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俞泓, 张蛟, 贾小伟, 李屹, 安军, 刘惠亮. 血栓抽吸对急性STEMI患者PCI术后组织突出的影响[J]. 武警医学, 2018,29(6): 611-614
YU Hong, ZHANG Jiao, JIA Xiaowei, LI Yi, AN Jun, LIU Huiliang. Effect of thrombus aspiration on protrusion of tissue in patients with acute STEMI after percutaneous coronary intervention[J]. Medical Journal of the Chinese People's Armed Police Forces, 2018,29(6): 611-614  

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Copyright©2018, 《武警医学》编辑部
血栓抽吸对急性STEMI患者PCI术后组织突出的影响
俞泓1, 张蛟2, 贾小伟3, 李屹2, 安军4, 刘惠亮1
1.100039 北京,武警部队心脏病研究所
2. 100039 北京,武警总医院心内科
3.100039 北京,武警总医院急诊科
4.100039 北京,武警总医院内分泌科
通讯作者：刘惠亮, E-mail:lhl518@vip.sina.com

作者简介:俞 泓,硕士研究生,医师。

收稿日期: 2017-12-22
摘要

目的 探讨血栓抽吸对ST段抬高型心肌梗死(STEMI)患者PCI术后组织突出的影响。方法 选择2014-02至2017-08接受直接PCI并行OCT检查的106例STEMI患者,包含血栓抽吸-PCI组( n=69)和标准PCI组( n=37)。在直接PCI术后立即进行OCT评估,以评估支架段的病变形态。结果 血栓抽吸-PCI组与标准PCI组最小支架面积相似[7.3(IQR:5.8~8.5) vs 7.3(IQR:6.0~8.7)mm2, P=0.818]。最大组织突出面积[0.6(IQR:0.2~1.1) vs 1.2(IQR:0.8~1.6)mm2, P<0.001],平均组织突出面积[0.1(IQR:0.1~0.2) vs 0.4(IQR :0.2~0.7)mm2, P<0.001],与标准PCI组相比,血栓抽吸-PCI组上述值明显较小。与标准PCI组相比,血栓抽吸-PCI组的最小管腔面积明显更大[7.1(IQR:6.2~8.0) vs 5.9(IQR:4.9~6.8)mm2, P<0.01]。结论 与标准PCI组相比,STEMI患者行血管成形术前血栓抽吸组的组织突出面积明显减小,管腔面积较大。直接PCI术中的血栓抽吸有利于影响支架区段的病变形态,因此可作为直接PCI术中一种有效的辅助治疗。

关键词: 急性心肌梗死; 光学相干断层成像; 经皮冠状动脉介入治疗; 支架; 血栓
中图分类号:R542.22
Effect of thrombus aspiration on protrusion of tissue in patients with acute STEMI after percutaneous coronary intervention
YU Hong1, ZHANG Jiao2, JIA Xiaowei3, LI Yi2, AN Jun4, LIU Huiliang1
1.Institute of Cardiology of Chinese People’s Armed Police Force,Beijing 100039,China;
2. Department of Cardiology, General Hospital of Chinese People’s Armed Police Force,Beijing 100039,China ;
3. Department of Emergency, General Hospital of Chinese People’s Armed Police Force,Beijing 100039,China ;
4. Department of Endocrinology,General Hospital of Chinese People’s Armed Police Force,Beijing 100039,China;
Abstract

Objective To assess the effect of thrombus aspiration by optical coherence tomography (OCT) before angioplasty on poststenting tissue protrusion in patients undergoing a primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).Methods A total of 106 patients with STEMI who had undergone primary PCI with concurrent OCT were examined in this study,including 69 recipients of thrombus aspiration- PCI and 37 recipients of standard PCI. OCT was performed immediately after primary PCI to assess lesion morphology in the stented segment.Results The minimum stent area was similar between the thrombus aspiration -PCI group and the standard PCI group [7.3 (IQR: 5.8-8.5) vs 7.3 (IQR: 6.0-8.7)mm2, P=0.818]. The maximum tissue protrusion area was[0.6 (IQR: 0.2-1.1) vs 1.2(IQR: 0.8-1.6) mm2, P<0.001], while the mean tissue protrusion area was[0.1 (IQR: 0.1-0.2) vs 0.4 (IQR: 0.2-0.7) mm2, P<0.001], both of which were significantly smaller in the thrombus aspiration -PCI group than in the standard PCI group. The minimum lumen area was significantly greater in the thrombus aspiration - PCI group than in the standard PCI group [7.1 (IQR: 6.2-8.0 vs 5.9 (IQR: 4.9-6.8) mm2, P<0.01].Conclusions Thrombus aspiration before angioplasty in patients with STEMI is associated with significantly smaller tissue protrusion areas and larger lumen poststenting areas than standard PCI. Thrombus aspiration in the primary PCI group favors the lesion morphology in the stent segment and therefore may be a useful adjuvant therapy for primary PCI.

