超声引导肝内胆管穿刺在老年高位恶性胆道梗阻中的应用

目的探讨超声引导下肝内胆管穿刺联合DSA胆道双支架植入内引流治疗老年高位恶性胆道梗阻(MHBO)的临床应用价值。方法收集老年MHBO患者108例,超声组54例在超声引导下行肝内胆管穿刺,DSA组54例在DSA下行肝内胆管盲穿;2组患者穿刺成功后,于DSA下视情况行胆道双支架植入内引流、胆道单支架植入并对侧外引流、胆道完全外引流及优势侧胆道外引流;分析2组患者肝内胆管穿刺、近期并发症及4种胆道引流方式的疗效。结果超声组患者胆管穿刺次数、穿刺对比剂用量、胆道出血及穿刺点疼痛发生率明显小于DSA组(P均0.05),1次穿刺成功率明显高于DSA组(P0.05)。4种胆道引流方式术后第14天肝功能指标及术后第21天总胆红素(TBIL)值组间两两比较差异均有统计学意义(P均0.05)。结论超声引导穿刺技术联合DSA胆道双支架植入内引流治疗老年MHBO有明显的临床实用价值。     

药物涂层球囊治疗股腘动脉硬化闭塞症的临床疗效及安全性

目的探讨药物涂层球囊(DCB)治疗股腘动脉硬化闭塞症的有效性及安全性。方法经预扩张筛选后,将拟接受经皮腔内血管成形术(PTA)的54例股腘动脉硬化闭塞症患者随机分为试验组(n=27)及对照组(n=27),PTA术中分别采用DCB及普通球囊。PTA术后随访6个月,比较2组疗效及安全性,并对术中出现的非限流性夹层患者进行对比分析。结果剔除失访者后,最终试验组26例、对照组20例患者纳入研究。试验组术后6个月踝肱指数(ABI)、股腘动脉最小管腔直径(MLD)均高于对照组(P均0.05);Rutherford分级、股腘动脉狭窄程度、晚期管腔丢失(LLL)值、再狭窄率及靶病变血运重建(TLR)发生率均低于对照组(P均0.05)。试验组及对照组出现非限流性夹层的患者分别为14例及8例;2组出现非限流性夹层的患者间术后6个月ABI、Rutherford分级差异均无统计学意义(P均0.05),其余各疗效评价指标差异均有统计学意义(P均0.05)。2组间主要不良事件发生率及截肢率差异均无统计学意义(P均0.05)。结论 DCB治疗股腘动脉硬化闭塞症的近期疗效优于普通球囊,且二者安全性相似;对于PTA术中出现非限流性夹层患者,DCB疗效仍优于普通球囊。     

Wingspan支架与冠脉支架在血管内支架成形术中的应用

目的 评价血管内支架成形术治疗颅内动脉狭窄的有效性和安全性. 方法 22例颅内动脉狭窄患者根据数字减影全脑血管造影(DSA)检查分为Wingspan组和冠脉球扩支架组,并给予血管内支架成形术治疗;比较两组手术成功率、术后动脉狭窄改善率及并发症发生率;随访半年,复查DSA. 结果 Wingspan组与冠脉支架组手术成功率分别为100％和90％,术后动脉狭窄改善率均＞70％,并发症发生率分别为16％和10％,两组间差异无统计学意义;Wingspan组与冠脉支架组手术时间分别为80分钟和102分钟,两者之间存在显著性差异.结论 血管内支架成形术可明显改善颅内动脉狭窄,降低脑血管事件的发生,安全有效.     

抗抑郁治疗对非ST段抬高ACS患者PCI术后抑郁状态及躯体症状的影响

目的:研究抗抑郁治疗对非ST段抬高急性冠脉综合征(ACS)患者经皮冠脉介入治疗(PCI)术后抑郁状态及躯体症状的影响.方法:对拟行首次PCI术的NSTE ACS合并抑郁的患者,随机分为治疗组和对照组,两组均接受支架置入术和常规冠心病药物治疗,治疗组给予针对抑郁的的相应心理干预和药物治疗,治疗6周后比较两组之间汉密尔顿抑郁量袁( HAMA)变化,以及躯体症状改善情况和主要心血管事件(MACE)发生率.结果:治疗组6周后HAMA评分较治疗前明显降低差异有统计学意义,对照组6周后HAMA评分较治疗前有所降低但差异无统计学意义.治疗组6周后24小时室性期前收缩次数较治疗前减低,受试者躯体不适症状治疗组较对照组显著减低,而两组患者主要心血管事件发生率无明显差异.结论:抗抑郁治疗可显著改善NSTE ACS患者PCI术后的抑郁情绪障碍和躯体症状.     

