【摘要】：本研究由基礎(chǔ)和臨床研究兩部分組成。基礎(chǔ)研究中，我們首先評價我們新開發(fā)的基于冠脈計(jì)算機(jī)斷層成像（CTA）的支架三維角度測量方法的可靠性，然后進(jìn)行支架彎曲后應(yīng)力變化的有限元分析，并與臨床結(jié)果進(jìn)行對照，最后明確冠脈支架gap診斷中g(shù)ap處CT值300Hu的合理性。臨床研究則為觀察冠脈支架gap組的臨床預(yù)后和分析支架gap的預(yù)測因素。藉此為CTA研究冠脈支架斷裂（CSF）提供理論依據(jù)和有力工具。 第一部分基礎(chǔ)研究中，使用我們新開發(fā)設(shè)計(jì)的基于CTA的支架三維角度測量方法，分別測量體外模型和患者體內(nèi)支架的角度。發(fā)現(xiàn)使用冠脈造影法（CA）測定的支架角度存在較大偏差。而我們設(shè)計(jì)的CTA中心線法有很好的準(zhǔn)確性和重復(fù)性，與常規(guī)的旋轉(zhuǎn)血管樹法在臨床和基礎(chǔ)研究中可以相互代替，但明顯可以減少測量時間。西莫羅斯藥物涂層支架（SES）彎曲后的有限元分析顯示，支架彎曲至140-145°時出現(xiàn)了明顯的應(yīng)力和應(yīng)變變化，這一結(jié)果同臨床資料的分析結(jié)果非常吻合。不同類型支架的CTA影像學(xué)上存在差異，CT值也不同，，但各支架支架梁完整時，未見支架CT值300Hu，提示將冠脈支架gap的界定值設(shè)為300Hu是合理的。另外，支架CT值與支架種類、直徑、血管內(nèi)造影劑CT值、支架金屬梁厚度、支架形態(tài)等因素有關(guān)。 第二部分為臨床資料的分析。我們對226名患者共植入的491個支架的CTA隨訪資料（其中83名患者共208枚支架，同時進(jìn)行了CA隨訪）進(jìn)行了回顧性分析，并重新嚴(yán)格定義了支架重疊、支架鈣化、準(zhǔn)確測量支架角度后，發(fā)現(xiàn)支架gap組的支架內(nèi)再狹窄（ISR）、靶病變血運(yùn)重建（TLR）的發(fā)生率較對照組均明顯升高（55.8%vs13.9%，P=0.000;32.6%vs10.3%, P=0.0003），支架內(nèi)血栓也有升高的趨勢（4.7%vs0.6%, P=0.1091）。支架長度、成角、重疊、鈣化、植入時間和室壁運(yùn)動障礙是支架gap的獨(dú)立危險因素（P=0.016；P=0.000; P=0.018; P=0.016; P=0.015; P=0.035）。 結(jié)論：1.整合了我們新開發(fā)的支架血管三維角度測量方法的CTA后處理工作站，可以準(zhǔn)確快速地測量體內(nèi)支架的成角，為冠脈支架的離體試驗(yàn)提供第一手準(zhǔn)確的臨床數(shù)據(jù)。并且初步試驗(yàn)顯示，支架角度-應(yīng)力的有限元分析的結(jié)果與我們的臨床數(shù)據(jù)基本吻合。 2. CTA影像學(xué)上將支架gap的CT界定值設(shè)為300Hu是合理的，為以支架gap的概念分析CSF提供了進(jìn)一步的理論依據(jù)。 3.在盡可能獲得了詳盡的臨床資料，重新明確支架重疊、鈣化和準(zhǔn)確測量支架成角后，發(fā)現(xiàn)新定義的支架gap發(fā)生后ISR和TLR率升高，支架gap與支架長度、成角、重疊、鈣化、植入時間和節(jié)段性室壁運(yùn)動障礙有關(guān)，從支架gap的影像學(xué)特點(diǎn)、臨床預(yù)后和其預(yù)測因素分析，進(jìn)一步明確了新定義的支架gap就是CSF。 4.新的支架gap概念的使用，將進(jìn)一步提高CSF的臨床檢出率，CTA將在臨床預(yù)后觀察、支架力學(xué)的基礎(chǔ)研究中發(fā)揮重要的作用。
[Abstract]:This study consists of two parts: basic and clinical. In basic research, we first evaluate the reliability of our newly developed three-dimensional angle measurement method based on coronary computed tomography (CTA), and then do finite element analysis of the stress changes after the stent bending. Compared with the clinical results, the rationality of CT value 300Hu at gap in gap diagnosis of coronary stents was determined. The clinical study was used to observe the clinical prognosis of coronary stent gap group and to analyze the predictive factors of stent gap. It provides a theoretical basis and a powerful tool for the study of coronary stent rupture (CSF) by CTA. In the first part of the basic research, we use our newly developed three-dimensional angle measurement method based on CTA to measure the angle of the stent in vitro and in vivo, respectively. It was found that the angle of stent measured by coronary angiography (CA) was significantly different. The CTA centerline method designed by us has good accuracy and repeatability. It can be replaced by the conventional rotating vascular tree method in clinical and basic research, but it can obviously reduce the measuring time. Finite element analysis after (SES) bending of Simulos drug-coated stent showed