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
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摘要
目的探讨冠状动脉介入治疗术中血管内超声(IVUS)指导下支架膨胀不全发生的相关危险因素。方法分析同时行术前和术后IVUS检查的102例患者(102个罪犯病变),包括临床特征、造影资料和IVUS数据;支架膨胀率定义为100×最小支架横截面积/参考管腔面积,以中位数分成两组:支架膨胀相对不良组[(66.2±8.8)%]和支架膨胀相对良好组[(88.9±8.0)%],两组患者基线资料比较差异均无统计学意义(均P>0.05)。比较两组患者血管病变特征,分析支架膨胀不良的相关危险因素。结果支架膨胀不良组有更多的造影下钙化病变(37.3%vs 17.7%,P<0.05)和IVUS下钙化病变(76.5%vs 56.9%,P<0.05),更大的最大钙化角度[85°(26°,120°)vs 28°(0°,102°),P<0.05],更长的病变长度[(38.5±10.1)mm vs(30.1±11.4)mm,P<0.01)],更小的最小支架内面积[(6.0±1.9)mm~2 vs(7.7±2.2)mm~2,P<0.01]。多变量回归分析发现最大钙化角度(OR=1.21,95%CI:1.02~1.44,P<0.05)和病变长度(OR 1.51,95%CI 1.12~2.04,P<0.01)是支架膨胀不良的独立危险因素。ROC曲线分析显示预测支架膨胀不良的截点,最大钙化角度是80°,AUC 0.643(P<0.01);而病变长度截点是32mm,AUC 0.715(P<0.01)。结论尽管有非顺应性后扩球囊辅助扩张,IVUS下支架膨胀不全并不少见,浅表钙化最大角度和病变长度是支架膨胀不全的重要预测因素。
Objective To investigate the risk factors of stent underexpansion in intravascular ultrasound(IVUS)-guided percutaneous coronary intervention(PCI). Methods The clinical data, angiographic and pre-, post-PCI IVUS findings of 102 patients(102 lesions) were reviewed. According to the stent expansion index ≥ median ormaximum arc of superficial calcium [85°(26°,120°)vs 28(0°,102°), P <0.05], longer lesion length[(38.5±10.1)mm vs(30.1±11.4)mm, P<0.01)], and smaller minimum stent area [(6.0±1.9)mm~2 vs(7.7±2.2)mm~2,P<0.01]. Multivariate logistic regression analysis revealed that maximum arc of superficial calcium(OR=1.21, 95% CI :1.02~1.44,P<0.05) and lesion length(OR=1.51, 95% CI: 1.12~2.04, P<0.01) were independently associated with stent underexpansion. By receiver-operating characteristic(ROC) analysis, the area under curve(AUC) was 0.643 for the maximum arc of superficial calcium and 0.715 for the lesion length. The cut-off values for predicting stent underexpansion were 80° and 32.0 mm, respectively(P<0.01). Conclusion Stent underexpansion phenomena is not uncommon, despite adjunctive post-dilatation with noncompliant balloon. Extent of superficial calcium and lesion length are the strongest determinants of stent underexpansion.
Objective To investigate the risk factors of stent underexpansion in intravascular ultrasound(IVUS)-guided percutaneous coronary intervention(PCI). Methods The clinical data, angiographic and pre-, post-PCI IVUS findings of 102 patients(102 lesions) were reviewed. According to the stent expansion index ≥ median or
引文
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[16]Nishida K,Kimura T,Kawai K,et al.Comparison of outcomes using the sirolimus-eluting stent in calcified versus noncalcified native coronary lesions in patients on-versus not on-chronic hemodialysis(from the j-Cypher registry)[J].Am J Cardiol,2013,112(5):647-655.
[17]Généreux P,Madhavan MV,Mintz GS,et al.Ischemic outcomes after coronary intervention of calcified vessels in acute coronary syndromes.Pooled analysis from the HORIZONS-AMI(Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction)and ACUITY(Acute Catheterization and Urgent Intervention Triage Strategy)trials[J].J Am Coll Cardiol,2014,63(18):1845-1854.
[18]Tang Z,Bai J,Su SP,et al.Cutting-balloon angioplasty before drug-eluting stent implantation for the treatment of severely calcified coronary lesions[J].J Geriatr Cardiol,2014,11(1):44-49.
[19]Li Q,He Y,Chen L,et al.Intensive plaque modification with rotational atherectomy and cutting balloon before drug-eluting stent implantation for patients with severely calcified coronary lesions:a pilot clinical study[J].BMC Cardiovasc Disord,2016,16:112.
