球囊肺动脉成形术治疗近端慢性血栓栓塞性肺动脉高压的安全性和有效性.pdf

Vascular intervention:血管介入746-介人放射学杂志2 0 2 3年8 月第32 卷第8 期JInterventRadiol2023,Vol.32,No.8球囊肺动脉成形术治疗近端慢性血栓栓塞性肺动脉高压的安全性和有效性王金志，陶新曹，谢万木，张帅，张竹，傅志辉，李宜珊，赵蕴伟，黄强，翟振国【摘要】目的评估球囊肺动脉成形术(BPA)治疗近端慢性血栓栓塞性肺动脉高压(CTEPH)的安全性和有效性。方法纳人2 0 16 年12 月至2 0 2 2 年1月在中日友好医院呼吸中心住院的CTEPH患者46例,均接受BPA。比较术前与术后患者的WHO心功能分级、6 min步行距离（6 MWD）、血N-末端脑钠肽前体（NT-proBNP)水平、混合静脉血氧饱和度（SvO2)、平均肺动脉压（mPAP）、心指数和肺血管阻力(PVR）。结果46 例行BPA治疗的CTEPH患者中，男性17 例，女性2 9例，年龄（57.0 12.7)岁。行12 6 次BPA,共治疗545支病变血管,平均每次治疗血管数2.7 支。术前患者的WHO心功能I、I V级分别为1例（2.2%）、2 4例（52.1%）、17 例（37.0%）、4例（8.7%），6 MWD为(359.6 112.3）m,Sv02为（6 4.58.8)%；术后WHO心功能I、I、IV级分别为6 例（13.0%）、31例（6 7.4%）、13例（2 8.3%）、2 例（4.3%）,6 MWD为（436.7 97.9）m,Sv O 2 为（6 6.45.5)%（均P0.05）。术后血浆NT-proBNP、mPA P、PVR、心指数、右心房压力均低于术前，分别为2 6 2（145，7 46）ng/L比955（2 42,2 7 8 1）ng/L、（2 9.2 9.9）mmH g 比（39.49.5）mmHg、(6.62.7)WU比（12.16.2)WU、（1.10.7）L/(mi n m)比（1.7 0.8）L/(minm)、（3.7 3.0）mmH g 比（5.14.4）mmH g（均P0.05）。咯血共5例次，再灌注肺水肿1例次，无其他并发症发生。结论BPA是治疗近端CTEPH患者安全、有效的方法。【关键词】慢性血栓栓塞性肺动脉高压；平均肺动脉压；肺动脉内膜剥脱术；球囊肺动脉成形术中图分类号：R654.44文献标志码：A文章编号：10 0 8-7 94X(2023)-08-0746-04The safety and efficacy of balloon pulmonary angioplasty in the treatment of proximal-type chronicthromboembolic pulmonary hypertensionWANG Jinzhi,TAO Xincao,XIE Wanmu,ZHANG Shuai,ZHANG Zhu,FU Zhihui,LI Yishan,ZHAO Yunwei,HUANG Qiang,ZHAI Zhenguo.Graduate School ofJiamusi University,Jiamusi City,Heilongjiang Province154007,ChinaZHANG Zhu,FU Zhihui,LI Yishan,ZHAO Yunwei,HUANG Qiang,ZHAI Zhenguo.Graduate School ofJiamusi University,Jiamusi City,Heilongjiang Province154007,ChinaCorresponding author:ZHAO Yunwei,E-mail:;HUANG Qiang,E-mail:;ZHAI Zhenguo,E-mail:Abstract)Objective To evaluate the safety and efficacy of balloon pulmonary angioplasty(BPA)intreating proximal-type chronic thromboembolic pulmonary hypertension(p-CTEPH).Methods A total of 46patients with p-CTEPH,who were admitted to the China-Japan Friendship Hospital of China betweenDecember 2016 and January 2022 to receive BPA,were enrolled in this study.The postoperative WorldHealth Organization cardiac functional class(WHO-FC),6-min walk distance(6-MWD),plasma level ofN-terminal pro-brain natriuretic peptide(NT-proBNP),mixed venous oxygen saturation(SvO2),mean pulmonaryartery pressure(mPAP),cardiac index(CI)and pulmonary vascular resistance(PVR)were compared with