医学影像学在神经介入治疗中的应用

医学影像学是在X线的基础上发展起来的，目前包括X线、CT、MRI、DSA及超声，并已全部实现了数字化，而医学影像学的每一步发展，首先受益者是神经系统，加之各种介入器材的进步，因此才使神经介入治疗得到进一步的发展，可谓两者密不可分，相互促进，共同发展。     

4365例多支冠状动脉病变介入治疗近期疗效评价

目的分析经皮冠状动脉介入治疗(PCI)对多支冠状动脉病变患者的近期临床疗效。方法1995～2005年实施PCI的4365例多支冠状动脉病变住院患者,其中急性冠状动脉综合征(ACS)3833例(87.8%),稳定性心绞痛532例(12.2%)。ACS患者中发病30天内急性心肌梗死(AMI)1480例(38.6%)、不稳定心绞痛(UAP)2353例(61.4%)。评价PCI的成功率、合并症及住院期间的临床疗效。结果PCI的病例成功率为96.9%(4230/4365),靶病变成功率为98.8%(11185/11320)。住院期间病死率1.3%(全因死亡56例),术中病死率0.05%(2例),PCI相关并发症发生率7.2%(314/4365)。PCI术后存活出院患者心绞痛症状缓解率为96.2%(4147/4309),住院时间13±9天。结论PCI治疗多支冠状动脉病变成功率高,手术相关并发症和院内死亡率低,近期疗效好。     

经皮冠状动脉内支架植入术的应用研究

目的：探讨经皮冠状动脉（简称冠脉）内支架植入术治疗冠脉阻塞性病变的疗效。材料和方法：作者对１７例２０支冠状动脉病变成功地施行了冠脉内支架植入术，共植入支架２３枚。病变血管中，左冠前降支８支，回旋支２支和右冠状动脉１０支，分别植入支架９枚、２枚和１２枚。结果：术后经冠脉造影证实疗效满意，冠脉狭窄程度由术前８７．５５％±１２．２４％降至术后１３．１９％±１０．１３％，无并发症发生。结论：经皮冠状动脉内支架植入术成功率高，并发症低，对提高冠脉成形术疗效、预防再狭窄有一定优势。     

紫杉醇支架冠状动脉造影随访结果分析

目的 观察紫杉醇洗脱支架治疗冠心病的临床实际疗效。方法 297例患者接受紫杉醇洗脱支架治疗,均接受了临床随访,134例于支架置入术后5-15个月行冠状动脉造影随访。结果 冠状动脉造影随访时,晚期管腔丢失支架内显著高于支架近端边缘及支架远端边缘（分别为0.37、0.18和0.12mm）,再狭窄率为10．4％,以支架内弥漫性狭窄为主,再血管化率为6．7％。1例患者于支架置入后4个月发生猝死,发生率为0．34％。1例于支架置入后5天发生支架内亚急性血栓形成,发生率0．34％。晚期血栓形成2例（术后12-24个月）,主要心血管不良事件发生率1．35％。结论 紫杉醇药物洗脱支架对复杂冠脉病变有较好的疗效,能显著降低支架后再狭窄率及靶血管的再血管化率。     

外周支架在经皮冠状动脉介入治疗中的应用

目的评价PALMAZ BLUE.014外周支架(简称BLUE支架)在经皮冠状动脉介入治疗(PCI)中的疗效和安全性。方法经冠状动脉造影确诊5例冠心病患者,其参照血管直径≥5.0 mm(简称大冠状动脉),术中采用BLUE支架,共置入5枚,其中前降支3枚,右冠状动脉2枚。结果 5枚支架均顺利置入冠状动脉狭窄段,支架置入术后,残余狭窄≤10%。住院期间及术后随访6~12个月,所有患者均未出现胸痛或胸闷症状,未发生支架内血栓、心肌梗死及再次血管重建。术后6~12个月均复查冠状动脉造影,5枚支架内未见明显再狭窄。结论 BLUE支架用于PCI术,安全性好,疗效满意,可作为大冠状动脉冠心病患者PCI治疗的策略之一。     

抗肿瘤血管生成在介入治疗中的应用前景

血管生成是肿瘤生长和转移的关键步骤,众多血管生成抑制剂的研究正进入Ⅱ/Ⅲ期临床试验.基因治疗因持久、高效且副反应少而受到重视.在基因运送中,介入放射技术可发挥独特作用,而且,肿瘤介入治疗与抗血管生成相结合的策略已显出必要性.     

