血管內(nèi)光學(xué)相干斷層成像在頸動脈粥樣硬化患者的診斷及介入治療中的應(yīng)用研究
發(fā)布時(shí)間：2018-09-19 13:11
【摘要】：第一部分頻域光學(xué)相干斷層成像(FD-OCT)技術(shù)在頸動脈斑塊評估及頸動脈支架術(shù)中應(yīng)用的安全性及可行性研究背景和目的:本研究通過探討FD-OCT技術(shù)在頸動脈系統(tǒng)中的應(yīng)用,分析了其在頸動脈斑塊評估及頸動脈支架術(shù)中應(yīng)用的安全性和可行性。對象與方法:本研究納入2014年1月至2015年5月在南京軍區(qū)南京總醫(yī)院神經(jīng)內(nèi)科行頸動脈血管成像檢查,確認(rèn)為頸動脈粥樣硬化并行OCT檢查及頸動脈支架置入術(shù)患者。每名患者的OCT圖像分別在CAS術(shù)前及術(shù)后獲取兩次。獲取時(shí)采用100%造影劑,速度8ml/s,總量15ml。兩名研究人員分別對所獲取的圖像進(jìn)行評分,評分為1-10分。采用Cohen’s統(tǒng)計(jì)分析對觀察者之間和觀察者內(nèi)部的可靠性進(jìn)行分析,以P0.05為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果:本研究共納入22名患者,進(jìn)行了44次掃描,成功獲取了40/44(90.9%)的合格圖像。在OCT操作過程中未出現(xiàn)手術(shù)相關(guān)的神經(jīng)系統(tǒng)并發(fā)癥(0%)。OCT所獲取的圖像質(zhì)量較高(平均7.5±0.9分)。在CAS術(shù)后,OCT圖像可以發(fā)現(xiàn)明確的纖維帽破損、支架貼壁不良及斑塊脫垂。在OCT圖像評分識別中,觀察者內(nèi)及觀察者間的有較高的一致性(κ=0.76 andκ=0.82,respectively;both p0.001)。結(jié)論:本研究為OCT技術(shù)在國內(nèi)首次應(yīng)用于頸動脈系統(tǒng)。研究證實(shí)了OCT技術(shù)在頸動脈系統(tǒng)中應(yīng)用的安全性及可行性。OCT可以為頸動脈斑塊的評估,頸動脈支架置入術(shù)的術(shù)后評估提供更為豐富的資料。第二部分癥狀性頸動脈粥樣硬化與無癥狀性頸動脈粥樣硬化OCT檢查的結(jié)果比較背景與目的:對于無癥狀性頸動脈粥樣硬化患者,斑塊性質(zhì)的判定和評估非常必要。本研究通過OCT技術(shù),比較癥狀性和非癥狀性頸動脈粥樣硬化斑塊的形態(tài)學(xué)特點(diǎn),為OCT技術(shù)在頸動脈系統(tǒng)中的應(yīng)用提供依據(jù)。對象與方法:研究納入2014年1月至2015年5月在南京軍區(qū)南京總醫(yī)院神經(jīng)內(nèi)科行頸動脈血管成像檢查,經(jīng)有無創(chuàng)檢查確診為頸動脈粥樣硬化,并行OCT檢查的患者。根據(jù)患者就診前6個(gè)月內(nèi)癥狀的有無,將患者分為兩組,即有癥狀組和無癥狀組。通過DSA及OCT確定患者病變血管的狹窄程度,記錄OCT圖像觀察到的斑塊特征,并進(jìn)行比較。兩組間的計(jì)數(shù)資料采用χ2檢驗(yàn)或Fisher檢驗(yàn)。應(yīng)用Cohen’s統(tǒng)計(jì)分析對觀察者之間和觀察者內(nèi)部的可靠性進(jìn)行分析。采用二分類Logistic回歸對癥狀發(fā)生的獨(dú)立危險(xiǎn)因素進(jìn)行分析。采用Bland-Altman plot檢驗(yàn)對OCT和DSA所測得的血管直徑狹窄程度的一致性進(jìn)行檢驗(yàn)。結(jié)果:共有52例病人完成OCT檢查。DSA檢查與OCT檢查技術(shù)在頸動脈直徑測量上有著良好的一致性和相關(guān)性。癥狀性患者的VI型斑塊發(fā)生率較高(68.0%vs.33.3%,respectively;p=0.025),巨噬細(xì)胞浸潤的發(fā)生率高(52.0%vs.22.2%,p=0.043),附壁血栓的發(fā)生率高(64.0%vs.37.0%,p=0.095),纖維化斑塊的發(fā)生率較低(40.0%vs.70.4%,respectively;p=0.050)。通過logistic回歸分析提示,VI型斑塊(OR:13.798,95%CI:1.38 to 137.675,p=0.025)與巨噬細(xì)胞浸潤(OR:5.856,95%CI:1.405 to24.406,p=0.015)是頸動脈狹窄患者癥狀發(fā)生的獨(dú)立危險(xiǎn)因素。結(jié)論:OCT技術(shù)可對頸動脈狹窄患者的血管狹窄程度進(jìn)行分析。癥狀性頸動脈狹窄患者的復(fù)雜型斑塊發(fā)生率較非癥狀性患者高。VI型斑塊、巨噬細(xì)胞浸潤是頸動脈狹窄患者癥狀發(fā)生的獨(dú)立危險(xiǎn)因素;第三部分頸動脈粥樣硬化脂質(zhì)斑塊對頸動脈支架貼壁情況的影響——基于OCT的觀察研究背景與目的:頸動脈支架目前已成為治療顱外頸動脈狹窄的主要方法之一。在行CAS的過程中,支架貼壁情況、斑塊脫垂以及纖維帽破損等情況多有發(fā)生。本研究通過分析CAS術(shù)后支架貼壁情況與脂質(zhì)斑塊之間的關(guān)系,繼而進(jìn)一步探討支架貼壁不良、斑塊脫垂及纖維帽破損等CAS術(shù)后情況對支架內(nèi)再狹窄的影響。對象與方法:研究連續(xù)納入2014年4月至2015年5月在南京軍區(qū)南京總醫(yī)院神經(jīng)內(nèi)科行頸動脈血管成像檢查,確認(rèn)為頸動脈粥樣硬化并行OCT檢查及CAS術(shù)的患者。所取圖像中的支架貼壁不良、斑塊脫垂及纖維膜破損等支架與斑塊之間的關(guān)系均被記錄。支架貼壁情況以所分析的支撐桿貼壁情況所占圖像支撐桿總數(shù)的百分比表示。同時(shí)記錄觀察到的支架貼壁不良、斑塊脫垂、纖維帽破損等圖像的具體層數(shù)。采用χ2檢驗(yàn)、Fisher檢驗(yàn)或one-way ANOVA對兩組間的計(jì)數(shù)資料進(jìn)行比較。采用Kruskal-Wallis檢驗(yàn)對兩組間纖維帽厚度的進(jìn)行比較。采用Cohen’s統(tǒng)計(jì)分析對觀察者之間和觀察者內(nèi)部的可靠性進(jìn)行分析。以P0.05為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果:本研究共納入26名患者,其中20名患者獲取質(zhì)量合格圖像,6名患者由于OCT圖像質(zhì)量不合格,予以排除。脂質(zhì)斑塊的支撐桿貼壁不良率為16.0%,非脂質(zhì)斑塊的支撐桿貼壁不良率為16.7%(p=0.953)。脂質(zhì)斑塊組支撐桿內(nèi)陷率為29.4%,非脂質(zhì)斑塊支撐桿內(nèi)陷率為23.7%(p0.001)。脂質(zhì)斑塊組支撐桿貼壁良好率為54.6%,非脂質(zhì)斑塊組支撐桿貼壁良好率為59.6%(p0.001)。脂質(zhì)斑塊組斑塊脫垂率為65.5%,非脂質(zhì)斑塊組斑塊脫垂率為49.1%(p0.001)。二組間纖維帽破損率也有明顯差異,脂質(zhì)斑塊組為49.8%,非脂質(zhì)斑塊組為33.7%(p0.001)。二組間支架貼壁不良率無明顯差異,脂質(zhì)斑塊組為12.3%,非脂質(zhì)斑塊組為14.9%(p=0.489)。支架貼壁不良、支架內(nèi)陷、斑塊脫垂及纖維帽破損患者在6個(gè)月隨訪時(shí),未發(fā)現(xiàn)明顯的支架內(nèi)再狹窄。結(jié)論:脂質(zhì)斑塊組與非脂質(zhì)斑塊組之間的支架貼壁不良率之間無顯著差異。而非脂質(zhì)斑塊組患者的斑塊脫垂、纖維帽破損等情況發(fā)生較低。在本研究中,6個(gè)月隨訪時(shí),支架貼壁不良、纖維帽破裂患者的支架內(nèi)再狹窄發(fā)生率未見明顯升高。第四部分應(yīng)用OCT觀察到頸動脈支架術(shù)后支架內(nèi)急性血栓形成1例并文獻(xiàn)復(fù)習(xí)支架內(nèi)急性血栓形成是較為少見的頸動脈支架并發(fā)癥。但是該并發(fā)癥若處理不及時(shí),則會導(dǎo)致血管閉塞,神經(jīng)功能缺損,甚至影響手術(shù)效果,威脅生命。OCT可以在頸動脈支架術(shù)前、術(shù)中及術(shù)后對頸動脈病變情況、頸動脈支架與管壁之間的關(guān)系以及支架內(nèi)急性血栓的形成進(jìn)行觀察和記錄。本研究通過1例病例報(bào)道,證實(shí)OCT能夠?qū)χЪ軆?nèi)急性血栓的形成進(jìn)行直觀的記錄和描述。第五部分血管內(nèi)光學(xué)相干斷層成像系統(tǒng)在腦血管介入治療中的評估術(shù)語、方法及臨床應(yīng)用綜述OCT作為一種使用近紅外光的新的血管內(nèi)成像方法,圖像分辨率相對于普通血管內(nèi)超聲檢查(IVUS)而言所具有的明顯優(yōu)勢。OCT可以為頸內(nèi)動脈動脈血管壁進(jìn)行更為詳盡的分析,提供更多的信息,其中包括對斑塊性質(zhì)的評估、對不穩(wěn)定斑塊的鑒別以及對頸動脈狹窄介入相關(guān)的血管反應(yīng)。該部分主要綜述介紹了OCT在腦血管介入治療中的評估術(shù)語、評估方法及臨床應(yīng)用現(xiàn)狀以及未來非發(fā)展展望。
