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血管内超声评估冠状动脉钙化...对PCI术后支架膨胀的影响_胡司淦.pdf

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1、介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023,Vol32,No4【摘要】目的探讨血管内超声(IVUS)评估冠状动脉钙化病变特征对经皮冠状动脉介入治疗(PCI)术后支架膨胀的影响。方法271例接受PCI术及IVUS检查患者,根据IVUS检查结果分为非钙化组(n=101)、钙化组(n=170),钙化组根据临床表型又分为急性冠状动脉综合征(ACS)组(n=123)、稳定型心绞痛(SAP)组(n=47)。比较两组临床基线资料、血管造影和IVUS检查结果,分析支架膨胀不全的影响因素。结果钙化组患者当前吸烟、多支血管病变比例高于非钙化组(均P0.05)。PCI术

2、中钙化组旋磨术(RA)、切割球囊(CB)应用比例明显高于非钙化组(均P0.01),非顺应性球囊(NCB)扩张压力高于非钙化组(P0.01),支架长度明显长于非钙化组(P0.01)。SAP组斑块长度、斑块负荷、最大钙化弧度指标高于ACS组(均P0.05)。ACS组血栓性病变比例高于SAP组,且靶血管存在明显正性重构(P=0.02)。多因素logistic回归分析显示,最大浅层钙化弧度(OR=2.093,95%CI:1.1443.829,P=0.017)和支架长度(OR=5.371,95%CI:1.69616.534,P=0.023)与支架膨胀不全密切相关。结论冠状动脉钙化病变的最大浅层钙化弧度和

3、支架长度与支架膨胀不全密切相关。IVUS对冠脉钙化病变特征判断、PCI术中指导及支架膨胀评估有重要价值。【关键词】血管内超声;经皮冠状动脉介入治疗;冠状动脉钙化;旋磨术中图分类号:R541.4文献标志码:B文章编号:1008-794X(2023)-04-354-05The impact of coronary artery calcium characteristics assessed by intravascular ultrasound on the stentexpansion after PCIHU Sigan,CHEN Tianping,CHEN Yao,LI Hui,KANG P

4、infang,GAO Dasheng.Department of Cardiovasology,First Affiliated Hospital of Bengbu Medical College,Bengbu,Anhui Province233004,ChinaCorresponding author:GAO Dasheng,E-mail:【Abstract】ObjectiveTo evaluate the impact of coronary artery calcium characteristics assessed byintravascular ultrasound(IVUS)o

5、n the stent expansion after percutaneous coronaryintervention(PCI).MethodsA total of 271 patients,who underwent PCI treatment and IVUS examination,were enrolled in thisstudy.According to IVUS examination results,the patients were divided into non-calcification group(n=101)andcalcificationgroup(n=170

6、).Based on the clinical characteristics,thepatientsofcalcificationgroupwereclassifiedinto acute coronary syndrome(ACS)group(n=123)and stable angina pectoris(SAP)group(n=47).The baselineclinical data,angiographic findings,and IVUS features were compared between the two groups,and the factorsaffecting

7、 the incomplete stent expansion were analyzed.ResultsThe proportion of patients who had currentsmoking habits and multiple diseased vessels in the calcification group was higher than that in the non-calcification group(P0.05).During PCI,the proportions of using rotational atherectomy(RA)and using cu

8、ttingballoon(CB)in the calcification group are higher than those in the non-calcification group(both P0.01),besides,in the calcification group the expansion pressure of non-compliant balloon(NCB)was higher than that in thenon-calcification group(P0.01),the stent length was remarkably longer than tha

9、t inthenon-calcificationgroup(P0.01).InSAPgroup,theplaquelength,plaqueburdenandthemaximumcalcium arc were significantly higherthan those in ACS group(all P0.05).The proportion of thrombotic lesions in ACS group was higher than that血管内超声评估冠状动脉钙化病变特征对 PCI 术后支架膨胀的影响胡司淦,陈天平,陈耀,李辉,康品方,高大胜 临床研究Clinical re