立体放射防护在介入治疗中的应用

目的:评价立体放射防护方法在介入治疗中的防护效果及其应用价值。方法:174例患者,介入治疗中分别采用床下铅橡胶帘、床边悬挂可活动式铅玻璃防护屏、医用铅防护服、铅防护围脖、铅防护眼镜及增加距离等X射线辐射防护措施,利用RAD60S个人报警剂量仪测量防护材料防护前后的X射线辐射剂量,并进行统计学分析。结果:铅玻璃防护屏、铅防护服、距离的增加可明显减少X射线辐射剂量,有显著性防护意义;X射线辐射剂量与透视和数字减影血管造影时间呈正相关,随着透视和减影造影时间的增加,医务人员和患者所接受的X射线辐射剂量明显增加。结论:立体防护在介入治疗中可有效减少X射线辐射剂量,保护医务人员和患者的身体健康。     

微导管在原发性肝癌介入治疗中的应用价值

目的:探讨微导管在原发性肝癌化疗性栓塞中的应用价值。方法:应用微导管对29例原发性肝癌患者行供血动脉超选择化疗栓塞术。结果:本组29例共行化疗性栓塞41次,术后血清AFP下降大于50%者24例(82.8%),肿瘤缩小>50%者6例(20.7%),肿瘤缩小在25%～50%者16例(55.2%),其余患者肿瘤体积无明显变化。术后肝功能损害轻微,无严重并发症。结论:微导管超选择插管治疗肝癌操作简单、方便,超选择成功率高,疗效好,术后并发症少,具有十分重要的临床应用价值。     

针刺内关穴对预防介入治疗术中不良反应的应用价值

目的:探讨针刺内关穴对预防介入治疗术中不良反应的应用价值。方法:将接受经动脉插管化疗栓塞术的患者,随机分为针刺组(31例)和对照组(32例)。针刺组在介入术前针刺右侧内关穴,得气后留针30～60min;对照组未采取预防措施。结果:针刺组、对照组介入术中不良反应发生率分别为19.4%,50.0%,2组比较差异有统计学意义(P<0.05)。结论:针刺内关穴能够有效预防介入治疗术中不良反应的发生,以保证介入操作的顺利进行。     

经皮经腔介入治疗技术在动脉狭窄性疾病中的应用

目的　探讨局部溶栓、经皮血管成形术 (percutaneoustranscatheteangioplasty ,PTA)和内支架置入术在治疗动脉狭窄或阻塞性疾病的作用。方法　 1987年 12月至 1997年 12月间 ,10 5例 115段动脉狭窄或阻塞接受了介入治疗。在 6 3段阻塞中 ,6 1段首选了局部溶栓 ;2段首选了PTA ;在 5 2段狭窄中 ,5 0段首选了PTA ;2段首选了内支架置入 ,这 2段为 2例病人 ,分别为胸腹主动脉交界处假性动脉瘤和腹主动脉夹层。结果　全组总的治疗成功率为 98 3% (113/ 115 ) ,PTA后内支架置入率为19 8% (16 / 81) ,并发症发生率为 1 7% (2 / 115 )。狭窄组和阻塞组的治疗成功率分别为 10 0 0 % (5 2 /5 2 )和 96 8% (6 1/ 6 3) ;PTA后内支架置入率分别为 14 0 % (7/ 5 0 )和 2 9 0 % (9/ 31) ;并发症发生率分别为 0 0 % (0 / 5 2 )和 3 2 % (2 / 6 3)。在阻塞组中 ,首选溶栓和未作溶栓的PTA后内支架置入率分别为2 4 1% (7/ 2 9)和 2 / 2 ;并发症发生率分别为 1 6 % (1/ 6 1)和 1/ 2。结论　经皮经腔技术治疗动脉狭窄性疾病是安全和有效的方法。合理应用局部溶栓、PTA和内支架置入术有助于提高疗效和减少并发症。     