theD0I:10.3969/j.issn.1008-794X.2023.08.004基金项目：中国医学科学院医学与健康科技创新工程(2 0 2 1-I2M-1-049)；中央高水平医院临床科研业务费资助(2022-NHLHCRF-LX-01-01-02)作者单位：1540 0 7 黑龙江佳木斯大学研究生学院（王金志，目前工作于鹤岗市人民医院）；中国医学科学院阜外医院呼吸与肺血管病中心（陶新曹）；中日友好医院呼吸中心呼吸与危重症医学科国家呼吸中心（谢万木、张帅、张竹、傅志辉、李宜珊、黄强、翟振国）；佳木斯大学附属第一医院呼吸与危重症医学科（赵蕴伟）通信作者：赵蕴伟韦E-mail:;黄强E-mail:;翟振国E-mail:747介人放射学杂志2 0 2 3年8 月第32 卷第8 期JInterventRadiol 2023,Vol.32,No.8preoperative ones.Results The 46 CTEPH patients included 17 males and 29 females with a mean age of(57.012.7)years.A total of 126 BPA procedures were performed and a total of 545 diseased vessels weretreated,with a mean of 2.7(1,8.15)vessels per BPA procedure.Before treatment,the preoperative WHO-FCgrade I was seen in one patient(2.2%),grade I in 24 patients(52.1%),grade II in 17 patients(37.0%)andgrade IV in 4 patients(8.7%),the 6-MWD was(359.6112.3)m,and the mean Sv02 was(64.58.8)%;after treatment,the WH0-FC grade I was seen in 6 patients(13.0%),grade II in 31 patients(67.4%),grade IIin 13 patients(28.3%)and grade IV in 2 patients(4.3%),the 6-MWD was(436.797.9)m,and the meanSv02 was(66.4 5.5)%;the differences in the above indexes between their preoperative values andpostoperative values were statistically significant(all P0.05).The postoperative NT-proBNP,mPAP,PVR,CIand right atrial pressure were 262(145,746)ng/L,(29.29.9)mmHg,(6.62.7)WU,(1.10.7)L/(minm),and(3.73.0)mmHg respectively,which were remarkably lower than the preoperative 955(242,2781)ng/L,(39.4+9.5)mmHg,(12.16.2)WU,(1.70.8)L(min:m),and(5.14.4)mmHg respectively,and the differencesin all the above indexes between their preoperative values and postoperative values were statistically significant(all P30 mmHg(1mmHg=0.133kPa)，5年存活率不到30%;mPAP50 mmHg,5 年存活率不到10%2 按照解剖分类，血栓位置在段水平以下定义为远端CTEPH(distal-typeCTEPH,d-CTEPH),血栓位置在段水平以上为近端CTEPH(proximal-type CTEPH,p-CTEPH)。肺动脉血栓内膜剥脱术(pulmonaryendarterectomy，PEA）是治疗CTEPH的首选方案，术后部分患者血流动力学、心肺功能、运动耐量趋于正常 3。然而，约有1/3患者由于远端血栓、高危获益比和个人意愿等原因无法行PEA治疗 4。靶向药物治疗可以改善CTEPH患者心肺功能，但无法解除肺动脉阻塞 5。2 0 0 1年球囊肺动脉成形术(balloonpulmonary angioplasty,BPA)首次用于 CTEPH的治疗,但因术后并发症较多，病死率较高，未被临床广泛应用。2 0 12 年日本学者采用改良式BPA明显降低了术后并发症的发生率 4。近10 年随着腔内血管技术的应用，提高了BPA的安全性与有效性 6 。本研究探讨BPA在p-CTEPH患者中的安全性和有效性。1材料与方法1.1研究对象2016年12 月至2 0 2 2 年1月中日友好医院呼吸中心诊断为p-CTEPH行BPA治疗的患者46 例。CT肺动脉造影、肺通气/灌注显像或肺动脉造影证实存在慢性血栓，右心漂浮导管检查mPAP25mmHg，肺小动脉楔压(PAWP)15mmHg。同时除外肺动脉肉瘤,肺血管炎等。