老年患者冠状动脉慢性完全闭塞病变正向技术开通的影响因素

Factors affecting successful recanalization of coronary chronic total occlusion with anterograde technique in the elderly patients

摘要:

目的 探讨老年患者冠状动脉慢性完全闭塞(CTO)病变应用正向技术开通成功的相关因素。方法 回顾性收集2013年1月至2014年12月在沈阳军区总医院心内科采用正向技术经皮冠状动脉介入(PCI)治疗的老年冠状动脉CTO患者301例。根据手术是否成功将患者分为PCI成功组250例及PCI失败组51例。收集并比较入选患者的基本资料、临床特征及住院期间不良事件发生情况。采用SPSS 21.0软件进行统计学分析。根据数据类型,组间比较采用独立样本t检验或χ²检验。二元logistic回归分析影响老年冠状动脉CTO病变开通成功的相关因素。结果 入选患者手术总体成功率83.1%(250/301)。2组患者在体质量、体质量指数、收缩压、糖尿病、吸烟、纽约心脏病学会(NYHA)分级、闭塞段扭曲、桥状侧支、闭塞时间分级和CTO靶血管等方面比较,差异有统计学意义(P＜0.05)。成功组和失败组在住院期间死亡率[0.8%(2/250) vs 1.9%(1/51)]、心力衰竭[4.4%(11/250) vs 3.9%(2/51)]、术后出血[3.2%(8/250) vs 3.9%(2/51)]、脑卒中[0%(0/250) vs 0%(0/51)]及围手术期心肌梗死[4.0%(10/250)vs 3.9%(2/51)]发生率比较,差异无统计学意义(P＞0.05)。二元logistic回归分析显示,女性(OR=5.608,95%CI 1.650～19.069,P=0.006)、高收缩压(OR=1.034,95%CI 1.004～1.064,P=0.024)、急性心肌梗死(AMI)史(OR=7.213,95%CI 1.070～48.645,P=0.042)、靶血管为左前降支(LAD)(OR=2.943,95%CI 1.085～7.984,P=0.034)及首先选用 Fielder XT 导丝(OR=2.570,95%CI 1.049～6.296,P=0.039)是增加正向技术开通老年冠状动脉CTO病变成功率的有利因素；糖尿病(OR=0.219,95%CI 0.086～0.562,P=0.002)、既往肾功能不全(OR=0.336,95%CI 0.117～0.967,P=0.043)、NYHA 分级较高(OR=0.238,95%CI 0.110～0.515,P=0.000)、闭塞段扭曲(OR=0.130,95%CI 0.017～0.969,P=0.047)及桥状侧支(OR=0.171,95%CI 0.046～0.634,P=0.008)是降低正向导丝开通老年冠状动脉CTO病变成功率的不利因素。结论 既往有AMI史、靶血管为LAD的高收缩压老年女性患者首先选用 Fielder XT 导丝可增大正向技术开通冠状动脉CTO病变的成功率,具有重要的临床参考价值。

Abstract:

Objective To investigate the factors affecting recanalization of coronary chronic total occlusion (CTO) using ante-rograde technique in the elderly. Methods A total of 301 CTO patients were recruited, who had undergone anterograde percutaneous coronary intervention (PCI) in the General Hospital of Shenyang Military Command from January 2013 to December 2014. According to whether the operation was successful, the patients were divided into PCI success group(n=250) and PCI failure group(n=51). Data were retrieved and compared of their basic information, clinical characteristics and adverse events. SPSS statistics 21.0 was used for statistical analysis. Depending on data type, independent samples t-test or Chi-square test was employed for comparison between groups. Binary logistics regression was performed to analyze the factors associated with success rate of CTO PCI. Results The overall success rate was 83.1%(250/301). There were significant differences between two groups in body mass, body mass index, systolic blood pressure (SBP), diabetes, smoking, New York Heart Association (NYHA) class, tortuosity in the occluded segment, bridging collateral vessels, occlusive time grading, and CTO target vessel (P<0.05). There were no significant differences between two groups in mortality [0.8%(2/250) vs 1.9%(1/51)], heart failure [4.4%(11/250) vs 3.9%(2/51)], postoperative bleeding [3.2%(8/250) vs 3.9%(2/51)], stroke [0%(0/250)vs 0%(0/51)] and perioperative myocardial infarction [4.0%(10/250) vs 3.9%(2/51)] (P>0.05). Binary logistic regression analysis showed female (OR=5.608,5%CI 1.650-19.069, P=0.006), high SBP(OR=1.034,5%CI 1.004-1.064, P=0.024), previous acute myocardial infarction (AMI) (OR=7.213,5%CI 1.070-48.645, P=0.042), left anterior descending (LAD) branch target lesion (OR=2.943,5%CI 1.085-7.984, P=0.034), using the Fielder XT guidewire first (OR=2.570,5%CI 1.049-6.295, P=0.039) were factors that increased procedural success rate; however, diabetes (OR=0.219,5%CI 0.086-0.562, P=0.002), a history of renal insufficiency (OR=0.336, 95%CI 0.117-0.967, P=0.043), higher NYHA class (OR=0.238,5%CI 0.110-0.515, P=0.000), tortuosity of the target vessel (OR=0.130,5%CI 0.017-0.969, P=0.047) and bridging collateral vessels (OR=0.171, 95%CI 0.046-0.634, P=0.008) were factors decreasing procedural success rate. Conclusion The success rate of coronary CTO with anterograde technique increases in the elderly female with an AMI history, LAD target lesion, higher SBP, and using Fielder XT guidewire first, providing valuable clinical reference.