本文選題：經(jīng)皮冠狀動(dòng)脈介入治療 + 冠狀動(dòng)脈鈣化��； 參考：《中國(guó)人民解放軍醫(yī)學(xué)院》2017年博士論文

【摘要】：研究背景:冠脈重度鈣化病變經(jīng)皮冠脈介入治療術(shù)(Percutaneous coronary intervention, PCI)中,支架膨脹不良發(fā)生率高,從而增加了心血管不良事件(Major adverse cardiac event, MACE)的發(fā)生率。經(jīng)冠脈旋磨術(shù)(Rotational atherectomy,RA)聯(lián)合切割球囊成形術(shù)(Cutting balloon angioplasty, CB)充分預(yù)處理重度鈣化病變,可能有利于支架良好膨脹,改善近遠(yuǎn)期預(yù)后,但是相關(guān)研究數(shù)據(jù)較少。此外,重度鈣化病變PCI治療中,相關(guān)鈣化參數(shù)如何影響支架膨脹不良,研究甚少。研究目的:1、評(píng)價(jià)旋磨術(shù)聯(lián)合切割球囊成形術(shù),充分預(yù)處理重度冠脈鈣化狹窄病變,支架置入的膨脹效果及MACE事件。利用冠脈造影定量分析(Quantitation coronary analyze, QCA),以及冠狀動(dòng)脈血管內(nèi)超聲(Intra-Vascular ultrasound, IVUS)評(píng)價(jià)支架膨脹不良的相關(guān)影響因素,探討重度鈣化病變中預(yù)處理的標(biāo)準(zhǔn)。2、利用冠脈光學(xué)相干斷層成像(Optical coherence tomography, OCT)評(píng)價(jià),經(jīng)過(guò)旋磨聯(lián)合切割球囊處理后的重度冠脈鈣化病變中,支架膨脹不良的相關(guān)影響因素。研究方法:1、回顧性分析2013年1月至2015年12月,在中國(guó)人民解放軍總醫(yī)院,行冠狀動(dòng)脈造影(Coronary artery angioplasty,CAG)及IVUS檢查的,92例冠脈高度鈣化伴狹窄的冠心病患者。其相關(guān)缺血病變均經(jīng)RA處理,根據(jù)是否聯(lián)合切割球囊分為RA聯(lián)合CB (RACB)組46例,以及單純旋磨(ROTA)組46例。根據(jù)鈣化程度,年齡,性別等因素,匹配了 40例僅經(jīng)普通球囊處理的冠脈高度鈣化患者,為普通球囊處理(POBA)組。所有患者均在病變預(yù)處理后,置入第二代藥物洗脫支架。在病變處理前,旋磨后,切割/普通球囊擴(kuò)張后,以及支架置入后,均使用QCA測(cè)量管腔直徑,和管腔直徑狹窄率。使用IVUS觀察病變鈣化相關(guān)參數(shù),以及預(yù)處理后鈣化環(huán)斷裂。分析支架膨脹不良的影響因素。2、前瞻性分析在我中心行冠脈旋磨術(shù)聯(lián)合切割球囊成形術(shù),并于術(shù)中行OCT檢查的重度鈣化病變的患者9例。在旋磨聯(lián)合切割預(yù)處理后,和支架置入后,使用OCT自動(dòng)回撤記錄病變相關(guān)血管段,記錄最小管腔面積,鈣化弧度,鈣化長(zhǎng)度,鈣化厚度,鈣化組織表面組織厚度,鈣化環(huán)斷裂,鈣化小結(jié),支架置入后支架面積,支架貼壁情況,以及組織脫垂情況。按2mm為一病變節(jié)段,共收集148個(gè)病變節(jié)段,其中105個(gè)鈣化節(jié)段。分析影響支架膨脹不良,貼壁不良的因素,以及影響鈣化環(huán)斷裂的因素。研究結(jié)果:1、在ROTA和RACB兩組中,病變處理前,以及旋磨后,管腔直徑和直徑狹窄率均未見(jiàn)統(tǒng)計(jì)學(xué)差異。但是在經(jīng)過(guò)不同球囊預(yù)處理后,RACB組的管腔直徑狹窄率明顯減低(從54.5%±8.9%降至36.1%±7.1%),而ROTA組的管腔直徑狹窄率僅輕度減低(從55.7%±7.8%到46.9%±9.4%),P0.001。支架置入后,RACB組的良好支架膨脹比例(71.7%)明顯高于ROTA組(54.5%),和POBA組(15%),P0.001。并且支架置入后的殘余管腔狹窄率在RACB組(6.0%±23%),明顯低于另兩組(RA 組 10.8%±3.3%,POBA 組 12.7%±2.1%), P0.001。2、病變預(yù)處理后管腔直徑狹窄率≤40%,與支架良好膨脹相關(guān)(OR=2994, 95%CI:1.297-6.911)。IVUS下觀察到的鈣化環(huán)斷裂,與病變預(yù)處理后管腔狹窄率≤40%呈正相關(guān)(r=0.581,P0.001)。3、OCT觀察的105段鈣化病變節(jié)段中,平均最小管腔面積2.4±0.76mm2,鈣化弧度164.3±86.4°,鈣化長(zhǎng)度1.72±0.39mm,鈣化厚度0.47±0.18mm,鈣化表層組織厚度0.15 ±0.14mm, 42個(gè)鈣化節(jié)段出現(xiàn)鈣化環(huán)斷裂(40%)。支架置入后,平均支架面積為5.26±1.11mm2,29個(gè)節(jié)段出現(xiàn)支架膨脹不良(27.6%), 29個(gè)節(jié)段出現(xiàn)支架貼壁不良,24個(gè)節(jié)段出現(xiàn)組織脫垂(22.9%)。4、OCT觀察下,支架膨脹不良的主要影響因素為鈣化環(huán)斷裂(OR=0.160,95%CI:0.050,0.516),以及預(yù)處理后的最小管腔面積(OR=1.87,95%CI:1.021, 3.425)。支架貼壁不良的主要影響因素為鈣化弧度(OR=1.006,95%CI:1.001,1.011)。鈣化環(huán)斷裂的主要影響因素為,鈣化弧度(OR=1.008,95%CI:1.002,1.015),以及鈣化表面組織厚度(OR=0.000,95%CI: 0.000,0.001)。研究結(jié)論:1、旋磨聯(lián)合切割球囊成形術(shù)預(yù)處理重度鈣化病變,可以增加鈣化環(huán)斷裂比例,減少管腔殘余狹窄率,有利于支架良好膨脹。2、預(yù)處理后管腔直徑狹窄≤40%,是支架膨脹良好的預(yù)測(cè)因素。而預(yù)處理后出現(xiàn)鈣化環(huán)斷裂,與預(yù)處理后管腔直徑狹窄≤40%相關(guān)。3、經(jīng)旋磨聯(lián)合切割球囊充分預(yù)處理鈣化病變后,OCT下觀察的支架膨脹不良以及貼壁不良的發(fā)生率較低。4、重度鈣化病變預(yù)處理后,鈣化環(huán)斷裂,以及管腔面積的增加,可能有助于支架良好膨脹。而旋磨聯(lián)合切割處理鈣化病變后,鈣化環(huán)斷裂的發(fā)生與OCT下觀察到的廣泛的鈣化弧度,以及鈣化表面組織厚度0.1mm相關(guān)。