纳人标准：年龄18岁；血栓位于段及水平以上，选择BPA治疗；患者签署手术知情同意书。排除标准：已行肺动脉内膜剥脱术患者；严重肾功能不全；急性心肌梗死；恶性心律失常；对碘造影剂过敏。本研究通过中日友好医院伦理委员会审核批准。1.2资料收集收集患者性别、年龄、吸烟史、饮酒史、高血压病史、糖尿病病史、冠心病病史、深静脉血栓形成病史、易栓症病史，以及靶向药物和抗凝药物应用情况，心功能分级，6 分钟步行距离（6 MWD）。右心导管测量右心房压、右心室压、肺动脉压（PAP)和肺血管阻力（PVR）,采用Fick法获得心排量,肺动脉血气分析获得混合静脉血氧饱和度(SvO2)。1.3BPA手术方法常规消毒铺巾，1%利多卡因局部麻醉穿刺，通过股静脉置人7 0 90 cm8FCO0K血管鞘（美国库克公司）或8 0 cm8FArrowSuperFlex血管鞘（美国Arrow公司），普通肝素50 U/kg，分别测量右心房748-介入放射学杂志2 0 2 3年8 月第32 卷第8 期JInterventRadiol2023,Vol.32,No.8压、右心室压、PAP、PVR，通过鞘管送入6 FJR4.0、JL4.0、JL3.5、A L1.0 或MPA1.0指引导管（美国强生公司)到达靶血管行选择性肺动脉造影。送人直径0.014英寸Sion、Si o n b lu e,Fi e ld e r X T R/X T/X T A,G a i a I、Gaia II、G a i a II、Co n q u e s t、Co n q u e s t p r o 导丝（日本ASAHI公司)通过病变处，送人直径1.2 5.0 mmIKAZUCHI球囊扩张导管（日本钟化株式会社）、Empria球囊扩张导管（美国强生公司）。根据血栓负荷、治疗后血管管腔狭窄恢复等情况，必要时更换0.035英寸（日本朝日英达科株式会社）超滑加长导丝送人8.0 10.0 mmC00K球囊扩张导管（美国COOK公司），414个大气压进行扩张，每次扩张时间6 30 s。当单次手术总放射辐射剂量不超过2000mGy或对比剂达到30 0 mL时停止手术。1.4BPA相关并发症BPA相关并发症主要包括肺血管损伤和再灌注肺水肿等。肺血管损伤多在术中出现咯血、咳嗽、胸痛等；再灌注肺水肿主要发生在术后2 448 h，表现为胸部X线片或胸部CT新出现手术部位的斑片样阴影，伴或不伴血氧饱和度下降或咳大量泡沫样痰。1.5统计学分析采用SPSS26.0统计软件，正态分布的连续变量采用x土s表示，比较采用独立样本t检验；非正态分布的连续变量采用M(P25,Prs)表示，比较采用Mann-WhitneyU检验。P40mmHg或PVR7WU时，发生再灌注肺水肿概率增加。近10 年随着BPA技术的发展、手术经验的积累，再灌注肺水肿发生率已经显著下降 18 本研究存在一定局限性，如缺少长期随访数据，未进行靶向药物和BPA联合疗效的评估。综上所述,BPA能改善p-CTEPH患者的运动耐量、心肺功能和血流动力学,且并发症的发生率相对较低。参考文献1中华医学会呼吸病学分会肺栓塞与肺血管病学组，中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会，全国肺栓塞与肺血管病防治协作组，等.中国肺动脉高压诊断与治疗指南（2 0 2 1版）J.中华医学杂志，2 0 2 1，10 1：11-51.2Riedel M,Stanek V,Widimsky J,et al.Longterm follow-up ofpatients with pulmonary thromboembolism.Late prognosis andevolution of hemodynamic and respiratory dataJJ.Chest,1982,81:151-158.3Ito R,Yamashita J,Sasaki Y,et al.Efficacy and safety of balloonpulmonary angioplasty for residual pulmonary hypertension afterpulmonary endarterectomyJJ.Int J Cardiol,2021,334:105-109.4 Delcroix M,Lang I,Pepke-Zaba J,et al.Long-term outcome ofpatients with chronic thromboembolic pulmonary hypertension:results from an international prospective registryJ.Circulation,2016,133:859-871.5Humbert M,Kovacs G,Hoeper MM,et al.2022 ESC/ERS guidelinesfor the diagnosis and treatment of pulmonary hypertension J.Eur Respir J,2023,61:2200879.6Jiang X,Peng FH,Liu QQ,et al.Optical coherence tomographyfor hypertensive pulmonary vasculatureJ.Int J Cardiol,2016,222:494-498.7Jais X,Brenot P,Bouvaist H,et al.Balloon pulmonary