10、search DOI:103969jissn1008794X202304009基金项目:安徽省高校自然科学研究重点项目(KJ2021A0818),蚌埠医学院科技发展基金(BYKF1889),安徽省高等学校省级质量工程项目(2020jyxm1211)作者单位:233004安徽蚌埠蚌埠医学院第一附属医院心血管科通信作者:高大胜E-mail:354介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023,Vol32,No4年龄老化、吸烟及糖尿病肾病与血管钙化密切相关1-2。经皮冠状动脉介入治疗(percutaneous coronaryintervention,PCI

11、)患者血管严重钙化病变发生率约为5.9%3。急 性 冠 状 动 脉 综 合 征(acute coronarysyndrome,ACS)研究中罪犯病变由钙化病变所引起占12.7%,以浅表钙化多见,最常累及前降支4。腔内影像学可提供钙化病变范围及严重程度等重要信息,有利于制定适宜的处理策略,对于评估支架植入前病变预处理效果、可能并发症及指导支架植入有重要价值。钙化病变预处理方式可影响支架膨胀程度,相关影响因素有待深入探讨。本研究分析271例PCI患者定量冠状动脉造影(quantitative coronaryangiography,QCA)、血管内超声(IVUS)相关指标,探讨钙化病变斑块特征、临

12、床特点及支架植入术后支架膨胀不全的影响因素。1材料与方法1.1一般资料收集2017年1月至2021年5月在蚌埠医学院第一附属医院接受PCI术治疗的271例冠状动脉钙化病变患者。入组标准:经IVUS及冠状动脉造影证实冠状动脉缺血相关狭窄70%;术中植入二代药物洗脱支架。排除标准:冠状动脉造影资料质量差,不能行QCA分析;IVUS资料缺失或不完全;伴有严重心力衰竭、心源性休克、恶性肿瘤等,不能准确评判冠心病亚型;QCA和IVUS数据判断存争议。根据IVUS检查结果将入组患者分为非钙化组、钙化组,钙化组根据临床表型分为ACS组、稳定型心绞痛(stable angina pectoris,SAP)组。

13、分别比较两组IVUS指标。1.2PCI手术采用Seldinger法穿刺股动脉或桡动脉,置入鞘管,注入普通肝素70100 U/kg,维持活化凝血时间(ACT)250 s;行IVUS检查,评价病变特征,制定适宜的干预策略。若超声导管不能通过病变段,用1.5 mm或2.0 mm球囊扩张处理,再行IVUS检查;若超声导管仍不能通过且符合旋磨术(rotationalatherectomy,RA)血管条件,则直接用RotablatorTM冠状动脉内旋磨治疗仪(美国Boston科技公司),按标准化操作程序行RA,其旋磨头大小选择依据IVUS所测的参考血管直径,旋磨头-血管直径比为0.50.6。对于非钙化病变

14、,采用预扩球囊或耐高压球囊行扩张治疗。对于需行RA治疗的钙化病变,RA术后再行IVUS观察病变形态并采集相关测量参数,若钙化弧度仍较大或呈环形钙化,予以切割球囊(cutting balloon,CB)处理;若钙化环被打断或钙化弧度上出现裂隙或薄弱区,予以非顺应性球囊(noncomplaint balloon,NCB)扩张;若经CB及NCB处理仍不能通过病变段,则用预扩球囊扩张后再次送入CB或NCB行扩张处理。CB或NCB扩张处理后再行IVUS检查,评价病变修饰情况。1.3IVUS检查采用IVUS仪(美国Boston科技公司),分别于PCI术前、RA术后、球囊处理后、支架植入后采集靶血管最小管腔

15、直径、最小管腔面积、狭窄程度及钙化弧度等指标,观察病变形态、成分构成、钙化厚度、钙化结节、钙化环裂隙、血管重构等信息;支架术后观察支架膨胀、贴壁情况,检测对称指数及残余狭窄程度等。1.4统计学分析采用SPSS软件包进行统计学处理。计量资料以均数标准差表示,组间比较用独立样本t检验;计数资料以例(%)表示,组间比较用2检验。采用logistic回归进行多因素分析,P0.05为差异有统计学意义。2结果2.1基线资料比较两组患者基线资料见表1。钙化组患者当前吸in SAP group,and there were obvious positive remodeling findings in tar

