本文選題：支架影像增強顯影　切入點：血管內(nèi)超聲　出處：《河北醫(yī)科大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:經(jīng)皮冠狀動脈介入治療(Percutaneous coronary intervention,PCI)冠狀動脈(冠脈)開口病變一直以來都具有挑戰(zhàn)和風(fēng)險。與開口病變介入治療相比,其心臟不良事件發(fā)生率也高。研究表明,支架定位不準確和支架擴張不良是影響冠脈開口病變介入治療預(yù)后的兩大主要因素。目前,血管內(nèi)超聲(Intravascular ultrasound,IVUS)是指導(dǎo)開口病變介入治療的金標準,然而在臨床實踐中其使用存在局限性。支架影像增強顯影技術(shù)(Stent Boost Subtract,SBS)是最近發(fā)展起來的一項新的介入成像技術(shù),該技術(shù)不僅能夠增強支架的可視性,同時還可以顯示支架與周圍血管壁及鄰近血管的關(guān)系。因此理論上該技術(shù)可以用來指導(dǎo)冠脈開口病變介入治療時支架精確定位、識別支架擴張不良。目前尚沒有專門關(guān)于SBS在冠脈開口病變介入治療中應(yīng)用的相關(guān)報道。本研究的目的正是以IVUS作為金標準,評價SBS在指導(dǎo)冠脈開口病變介入治療中的應(yīng)用。方法:本研究為單中心回顧性研究,我們共回顧性分析了從2012年3月份至2014年12月份就診于我科并符合入選標準的55例行開口病變血管成形術(shù)的患者,所有患者置入支架前、后均行SBS與IVUS檢查。納入標準:符合開口病變PCI適應(yīng)癥,冠狀動脈造影提示原發(fā)的冠狀動脈開口病變,即距離主動脈-冠狀動脈開口(左主干或右冠狀動脈)或非主動脈-冠狀動脈開口(左前降支、回旋支或中間支)3mm以內(nèi),同時并未累及近端或遠端鄰近分支血管病變(Fig.2),同時有置入支架的臨床指征。排除標準:(1)年齡18歲或80歲;(2)累及一個以上開口的分叉病變;(3)左主干短粗:長度8mm、直徑5mm;(4)支架貫穿左主干和前降支或回旋支(cross-over);(5)橋血管開口;(6)慢性完全阻塞性病變;(7)未于支架置入前和(或)支架置入后行SBS和(或)IVUS檢查;(8)圖像質(zhì)量較差影響結(jié)果分析;(9)冠狀動脈造影檢查后行外科搭橋術(shù);(10)術(shù)中出現(xiàn)無復(fù)流、慢血流或夾層等相關(guān)并發(fā)癥;(11)有支架置入禁忌證或未行支架置入術(shù)。我們明確了SBS與IVUS對支架精確定位及充分擴張的定義。SBS與IVUS對支架精確定位的標準為支架近端邊緣距離病變開口位置1mm。SBS關(guān)于最小支架面積(Minimum stent area,MSA)的定義:π×(最小支架直徑(Minimum stent diameter,MSD)/2)2。SBS技術(shù)支架充分擴張的標準為:(1)沒有局部擴張不充分或者支架柱凸起,沒有支架連續(xù)性中斷的影像征象;(2)最小支架直徑70%參考支架直徑;(3)最小支架直徑2.0mm。IVUS關(guān)于支架充分擴張的標準為:(1)當參考血管直徑≥2.8mm時,MSA≥5.0 mm2;當參考血管直徑2.8mm時,MSA≥4.5mm2;(2)支架對稱指數(shù)(最小支架直徑/最大支架直徑)≥0.7;(3)沒有嚴重夾層、壁間血腫,且靶病變完全覆蓋。經(jīng)皮冠狀動脈血管成形術(shù)均由從事多年冠脈介入診療技術(shù)的專家依據(jù)國際標準化介入診療指南操作完成。所有入選患者在支架置入前、后均行SBS檢查和IVUS檢查,根據(jù)IVUS檢查結(jié)果決定是否行高壓后擴張或補放支架。冠狀動脈造影檢查均采用Allura Xper FD10或FD20數(shù)字平板機(Philips Healthcare,Best,The Netherlands)進行。既往PCI數(shù)據(jù)從我科導(dǎo)管室PCI數(shù)據(jù)庫中調(diào)取。對既往PCI術(shù)前造影數(shù)據(jù)行QCA分析。分析軟件采用具有自動檢測邊界功能的QAngio XA version 7.2軟件包(Medis Medical Imaging System,Netherlands)。分析指標包括病變處直徑狹窄率、最小管腔直徑、病變長度及參考管腔直徑。SBS成像由配有SBS分析系統(tǒng)的Allura Xper FD 20/10數(shù)字平板血管造影機(Philips Medical Systems,Best,The Netherlands)完成。SBS圖像分析采用造影機自帶的SBS圖像分析系統(tǒng)進行分析。SBS軟件可以自動對最小支架直徑以及參考支架直徑(即支架邊緣直徑)進行分析。IVUS檢查設(shè)備由IVUS超聲導(dǎo)管、導(dǎo)管回撤系統(tǒng)和超聲主機三部分組成。所有IVUS檢查均采用標準冠狀動脈內(nèi)介入導(dǎo)管操作技術(shù)進行操作。既往IVUS數(shù)據(jù)從我科導(dǎo)管室IVUS數(shù)據(jù)庫中調(diào)取并對其進行分析。分析指標包括最小支架面積及支架精確定位等。統(tǒng)計學(xué)分析:應(yīng)用SPSS13.0對數(shù)據(jù)進行統(tǒng)計學(xué)分析,計數(shù)資料以頻數(shù)和百分位數(shù)表示。連續(xù)變量數(shù)據(jù)采用M±S。SBS與IVUS二者之間MSA的相關(guān)性采用直線回歸分析,二者之間一致性分析采用Bland-Altman分析。以IVUS檢查結(jié)果為“金標準”,計算SBS評價冠脈開口病變介入治療時支架擴張不良的靈敏度和特異度,陽性預(yù)測價值和陰性預(yù)測價值。