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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2019, Vol. 16 ›› Issue (10) : 762 -767. doi: 10.3877/cma.j.issn.1672-6448.2019.10.009

所属专题： 文献；

外周血管超声影像学

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
王力力1, 华扬1,†(), 贾凌云1, 刘玉梅1, 周瑛华1, 李秋萍1, 唐煜1   
  1. 1. 100053　北京，首都医科大学宣武医院血管超声诊断科
  • 收稿日期:2019-06-12 出版日期:2019-10-01
  • 通信作者: 华扬

Incidence and influencing factors of restenosis after subclavian artery stent implantation

Lili Wang1, Yang Hua1,†(), Lingyun Jia1, Yumei Liu1, Yinghua Zhou1, Qiuping Li1, Yu Tang1   

  1. 1. Department of Vascular Ultrasonagraphy, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
  • Received:2019-06-12 Published:2019-10-01
  • Corresponding author: Yang Hua
  • About author:
    Corresponding author: Hua Yang, Email:
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引用本文：

王力力, 华扬, 贾凌云, 刘玉梅, 周瑛华, 李秋萍, 唐煜. 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[J/OL]. 中华医学超声杂志（电子版）, 2019, 16(10): 762-767.

Lili Wang, Yang Hua, Lingyun Jia, Yumei Liu, Yinghua Zhou, Qiuping Li, Yu Tang. Incidence and influencing factors of restenosis after subclavian artery stent implantation[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2019, 16(10): 762-767.

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。

关键词: 超声检查，多普勒，彩色, 锁骨下动脉, 支架, 再狭窄
Objectives

To 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.

Methods

From 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.

Results

The 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.

Conclusion

Long 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.

Key words: Ultrasonography, Doppler, color, Subclavian artery, Stent, Restenosis
表1 SAS术后无再狭窄组与再狭窄组患者一般临床资料比较［例（%）］
临床资料 无再狭窄组（141例） 再狭窄组（31例） 统计值 P值
年龄（岁，±s） 65.9±8.1 67.8±6.9 t=1.177 0.241
男性 101（71.6） 28（90.3） χ2=4.735 0.030
高血压 77（54.6） 15（48.4） χ2=0.396 0.529
冠心病 21（14.9） 3（9.7） χ2=0.576 0.448
糖尿病 43（30.5） 11（35.5） χ2=0.293 0.588
高血脂 43（30.5） 14（45.2） χ2=2.467 0.116
吸烟 88（62.4） 25（80.6） χ2=3.749 0.053
图1 右侧锁骨下动脉重度狭窄患者支架置入术前、术后超声及数字减影血管造影（DSA）图像。图a~c为支架置入术前图像，其中图a为颈动脉超声二维图像示右侧锁骨下动脉斑块，局部内径变细，残余内径1.9 mm（箭头所示）；图b为彩色多普勒血流显像示右侧锁骨下动脉血流充盈不全，局部血流束变细，狭窄段收缩期峰值流速为408 cm/s，舒张期末流速为87 cm/s；图c为DSA示右侧锁骨下动脉起始段重度狭窄（箭头所示）。图d~f为支架置入术后1周复查图像，其中图d为颈动脉超声二维图像示支架长度19.1 mm，支架内径5.6 mm（箭头所示）；图e为彩色多普勒血流显像示右侧锁骨下动脉起始段血流充盈改善，流速及频谱形态恢复正常；图f为DSA示支架置入术后管腔恢复正常（箭头所示）
表2 SAS术后再狭窄组与无再狭窄组狭窄段PSV随访变化分析（cm/s，±s）
组别 例数 PSV测值 F值 P值
术前 术后1周 术后3个月 术后6个月 术后12个月
再狭窄组 31 440.4±193.9 231.0±67.0a 285.3±88.3a 331.2±107.7ab 363.7±141.4b 11.685 <0.001
无再狭窄组 141 436.9±163.8 166.9±46.0a 165.8±45.6a 183.1±45.0a 187.7±49.4a 262.5 <0.001
t值 ? -0.104 -6.417 -10.525 -11.339 -11.926 ? ?
P值 ? 0.917 <0.001 <0.001 <0.001 <0.001 ? ?
表3 影响锁骨下动脉支架术后再狭窄的单因素分析
因素 无再狭窄组（141例） 再狭窄组（31例） 统计值 P值
SA狭窄侧别［左侧，例（%）］ 96（68.1） 22（71.0） χ2=0.098 0.754
SA狭窄长度≥2 cm ［例（%）］ 47（33.3） 19（61.3） χ2=8.399 0.004
支架类型［例（%）］ ? ? χ2=11.187 0.001
? 球囊扩张式支架 125（88.7） 20（64.5） ? ?
? 自膨式支架 16（11.3） 11（35.5） ? ?
术后测量支架长度（cm，±s） 2.7±0.8 3.0±0.7 t=2.106 0.037
术后测量支架内径（cm，±s） 0.6±0.1 0.54±0.12 t=3.065 0.003
支架置入前长度（cm，±s） 2.4±0.7 2.9±0.7 t=3.252 0.001
支架置入前内径（cm，±s） 0.86±0.05 0.86±0.06 t=0.154 0.877
残余狭窄［例（%）］ 2（1.4） 6（19.4） χ2=18.435 0.000
表4 影响锁骨下动脉支架术后再狭窄的多因素Logistic回归分析
因素 β SE Waldχ2 P OR 95%CI
SA狭窄长度≥2 cm 1.292 0.483 7.160 0.007 3.640 1.413~9.379
残余狭窄 3.085 1.167 6.981 0.008 21.860 2.218~215.479
球囊扩张式支架 1.011 0.668 2.288 0.130 2.747 0.742~10.178
支架置入前长度 0.030 0.054 0.311 0.577 1.031 0.927~1.146
术后测量支架长度 0.062 0.419 0.022 0.882 1.064 0.468~2.418
术后测量支架内径 -0.122 0.285 0.184 0.668 0.885 0.506~1.548
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