[Abstract]:Part I: The safety and feasibility of frequency domain optical coherence tomography (FD-OCT) in carotid plaque assessment and carotid artery stenting. Background and purpose: This study analyzed the safety of FD-OCT in carotid plaque assessment and carotid artery stenting by exploring the application of FD-OCT in carotid artery system. Objectives and Methods: From January 2014 to May 2015, carotid angiography was performed in the Department of Neurology, Nanjing General Hospital of Nanjing Military Region, Nanjing Military Region. The two researchers scored 1-10 points on the images respectively. Cohen's statistical analysis was used to analyze the reliability between the observers and within the observers. The difference was statistically significant (P 0.05). Results: A total of 22 patients were included in the study and 44 scans were performed. 40/44 (90.9%) of the eligible images were obtained successfully. There were no surgical-related neurological complications (0%) during OCT. The quality of the images obtained by OCT was high (mean 7.5.9 points). After CAS, clear fibrous cap damage, poor stent attachment and plaque prolapse could be found in the OCT images. Conclusion: This study is the first application of OCT in carotid artery system in China. The study confirms the safety and feasibility of OCT in carotid artery system. OCT can be used to evaluate carotid plaque and carotid artery stenting. The second part is the comparison of the results of symptomatic carotid atherosclerosis and asymptomatic carotid atherosclerosis OCT. Background and purpose: For asymptomatic carotid atherosclerosis patients, it is necessary to determine and assess the nature of the plaque. The morphological characteristics of carotid atherosclerotic plaques provide the basis for the application of OCT in carotid artery system. Objectives and Methods: The study included carotid angiography in the Department of Neurology, Nanjing General Hospital of Nanjing Military Region from January 2014 to May 2015. The patients were diagnosed as carotid atherosclerosis by invasive examination and OCT examination. Patients were divided into two groups according to the symptoms within 6 months before treatment: symptomatic group and asymptomatic group. The degree of stenosis of the lesion vessels was determined by DSA and OCT, and the plaque features observed by OCT images were recorded and compared. The counting data between the two groups were analyzed by_2 test or Fisher test. Cohen's statistical analysis was used. The reliability between observers and within observers was analyzed. The independent risk factors for symptoms were analyzed by binary logistic regression. The consistency of the degree of stenosis of vessel diameter measured by OCT and DSA was examined by Bland-Altman plot test. Results: A total of 52 patients completed OCT, DSA and OCT. Symptomatic patients had higher incidence of VI plaque (68.0% vs. 33.3%, respectively; P = 0.025), higher incidence of macrophage infiltration (52.0% vs. 22.2%, P = 0.043), higher incidence of mural thrombosis (64.0% vs. 37.0%, P = 0.095), and lower incidence of fibrotic plaque (40.0.0% vs. 22.2%, P = 0.043). Logistic regression