16、get vessel in ACS group(P=0.02).Multivariatelogisticregressionanalysisindicatedthatthemaximum arcofsuperficialcalcium(OR=2.093,95%CI=1.144-3.829,P=0.017)and stent length(OR=5.371,95%CI=1.696-16.534,P=0.023)were closely related to theincomplete stent expansion.ConclusionThe maximum superficial calcif

17、ication arc of coronary artery calcifiedlesions and the stent length are closely related to the incomplete stent expansion.IVUS has important valuesin judging the characteristics of coronary calcified lesions,in guiding PCI manipulation,and in evaluatingexpansion condition of stent.(J Intervent Radi

18、ol,2023,32:354-358)【Key words】intravascular ultrasound;percutaneous coronary intervention;coronary calcification;rotational atherectomy355介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023,Vol32,No4烟比例高于非钙化组(P0.05),两组间年龄、性别、体重指数(BMI)、心肌梗死史、伴高血压、脑卒中史及生化实验室检查等指标差异无统计学意义(均P0.05)。2.2冠状动脉造影结果钙化组患者多支血管比例明显高于非钙化

19、组(P0.05),两组间靶血管狭窄程度、慢性完全闭塞病变(CTO)、分叉病变比例比较差异无统计学意义(均P0.05),见表2。2.3PCI术中治疗情况钙化组患者RA、CB应用比例明显高于非钙化组(均P0.01),NCB扩张压高于非钙化组(P0.01),支架长度明显长于非钙化组(P0.01);支架植入术后非钙化组中支架内最小面积大于钙化组(P=0.01),支架膨胀率高于钙化组(P=0.006),见表3。2.4钙化组IVUS指标钙化组中SAP组斑块长度、斑块负荷、最大钙化弧度指标高于ACS组(均P0.05),深层钙化比例高于ACS组(P=0.037);ACS组血栓性病变比例高于SAP组,且靶血管存

20、在明显正性重构(P=0.02),易损斑块中薄纤维帽斑块比例高于SAP组(P=0.024),见表4,图1。表1两组患者基线资料参数非钙化组(n=101)钙化组(n=170)t/2值P值年龄(岁)64.3010.24 64.8411.03 0.400 0.689男性n(%)75(74.26)111(65.29)2.365 0.124腰臀比0.940.120.920.18 0.993 0.322腰围(cm)95.363.9794.753.37 1.347 0.179BMI(kg/m2)23.974.2124.165.12 0.315 0.753心肌梗死史n(%)6(5.94)15(8.82)0.73

21、7 0.391当前吸烟n(%)35(34.65)81(47.65)4.369 0.037脑卒中史n(%)26(25.74)53(31.18)0.906 0.341伴高血压n(%)68(67.33)106(62.35)0.682 0.409伴糖尿病n(%)26(25.74)42(24.71)0.036 0.849高胆固醇血症n(%)25(24.75)36(21.18)0.465 0.496骨质疏松症n(%)9(8.91)16(9.41)0.019 0.890肾衰竭n(%)8(7.92)17(10.00)0.327 0.567血液透析n(%)1(0.99)3(1.76)0.000 0.992PCI

22、史n(%)11(10.89)23(13.53)0.402 0.526冠状动脉旁路移植史n(%)01(0.59)HGB(g/L)132.2423.29 126.4532.56 1.565 0.119PLT(109/L)195.5768.25 188.3478.35 0.770 0.442TC(mmol/L)5.931.025.740.94 1.558 0.120TG(mmol/L)1.670.241.720.34 1.298 0.195HDL-C(mmol/L)1.460.251.420.37 0.963 0.336LDL-C(mmol/L)3.420.373.370.26 1.303 0.19