Keyword: acute myocardial infarction; optical coherence tomography; percutaneous coronary intervention; stents; thrombus

目前, 经皮冠状动脉介入(percutaneous coronary intervention, PCI)已经成为急性ST段抬高型心肌梗死(ST-elevation myocardial infarction, STEMI)的首选治疗方法, 并对冠状动脉血流的再恢复极为有效[1, 2, 3]。直接PCI后的主要并发症与冠状动脉血栓相关, 远端血栓栓塞与心肌再灌注损伤、梗死面积及预后不良有关[4, 5]。支架内突出的残留血栓与将来的主要不良心血管事件如支架血栓的形成有关[6]。血栓抽吸是直接PCI的一种有效辅助治疗。有研究表明, 在直接PCI术前行血栓抽吸可以保留血管完整性, 避免血栓栓塞, 降低梗死面积[5, 7, 8, 9]。然而, 目前国内尚未见血管成形术之前行血栓抽吸预防后期组织突出疗效的相关研究。本研究旨在探讨血栓抽吸对STEMI患者PCI术后组织突出的影响, 为临床诊治提供依据。

1 对象与方法
1.1 对象

选择2014-02至2017-08的武警总医院OCT登记册中, 直接PCI术后立即进行OCT检查的106例STEMI患者。入选标准:(1)持续胸痛至少30 min; (2)症状发作后6 h内到达医院; (3)12导联心电图中的两个或更多连续导联中ST段抬高至少0.1 mV; (4)心肌酶升高, 血清肌酸激酶同工酶(CK-MB)水平比正常值高两倍以上。所有患者的冠状动脉中发生了与新生心肌梗死相关的病变, 并植入了药物洗脱支架。OCT成像的排除标准是心源性休克、慢性肾衰竭或极度曲折的血管。

1.2 方法

PCI术前患者服用阿司匹林(300 mg)及氯吡格雷(600 mg负荷量)。所有患者术前均没有接受过溶栓治疗, 对于存在血栓负荷较重、支架血栓的患者, 临床医师在征求家属知情同意后执行血栓抽吸。标准 PCI组不行血栓抽吸, 只进行球囊扩张和支架置入。血栓抽吸- PCI组在PCI术前先行血栓抽吸, 其后操作与标准PCI组患者相同。

1.3 OCT图像分析

在直接PCI术后, 立即使用C7-XR系统(圣犹达, 美国)进行OCT。自动校准后, 成像导管在冠状动脉内给用硝酸甘油(100 μ g)后沿0.014英寸(1英寸=2.54 cm)导引导丝送至病变部位。手推对比剂清除区域内的血液, 自动回撤 OCT 导管获得图像, 要求 OCT 采集到支架近端及远端边界外侧5 mm距离的图像, 成像要清晰。组织脱垂定义为组织经支架小梁突出管腔中> 500 μ m[10]。组织突出被定义为在OCT图像之间连接相邻支柱的圆弧内延伸的支架支柱之间的组织脱垂。在支架部分的1 mm的纵向间隔处测量支架的横截面积、管腔(支架内管腔+支架外官腔)和组织突出面积[11]。图像测量内容包括:最小支架面积、最小管腔面积、最大组织突出面积、平均组织突出面积。

1.4 统计学处理

采用SPSS16.0统计软件进行分析。计量资料用中位数和四分位数范围(IQR)表示, 符合正态分布采用t检验, 不符合正态分布则用秩和检验; 计数资料采用百分比表示, 采用χ 2检验。P< 0.05表示差异具有统计学意义。