analysis showed that VI plaque (OR: 13.798, 95% CI: 1.38 to 137.675, P = 0.025) and macrophage infiltration (OR: 5.856, 95% CI: 1.405 to 24.406, P = 0.015) were independent risk factors for carotid stenosis. The incidence of complex plaques in symptomatic carotid stenosis was higher than that in asymptomatic carotid stenosis patients. VI plaque and macrophage infiltration were independent risk factors for carotid stenosis symptoms. Part III Effects of carotid atherosclerotic lipid plaque on carotid stent adherence: An OCT-based study BACKGROUND AND OBJECTIVE: Carotid artery stent has become one of the main methods for the treatment of extracranial carotid artery stenosis. During CAS, stent adherence, plaque prolapse and fibrous cap damage often occur. This study analyzed the relationship between stent adherence and lipid plaque after CAS, and then further explored the branches. Objectives and Methods: Carotid artery angiography was performed in the Department of Neurology, Nanjing General Hospital of Nanjing Military Region from April 2014 to May 2015. The patients were identified as carotid atherosclerosis with OCT and CAS. The relationship between the scaffold and the plaque was recorded in the images. The scaffold adherence was expressed as a percentage of the total number of the scaffolds. The specific layers of the scaffolds were also recorded, such as poor adherence, plaque prolapse, and fiber cap damage. Counting data were compared between the two groups using_2 test, Fisher test or one-way ANOVA. Kruskal-Wallis test was used to compare the thickness of Fiber Caps between the two groups. Cohen's statistical analysis was used to analyze the reliability between the observers and among the observers. Results: The difference was statistically significant between the two groups (P 0.05). Twenty-six patients were enrolled in the study, 20 of whom obtained qualified images and 6 of whom were excluded because of the poor quality of OCT images. The rate of plaque prolapse was 65.5% in the lipid plaque group and 49.1% in the non-lipid plaque group. There was no significant difference in the rate of stent adherence between the two groups, with 12.3% in the lipid plaque group and 14.9% in the non-lipid plaque group. There was no significant difference in the rate of poor stent adherence between the two groups. The incidence of plaque prolapse and fibrous cap damage was lower in the non-lipid plaque group. Acute thrombosis in stent is a rare complication of carotid artery stent. However, if the complication is not handled promptly, it will lead to vascular occlusion, neurological deficits, and even affect the outcome of surgery, threatening life. OCT can be used to treat the carotid artery before, during and after stenting. Pulse lesions, the relationship between carotid artery stents and the wall, and the formation of acute thrombosis in stents were observed and recorded. One case report confirmed that OCT could visually record and describe the formation of acute thrombosis in stents. Part V Intravascular optical coherence tomography system for cerebrovascular interventional therapy The evaluation terminology, methods and clinical application of OCT as a new intravascular imaging method using near-infrared light have obvious advantages over conventional intravascular ultrasound (IVUS). OCT can provide more detailed analysis of the internal carotid artery wall and provide more information, including To evaluate the nature of the plaque, identify the unstable plaque and the vascular response to interventional treatment of carotid artery stenosis. This part reviews the evaluation terminology, evaluation methods and clinical application of OCT in cerebrovascular interventional therapy, as well as the future non-development prospects.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R543.4
