本文關鍵詞： 高強度聚焦超聲 難治性高血壓 安全性 可行性 影響因素　出處：《重慶醫(yī)科大學》2017年碩士論文　論文類型：學位論文

【摘要】：研究背景交感神經的過度激活一直被認為是高血壓發(fā)病和維持的重要因素,近年來經導管射頻消融腎去交感神經術(renal denervation,RDN)可能是難治性高血壓(resistant hypertension,RH)的一種治療方式,但其存在介入操作相關并發(fā)癥和腎動脈損傷等弊端。高強度聚焦超聲(high intensity focused ultrasound,HIFU)作為一種新的無創(chuàng)消融治療手段,其療效在臨床實踐中已被證實。HIFU應用已經擴展到心血管領域,已有HIFU成功消融犬模型腎交感神經的報道。目的本文評價臨床上HIFU技術無創(chuàng)消融腎交感神經治療RH的安全性和可行性;探討HIFU治療RH的影響因素,便于改進臨床治療方案。方法對40例RH患者行HIFU去腎交感神經術治療,術中在彩色多普勒超聲(CDFI)引導下找出腎動脈長軸的最佳消融層面。分別取每側腎動脈近段、中段和腎門前段確定5~6個離散的靶點縱向螺旋分布覆蓋腎動脈的4個象限,靶點的縱向間隔約5 mm。每個點分別以功率(200~300)W×2 s聲能消融,平均每個點重復50次,每次間隔2 s。所有患者兩側腎動脈都接受治療。治療后隨訪患者6個月,評估術中及術后不良反應及并發(fā)癥情況,術后血壓下降效果、降壓藥物種類、腎動脈收縮期流速峰值和腎功能情況。根據(jù)血壓下降幅度分為顯效組和有效組,比較兩組之間腹壁厚度、輻照時間、輻照強度等相關因素。結果1.40例患者均完成手術,治療中主要不適為治療區(qū)疼痛,一般在術后24 h內緩解。術后不良反應均在SIR-A~B級,無一例SIR-C~F級不良反應發(fā)生。2.術后患者左、右腎動脈收縮期流速峰值較術前無差異(P=0.635,P=0.688)。術后患者隨訪1、6個月血尿素氮(BUN)、血肌酐(s Cr)、腎小球濾過率(e GFR)較基線無統(tǒng)計學差異(P=0.772,P=0.652,P=0.366)。3.術后隨訪1、3、6個月較基線診室收縮壓下降21.5、23.3、22.4mm Hg(P=0.000),診室舒張壓下降11.1、12.9、12.0 mm Hg(P=0.000);24 h動態(tài)收縮壓下降13.6、15.2、14.3 mm Hg(P=0.000),24 h動態(tài)收縮壓下降5.5、6.0、4.4 mm Hg(P=0.000);藥物種類下降0.8、0.9、1.0種(P=0.000)。4.顯效組和有效組在年齡、身高、體重、輻照時間、輻照強度沒有差異,而腹壁厚度差異有統(tǒng)計學意義(P0.05)。結論HIFU近期治療難治性高血壓是安全和可行的,但仍需深入及長期安全性、有效性探索。腹壁厚度是影響HIFU治療RH的臨床因素,腹壁厚度較薄的患者術后療效較好。
[Abstract]:Background the excessive activation of sympathetic nerve has been considered as an important factor in the pathogenesis and maintenance of hypertension. In recent years renal denervation has been ablated by radiofrequency catheter ablation. RDN may be a treatment for refractory hypertension- resistant RHs. However, there were complications associated with interventional procedures and renal artery injury. High intensity focused ultrasound (HIFU) was associated with high intensity focused ultrasound. HIFU) as a new non-invasive ablation therapy, its efficacy has been confirmed in clinical practice. HIFU has been extended to the field of cardiovascular. The successful ablation of renal sympathetic nerve in canine model by HIFU has been reported. Objective to evaluate the safety and feasibility of noninvasive ablation of renal sympathetic nerve by HIFU. To explore the influencing factors of HIFU in the treatment of RH and to improve the clinical treatment methods 40 patients with RH were treated with HIFU. The optimal ablation plane of the long axis of renal artery was found under the guidance of CDFI. The proximal segments of each renal artery were taken respectively. The longitudinal spiral distribution of 5 ~ 6 discrete targets was determined to cover the 4 quadrants of renal artery in the middle and anterior segments of the kidney. The longitudinal interval of the target was about 5 mm. each spot was ablated with 300 W 脳 2 s sound energy, and each point was repeated 50 times on average. The patients were followed up for 6 months after treatment to evaluate the adverse reactions and complications during and after operation, the effect of lowering blood pressure and the kinds of antihypertensive drugs. The peak systolic velocity and renal function of renal artery were divided into two groups according to the decrease of blood pressure. The thickness of abdominal wall and irradiation time were compared between the two groups. Results 1.The main discomfort in the treatment was pain in the treatment area, which was generally relieved within 24 hours after operation. The adverse reactions were in the SIR-A~B grade. There was no SIR-C~F grade adverse reaction. 2. The peak systolic velocity of left and right renal artery was not different from that of preoperation. The patients were followed up 1. There was no significant difference in blood urea nitrogen bun, creatinine creatinine, glomerular filtration rate and glomerular filtration rate between 6 months and baseline. The systolic blood pressure (SBP) in 6 months was lower than that in the baseline diagnosis room by 21.5 ~ 23.3mm / 22.4 mm / g P0. 000). The diastolic blood pressure decreased by 11.1U 12.9mm / 12.0mm / g P0. 000mm; The dynamic systolic blood pressure decreased by 13.6g / 15.2mm / 14.3 mm / kg / min for 24 h, and the dynamic systolic blood pressure decreased by 5.5U / L at 24 h / h. 4.4mm Hgfus (0.000mm); There was no difference in age, height, weight, irradiation time and radiation intensity between the effective group and the effective group. The difference of abdominal wall thickness was statistically significant (P 0.05). Conclusion it is safe and feasible to treat refractory hypertension in the near future with HIFU, but it still needs to be further and long-term safe. The thickness of abdominal wall is a clinical factor affecting the treatment of RH by HIFU. The patients with thinner thickness of abdominal wall have better effect after operation.
【學位授予單位】：重慶醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R544.1

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