支架辅助栓塞未破裂颅内动脉瘤术后颅内微缺血危险因素

目的分析支架辅助栓塞(SAE)治疗未破裂颅内动脉瘤后发生颅内微缺血(IMI)的危险因素。方法回顾性分析236例接受SAE治疗的未破裂颅内动脉瘤患者,根据术后3天内头部MR弥散加权成像(DWI)检查结果判断是否发生IMI;采用单因素分析和多因素Logistic回归分析筛选IMI危险因素。结果 236例中,97例(97/236, 41.10%)发生IMI(IMI组),139例未发生IMI(非IMI组,n=139)。2组间合并糖尿病、缺血性卒中病史、血小板抑制不足、前交通动脉瘤、伴瘤内附壁血栓、支架贴壁不良及微弹簧圈襻疝出瘤囊差异有统计学意义(P均0.05)。多因素Logistic回归分析结果显示,血小板抑制不足、前交通动脉瘤、伴瘤内附壁血栓、支架贴壁不良及微弹簧圈襻疝出瘤囊是IMI的独立危险因素(P均0.05)。结论 SAE治疗未破裂颅内动脉瘤后可发生IMI;血小板抑制不足、前交通动脉瘤、伴瘤内附壁血栓、支架贴壁不良及微弹簧圈襻疝出瘤囊促进IMI发生。     

超声与DSA引导阻滞治疗神经根型颈椎病的临床比较

目的 探讨超声与数字减影血管造影技术(digital subtraction angiography, DSA)引导阻滞治疗神经根型颈椎病(cervical spondylotic radiculopathy, CSR)的临床疗效。方法 选择该院2020年2月～2022年2月收治的88例CSR患者为研究对象,均采用颈椎脊神经根阻滞治疗,根据不同穿刺引导方式分为两组：46例采用超声引导,设为超声组;42例采用DSA引导,设为DSA组。比较两组患者一次穿刺成功率、穿刺时间、手术时间,记录术后不良反应发生情况,比较术前、术后当天、术后1个月时的疼痛视觉模拟评分(visual analog scale, VAS)、颈椎功能障碍指数(neck disability index, NDI)。结果 超声组一次穿刺成功率高于对照组,穿刺时间、手术时间短于对照组(P<0.05);超声组不良反应总发生率显著低于对照组(P<0.05);两组术后当天、术后1个月的VAS、NDI均显著低于术前(P<0.05),但组间差异无统计学意义(P>0.05)。结论 超声与DSA引导阻滞治疗CSR均...     

多平面重建技术与经验性定位在主动脉夹层腔内修复术中的对比分析

目的比较多平面重建(MPR)技术与经验性定位在Stanford B型主动脉夹层腔内修复术中的临床应用价值。方法选择2012年5月至2013年3月Stanford B型主动脉夹层患者40例(A组):术前分别采用经验性和MPR两种方法获得C形臂的旋转角度和倾斜角度,比较两种方法的差异;术中采用MPR技术确定角度,统计支架释放后近端标记点的散开率和各种并发症的发生率。另42例Stanford B型主动脉夹层患者采用经验性方法释放支架(B组):计算近端标记点散开率和各种并发症的发生率。分析两组支架标记点散开率和并发症发生率。结果 A组内经验性方法和MPR方法之间旋转角度及倾斜角度比较,差异有统计学意义(P均<0.05);A、B两组标记点散开率比较,差异有统计学意义(5.0%vs 42.9%,P<0.05);A、B两组并发症发生率比较,差异有统计学意义(5.0%vs 21.4%,P<0.05)。结论结合MPR技术进行Stanford B型主动脉夹层腔内治疗术中定位调整,指导手术操作,具有较好的可行性、有效性及安全性。     