[2]Bundhun PK,Yanamala CM.Comparing Stent Thrombosis associated with Zotarolimus Eluting Stents versus Everolimus Eluting Stents at 1 year follow up:a systematic review and meta-analysis of 6 randomized controlled trials[J].BMC Cardiovasc Disord,2017,17(1):84.
[3]Mintz GS,Guagliumi G.Intravascular imaging in coronary artery disease[J].Lancet,2017,390(10096):793-809.
[4]Song HG,Kang SJ,Ahn JM,et al.Intravascular ultrasound assessment of optimal stent area to prevent in-stent restenosis after zotarolimus-,everolimus-,and sirolimus-eluting stent implantation[J].Catheter Cardiovasc Interv,2014,83(6):873-878.
[5]Lee SY,Shin DH,Kim JS,et al.Intravascular Ultrasound Predictors of Major Adverse Cardiovascular Events After Implantation of Everolimus-eluting Stents for Long Coronary Lesions[J].Rev Esp Cardiol(Engl Ed),2017,70(2):88-95.
[6]杨建敏,张邢炜,王宁夫,等.炎症因子预测冠状动脉高危斑块的血管内超声研究[J].浙江医学,2012,34(15):1267-1275.
[7]Shan P,Mintz GS,Witzenbichler B,et al.Does calcium burden impact culprit lesion morphology and clinical results?An ADAPTDES IVUS substudy[J].Int J Cardiol,2017,248:97-102.
[8]Figueiredo Neto JA,Nogueira IA,Figueiro MF,et al.Angioplasty guided by intravascular ultrasound:meta-analysis of randomized clinical trials[J].Arq Bras Cardiol,2013,101(2):106-116.
[9]Sbruzzi G,Quadros AS,Ribeiro RA,et al.Intracoronary ultrasoundguided stenting improves outcomes:a meta-analysis of randomized trials[J].Arq Bras Cardiol,2012,98(1):35-44.
[10]Hong SJ,Kim BK,Shin DH,et al.Effect of Intravascular Ultrasound-Guided vs Angiography-Guided EverolimusEluting Stent Im-plantation:The IVUS-XPL Randomized Clinical Trial[J].JAMA,2015,314(20):2155-2163.
[11]Shin DH,Hong SJ,Mintz GS,et al.Effects of Intravascular Ultrasound-Guided Versus Angiography-Guided New-Generation Drug-Eluting Stent Implantation:Meta-Analysis With Individual Patient-Level Data From 2,345 Randomized Patients[J].JACC Cardiovasc Interv,2016,9(21):2232-2239.
[12]Jang JS,Song YJ,Kang W,et al.Intravascular ultrasoundguided implantation of drug-eluting stents to improve outcome:a meta-analysis[J].J Am Coll Cardiol Intv,2014,7(3):233-243.
[13]Ahn JM,Kang SJ,Yoon SH,et al.Meta-analysis after intravascular ultrasound-guided versus angiography-guided drugeluting stent implantation in 26,503 patients enrolled in three randomized and fourteen observation studies[J].Am J Cardiol,2014,113(8):1338-1347.
[14]Witzenbichler B,Maehara A,Weisz G,et al.Relationship between intravascular ultrasound guidance and clinical outcomes after drug-eluting stents:the assessment of dual antiplatelet therapy with drug-eluting stents(ADAPT-DES)study[J].Circulation,2014,129(4):463-470.
[15]Bourantas CV,Zhang YJ,Garg S,et al.Prognostic implications of coronary calcification in patients with obstructive coronary artery disease treated by percutaneous coronary intervention:a patient-level pooled analysis of 7 contemporary stent trials[J].Heart,2014,100(15):1158-1164.
[16]Nishida K,Kimura T,Kawai K,et al.Comparison of outcomes using the sirolimus-eluting stent in calcified versus noncalcified native coronary lesions in patients on-versus not on-chronic hemodialysis(from the j-Cypher registry)[J].Am J Cardiol,2013,112(5):647-655.
[17]Généreux P,Madhavan MV,Mintz GS,et al.Ischemic outcomes after coronary intervention of calcified vessels in acute coronary syndromes.Pooled analysis from the HORIZONS-AMI(Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction)and ACUITY(Acute Catheterization and Urgent Intervention Triage Strategy)trials[J].J Am Coll Cardiol,2014,63(18):1845-1854.
[18]Tang Z,Bai J,Su SP,et al.Cutting-balloon angioplasty before drug-eluting stent implantation for the treatment of severely calcified coronary lesions[J].J Geriatr Cardiol,2014,11(1):44-49.
[19]Li Q,He Y,Chen L,et al.Intensive plaque modification with rotational atherectomy and cutting balloon before drug-eluting stent implantation for patients with severely calcified coronary lesions:a pilot clinical study[J].BMC Cardiovasc Disord,2016,16:112.