雙側(cè)P0.05被認為有統(tǒng)計學(xué)差異。結(jié)果:(1)根據(jù)先前定義的關(guān)于SBS和IVUS支架定位的標準,對比IVUS結(jié)果,SBS指導(dǎo)PCI中48處(82.8%)病變支架定位是精確的,6處(10.3%)病變支架近端邊緣距離病變開口以遠1mm,4處(6.9%)病變支架近端邊緣突出病變開口1mm。(2)根據(jù)先前定義的關(guān)于SBS和IVUS支架擴張的標準,SBS檢測到50處(86.2%)支架充分擴張及8處(13.8%)支架擴張不良;IVUS檢測到48處(82.8%)支架充分擴張及10處(17.2%)支架擴張不良。SBS預(yù)測支架擴張不良的特異度和靈敏度分別為100%和80%,陽性預(yù)測價值和陰性預(yù)測價值分別為100%和96%。(3)SBS檢測到的最小支架面積(MSA)與IVUS檢測到的最小支架面積(MSA)之間存在有統(tǒng)計學(xué)意義上的正相關(guān),回歸系數(shù)為0.91,P0.001。結(jié)論:SBS作為一種簡單快捷的介入影像技術(shù),能夠有效指導(dǎo)冠脈開口病變PCI時的支架定位,以及輔助判斷支架擴張情況。
[Abstract]:Objective: percutaneous coronary intervention (Percutaneous coronary, intervention, PCI) of coronary artery (coronary ostial lesion) has always been the challenges and risks. Compared with the opening of interventional treatment, the incidence of adverse cardiac events was also high. The study shows that the stent positioning is not accurate and stent expansion is two main factors influencing the bad coronary ostial lesions prognosis. At present, intravascular ultrasound (Intravascular ultrasound, IVUS) is the gold standard to guide interventional treatment of ostial lesions, but in clinical practice the use of limitations. Image enhancement technology support (Stent Boost Subtract, SBS) is a new imaging technique developed recently and the technology can not only enhance the visibility of the stent, but also can show the relationship between supports and surrounding the vascular wall and adjacent blood vessels. In theory, the technology can be used To guide the interventional therapy of coronary ostial lesion support accurate positioning, identification of stent expansion is poor. There is no special reports about the application of SBS in the interventional treatment of coronary ostial lesions. The purpose of this study is to evaluate the SBS IVUS as the gold standard, under the guidance of interventional therapy of coronary ostial lesion. Methods: This study for a single center retrospective study, we retrospectively analyzed from 2012 March to 2014 December in our department and meet the criteria of 55 patients with ostial lesion angioplasty and stenting in all patients before and after underwent SBS and IVUS examination. Inclusion criteria: in accordance with the opening of coronary artery lesions PCI indications angiography showed that primary coronary artery disease, coronary artery opening distance (left main or right coronary artery) or non coronary artery opening (left anterior descending branch of circumflex 鏀垨涓棿鏀，

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