本文選題：無保護(hù)左主干病變 + 左主干分叉病變��； 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：【背景】隨著技術(shù)的發(fā)展以及檢查設(shè)備的完善,人們對(duì)左主干病變的認(rèn)識(shí)也在不斷變化與成熟。冠狀動(dòng)脈造影(CAG)的出現(xiàn)以及血管內(nèi)超聲(IVUS)的應(yīng)用等讓我們能夠更加直觀準(zhǔn)確的辨認(rèn)左主干病變,評(píng)估左主干病變解剖特點(diǎn),而有關(guān)左主干病變的研究也層出不窮。長(zhǎng)期以來冠狀動(dòng)脈旁路移植術(shù)(CABG)是無保護(hù)左主干(ULMCA)病變治療的標(biāo)準(zhǔn)方案,介入治療曾經(jīng)是ULMCA的禁忌。近年來隨著藥物涂層支架的出現(xiàn),有關(guān)CABG與介入治療的隨機(jī)臨床試驗(yàn)研究的開展,這種根深蒂固的觀念逐漸動(dòng)搖,臨床指南也隨之做出了重大更新,將無保護(hù)左主干病變的介入治療由原來的禁忌癥修改升級(jí)為IIa,B類適應(yīng)癥(SYNTAX≤32分),甚至對(duì)經(jīng)過選擇的左主干病變可作為介入治療的I,B類適應(yīng)癥(SYNTAX≤22),指南的更新無疑為介入醫(yī)生提供了強(qiáng)有力的證據(jù)。隨著介入設(shè)備的發(fā)展、介入技術(shù)的成熟、新一代冠脈支架的問世,目前ULMCA病變的介入治療已成為能與CABG術(shù)相媲美的血運(yùn)重建方式。左主干病變中最為復(fù)雜多變的病變類型便是左主干分叉部病變,其介入治療策略簡(jiǎn)單可概括為兩種方式:單支架與雙支架。此二者各有其優(yōu)缺點(diǎn):如單支架術(shù)式簡(jiǎn)單,符合“越簡(jiǎn)單越好”的介入原則,對(duì)原始血管改造較少,對(duì)于患者及術(shù)者更易接受,然而單支架置入有其弊端,例如Crossover技術(shù)對(duì)邊支影響不確定;雙支架能夠獲得較好的即刻效果,然而其術(shù)式相對(duì)復(fù)雜,改變了原始血管結(jié)構(gòu),遠(yuǎn)期預(yù)后可能受到影響。臨床上有關(guān)此類病變的介入治療策略選擇仍存爭(zhēng)議,相關(guān)研究結(jié)果也不盡相同。兩種治療策略對(duì)無保護(hù)左主干分叉部病變治療孰優(yōu)孰劣仍無定論,可用于臨床參考的數(shù)據(jù)資料也相對(duì)缺乏�！灸康摹勘疚耐ㄟ^對(duì)無保護(hù)左主干分叉部病變患者臨床基礎(chǔ)資料及介入相關(guān)信息進(jìn)行回顧性分析,探究無保護(hù)左主干分叉部病變不同的介入治療策略對(duì)臨床結(jié)果的影響,為介入醫(yī)生臨床治療左主干病變提供更多文獻(xiàn)參考與依據(jù)�！痉椒ā咳脒x2012年1月至2016年1月收入鄭州大學(xué)第一附屬醫(yī)院心血管內(nèi)科,冠脈造影示無保護(hù)左主干分叉部病變患者136例,并收集其詳細(xì)的臨床資料,包括病史、檢查檢驗(yàn)、介入手術(shù)相關(guān)資料、術(shù)后并發(fā)癥發(fā)生情況、住院期間主要心血管事件(mace)發(fā)生情況以及1年隨訪資料,進(jìn)行回顧性統(tǒng)計(jì)分析。mace事件包括心源性死亡、心肌梗死(mi)、靶病變血運(yùn)重建(tlr)。納入標(biāo)準(zhǔn):1.冠脈造影示左主干分叉部病變(管腔狹窄50%);2.左主干不存在通暢的橋血管或者良好的的自身側(cè)枝;3.均使用藥物涂層支架(des)治療。排除標(biāo)準(zhǔn):1.急性或者慢性左主干閉塞;2.左主干嚴(yán)重鈣化需旋磨者;3.左主干分叉部位原有支架置入者;4.因介入操作導(dǎo)致左主干遭受損傷行補(bǔ)救性支架置入者;5.惡性進(jìn)展性疾病,預(yù)期壽命小于1年者;6.有cabg術(shù)病史者;7.嚴(yán)重心肺功能不全者;8.嚴(yán)重肝腎功能不全者;9.左主干合并其他嚴(yán)重瓣膜病、心肌病以及惡性心律失常者。納入的136例患者,按照左主干分叉部位置入支架情況分為:單支架組(n=74)與雙支架組(n=62)。記錄所有入選患者臨床資料、造影資料以及隨訪結(jié)果,應(yīng)用統(tǒng)計(jì)學(xué)軟件spss17.0對(duì)兩組患者的相關(guān)資料進(jìn)行統(tǒng)計(jì)分析,以p0.05為差異有統(tǒng)計(jì)學(xué)意義�！窘Y(jié)果】(1)共入選136例左主干分叉部病變患者,置入單支架患者74例,置入雙支架患者62例,所有患者均未出現(xiàn)嚴(yán)重的圍手術(shù)期并發(fā)癥(包括急性腦出血事件、急性消化道出血、造影劑腎病及腦病、急性支架內(nèi)血栓形成、急性心包填塞等);且兩組患者住院期間mace事件發(fā)生率為0。(2)單支架組患者syntax評(píng)分較雙支架組高,其中輕度病變者(即syntax≤22分)單支架組較雙支架組所占比例高,而中重度病變者(syntax≥23分)雙支架組較單支架組所占比例高,差異有統(tǒng)計(jì)學(xué)意義;真性分叉(medina(3)1,1,1、1,0,1型)在單支架組較雙支架組少,而假性分叉(Medina 1,1,0型)在單支架組較雙支架組多,差異有統(tǒng)計(jì)學(xué)意義。(3)1年隨訪期間MACE事件發(fā)生率雙支架組較單支架組高,差異有統(tǒng)計(jì)學(xué)意義(p0.05);雙支架組TLR較單支架組高(p0.05),而兩組心源性死亡率、MI發(fā)生率均無統(tǒng)計(jì)學(xué)差異(p0.05)。對(duì)兩組患者SYNTAX評(píng)分、Medina分型進(jìn)行分層分析結(jié)果顯示:SYNTAX提示輕度病變患者中,單支架組MACE發(fā)生率較雙支架組明顯較小(p0.05),且主要體現(xiàn)在TLR上(p0.05);中重度病變患者中,兩組MACE事件發(fā)生無顯著差異;兩組無論真性分叉(Medina1,1,1、1,0,1)還是假性分叉(Medina1,1,0)病變,其MACE發(fā)生率以及TLR等均無顯著差異�！窘Y(jié)論】1.準(zhǔn)確評(píng)估左主干病變性質(zhì)及解剖特點(diǎn),對(duì)于選擇介入策略至關(guān)重要。2.對(duì)于病變性質(zhì)及解剖特點(diǎn)較為簡(jiǎn)單的左主干分叉部病變患者,單支架策略可能為更合適的選擇;而對(duì)于病變性質(zhì)及解剖特點(diǎn)較為復(fù)雜的左主干分叉部病變患者,單支架策略并不弱于雙支架策略。
[Abstract]:[background] with the development of technology and the perfection of the inspection equipment, people's understanding of the left main disease is also changing and maturing. The appearance of CAG and the application of intravascular ultrasound (IVUS) make it more intuitive and accurate to identify the left main lesion and evaluate the anatomical characteristics of the left main disease, and the left The study of main stem lesions is also emerging. Coronary artery bypass grafting (CABG) has long been a standard scheme