本文編號：2250225
[Abstract]:Part I: The safety and feasibility of frequency domain optical coherence tomography (FD-OCT) in carotid plaque assessment and carotid artery stenting. Background and purpose: This study analyzed the safety of FD-OCT in carotid plaque assessment and carotid artery stenting by exploring the application of FD-OCT in carotid artery system. Objectives and Methods: From January 2014 to May 2015, carotid angiography was performed in the Department of Neurology, Nanjing General Hospital of Nanjing Military Region, Nanjing Military Region. The two researchers scored 1-10 points on the images respectively. Cohen's statistical analysis was used to analyze the reliability between the observers and within the observers. The difference was statistically significant (P 0.05). Results: A total of 22 patients were included in the study and 44 scans were performed. 40/44 (90.9%) of the eligible images were obtained successfully. There were no surgical-related neurological complications (0%) during OCT. The quality of the images obtained by OCT was high (mean 7.5.9 points). After CAS, clear fibrous cap damage, poor stent attachment and plaque prolapse could be found in the OCT images. Conclusion: This study is the first application of OCT in carotid artery system in China. The study confirms the safety and feasibility of OCT in carotid artery system. OCT can be used to evaluate carotid plaque and carotid artery stenting. The second part is the comparison of the results of symptomatic carotid atherosclerosis and asymptomatic carotid atherosclerosis OCT. Background and purpose: For asymptomatic carotid atherosclerosis patients, it is necessary to determine and assess the nature of the plaque. The morphological characteristics of carotid atherosclerotic plaques provide the basis for the application of OCT in carotid artery system. Objectives and Methods: The study included carotid angiography in the Department of Neurology, Nanjing General Hospital of Nanjing Military Region from January 2014 to May 2015. The patients were diagnosed as carotid atherosclerosis by invasive examination and OCT examination. Patients were divided into two groups according to the symptoms within 6 months before treatment: symptomatic group and asymptomatic group. The degree of stenosis of the lesion vessels was determined by DSA and OCT, and the plaque features observed by OCT images were recorded and compared. The counting data between the two groups were analyzed by_2 test or Fisher test. Cohen's statistical analysis was used. The reliability between observers and within observers was analyzed. The independent risk factors for symptoms were analyzed by binary logistic regression. The consistency of the degree of stenosis of vessel diameter measured by OCT and DSA was examined by Bland-Altman plot test. Results: A total of 52 patients completed OCT, DSA and OCT. Symptomatic patients had higher incidence of VI plaque (68.0% vs. 33.3%, respectively; P = 0.025), higher incidence of macrophage infiltration (52.0% vs. 22.2%, P = 0.043), higher incidence of mural thrombosis (64.0% vs. 37.0%, P = 0.095), and lower incidence of fibrotic plaque (40.0.0% vs. 22.2%, P = 0.043). Logistic regression analysis showed that VI plaque (OR: 13.798, 95% CI: 1.38 to 137.675, P = 0.025) and macrophage infiltration (OR: 5.856, 95% CI: 1.405 to 24.406, P = 0.015) were independent risk factors for carotid stenosis. The incidence of complex plaques in