23、4Lp(a)(mg/L)174.9734.73 169.2727.41 1.495 0.136UA(mol/L)396.2697.26 410.4688.25 1.233 0.219Cr(mol/L)126.4536.14 135.7344.18 1.785 0.075hs-CRP(mmol/L)5.531.125.410.93 0.951 0.343表4钙化组患者ACS与SAP临床表型IVUS检测结果参数ACS(n=123)SAP(n=47)t/2值P值斑块长度(mm)26.6511.3530.8412.632.086 0.039血管重构指数1.030.140.960.242.357 0.0

24、20最小管腔面积(mm2)3.431.873.331.320.336 0.737薄纤维帽斑块76(61.79)20(42.55)5.119 0.024钙化结节n(%)19(15.45)2(4.26)0.054 0.047斑块负荷(%)82.3210.2586.659.542.510 0.013最大钙化弧度()197.37101.36 236.95118.59 2.170 0.031血栓性病变n(%)16(13.01)05.310 0.021钙化部位n(%)浅层34(27.64)8(17.02)2.062 0.151深层39(31.71)23(48.94)4.357 0.037混合50(40.6

25、5)16(34.04)0.625 0.429易损斑块n(%)最小管腔面积4.0mm298(79.67)43(91.49)3.355 0.067表2两组冠状动脉造影结果比较参数非钙化组(n=101)钙化组(n=170)t/2值P值罪犯血管n(%)前降支或对角支67(66.34)127(74.71)2.182 0.140回旋支、钝缘支或中间支32(31.68)52(30.59)0.036 0.851左主干27(26.73)33(19.41)1.970 0.160狭窄程度(%)85.2511.58 87.3610.27 1.559 0.120右冠状动脉、后降支、左室后支59(58.42)118(69

26、.41)3.381 0.066多支病变n(%)68(67.33)138(81.18)6.666 0.010CTOn(%)10(9.90)16(9.41)0.017 0.895分叉病变n(%)16(15.84)31(18.24)0.253 0.615表3PCI术中治疗情况参数非钙化组(n=101)钙化组(n=170)t/2值P值RAn(%)014(8.24)8.7710.003CBn(%)13(12.87)95(55.88)48.898 0.01耐高压球囊n(%)98(97.03)170(100)2.7530.097NCB扩张压(atm)15.355.2518.266.253.927 0.01膨

27、胀率(%)82.2512.85 75.2523.522.7550.006支架内最小面积(mm2)7.651.516.972.362.5960.010支架长度(mm)29.6410.52 38.949.377.543 0.01ACS患者多为钙化结节、浅层钙化并伴有血管正性重构;SAP患者多为弥漫性长钙化病变,混合性钙化并伴有负性重构图1不同临床表型钙化病变特征356介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023,Vol32,No42.5支架膨胀不良因素多因素logistic回归分析显示,最大浅层钙化弧度(OR=2.093,95%CI:1.1443.829

28、,P=0.017)和支架长度(OR=5.371,95%CI:1.69616.534,P=0.023)与支架膨胀不全密切相关。见图2。3讨论冠状动脉严重钙化在血管造影上被定义为注射对比剂前随着心脏运动的钙化阴影位于动脉壁两侧并持续存在,钙化长度15 mm,至少部分延伸至靶病变内,通过IVUS判断,至少一横截面上存在270钙化弧度5。相较于冠状动脉造影严重低估冠状动脉钙化程度,IVUS和光学相干层析成像(OCT)可对钙化分布和严重程度做出准确检测与评估。Wang等6对440个病变分析显示,血管造影、IVUS、OCT对钙化的检出比例分别为40.2%、82.7%、76.8%。本研究中IVUS检出钙化比

29、例明显高于血管造影,灵敏度较高,对于判断斑块分布、成分和特征具重要价值。血管钙化与年龄、慢性肾病、吸烟及糖尿病密切相关7。本研究中钙化组当前吸烟患者比例明显高于非钙化组,与既往报道类似8。吸烟可加速血管钙化,尤其是伴有糖尿病及糖尿病加肾脏损害患者,钙化发生率进一步增高9。本研究中钙化组患者多支病变比例较非钙化组明显增多,提示血管钙化累及范围较广,系全身动脉血管床弥漫性硬化过程,但靶血管狭窄程度、CTO病变、分叉病变比例较非钙化组差异无统计学意义,提示血管钙化多呈慢性稳定进展过程。本研究发现SAP组患者病变长度、狭窄程度、最大钙化弧度均较ACS组严重,且血管受长期钙化斑块累及侵蚀存在明显负性重构