for the treatment of unprotected left main stem (ULMCA) lesions. Interventional therapy has been a taboo of ULMCA. In recent years, with the emergence of drug coated stents, a randomized clinical trial of CABG and interventional therapy has been carried out, which is deeply rooted The concept is gradually shaken, and the clinical guide has also made a major update. The intervention therapy of the unprotected left main lesion is upgraded from the original contraindication to IIa, B (SYNTAX < 32), even the selected left main lesion can be used as I for interventional therapy and B (SYNTAX < < 22). The update of the guide is undoubtedly involved in the intervention. Doctors provide strong evidence. With the development of the interventional equipment and the maturation of interventional techniques, the advent of a new generation of coronary stents, the interventional therapy of ULMCA lesions has become a way of revascularization comparable to that of CABG. The most complex and changeable pathological type of the left main disease is the left main bifurcation lesion and its interventional therapy The strategy can be summed up in two ways: single stents and double stents. Each of these two has its advantages and disadvantages. For example, single stent is simple and fits the principle of "simpler and better". It has less modification to the original blood vessels and more acceptable to patients and operators. However, single stent placement has its drawbacks, such as the uncertainty of Crossover technology on the side. The double stent has a better immediate effect, but its operation is relatively complex, the original vascular structure is changed and the long-term prognosis may be affected. The selection of intervention strategies for such lesions is still controversial and the results are not the same. The two treatment strategies are better for the treatment of the unprotected left main bifurcation lesion. It is still inconclusive and can be used for clinical reference data. Doctors provide more reference and basis for clinical treatment of left main disease. [Methods] 136 patients were enrolled in the Department of cardiovascular medicine, the First Affiliated Hospital of Zhengzhou University from January 2012 to January 2016. Coronary angiography showed no protection of left main branches of the left main lesion, and collected the detailed clinical data, including medical history, examination and intervention. Data, postoperative complications, the incidence of major cardiovascular events (MACE) and 1 years of follow-up during hospitalization, and a retrospective statistical analysis of.Mace events included cardiac death, myocardial infarction (MI) and target lesion revascularization (TLR). 1. coronary angiography showed the left main bifurcation lesion (50%); 2. left main trunk There were no smooth bridge vessels or good lateral branches; 3. were treated with drug coated stents (DES). Exclusion criteria: 1. acute or chronic left main stem occlusion; 2. left main trunk calcification for severe calcification; 3. left main stem bifurcations in the original stents; 4. the left main trunk was damaged by interventional operation for remedial stent placement. Patients with 5. malignant progressive diseases, life expectancy less than 1 years; 6. patients with CABG history; 7. patients with severe cardiopulmonary insufficiency; 8. severe liver and kidney insufficiency; 9. left main trunk with other severe valvular disease, cardiomyopathy and malignant arrhythmia. 