2 结 果
2.1 一般资料

106例中, 69例在血管成形术之前进行了成功的血栓抽吸(血栓抽吸-PCI组), 37例接受无血栓抽吸的PCI(标准PCI组)。血栓抽吸-PCI组与标准PCI组之间的年龄、性别和心血管危险因素之间的差异均无统计学意义(P> 0.05, 表1)。

表1 两组急性STEMI患者临床一般资料比较(n; %)
2.2 PCI相关情况

血栓抽吸-PCI组与标准PCI组之间的梗死相关血管、穿刺入径、置入支架数量、PCI后远端栓塞结果比较, 差异均无统计学意义。但与标准PCI相比, 血栓抽吸-PCI组的慢血流及无复流发生率明显更低, 差异具有统计学意义(P< 0.05, 表2)。

表2 两组急性STEMI血管造影结果和PCI程序特征(n; %)
2.3 治疗效果

血栓抽吸-PCI组与标准PCI组最小支架面积相似(P= 0.818)。与标准PCI组相比, 血栓抽吸-PCI组的最小管腔面积更大(P< 0.001)。血栓抽吸-PCI组最大组织突出面积、平均组织突出面积均小于标准PCI组, 差异均具有统计学意义(P< 0.05, 表3)。

表3 两组PCI术后立即进行OCT检查 中位数(四分位数范围)
3 讨 论

给STEMI患者病变血管处置入支架时, 部分血栓会通过金属支架网突出到内腔中并限制冠状动脉血流。目前有一项血管内超声(intravenousultrasound, IVUS)研究报告了STEMI患者支架置入术后组织突出的临床结果。该研究显示, IVUS记录的组织突出与早期支架内血栓形成有关, 但与支架内再狭窄无关[6]。OCT与IVUS相类似, 而OCT的轴向和横向分辨率分别为10~20 μ m和70~90 μ m, 因而可以更精确地识别冠状动脉内的血栓[12]。因此, 我们可以使用OCT来评估血管成形术前血栓抽吸对STEMI患者行直接PCI后组织突出的影响。

TASTE(thrombus aspiration in ST-elevation in myocardial infarction in Scandanavia)试验是第一个评估AMI中常规使用血栓抽吸术的疗效及其对病死率的影响, 其研究显示, 血栓抽吸后30 d内对病死率、支架血栓形成率、靶血管血运重建率、卒中率或神经并发症方面的益处不大[13, 14, 15]。尽管2017 ESC STEMI指南不推荐直接PCI时常规行血栓抽吸, 但同时指出, 在导引导丝或球囊通过后, 若残余血栓负荷较大, 仍可考虑血栓抽吸[16]。2017年6月发布的中国《冠状动脉血栓抽吸临床应用专家共识》同样指出, STEMI患者直接PCI时不推荐常规血栓抽吸, 但对于血栓负荷较重、TIMI血流 0~1级、血管直径或供血范围较大、支架血栓及含有大量新鲜血栓的静脉桥血管病变患者, 仍可考虑使用[17]。血栓抽吸通过负压抽吸冠状动脉内梗死相关血栓, 使冠状动脉内的血栓负荷降低, 有利于溶栓药物的治疗, 降低再梗死的发生率[18]。

本研究发现, 与标准PCI组相比, 血栓抽吸-PCI组的最大组织突出面积及平均组织突出面积明显较小。表明血栓抽吸可以减少组织突出面积, 并同时增加了支架置入后的血流量。因此, 血栓抽吸能够降低心肌梗死患者术后慢血流和无复流的发生率, 从而改善患者的血流再灌注和心功能。这与既往研究结果相一致[19, 20, 21]。但是, 血栓抽吸能否降低患者主要不良心血管事件的发生率和病死率仍需进一步研究, 这也是本研究局限所在, 未能将患者术后的心梗再发率及生存率等随访资料纳入研究指标中。因此, 需要进一步随访研究来评估血栓抽吸后组织突出面积的减少是否直接与STEMI患者行直接PCI后临床结果的改善相关。

综上所述, 本研究通过OCT评估STEMI患者血管成形术前的血栓抽吸与标准PCI术后相比, 前者术后慢血流和无复流的发生率更低, 组织突出面积明显减小, 腔内面积较大。因此血栓抽吸可作为直接PCI术中一种有效的辅助治疗, 有利于影响支架区段的病变形态。

The authors have declared that no competing interests exist.

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