30、,累及范围以深层钙化较多,浅层钙化表现为结节弥漫性钙化为主,而ACS患者病变节段血管出现明显正性重构,病变局部可观察到钙化结节。钙化结节是一种小结节样钙化的爆发性堆积物,其上覆有厚钙化层和血栓,与ACS密切相关,钙化结节存在于约4.2%动脉粥样硬化病变中,OCT对其有良好的显示作用10。本研究中SAP组以弥漫性钙化、结节性钙化为主,这与ACS组影像学特征明显不同,ACS组钙化结节发生率明显高于SAP组,薄纤维帽斑块数量也高于SAP组,这与既往研究一致11-14,提示IVUS检测有助于术前准确评估病变性质、斑块易损性及术中可能发生的并发症。术前评估冠状动脉钙化特征有利于选择最适合的处理方式,提高

31、手术成功率,改善远期预后。本研究基于IVUS检查结果,钙化组有8.24%患者接受RA治疗,同时CB应用比例明显高于非钙化组,NCB扩张压亦高于非钙化组,但术后所获得支架内最小面积及支架膨胀率仍较非钙化组差。术中球囊扩张时易于向非钙化处偏移,如果钙化程度较重,尤其是环形钙化且厚度较大者,植入支架后易产生环形束缚,支架膨胀不良发生率明显增高,导致手术成功率降低,且术后急性血栓事件及再狭窄概率增高。RA对斑块的销蚀作用是有限的,更多是对斑块表面修饰,从而使钙化环应力产生改变,因此RA后斑块上能观察到小裂隙和钙化薄弱区,这为后续球囊处理提供了便利,既利于CB和NCB通过钙化病变段,也利于球囊在裂隙区和

32、薄弱区高压扩张情况下形成应力突破,从而打开钙化环或裂隙区增宽,但钙化弧仍未改善,表明RA后仅改变了钙化形态,并不会出现钙化体积明显销蚀,这与既往文献报道相似15-17。本研究中观察到IVUS对钙化结节较为敏感,其表现为突出管腔的钙化凸起,经RA处理后有较为理想的修饰作用,有利于支架、球囊等器械通过,也对支架膨胀起到一定作用18-20。多因素logistic回归分析显示,最大浅层钙化弧度和支架长度与支架膨胀不全密切相关,支架越长发生膨胀不全机会越大,提示在双联抗血小板药物选择和应用浅层钙化弧度90,支架膨胀贴壁良好;浅层钙化弧度180,支架膨胀贴壁良好;浅层钙化弧度230,支架膨胀欠佳图2最大浅

33、层钙化弧度与支架膨胀不全密切相关357介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023,Vol32,No4上要有所侧重。然而有研究采用OCT分析PCI治疗中47例患者50处中度钙化斑块的支架膨胀情况,结果显示最大钙化厚度为支架扩张的独立预测因子,预测支架术后膨胀率80%时的最大钙化厚度为880 m21。也有研究分析认为,PCI术后即刻支架膨胀不良与斑块长度及钙化弧度相关22。因此,不能排除不同腔内影像学方法所测量数据存在差异,需要对不同腔内影像学检测方法进行更大样本的对比分析,以便进一步改进干预策略。综上所述,PCI治疗过程中识别钙化斑块是优化支架植入的

34、关键,在IVUS、OCT等腔内影像学指导下应用RA术充分预处理钙化病变后再植入支架,有利于提高手术成功率,减少支架膨胀不全、支架内血栓和再狭窄发生。参 考 文 献1Hou ZH,Lu B,Li ZN,et al.Coronary atherosclerotic plaque volumequantified by computed tomographic angiography in smokerscompared to nonsmokersJ.Acad Radiol,2019,26:1581-1588.2Lee M,Gnreux P,Shlofmitz R,et al.Orbital ath