136 patients were divided into single stents according to the position of the left main trunk. N=74) and the double stent group (n=62). Record all the selected patients' clinical data, imaging data and follow-up results. Statistical software SPSS17.0 was used to analyze the related data of two groups of patients with statistical significance. [results] (1) a total of 136 patients with left main bifurcation lesions were selected and 74 cases were placed in single stents. There were 62 patients with double stents. All patients had no serious perioperative complications (including acute cerebral hemorrhage, acute gastrointestinal bleeding, contrast nephropathy and encephalopathy, acute stent thrombosis, acute pericardial tamponade, etc.); and the incidence of mace events in the two groups was 0. (2) in the single stenting group, with a higher SYNTAX score. The proportion of stent group was higher, and the proportion of mild lesion (syntax < 22) single stent group was higher than that of double stenting group, while the proportion of middle and severe lesion (syntax > 23) double stent group was higher than that of single stents group, and the difference was statistically significant. The true bifurcation (Medina (3) 1,1,1,1,0,1 type) was less in the single stents group than in the double stents group, and the false branching (Medina 1,1, Medina). The difference was statistically significant in the single stenting group compared with the double stenting group. (3) the incidence of MACE events during the 1 year follow-up was higher than that in the single stents group (P0.05), and the TLR in the two stents group was higher than that of the single stents group (P0.05), but there was no statistical difference between the two groups of cardiac mortality and the incidence of MI (P0.05). The SYNTAX evaluation of the two groups of patients was not statistically significant (P0.05). The results of stratified analysis of Medina typing showed that the incidence of MACE in the single stent group was significantly smaller than that in the double stenting group (P0.05) in the patients with mild lesions (P0.05), and mainly on TLR (P0.05). There were no significant differences in the two groups of MACE events in the patients with moderate and severe lesions, and the two groups were either genuine bifurcation (Medina1,1,1,1,0,1) or false bifurcation (M). Edina1,1,0) there were no significant differences in the incidence of MACE and TLR. [Conclusion] 1. the accurate assessment of the nature and anatomical characteristics of the left main artery disease is critical to the choice of the intervention strategy for the patients with the left main branch of the left main lesion, which is very simple for the nature of the lesion and the anatomical characteristics of the left trunk, and the single stent strategy may be a more appropriate choice. Single stent strategy is not less effective than dual stent strategy in patients with complex left main bifurcation lesions.

【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R54

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2 肖麗燕;分叉角度、邊支rewire位置對(duì)DK-Crush雙支架置入后分叉部支架形態(tài)學(xué)影響的體外研究[D];福建醫(yī)科大學(xué);2016年

3 肖峰;顱內(nèi)動(dòng)脈分叉部血管結(jié)構(gòu)與分叉部動(dòng)脈瘤形成的相關(guān)性研究[D];浙江大學(xué);2012年

4 馬秀娥;SYNTAX評(píng)分在無保護(hù)左主干病變中的應(yīng)用價(jià)值[D];河北醫(yī)科大學(xué);2015年

5 郭震;多排螺旋CT冠狀動(dòng)脈成像在左主干病變?cè)\斷中的應(yīng)用[D];河北醫(yī)科大學(xué);2015年

6 趙彬;血管內(nèi)超聲檢查在左主干病變中的應(yīng)用價(jià)值[D];河北醫(yī)科大學(xué);2015年

7 劉p蓐

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