DSA引导下经皮胃造瘘术治疗食管癌伴吞咽困难

目的观察DSA引导下经皮胃造瘘术(PRG)治疗食管癌伴吞咽困难的效果。方法回顾性分析194例食管癌伴吞咽困难患者,按照是否接受PRG治疗分为PRG组(DSA引导下PRG后行肠内营养,n=80)和非PRG组(置入食管支架后经口饮食,n=114),比较2组患者术前及术后1个月时体质量指数(BMI)及血清白蛋白、前白蛋白、血红蛋白水平和并发症发生率。结果 2组患者术前BMI及血清白蛋白、前白蛋白、血红蛋白水平差异均无统计学意义(P均0.05),术后2组血清白蛋白、前白蛋白、血红蛋白水平均低于术前(P均0.05)。术后1个月PRG组血清白蛋白、前白蛋白及血红蛋白水平均高于非PRG组(P均0.05)。随访期内,PRG组吸入性肺炎、食管-气管瘘发生率低于非PRG组(P均0.05)。结论 DSA引导下PRG能够显著改善食管癌伴吞咽困难患者营养状态,减少吸入性肺炎、食管-气管瘘发生。     

可扩张支架置入联合新辅助化疗后行择期左半结肠根治术治疗梗阻性左半结肠癌

目的研究梗阻性左半结肠癌患者可扩张支架置入解除梗阻联合新辅助化疗(NC)后择期行左半结肠根治术的临床疗效。方法选取2018年1月至2019年3月两家医院治疗的梗阻性左半结肠癌患者70例,根据治疗方法不同分为两组,各35例。联合组患者在数字减影造影(DSA)引导下可扩张支架置入解除梗阻同期联合NC治疗后择期行左半结肠根治术,对照组患者不做NC治疗,其余治疗相同。采用软件SPSS23.0进行统计学分析。围术期指标等计量资料采用■表示,行独立t检验;并发症等计数资料采用χ~2检验,P0.05表示差异有统计学意义。结果两组患者支架置入并发症总发生率比较差异无统计学意义(14.3%vs. 20.0%,P=0.526),联合组患者新辅助化疗毒副反应轻,符合手术指征。联合组患者手术时间、术中出血量、术中造口数量、术后引流量、首次排便/进食时间、术后住院时间及术后并发症均显著优于对照组,组间差异有统计学意义(P0.05)。结论 DSA引导下可扩张支架置入术联合NC后择期行左半结肠根治术治疗梗阻性左半结肠癌,具有缩短手术时间、降低造口率和并发症发生率,有利于患者术后康复。     

ERCP放置胆道内支架行姑息性胆道引流术治疗低位恶性梗阻性黄疸的临床疗效分析

目的探究经内镜胰胆管造影(ERCP)支架植入胆道引流术应用于姑息性治疗低位恶性梗阻性黄疸的临床效果。方法对134例低位恶性梗阻性黄疸患者临床资料进行回顾性分析,行ERCP支架植入胆道引流术者纳入ERCP组(n=58),行经皮肝穿刺胆管引流术(PTCD)联合支架植入者纳入PTCD组(n=76)。比较术前及术后3d时,两组肝功能指标[总胆红素(TBil)、直接胆红素(DBil)、丙氨酸氨基转移酶(ALT)],分析两组围术期基本指标、近期并发症及总生存期差异。结果术后3d时,两组血清TBil、DBil、ALT水平均较术前有显著下降(P0.05),但组间同一时间比较均无统计学意义(P0.05)。两组手术成功率比较无统计学意义(P0.05),而ERCP组住院时间、治疗费用均明显少于PTCD组(P0.05)。两组出血、胆瘘、十二指肠穿孔、急性胰腺炎发生率比较均无统计学意义(P0.05),而ERCP组感染、电解质紊乱、支架移位/堵塞发生率明显低于PTCD组(P0.05)。两组中位总生存期比较无统计学意义(P0.05)。结论 ERCP支架植入胆道引流术治疗低位恶性梗阻性黄疸效果较突出,且相较于PTCD联合支架植入方案安全性更为理想,对加快患者术后康复有利。     