周围动脉疾患合并冠心病的介入治疗

目的：探讨周围动脉疾患合并冠心病的介入治疗安全性和临床效果。方法：13例患者均施行了选择性冠状动态造影及胸或腹主动脉造影。18支周围动脉疾患中采用单纯球囊扩张术（PTA）11支,支架置入术5支,溶栓术2支。结果：血管造影发现肾动脉狭窄3例（4支）,髂动脉狭窄6例（7支）,右锁骨下动脉狭窄、右锁骨下动态伴双肾动脉狭窄、左锁骨下动脉狭窄伴左骼动脉阻塞、左股动脉阻塞各1例。合并冠心病左主干伴3支病变2例,3支病变9例,2支病变和单支病变各1例。技术成功17例,其中单纯球囊扩张术11支,支架置入术5支,溶栓术1支。临床治愈－改善12例。除1例冠状动脉造影后发生急性肾功能不全外,余无心脏并发症及与操作有关的并发症发生。     

冠状动脉介入治疗后心肌再灌注损伤与冠状动脉侧支循环关系的探讨

目的 :探讨冠心病患者经皮冠状动脉介入治疗 (PCI)前后血丙二醛 (MDA)、超氧化物歧化酶 (SOD)及左心室功能的变化及其与冠状动脉侧支循环的关系。方法 :选择接受PCI的 75例冠心病患者 ,根据冠状动脉造影结果分为无侧支循环组 (4 4例 )和侧支循环组 (31例 ) ,在术前及术后分别测定静脉血MDA、SOD水平 ,用超声心动图测定左心室射血分数(LVEF)及Tei指数。结果 :两组术后 2h静脉血MDA升高、SOD降低 (均P <0 .0 1) ,术后 2 4h无侧支循环组MDA回降、SOD上升 ,与术前比较仍有显著性差异 (P <0 .0 1) ;两组间PCI后MDA、SOD及Tei指数有显著性差异 (P <0 .0 5 ,P <0 0 1)。结论 :冠状动脉侧支循环能减轻冠心病患者PCI治疗后的心肌再灌注损伤。     

64层螺旋CT检测冠状动脉粥样硬化斑块的初步研究

目的对比冠状动脉内超声（IVUS）检查的结果，评价64层螺旋CT冠状动脉成像（MSCTCA）在显示和分析冠状动脉粥样硬化病变方面的可行性和准确性。方法对15例可疑冠心病的患者进行64层MSCTCA检查，获取相关的数据，应用后处理技术对冠状动脉粥样斑块进行评估分析，并以3周内实施的IVUS结果为金标准进行对比。同时，对2种方法所获得的计量资料（即：血管段某一点的血管腔内面积、血管截面积）进行对比分析，获得直线回归方程（Y：IVUS值，X：64层MSCT值）。结果所有病例可用于评估的86个无明显狭窄冠状动脉样本中，IVUS显示有斑块病变的血管段为38段，64层MSCTA显示36段，2段诊断为正常血管。64层MSCTA对出现粥样硬化斑块节段诊断的敏感性为94．7％，特异性为100．0％，总符合率为97．7％，误诊率为0，漏诊率为5．3％，阳性预测值100．0％，阴性预测值96．0％。经Kappa检验，Kappa值为0．953，P〈0．05。直线回归方程对于2种方法所获得的管腔内面积：Y=0．817＋0．832X，P〈0．01；血管的截面积：Y=-0．331＋1．019X，P〈0．01。结论64层MSCTCA在显示冠状动脉粥样硬化斑块病变时，能较为清晰地显示管壁斑块病变的构成情况，对于病变的类型及严重程度的评估比较准确和客观。对于临床怀疑冠心病患者的门诊筛查和初步诊断，具有较好的可行性和准确性。     

