冠脈內(nèi)超聲評(píng)價(jià)冠心病介入療效的研究

1、    冠脈內(nèi)超聲評(píng)價(jià)冠心病介入療效的研究        【摘要】目的應(yīng)用冠脈內(nèi)超聲(ICUS)評(píng)價(jià)冠心病患者經(jīng)皮冠狀動(dòng)脈球囊成形術(shù)(PTCA)及冠脈內(nèi)支架植入術(shù)的療效。方法14例患者在冠脈介入性診斷和治療前后行ICUS檢查。共檢查14支靶血管,包括左前降支9支,左旋支1支,右冠脈4支。結(jié)果 6例PTCA術(shù)后即刻ICUS檢查發(fā)現(xiàn)5例存在血管夾層和斑塊破裂,占 83.3%,5處夾層部位均為鈣化或混合斑塊。其中2例尚可見小內(nèi)膜撕裂片在管腔內(nèi)隨血流飄動(dòng),而冠狀動(dòng)脈造影(CAG)僅發(fā)

2、現(xiàn)1例(16.7%)有明顯夾層(P0.038); 7例支架植入術(shù)后CAG結(jié)果均滿意,但符合ICUS最佳支架植入標(biāo)準(zhǔn)者僅2例(28.6%)(P0.013),另5例靶病變?yōu)殁}化、混合斑塊者,支架膨展差或存在游離腔隙。其中4例在支架邊緣處存在內(nèi)膜撕裂,2例在術(shù)后3個(gè)月和6個(gè)月分別發(fā)生支架及支架近端再狹窄; 19例次超聲檢查中,發(fā)生一過性靶血管痙攣1例。結(jié)論ICUS能準(zhǔn)確判斷PTCA術(shù)后并發(fā)癥,對(duì)支架成功植入有重要指導(dǎo)價(jià)值,可作為一種與CAG互為補(bǔ)充的診斷方法?！娟P(guān)鍵詞】超聲檢查,介入性;血管成形術(shù),經(jīng)腔,經(jīng)皮冠狀動(dòng)脈;冠脈內(nèi)支架植入術(shù) Assessment of coronary intervent

3、ional therapy results by intracoronary ultrasoundSHI Haiming,ZHU Jun,LUO Xinping（Department of Cardiology,Huashan Hospital,Shanghai Medical University,Shanghai 200040,China）【Abstract】ObjectiveTo evaluate the coronary artery response to percutaneous transluminal coronary angioplasty (PTCA) and intrac

4、oronary stenting by intracoronary ultrasound(ICUS).MethodsICUS was performed in 14 patients before and after coronary intervention procedures.Target vessels imaged by ICUS included nine LAD,one LCX and four RCA.Results Six patients underwent ICUS imaging after PTCA.In five cases (83.3%),the dissecti

5、on or plaque fracture at the site of angioplasty was observed,and small intimal flaped into the lumen in two of them.The plaque composition of these target lesions was calcified or mixed plaque.However,only one of them (16.7%) had been diagnosed angiographically(P0.038). ICUS was performed in seven

6、patients after intraconorary stenting.Coronary angiograms were considered as an acceptable results in all cases with stenting,but only two of them achieved the ICUS criteria for optimal stent deployment,five cases showed incomplete stent apposition or inadequate stent expansion(P0.013),vessel intima

7、l tearing were found at the edge of stents in four cases ,two of them revealed restenosis at the margin of the stent or in-stent during three and six months after stenting,respectively. Only one case had transient vessel spasm during the procedures,but recovered after catheter pullback and intracoro

8、nary nitroglycerin.ConclusionsICUS can assess the coronary angioplasty results accurately and has an important role in guiding the optimal stent placement.【Key words】Ultrasonography,interventional;Angioplasty,transluminal, percutaneous coronary;Intracoronary Stenting冠脈內(nèi)超聲(ICUS)是近年來發(fā)展起來的一項(xiàng)新的侵入性影像檢查技術(shù)

9、,國外已常規(guī)應(yīng)用于冠心病的介入性診斷治療中。本研究通過與冠狀動(dòng)脈造影(CAG)對(duì)比,旨在評(píng)價(jià)ICUS對(duì)冠心病患者經(jīng)皮冠狀動(dòng)脈球囊成形術(shù)(PTCA)及支架植入術(shù)的介入療效,探討其臨床實(shí)用價(jià)值。資 料 與 方 法23:支架完全膨展,支架與內(nèi)膜表面間無游離腔;支架均勻膨展且對(duì)稱指數(shù)>0.8;支架內(nèi)管腔橫截面積近似于參照血管腔橫截面積。四、統(tǒng)計(jì)學(xué)處理采用四格表精確概率法,P<0.05有顯著性差異。結(jié)果共檢查14支靶血管,包括左前降支9支,左旋支1支,右冠脈4支。19例次成像中,PTCA前、后各6例次,支架植入后7例次。6例在PTCA術(shù)后即刻行ICUS檢查,發(fā)現(xiàn)5例血管壁存在夾層或斑塊破裂,

10、占 83.3%,其中2例在實(shí)時(shí)像上尚可見撕裂的小內(nèi)膜片在管腔內(nèi)隨血流飄動(dòng),而CAG僅見1例有明顯夾層(P0.038)。這5例夾層部位均為鈣化或混合斑塊,并成功植入了支架(1,2)。有7例在支架植入后進(jìn)行了超聲檢查。7例造影結(jié)果均滿意,但符合超聲植入標(biāo)準(zhǔn)者僅2例,占 28.6%(P0.013)。另5例靶病變?yōu)殁}化、混合斑塊者,支架膨展差或貼壁不佳或存在游離腔。4例在支架邊緣處可見內(nèi)膜撕裂,其近端亦均為鈣化斑塊。其中2例支架未能完全覆蓋靶病變且支架近端有內(nèi)膜撕裂及裂隙,此2例分別在術(shù)后3個(gè)月、6個(gè)月經(jīng)造影證實(shí)發(fā)生支架及支架近端再狹窄。    1A經(jīng)皮冠狀動(dòng)脈

