马嘉琪,周游,陈章炜,夏妍,钱菊英

• 1:复旦大学附属中山医院心内科上海市心血管病研究所国家放射与治疗临床医学研究中心

摘要(Abstract)：

目的 探讨冠状动脉慢性完全闭塞（CTO）病变经皮冠状动脉介入治疗（PCI）术中发生慢血流/无复流的危险因素，同时明确其对远期靶血管管腔通畅率的影响。方法 回顾性纳入复旦大学附属中山医院心内科于2015年3月至2020年2月成功实行PCI且术后至少复查过1次冠状动脉造影的CTO病变患者共514例。根据术中靶血管校正心肌梗死溶栓治疗试验（TIMI）血流记帧法计数（CTFC）分为血流正常组和慢血流/无复流组，比较两组患者临床病史、血液生化指标、超声心动图资料、PCI资料及复查冠状动脉造影结果，明确术中慢血流/无复流对远期管腔通畅率的影响，应用多因素Logistic回归模型分析冠状动脉CTO-PCI即刻慢血流/无复流的危险因素。结果 根据PCI术后CTFC将入组患者分为血流正常组（276例）和慢血流/无复流组（238例）。慢血流/无复流组患者与血流正常组比较，既往心肌梗死史及既往尝试开通失败比例更高（均P=0.007）、靶血管为右冠状动脉比例更高（P<0.001）、血清脂蛋白a>300 mg/L比例更高（P=0.001）。慢血流/无复流患者支架内再狭窄率（22.7%比14.5%,P=0.017）及管腔丢失率[（21.0±2.32）%比（14.0±1.92）%,P=0.007]更高。多因素Logistic回归分析结果显示，既往心肌梗死病史（OR 1.58,95%CI 1.06～2.38,P=0.025）、既往尝试开通失败史（OR 1.05,95%CI 1.01～2.36,P=0.049）、血清脂蛋白a>300 mg/L(OR 1.77,95%CI 1.22～2.58,P=0.003)为CTO病变患者PCI术中发生慢血流/无复流的独立危险因素。结论 既往心肌梗死史、既往尝试开通失败史、脂蛋白a>300mg/L为CTO病变患者PCI术中发生慢血流/无复流的独立危险因素，且发生慢血流/无复流的患者出现管腔丢失及支架内再狭窄比例明显升高。

关键词(KeyWords)： 慢性完全闭塞;经皮冠状动脉介入治疗;慢血流/无复流

Abstract:

Keywords:

基金项目(Foundation): 国家自然科学基金面上项目（82170338、81970295）;; 国家重点研发计划（2019YFC0840600）

作者(Author): 马嘉琪,周游,陈章炜,夏妍,钱菊英

参考文献(References)：

• [1] Claessen BE, Dangas GD, Weisz G, et al. Prognostic impact of a chronic total occlusion in a non-infarct-related artery in patients with ST-segment elevation myocardial infarction:3-year results from the HORIZONS-AMI trial[J]. Eur Heart J,2012,33(6):768-775. DOI:10.1093/eurheartj/ehr471.
• [2] Claessen BE, van der Schaaf RJ, Verouden NJ, et al.Evaluation of the effect of a concurrent chronic total occlusion on long-term mortality and left ventricular function in patients after primary percutaneous coronary intervention[J]. JACC Cardiovasc Interv, 2009,2(11):1128-1134. DOI:10.1016/j.jcin.2009.08.024.
• [3] Galassi AR, Tomasello SD, Reifart N, et al. In-hospital outcomes of percutaneous coronary intervention in patients with chronic total occlusion:insights from the ERCTO(European Registry of Chronic Total Occlusion)registry[J].EuroIntervention, 2011,7(4):472-479. DOI:10.4244/EIJV7I4A77.
• [4] Jaguszewski M, Targonski R, Fijalkowski M, et al.Recanalization of isolated chronic total occlusions in patients with stable angina[J]. Int J Cardiol, 2013,167(4):1542-1546. DOI:10.1016/j.ijcard.2012.04.097.
• [5] Stone GW, Cox D, Garcia E, et al. Normal flow(TIMI-3)before mechanical reperfusion therapy is an independent determinant of survival in acute myocardial infarction:analysis from the primary angioplasty in myocardial infarction trials[J].Circulation, 2001,104(6):636-641. DOI:10.1161/hc3101.093701.
• [6] Ramjane K, Han L, Jin C. The diagnosis and treatment of the no-reflow phenomenon in patients with myocardial infarction undergoing percutaneous coronary intervention[J]. Exp Clin Cardiol, 2008,13(3):121-128.
• [7] Piana RN, Paik GY, Moscucci M, et al. Incidence a n d treatment of ‘no-reflow’ after percutaneous coronary intervention[J]. Circulation, 1994,89(6):2514-2518.DOI:10.1161/01.cir.89.6.2514.
• [8] Resnic FS, Wainstein M, Lee MK, et al. No-reflow is an independent predictor of death and myocardial infarction after percutaneous coronary intervention[J]. Am Heart J, 2003,145(1):42-46. DOI:10.1067/mhj.2003.36.
• [9] Ramirez-Moreno A, Cardenal R, Pera C, et al. Predictors and prognostic value of myocardial injury following stent implantation[J]. Int J Cardiol, 2004,97(2):193-198. DOI:10.1016/j.ijcard.2003.07.031.
• [10] Yip HK, Chen MC, Chang HW, et al. Angiographic morphologic features of infarct-related arteries and timely reperfusion in acute myocardial infarction:predictors of slowflow and no-reflow phenomenon[J]. Chest, 2002,122(4):1322-1332. DOI:10.1378/chest.122.4.1322.
• [11] Wang Y, Zhao HW, Wang CF, et al. Incidence, predictors,and prognosis of coronary slow-flow and no-reflow phenomenon in patients with chronic total occlusion who underwent percutaneous coronary intervention[J]. Ther Clin Risk Manag, 2020,16:95-101. DOI:10.2147/TCRM.S233512.
• [12] Lee SH, Cho JY, Kim JS, et al. A comparison of procedural success rate and long-term clinical outcomes between in-stent restenosis chronic total occlusion and de novo chronic total occlusion using multicenter registry data[J]. Clin Res Cardiol,2020,109(5):628-637. DOI:10.1007/s00392-019-01550-7.
• [13] Theodoropoulos K, Mennuni MG, Dangas GD, et al.Resistant in-stent restenosis in the drug eluting stent era[J].Catheter Cardiovasc Interv, 2016,88(5):777-785. DOI:10.1002/ccd.26559.
• [14] Vinayakumar D,Raikar MP,Mohanan KS. Percutaneous coronary interventions in chronic total occlusion-profile,technique and outcome-the malabar experience[J]. J Saudi Heart Assoc,2020,32(2):274-283.DOI:10.37616/2212-5043.1082.
• [15] Gibson CM, Cannon CP, Daley WL, et al. TIMI frame count:a quantitative method of assessing coronary artery flow[J]. Circulation, 1996,93(5):879-888. DOI:10.1161/01.cir.93.5.879.
• [16] Mazhar J, Mashicharan M, Farshid A. Predictors and outcome of no-reflow post primary percutaneous coronary intervention for ST elevation myocardial infarction[J]. Int J Cardiol Heart Vasc, 2016,10:8-12. DOI:10.1016/j.ijcha.2015.11.002.
• [17] Tasar O, Karabay AK, Oduncu V, et al. Predictors a n d outcomes of no-reflow phenomenon in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention[J]. Coron Artery Dis, 2019,30(4):270-276. DOI:10.1097/MCA.0000000000000726.
• [18] Pantea-Rosan LR, Pantea VA, Bungau S, et al. No-reflow after PPCI-a predictor of short-term outcomes in STEMI patients[J]. J Clin Med, 2020,9(9). DOI:10.3390/jcm9092956.
• [19]夏妍，卢淡泊，陈章炜，等.修正休克指数和支架覆盖表面积对急性ST段抬高型心肌梗死患者冠状动脉介入术中无复流的影响[J].中国临床医学，2021,28(2):185-191.DOI:10.12025/j.issn.1008-6358.2021.20202744.
• [20]刘严慈，彭红玉，柳景华，等.慢性完全闭塞病变血运重建后围术期心肌梗死发生率及危险因素分析[J].中国介入心脏病学杂志，2022,30(8):573-579. DOI:10.3969/j.issn.1004-8812.2022.08.002.
• [21] Allencherril J, Jneid H, Atar D, et al. Pathophysiology,diagnosis, and management of the no-reflow phenomenon[J].Cardiovasc Drugs Ther, 2019,33(5):589-597.DOI:10.1007/s10557-019-06901-0.
• [22]朱博文，苏晓灵.冠状动脉慢血流现象产生机制及危险因素的研究进展[J].中国介入心脏病学杂志，2021,29(4):232-234. DOI:10.3969/j.issn.1004-8812.2021.04.011.
• [23]蒋俊，陈亮，张娟，等.血清胱抑素C与ST段抬高型心肌梗死急诊PCI术后无复流现象的相关性分析[J].江苏医药，2021,47(2):181-184. DOI:10.19460/j.cnki.0253-3685.2021.02.019.
• [24]曹娜，王记中，魏倩倩.急性心肌梗死PCI术后无复流现象的影响因素[J].临床心电学杂志，2021,30(3):207-209.DOI:10.3969/j.issn.1005-0272.2021.03.012.
• [25]王帅，赵凯，贺光磊，等.急性ST段抬高型心肌梗死患者淋巴细胞/单核细胞比值与无复流及短期预后的相关性[J].滨州医学院学报，2021,44(4):252-256. DOI:10.19739/j.cnki.issn1001-9510.2021.04.003.
• [26] Miksenas H, Januzzi JJ, Natarajan P. Lipoprotein(a)and cardiovascular diseases[J]. JAMA, 2021,326(4):352-353. DOI:10.1001/jama.2021.3632.
• [27] Tsimikas S. A test in context:lipoprotein(a):diagnosis,prognosis, controversies, and emerging therapies[J]. J Am Coll Cardiol, 2017,69(6):692-711. DOI:10.1016/j.jacc.2016.11.042.