Patient radiation exposure during coronary angiography and intervention

Purpose: To prospectively register fluoroscopic and cine times in a random fashion, and to measure patient radiation exposure from routine coronary angiography and coronary balloon angioplasty. We also evaluated an optional dose reduction system used during interventions.Material and Methods: The incident radiation to the patient was measured as kerma area product (KAP) in Gycm², obtained from an ionisation chamber mounted on the undercouch tube during 65 coronary angiography procedures and another 53 percutaneous transluminal coronary angioplasties (including 29 stent procedures), mostly directly following complete coronary angiography.Results and Conclusion: The values from coronary angiography were comparable to other reports with a mean fluoroscopic time of 4.4 min and a mean KAP value of 62.6 Gycm². The corresponding figures from coronary balloon angioplasty without stenting were lower than otherwise reported, with 8.2 min and 47.9 Gycm², respectively. The use of coronary stents did prolong the mean fluoroscopic time (10.5 min) but did not significantly enhance the patient mean radiation dose (51.4 Gycm²). The dose reduction technique resulted in a significant KAP value reduction of 57%. In conclusion, with regard to radiation exposure, coronary angiography and balloon angioplasty are considered safe procedures.     

Radiation dose optimization in coronary angiography and percutaneous coronary intervention (PCI). II. Clinical evaluation

In a previous part of this study, the fluoroscopy dose rate was reduced in a cardiac catheterization laboratory. The objectives of the present study were to evaluate the effects in a clinical population undergoing percutaneous coronary intervention (PCI) of the dose-reducing measures detailed previously. Kerma area-product (KAP) values were first recorded for 154 patients undergoing PCI. Then, the fluoroscopy KAP rate was reduced from 44 to 16 mGy cm²/s by increasing filtration and reducing the image intensifier dose request. After this optimization, KAP was recorded for another 138 PCI procedures. After adjustment for differing proportions of combined procedures (coronary angiography+PCI), the total KAP was reduced to 67% of the original value with a 95% confidence interval from 57 to 78%, statistically significant. The mean total KAP values were 93.6 Gy cm² before and 69.1 Gy cm² after optimization. The KAP for digital acquisition did not change significantly. It is possible to make a large dose reduction in PCI by reducing the fluoroscopy dose rate. This dose reduction is beneficial for both patients and staff. Electronic Publication     

Radiation dose optimization in coronary angiography and percutaneous coronary intervention (PCI). I. Experimental studies

The objectives of this study were to evaluate the influence on image quality and dose to the patient and operator of various equipment settings for percutaneous coronary intervention (PCI), and to optimize the set-up. With an Alderson phantom, different settings, such as projection, protective screens, filtration, image intensifier size and collimation, were evaluated. Kerma-area product (KAP) was recorded as a measure of patient dose and scattered radiation was measured with an ionization chamber. Effective dose for a standardized PCI procedure was measured with thermoluminescent dosimeters inside the phantom. Image quality was evaluated with a contrast-detail phantom. Based on these findings, the equipment set-up was optimized to a low fluoroscopy dose rate with a sufficient image quality. Several operating parameters affected dose, particularly scattered radiation. The optimization reduced the fluoroscopy KAP rate from 44 to 16 mGy cm(2)/s using 15 cm of acrylic. The effective dose was reduced from 13 to 4.6 mSv for a standardized PCI procedure. Radiation dose to patient and operator in PCI is heavily dependent on both equipment set-up and operating parameters which can be influenced by the operator. With a careful optimization, a large reduction of radiation dose is possible.     

64层螺旋CT心脏冠状动脉检查质量控制和扫描参数优化研究

目的 分析影响64层螺旋CT冠状动脉成像质量的各种因素，对扫描方法进行质量控制和优化。方法 对78例怀疑冠心病或冠心病复查患者进行64层螺旋CT冠状动脉检查，回顾性分析成像质量，探讨心率替代（override）功能的应用价值，分组分析扇区选择与心率对图像质量的影响以及心率与对比剂增强效果的相关性，优化扫描参数。结果 （1）心率替代功能的合理使用可以提高CT冠状动脉的成像质量；（2）心率70次／min以下的单扇区重组图像质量可以满足要求；70-79次／min之间的心率，选择双扇区重组图像的评分要高于单扇区；（3）预测对比剂总量70m1组的平均心率为60．7次／min，65．7％（23／35）的患者增强药量稍显不足；总量为60ml组的平均心率为71．1次／min，52．9％（18／34）的患者增强效果良好。结论 根据心率选择心率替代功能的使用，适当的扇区扫描模式和对比剂总量可以提高图像质量和冠状动脉检查的可靠性。     