symptomatic carotid stenosis was higher than that in asymptomatic carotid stenosis patients. VI plaque and macrophage infiltration were independent risk factors for carotid stenosis symptoms. Part III Effects of carotid atherosclerotic lipid plaque on carotid stent adherence: An OCT-based study BACKGROUND AND OBJECTIVE: Carotid artery stent has become one of the main methods for the treatment of extracranial carotid artery stenosis. During CAS, stent adherence, plaque prolapse and fibrous cap damage often occur. This study analyzed the relationship between stent adherence and lipid plaque after CAS, and then further explored the branches. Objectives and Methods: Carotid artery angiography was performed in the Department of Neurology, Nanjing General Hospital of Nanjing Military Region from April 2014 to May 2015. The patients were identified as carotid atherosclerosis with OCT and CAS. The relationship between the scaffold and the plaque was recorded in the images. The scaffold adherence was expressed as a percentage of the total number of the scaffolds. The specific layers of the scaffolds were also recorded, such as poor adherence, plaque prolapse, and fiber cap damage. Counting data were compared between the two groups using_2 test, Fisher test or one-way ANOVA. Kruskal-Wallis test was used to compare the thickness of Fiber Caps between the two groups. Cohen's statistical analysis was used to analyze the reliability between the observers and among the observers. Results: The difference was statistically significant between the two groups (P 0.05). Twenty-six patients were enrolled in the study, 20 of whom obtained qualified images and 6 of whom were excluded because of the poor quality of OCT images. The rate of plaque prolapse was 65.5% in the lipid plaque group and 49.1% in the non-lipid plaque group. There was no significant difference in the rate of stent adherence between the two groups, with 12.3% in the lipid plaque group and 14.9% in the non-lipid plaque group. There was no significant difference in the rate of poor stent adherence between the two groups. The incidence of plaque prolapse and fibrous cap damage was lower in the non-lipid plaque group. Acute thrombosis in stent is a rare complication of carotid artery stent. However, if the complication is not handled promptly, it will lead to vascular occlusion, neurological deficits, and even affect the outcome of surgery, threatening life. OCT can be used to treat the carotid artery before, during and after stenting. Pulse lesions, the relationship between carotid artery stents and the wall, and the formation of acute thrombosis in stents were observed and recorded. One case report confirmed that OCT could visually record and describe the formation of acute thrombosis in stents. Part V Intravascular optical coherence tomography system for cerebrovascular interventional therapy The evaluation terminology, methods and clinical application of OCT as a new intravascular imaging method using near-infrared light have obvious advantages over conventional intravascular ultrasound (IVUS). OCT can provide more detailed analysis of the internal carotid artery wall and provide more information, including To evaluate the nature of the plaque, identify the unstable plaque and the vascular response to interventional treatment of carotid artery stenosis. This part reviews the evaluation terminology, evaluation methods and clinical application of OCT in cerebrovascular interventional therapy, as well as the future non-development prospects.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R543.4
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