35、erectomy fortreating de novo,severely calcified coronary lesions:3-yearresults of the pivotal ORBIT trialJ.Cardiovasc Revasc Med,2017,18:261-264.3Gnreux P,Madhavan MV,Mintz GS,et al.Ischemic outcomesafter coronary intervention of calcified vessels in acute coronarysyndromes.Pooled analysis from the

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37、ary syndromesJ.JACC Cardiovasc Interv,2019,12:531-540.5LeeMS,AnoseBM,MartinsenBJ,etal.Orbitalatherectomytreatmentof severely calcified native coronary lesions in patients with priorcoronary artery bypass grafting:acute and one-year outcomes fromtheORBITtrialJ.CardiovascRevascMed,2018,19:498-502.6Wan

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40、erectomy in calcifiedcoronary lesions:from the ROCK registry,South KoreaJ.AnnSaudi Med,2021,41:191-197.10Lee T,Mintz GS,Matsumura M,et al.Prevalence,predictors,andclinical presentation of a calcified nodule as assessed by opticalcoherence tomographyJ.JACC Cardiovasc Imaging,2017,10:883-891.11Yonetsu

41、 T,Jang IK.Advances in intravascular imaging:new insightsinto the vulnerable plaque from imaging studiesJ.Korean Circ J,2018,48:1-15.12Tazaki R,Tanigawa J,Fujisaka T,et al.Plasma pentraxin3 level isassociated with plaque vulnerability assessed by optical coherencetomography in patients with coronary

42、 artery diseaseJ.Int HeartJ,2016,57:18-24.13Abreu Marino BC,Buljubasic N,Akkerhuis M,et al.Adiponectinin relation to coronary plaque characteristics on radiofrequencyintravascular ultrasound and cardiovascular outcomeJ.Arq BrasCardiol,2018,111:345-352.14Cuenza LR,Jayme AC,Khe Sui JH.Clinical outcome

43、s of patientsundergoing rotational atherectomy followed by drug-eluting stentimplantation:asingle-centerreal-world experienceJ.Heart Views,2017,18:115-120.15LeeMS,GordinJS,StoneGW,etal.Orbitalandrotationalatherectomyduring percutaneous coronary intervention for coronary arterycalcificationJ.Catheter

44、 Cardiovasc Interv,2018,92:61-67.16 韩风杰,郑海军,郑献召,等血管内超声指导下的旋磨术联合切割球囊预处理冠状动脉重度钙化病变:120例前瞻性随机对照试验J南方医科大学学报,2021,41:1044-104917Abdel-Wahab MA,oelg R,Byrne RA,et al.High-speed rotationalatherectomy versus modified balloons prior to drug-eluting stentimplantation in severely calcified coronary lesionsJ.Ci

45、rc Cardio-vasc Interv,2018,11:e007415.18Hemetsberger R,Toelg R,Mankerious N,et al.Impact of calcifiedlesion complexity on the success of percutaneous coronaryintervention with upfront high-speed rotational atherectomy ormodified balloons:a subgroup-analysis from the randomizedPREPARE-CALC trialJ.Car

46、diovasc Revasc Med,2021,33:26-31.19Morofuji T,Kuramitsu S,Shinozaki T,et al.Clinical impact ofcalcified nodule in patients with heavily calcified lesions requiringrotational atherectomyJ.Catheter Cardiovasc Interv,2021,97:10-19.20 汤喆,白静,王禹,等冠状动脉重度钙化病变介入治疗进展J中华老年心脑血管病杂志,2017,19:545-54621Matsuhiro Y,Nakamura D,Shutta R,et al.Maximum calciumthickness is a useful predictor for acceptable stent expansion inmoderate calcified lesionsJ.Int J Cardiovasc Imaging,2020,36:1609-1615.22 单培仁,蔡雪黎,项光泽,等血管内超声指导下冠状动脉支架术后即刻支架膨胀不全相关危险因素分析J浙江医学,2018,40:243-247(收稿日期:2022-02-05)(本文编辑:边佶)358

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