[Abstract]:Background: the incidence of stent dilatation is high in Percutaneous coronary intervention (PCI), which increases the incidence of adverse cardiovascular events (Major adverse cardiac event, MACE). Coronary artery rotation (Rotational atherectomy, RA) combined balloon angioplasty (Rotational atherectomy, RA) Tting balloon angioplasty, CB) fully preconditioning severe calcification, may be beneficial to the good expansion of the stent, improve the near and long term prognosis, but the related research data are few. In addition, in the PCI treatment of severe calcification, how the related calcification parameters affect the stent dilatation is very rare. 1. Plasty, fully preprocessing of severe coronary artery calcification, the expansion effect of stent implantation and MACE events. Using Quantitation coronary analyze (QCA), and coronary artery intravascular ultrasound (Intra-Vascular ultrasound, IVUS) to evaluate the related factors of stent dilatation, and to explore the severe calcification disease. The standard.2, Optical coherence tomography (OCT), was used to evaluate the related factors of poor stent dilatation in severe coronary artery calcification after a combined balloon treatment. 1. A retrospective analysis from January 2013 to December 2015 in the Chinese people's Liberation Army. Hospital, Coronary artery angioplasty (CAG) and IVUS examination, 92 patients with coronary artery height calcification with stenosis of coronary heart disease. The related ischemic lesions were treated by RA, according to whether the joint sacs were divided into RA combined with CB (RACB) in 46 cases, and 46 cases of single pure rotation (ROTA) group. 40 patients with coronary artery height calcification only treated with common balloon treatment were matched for the common balloon treatment (POBA) group. All patients were treated with second generation drug eluting stents after the lesion preconditioning. After the lesion, the diameter of the lumen and the diameter of the lumen were measured and the diameter of the lumen and the diameter of the lumen were measured with QCA after the rotation, the dilation of the common balloon and the support. Stenosis rate. IVUS observation of calcification related parameters and pre treated calcified ring fracture. Analysis of the influence factors of stent dilatation.2. Prospective analysis of 9 patients with severe calcification with OCT examination in the center of coronary artery grinding combined with cutting balloon angioplasty and in the operation, after the combined rotation of grinding, and the branch. After the stent was placed, OCT was automatically retracted to record the vascular segments of the lesion, recording the minimum lumen area, calcification arc, calcification length, calcification thickness, calcified tissue thickness, calcified ring fracture, calcified nodule, stent area, stent placement, and tissue prolapse. A total of 148 segments were collected by 2mm. Diseased segments, 105 calcified segments. Analysis of factors affecting poor stent dilatation, poor adherence to the wall, and factors affecting the calcification ring fracture. 