Different prognostic importance of elevated troponin I after percutaneous coronary intervention in acute coronary syndrome and stable angina pectoris

Objectives. To investigate the prognostic importance of cardiac troponin I (cTnI) elevation after percutaneous coronary intervention (PCI) in different clinical settings. Design. The study includes 238 patients presenting with acute coronary syndrome (ACS) and 194 patients with stable angina pectoris (SAP). The composite end point of death or hospitalization due to non-fatal myocardial infarction, repeated revascularization or unstable angina, was determined during one year of follow-up. Results. cTnI elevation after PCI was more frequent in ACS patients than SAP patients. ACS patients with cTnI elevation after PCI had significantly higher number of events than patients with unchanged cTnI status after PCI. SAP patients had generally lower event rate than ACS patients. The event rate was also significantly higher among ACS patients than SAP patients at comparable degrees of cTnI elevation after PCI. There was no difference in events among SAP patients with or without cTnI elevation after PCI. Conclusion. cTnI elevation after PCI predicts adverse outcome after one year in patients with ACS, but not in patients with SAP.     

Octogenarians died mainly of cardiovascular diseases five years after acute coronary syndrome

Abstract

Objective. A substantial part of deaths and readmissions in octogenarians with acute coronary syndrome (ACS) is assumed to be of non-cardiovascular causes. However, limited data on cause-specific long-term mortality and hospital readmissions are available. This study was aimed to investigate 5-year cause-specific deaths and re-hospitalizations as well as their prognostic predictors among octogenarians with ACS managed with percutaneous coronary intervention (PCI). Methods. A total of 181 octogenarians managed with PCI on ACS indication during 2006–2007 at Sahlgrenska University Hospital were included. The time-period was chosen to allow a follow-up period of five years. Results. All-cause 5-year mortality was 46%. Approximately 70% of deaths were cardiovascular. All-cause hospital readmissions were 71%. The majority of readmissions were due to non-cardiovascular diseases, 61% of all readmissions. Cox proportional-hazard regression analyses for cardiovascular mortality identified female sex and culprit lesion in left coronary arteries as independent predictors. Negative binomial regression models showed female sex and complications during index hospitalization as independent predictors of increased cardiovascular re-hospitalizations and prior smoking as independent predictor of increased non-cardiovascular re-hospitalizations. Conclusions. In an octogenarian cohort presented with ACS treated with PCI, cardiovascular diseases were the main causes of deaths, whereas non-cardiovascular diseases were the main causes of re-hospitalizations.     

Clinical use of optical coherence tomography to identify angiographic silent stent thrombosis

Objectives. Patients previously treated with coronary stents may suffer an acute coronary syndrome (ACS) without any evidence of thrombus formation on coronary angiography (CAG). This may be due to partial, nonocclusive stent thrombosis with microembolization. In this paper, we illustrate possible mechanisms both with optical coherence tomography (OCT) and histology. Design. We present two cases with ACS from very late stent thrombosis who have been previously treated with first-generation drug-eluting stents (DES). Results. The first patient had ACS 15 months after DES implantation. The angiogram (CAG) was near normal with slight peri-stent contrast staining. OCT revealed abnormalities including thrombus not visible on CAG. These are findings that may explain the ACS. The second patient had subclinical episodes with chest pain after DES implantation. The patient died from stent thrombosis in a DES. Postmortem histological examination of the coronary arteries revealed stent struts with little or no neointimal coverage, persistent peri-strut fibrin deposition, inflammatory cells, malapposition, and small luminal platelet-rich thrombi. Old spotty myocardial infarctions were found in the supplied territory possibly caused by earlier episodes of embolizing thrombus. Conclusions. In patients with previous implanted DES presenting with ACS, OCT may detect abnormalities and thrombus formation not visible on CAG. Such findings may impact the treatment strategy in these patients.     