基于冠状动脉CT血管成像的斑块定量分析及其与心肌缺血损伤的相关性研究

目的使用第三代双源冠状动脉CT血管成像(CCTA)及斑块定量技术分析冠状动脉斑块成分特征,探讨其与心肌缺血的相关性,并评价各项定量特征在评估心肌缺血中的价值。方法回顾性分析2018年6月至2019年9月于山东省立医院行CCTA和冠状动脉造影(ICA)检查的742例初诊冠心病患者,纳入ICA证实存在单支病变局限性狭窄的患者109例。将患者根据心肌酶升高伴心脏室壁运动不良和心肌酶及心脏室壁运动正常分为心肌缺血性损伤组(n=75)和心肌无缺血损伤组(n=34)。测量斑块的特征参数,包括斑块长度、斑块总体积、钙化斑块体积、脂质斑块体积、纤维斑块体积、斑块负荷、最小管腔面积、最大面积狭窄率(MAS%)、重塑指数、偏心指数、"餐巾纸环"征、斑点状钙化。采用卡方检验、Mann-Whitney U非参数检验、两独立样本t检验、多因素logistic回归及DeLong检验进行统计学分析。结果在冠状动脉管腔狭窄定量指标方面,心肌缺血损伤组的MAS%为85.00%(80.00%,92.00%),心肌无缺血损伤组的MAS%为63.00%(60.00%,65.00%),两组间差异具有统计学意义(Z=-4.32,P=0.001)。在斑块成分定量指标方面,心肌缺血损伤组的斑块总体积(TPV)、斑块负荷(TPB)、纤维成分斑块体积(FPV)、脂质成分斑块体积(LPV)、脂质成分斑块占比(LPR)分别为150.13(104.44,202.20)mm^3、75.67%±9.90%、95.73(66.57,134.23)mm^3、32.18(18.93,54.55)mm^3、25.13%±13.71%,心肌无缺血损伤组的相应指标分别为109.94(79.39,121.67)mm^3、65.37%±6.94%、67.35(57.67,90.11)mm^3、16.64(13.26,24.73)mm^3、18.44%±7.09%,两组间差异具有统计学意义(Z=-2.59,P=0.010;t=3.11,P=0.003;Z=-2.16,P=0.031;Z=-2.18,P=0.029;t=2.19,P=0.037)。Logistic回归分析显示,MAS%(OR=1.55,P=0.021)是心肌缺血性损伤的独立预测因子。MAS%、LPV、LPR、TPV、TPB、FPV的ROC曲线下面积分别为0.84、0.82、0.77、0.72、0.74、0.67,差异均具有统计学意义(P<0.05)。结论在CCTA斑块定量分析中,MAS%、TPV、TPB、FPV、LPV、LPR是影响心肌缺血性损伤的主要因素;MAS%是心肌缺血性损伤的独立预测因子;且MAS%及LPV诊断心肌缺血的准确性更高。     

Role of 320-slice multislice computed tomography coronary angiography in the assessment of coronary artery stenosis

Objective

To evaluate the effectiveness of the multislice CT coronary angiography, as a non-invasive imaging tool in assessment of coronary artery stenosis.

Patients and methods

The study included 50 patients who were referred for MSCT coronary angiography followed by catheter coronary angiography. Patients with previous coronary bypass grafts and those with coronary stents were excluded. History of contrast allergy, renal impairment and severe chest conditions were exclusion criteria. The coronary angiographic CT studies were performed using a 320 CT scanner. The catheter coronary angiographic studies were performed via femoral arterial puncture. The results of CT angiography were compared with the gold standard catheter angiography.

Results

The positive predictive value and negative predictive value of MSCT coronary angiography in detection of coronary artery stenosis were 94% and 100%, respectively.

Conclusion

In conclusion, MSCT coronary angiography is a very helpful and rapid non-invasive coronary imaging modality that was able to detect and grade coronary artery stenosis better than other noninvasive examinations used to detect CAD, such as exercise stress testing. Due to its very high negative predictive value, it may eliminate the need for invasive coronary procedures in the presence of normal coronary imaging.