1. In the ROTA and RACB two groups, there were no statistically significant differences in the diameter and diameter of the lumen before and after the treatment of the lesions, but after a different balloon preconditioning, RACB The stenosis rate of the lumen diameter of the group decreased significantly (from 54.5% + 8.9% to 36.1% + 7.1%), and the stenosis rate of the lumen diameter in the ROTA group was only slightly lower (from 55.7% + 7.8% to 46.9% + 9.4%). After the P0.001. stent implantation, the good expansion ratio of the RACB group (71.7%) was significantly higher than that of the ROTA group (54.5%), and the POBA group (15%), P0.001. and the remnants of the stent implantation. The stenosis rate of the lumen in the RACB group (6% + 23%) was significantly lower than that in the other two groups (group RA, 10.8% + 3.3%, group POBA 12.7% + 2.1%), P0.001.2. The stenosis rate of the lumen diameter was less than 40% after the lesion preconditioning. The calcium ring fracture was observed under OR=2994, 95%CI:1.297-6.911.IVUS, and the stenosis rate of the lumen was less than 40% Cheng Zhengxiang after the lesion pretreated. In the 105 segment calcification segment observed by r=0.581, P0.001.3 and OCT, the average minimum lumen area was 2.4 + 0.76mm2, calcified radians were 164.3 + 86.4 degrees, calcification was 1.72 + 0.39mm, calcification was 0.47 + 0.18mm, calcified surface tissue thickness was 0.15 + 0.14mm, and 42 calcified segments appeared calcified ring fracture (40%). The average stent area was 5.26 The stent dilatation (27.6%) was found in the 1.11mm2,29 segment, and the stent was poor in the 29 segment, and the 24 segment appeared tissue prolapse (22.9%).4. Under the OCT observation, the main influence factor of the stent dilatation was the calcified ring fracture (OR=0.160,95%CI:0.050,0.516), and the minimum lumen area after the pretreatment (OR=1.87,95%CI:1.021, 3.425). The main influencing factors of poor adherence were calcified arc degree (OR=1.006,95%CI:1.001,1.011). The main factors affecting calcification ring fracture were calcified radian (OR=1.008,95%CI:1.002,1.015) and calcified surface tissue thickness (OR=0.000,95%CI: 0.000,0.001). 1. The results of the study were as follows: the combined resection of ball sacculoplasty for severe calcification, It can increase the fracture ratio of the calcification ring, reduce the residual stenosis rate of the lumen, and be beneficial to the good expansion of the stent.2. The stenosis of the diameter of the cavity is less than 40% after pretreatment, and it is a predictor of the good expansion of the stent. The calcification ring fracture after pretreatment and the stenosis of the diameter of the lumen after the pretreatment are less than.3, and the calcification is fully pretreated by the milling combined with the balloon. After the lesions, the stent expansion under OCT and the incidence of poor adherence were lower.4. The calcification ring fracture and the increase of the lumen area may contribute to the good expansion of the stent after severe calcification, and the occurrence of calcified ring fracture and the extensive calcification arc observed under OCT Degree, as well as calcified surface tissue thickness 0.1mm related.

【學(xué)位授予單位】：中國(guó)人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.4

【參考文獻(xiàn)】

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