超声二维应变评价冠状动脉介入治疗后左心室心肌收缩功能

目的应用超声二维应变（2DS）技术观察单支和多支冠状动脉病变心绞痛患者经皮冠状动脉介入治疗（PCI）后左心室局部心肌径向收缩功能改变有无差异。方法将63例心绞痛患者根据冠状动脉造影结果分为单支病变组（n=33）和多支病变组（n=30）,另选志愿者30名作为正常对照组,分别记录PCI术前、术后3个月及正常对照组左心室基底水平、乳头肌水平及心尖部水平18个室壁节段的二维灰阶图像。应用GE Echo PAC软件测量左心室短轴各室壁节段收缩期峰值径向应变。结果与正常对照组比较,单支病变组和多支病变组PCI术前大部分心肌节段和术后3个月部分心肌节段的左心室收缩期短轴峰值径向应变减低（P〈0.05）;单支病变组PCI术后3个月73.51%（136/185）心肌缺血节段恢复到正常水平,与多支病变组54.11%（158/292）差异有统计学意义（P〈0.01）。结论不同冠状动脉病变心绞痛患者PCI术后左心室径向收缩功能改善情况有所不同。     

冠状动脉支架植入术后患者320排减影冠状动脉CT血管造影图像质量的影响因素

目的 观察冠状动脉支架植入术后患者320排减影冠状动脉CT血管造影(Sub-CCTA)图像质量的影响因素。方法 前瞻性纳入40例冠状动脉支架植入术后冠心病患者,获取320排冠状动脉血管造影(CCTA)及Sub-CCTA,评估图像质量;观察患者基本信息、心率、心脏解剖结构参数和支架情况与Sub-CCTA图像质量的相关性,分析其影响因素。结果 Sub-CCTA图像质量评分与患者性别(r=-0.326,P<0.01)、平均心率(r=-0.328,P<0.01)、心脏左横径(r=0.319,P<0.01)及支架位置(r=0.410,P<0.01)相关。将上述因素纳入logistic分析,结果显示平均心率、心脏左横径及支架位置为Sub-CCTA图像质量的影响因素;基于上述各项建立的模型评估Sub-CCTA图像质量的敏感度、特异度、阳性预测值及阴性预测值分别为89.21%、63.34%、76.73%及81.00%。结论 冠状动脉支架植入术后患者平均心率、心脏左横径及支架位置为其Sub-CCTA图像质量的影响因素。     

直接上方入路与后外侧入路在高龄股骨颈骨折半髋置换术中的早期疗效比较

目的:对比分析直接上方入路(direct superior approach,DSA)与后外侧入路(posterior lateral approach,PLA)在高龄股骨颈骨折半髋置换术中的早期临床疗效。方法:回顾性分析2020年1月至 2021 年12月收治的72例接受半髋置换手术老年股骨颈骨折患者的临床资料,其中36例采用微创DSA入路,男10例,女26例,年龄(82.82±4.05)岁;36例采用传统PLA入路,男14例,女22例,年龄(82.79±3.21)岁。比较两组患者围手术期相关指标、不同时间点Harris评分。结果:DSA组手术时间(79.41±17.39) min,比PLA组(98.45±26.58) min更短;切口长度(8.33±2.69) cm,比PLA组(11.18±1.33) cm短;术中失血量(138.46±71.58) ml,比PLA组(173.51±87.17) ml更少;初次下地时间(3.04±0.95) d,比PLA组(4.52±1.10) d更早;住院时长(8.70±1.89) d,比PLA组(10.67±2.35) d短(P<0.05)。两组术前Harris评分差异无统计学意义(P>0.05),术后1个月DSA组Harris功能和总分高于PLA组(P<0.05),而术后12个月两组比较,差异无统计学意义(P>0.05)。结论:在半髋置换手术中,DSA入路较PLA入路在手术时间、术中出血量、切口长度、初次下地时间、住院时长以及术后1个月的Harris评分等临床指标更优,在促进高龄股骨颈骨折患者术后早期康复上具有明显优势。     

