锁骨下动脉支架置入术后再狭窄的发生率及其影响因素分析

目的应用彩色多普勒超声分析锁骨下动脉重度狭窄或闭塞性病变患者支架置入术后再狭窄的发生率及其影响因素。 方法回顾性纳入2016年1月至2018年4月于首都医科大学宣武医院经彩色多普勒血流显像（CDFI）筛查及数字减影血管造影（DSA）证实的锁骨下动脉重度狭窄或闭塞患者共172例，所有患者均行锁骨下动脉支架（SAS）介入治疗。根据SAS术后随访检查结果将172例患者分为再狭窄组（31例）与无再狭窄组（141例）。于术前、术后1周、3、6、12个月采用CDFI检测记录狭窄病变的内径、长度，狭窄段及狭窄以远段的收缩期峰值流速（PSV₁、PSV₂）、舒张期末流速（EDV）。分析SAS术后再狭窄发生率，比较2组患者术前与术后各随访时间段血流动力学参数变化，应用单因素及多因素Logistic回归方法分析SAS术后再狭窄的影响因素。 结果172例患者支架置入成功率为95.3%（164/172），术后12个月再狭窄检出率为18.0%（31/172）。与术前相比，术后锁骨下动脉内径明显增宽［（1.5±0.7）mm vs（5.9±1.0）mm，t=49.384，P<0.001］，狭窄段PSV₁较术前明显改善［（437.7±169.5）cm/s vs（178.5±56.0）cm/s，t=19.905，P<0.001］，狭窄以远段PSV₂明显升高［（72.5±31.3）cm/s vs（124.3±34.8）cm/s，t=-15.267，P<0.001］。再狭窄组PSV₁在术后3、6、12个月逐渐升高，在术后12个月时PSV₁平均值达最高（363.7±141.4）cm/s，与术前比较无显著性差异（P>0.05）；无再狭窄组的PSV₁术后3、6、12个月与术后1周比较，差异均无统计学意义（P均>0.05）。狭窄病变长度≥2 cm（OR=3.640，95%CI：1.413~9.379，P<0.01）、支架内残余狭窄（OR=21.860，95%CI：2.218~215.479，P<0.01）是SAS术后再狭窄的独立危险因素。 结论锁骨下动脉长段病变、术后残余狭窄是影响支架术后再狭窄的重要因素。CDFI能够客观、准确评价SAS术前、术后血流动力学变化，并早期发现再狭窄，对提高支架远期疗效具有重要的临床价值。

Incidence and influencing factors of restenosis after subclavian artery stent implantation

ObjectivesTo detect the incidence of in-stent restenosis and the influencing factors in patients after subclavian artery stenting (SAS) for severe stenosis or occlusion by ultrasonography. MethodsFrom January 2016 to April 2018, a total of 172 patients with severe subclavian artery stenosis or occlusion screened by color Doppler flow imagining (CDFI) and confirmed with digital subtraction angiography (DSA) at Xuanwu Hospital were retrospectively recruited. All patients received interventional SAS treatment. According to SAS follow-up via ultrasound, the patients were divided into either a restenosis group (31 patients) or a non-restenosis group (141 patients). CDFI was taken both before and after stent implantation (1 week, 3 months, 6 months, and 12 months after stenting). The residual diameter, length of stenosis, peak systolic velocity (PSV₁ and PSV₂), and end diastolic velocity (EDV) at the lesion and distal to the stenosis were recorded. The incidence of restenosis after SAS was analyzed, and the hemodynamic changes before and after the operation were compared between the two groups. Univariate and multivariate Logistic regression analyses were performed to identify the influencing factors of in-stent restenosis. ResultsThe success rate of stent implantation was 95.3% (164/172), while the incidence of in-stent restenosis was 18.0% (31/172) 12 months after surgery. After SAS, the diameter was increased [(1.5±0.7) mm vs (5.9±1.0) mm, t=49.384, P<0.001], PSV₁ at the lesion site was decreased [(437.7±169.5) cm/s vs (178.5±56.0) cm/s, t=19.905, P<0.001], while PSV₂ distal to the stenosis was significantly increased [(72.5±31.3) cm/s vs (124.3±34.8) cm/s, t=-15.267, P<0.001]. During the follow-up period, the PSV₁ was gradually increased in the restenosis group. At the end of 12 months after SAS, the mean value of PSV1 reached the peak [(363.7±141.4) cm/s], which had no difference compared to the preoperative PSV₁ (P>0.05), whereas there was no difference in PSV₁ at 3, 6, and 12 months after surgery compared with that at 1 week after surgery in the non-restenosis group (P>0.05). Long-segment lesions (range≥2 cm, OR=3.640, 95%CI: 1.413~9.379, P<0.01) and residual stenosis (OR=21.860, 95%CI: 2.218~215.479, P<0.01) were independent risk factors for SAS restenosis. ConclusionLong lesion range of the subclavian artery and residual stenosis are important factors affecting stenting restenosis. CDFI can objectively and accurately evaluate hemodynamic changes before and after SAS, which is helpful to early prevention of restenosis and improving long-term efficacy.