11、球囊成形術(shù)后冠狀動(dòng)脈造影并未發(fā)現(xiàn)血管夾層;1B冠脈內(nèi)超聲顯示存在明顯夾層    2A在靶病變處植入16 mm Nir支架后冠狀動(dòng)脈造影并未發(fā)現(xiàn)血管夾層;2B冠脈內(nèi)超聲顯示夾層消失14例19例次成像中,發(fā)生一過性血管痙攣1例。整個(gè)操作過程相對(duì)安全,無因嚴(yán)重并發(fā)癥而終止檢查或治療者。討論當(dāng)前,冠脈介入療效的評(píng)價(jià)仍主要依賴于CAG結(jié)果,但CAG往往低估病變的嚴(yán)重程度,由于ICUS可以直接獲得血管壁的解剖學(xué)信息,清晰顯示血管壁斑塊組成以及血管夾層等,為指導(dǎo)臨床介入治療和療效評(píng)價(jià)等提供了更為有效的手段。本組6例PTCA術(shù)后即刻行ICUS檢查發(fā)現(xiàn)靶病變處 83.3%

12、存在血管夾層或斑塊破裂,其中25%尚可見小內(nèi)膜片(pocket flaps)在管腔內(nèi)隨血流飄動(dòng),而CAG僅有1例(16.7%)可見明顯夾層,P0.038,提示ICUS在發(fā)現(xiàn)PTCA術(shù)后夾層上較CAG更為敏感。5例出現(xiàn)夾層的患者均植入了支架,臨床效果良好。國外資料也表明,PTCA術(shù)后ICUS可發(fā)現(xiàn) 60%80%的病例有斑塊夾層,而CAG只能識(shí)別出一半左右4,5。其原因可能為斑塊破裂使造影劑進(jìn)入破裂的裂隙及夾層組織內(nèi),從而造影出現(xiàn)即刻管腔增大的假象。另外,存在夾層的這5處靶病變均為鈣化或混合斑塊,也符合鈣化斑塊更易發(fā)生血管夾層的觀點(diǎn)6,7。一般認(rèn)為局部的鈣化沉積和斑塊內(nèi)剪切力的增加對(duì)促成夾層有直接

13、作用8。支架是治療PTCA急性并發(fā)癥及預(yù)防再狹窄的重要手段之一。由于在CAG下放置相對(duì)較盲目,而ICUS可以清晰、直觀地看到支架在冠脈腔內(nèi)的膨展情況,了解支架與血管壁之間的貼壁對(duì)合情況,準(zhǔn)確判斷支架是否完全覆蓋靶病變以及是否位于血管真腔中等。國外研究表明,在CAG顯示膨展良好的支架中,仍有近80%在超聲上表現(xiàn)為支架膨展不完全或吻合不佳9,10,并未達(dá)到理想的支架植入。其原因可能是造影劑填充了支架與血管內(nèi)膜層之間的空隙,造成造影的偽正常結(jié)果。本組符合超聲最佳植入標(biāo)準(zhǔn)者也僅占28.6%(P0.013)。5例(71.4%)膨展貼壁差,存在游離腔者,靶病變處多為混合斑塊或鈣化斑塊,雖經(jīng)16個(gè)大氣壓擴(kuò)張

14、,仍不能達(dá)到支架對(duì)稱膨展。推測(cè)可能由于球囊過小或者鈣化、纖維鈣化斑塊與軟斑塊相比,更加不易變形,支架受斑塊壓縮所致,提示支架充分膨展、對(duì)稱的能力直接與斑塊成分有關(guān),斑塊成分及其相對(duì)順應(yīng)性直接影響支架植入的參數(shù),鈣化病變干擾支架的植入1,11。本研究還發(fā)現(xiàn)支架邊緣處組織常發(fā)生撕裂,形成飄動(dòng)的小內(nèi)膜組織片。本組有4例在支架邊緣處發(fā)生內(nèi)膜撕裂或小裂隙,且支架近端均為鈣化斑塊。其中2例支架高壓植入后未能完全覆蓋住靶病變,而且支架近端有內(nèi)膜撕裂及裂隙,分別在數(shù)月后發(fā)生支架內(nèi)及支架近端再狹窄,提示支架近端內(nèi)膜撕裂及裂隙可能是日后再狹窄的誘因之一12。Hoffmann等13也發(fā)現(xiàn)Palmaz-Schatz支

15、架邊緣處有近26%發(fā)生再狹窄,支架邊緣再狹窄處的內(nèi)膜增生比非再狹窄處的內(nèi)膜增生明顯,圍術(shù)期支架邊緣再狹窄的主要預(yù)測(cè)因素為連續(xù)參照段的斑塊負(fù)荷。支架植入何種病變,需要何種壓力,有待進(jìn)一步研究。上述初步結(jié)果提示:ICUS能夠準(zhǔn)確判斷PTCA術(shù)后血管夾層等并發(fā)癥,對(duì)支架的成功植入有重要指導(dǎo)價(jià)值,而且操作安全可行,可作為一種與CAG互為補(bǔ)充的診斷工具。作者單位:施海明（200040上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科）朱軍（200040上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科）羅心平（200040上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科）王受益（200040上海醫(yī)科大學(xué)附屬華山醫(yī)院心內(nèi)科）范維琥（200040上海醫(yī)科大學(xué)附屬華

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