angioplastyversusriociguat for the treatment of inoperable chronicthromboembolic pulmonary hypertension(RACE):a multicentre,phase 3,open-label,randomised controlled trial and ancillaryfollow-up studyJJ.Lancet Respir Med,2022,10:961-971.8 Kawakami T,Ogawa A,Miyaji K,et al.Novel angiographicclassification of each vascular lesion in chronic thromboe-mbolicpulmonary hypertension based on selective angiogram and resultsof balloon pulmonary angioplastyJJ.Circ Cardiovasc Interv,2016,9:e003318.9Hsieh WC,Jansa P,Huang WC,et al.Residual pulmonaryhypertension after pulmonary endarterectomy:a meta-analysisJ.J Thorac Cardiovasc Surg,2018,156:1275-1287.10Alegria S,Cale R,Ferreira F,et al.Optical coherence tomography-guided balloon pulmonary angioplasty of a web lesion JJ.Rev PortCardiol(Engl Ed),2019,38:227-228.11 Shimokawahara H,Ogawa A,Matsubara H.Balloon pulmonaryangioplasty for chronic thromboembolic pulmonary hypertension:advances in patient and lesion selection JJ.Curr Opin Pulm Med,2021,27:303-310.12 Hug KP,Gerry CJ,Cannon J,et al.Serial right heart catheterassessment between balloon pulmonary angioplasty sessionsidentify procedural factors that influence response to treatmentJ.J Heart Lung Transplant,2021,40:1223-1234.13 Araszkiewicz A,Darocha S,Pietrasik A,et al.Ballon pulmonaryangioplasty for the treatment of residual or recurrent pulmonaryhypertension after pulmonary endarterectomy J.Int J Cardiol,2019,278:232-237.14 Cannon JE,Su L,Kiely DG,et al.Dynamic risk stratification ofpatient long-term outcome after pulmonary endarterectomy:results from the United Kingdom National Cohort JJ.Circulation,2016,133:1761-1771.15 Tanabe N,Kawakami T,Satoh T,et al.Balloon pulmonaryangioplasty for chronic thromboembolic pulmonary hypertension:a systematic reviewJ.Respir Investig,2018,56:332-341.16 Wiedenroth CB,Deissner H,Adameit MSD,et al.Complicationsof balloon pulmonary angioplasty for inoperable chronic throm-boembolic pulmonary hypertension:Impact on the outcomeJ.JHeart Lung Transplant,2022,41:1086-1094.17 Darocha S,Roik M,Kopec G,et al.Balloon pulmonary angioplastyin chronic thromboembolic pulmonary hypertension:a multicentreregistryJJ.Eurolntervention,2022,17:1104-1111.18 Kim NH,Delcroix M,Jais X,et al.Chronic thromboembolicpulmonary hypertensionJ.Eur Respir J,2019,53:1801915.（收稿日期：2 0 2 2-11-19）