平均血小板体积联合Gensini评分预测ST段抬高型心肌梗死患者急诊经皮冠状动脉介入术近期预后

目的探讨平均血小板体积(MPV)联合Gensini评分预测急性ST段抬高型心肌梗死(STEMI)患者急诊经皮冠状动脉介入术(PCI)近期预后的价值。方法对186例接受急诊PCI治疗的STEMI患者,术前完善相关实验室检查、检测MPV,并根据冠状动脉造影检查结果进行Gensini评分;术后随访记录主要不良心血管事件(MACE)发生情况,并进行统计学分析。结果 186例中,PCI术后36例发生MACE(MACE组),150例未发生MACE(非MACE组)。2组间总胆固醇(TC)、血小板计数(Plt)、D-二聚体、N末端脑钠肽前体(NT-proBNP)、MPV、Gensini评分及病变累及冠状动脉3支血管的比例差异均有统计学意义(P均0.05)。MPV、Gensini评分、Plt、NT-proBNP及病变累及冠状动脉3支血管是STEMI患者PCI术后发生MACE的独立危险因素(P均0.05)。以MPV(阈值0.86 fl)联合Gensini评分(阈值82.17分)预测STEMI患者急诊PCI术后发生MACE的ROC曲线AUC为0.92[95%CI(0.87,0.98)],敏感度为92.70%,特异度为83.33%。结论 STEMI患者急诊PCI术后近期MACE的发生与术前MPV及Gensini评分有关;MPV联合Gensini评分可用于筛查PCI术后高危患者。     

冠状动脉瘤样扩张与弥漫性扩张的血管造影特征及心血管危险因素

目的比较冠状动脉瘤样扩张(CAA)与弥漫性扩张(CAE)血管造影特征及心血管危险因素的差异。方法回顾性分析16 778例冠状动脉造影图像。结果 211例存在冠状动脉扩张,包括132例CAA、79例CAE。CAA发病率、合并冠状动脉疾病发生率及其Gensini评分均明显高于CAE(P均0.05);CAA患者冠状动脉血管平均直径小于CAE (P0.05),心肌梗死溶栓(TIMI)血流分级均低于CAE(P均0.05)。血脂异常、吸烟及冠状动脉病家族史为CAA的独立危险因素(P均0.05)。结论 CAA与CAE在血管造影特征及心血管危险因素方面存在显著差异。     

急性冠脉综合征患者家庭-社区-医院协同化救治的效果

目的探讨家庭-社区-医院协同化救治急性冠脉综合征方案的实施及效果。方法将124例急性ST段抬高型心肌梗死患者分为干预组63例和对照组61例,分别实施家庭-社区-医院协同化救治和常规救治方案,比较两组入院方式、院前时间、院内救治时间及临床结局。结果两组入院方式、症状出现-首次医疗接触时间、入院-首次心电图时间、决定介入治疗-知情同意时间、知情同意-启动导管室时间、门球时间、症状出现-球囊扩张时间及临床结局除病死率外比较,差异有统计学意义(P<0.05,P<0.01)。结论家庭-社区-医院协同化救治方案,可以缩短急性ST段抬高型心肌梗死患者救治时间,降低平均住院日,减少住院费用,降低30 d内非计划全因再入院率。     

Myocardial infarction with non-obstructive thrombus validated by optical coherence tomography

Purpose. Coronary angiography provides no details on underlying pathology in acute coronary syndromes (ACS). Optical coherence tomography (OCT) can visualize coronary atherosclerosis, thrombus formation, and plaque rupture in patients with myocardial infarction (MI) where coronary angiography is unclear. Materials and methods. We present a case series containing six young patients with ACS, four of them due to non-obstructive thrombus, in whom the operators refrained from stent implantation despite an identifiable culprit lesion with OCT-validated thrombus formation. Results. The median age was 31.5 years. In four of these six patients, no invasive intervention was performed while the remaining two patients underwent thrombus aspiration and balloon angioplasty without stent implantation. Four patients were examined at the primary evaluation and all patients were examined by OCT between 3–5 days after initial examination. This short-term follow-up with OCT showed non-obstructive thrombus formation in all patients with varying degrees of thrombus resolution. No adverse cardiac events were reported after a median follow up of 5.5 months. Conclusions. OCT can visualize thrombus formation in young ACS patients with non-obstructive thrombus or following thrombus reduction by aspiration and balloon dilatation. These patients seems safely treated with a conservative medical approach rather than with stent implantation.