.4;R816.2
【参考文献】
相关硕士学位论文 前2条
1 徐江;心血管支架在病变血管中力学行为的初步研究[D];西南交通大学;2011年
2 赵阳;血管支架柔顺性有限元分析及介入配件的临床试验研究[D];大连理工大学;2009年
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