that obvious stress and strain changes occurred at 140-145 擄bending of the stent, which was in good agreement with the clinical data. There were differences in CTA imaging and CT values among different stents, but no stent CT value 300 Hu. when each beam was intact, it suggested that it was reasonable to set the gap value of coronary stent to 300Hu. In addition, stent CT value was related to stent type, diameter, intravascular contrast agent CT value, stent metal beam thickness, stent shape and so on. The second part is the analysis of clinical data. We retrospectively analyzed the CTA data of 491 stents implanted in 226 patients (of which 83 patients had 208 stents and followed up with CA), and redefined stents overlapping and stent calcification. After accurate measurement of stent angle, it was found that the incidence of revascularization (TLR) in stent restenosis (ISR), target in stent gap group was significantly higher than that in control group (55.8 vs 13.9). 32.6 vs 10.3, P0. 0003), the thrombus in the stent also increased (4. 7 vs 0. 6, P0. 1091). Stent length, angulation, overlap, calcification, implantation time and ventricular wall motion disorder were independent risk factors for stent gap (P0. 016, P0. 018, P0. 016, P0. 015, P0. 035). Conclusion: 1. The CTA post processing workstation which integrates our newly developed three-dimensional angle measurement method of stent vessel can accurately and quickly measure the angle of stent in vivo and provide the first hand and accurate clinical data for the in vitro test of coronary stent. The preliminary results show that the results of the finite element analysis of angle-stress are in good agreement with our clinical data. 2. It is reasonable for CTA imaging to set the CT threshold of stent gap to 300Hu, which provides a further theoretical basis for the analysis of CSF with the concept of stent gap. 3. After obtaining as detailed clinical data as possible, redefining stent overlap, calcification and accurate measurement of stent angle, it was found that ISR and TLR rates increased after the occurrence of newly defined stent gap, and stent gap and stent length, angle, overlap, calcification. The implantation time is related to segmental ventricular wall motion disorder. From the analysis of imaging features, clinical prognosis and predictive factors of stent gap, it is further clear that the newly defined stent gap is CSF.. 4. The application of the new concept of stent gap will further improve the clinical detection rate of CSF. CTA will play an important role in clinical prognosis observation and basic research of stenting mechanics.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2013
【分類號】：R541.4;R816.2

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相關(guān)碩士學(xué)位論文 前2條

1 徐江;心血管支架在病變血管中力學(xué)行為的初步研究[D];西南交通大學(xué);2011年

2 趙陽;血管支架柔順性有限元分析及介入配件的臨床試驗(yàn)研究[D];大連理工大學(xué);2009年

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