准分子激光消蚀术联合药物涂层球囊治疗复杂股腘动脉支架再狭窄的安全性和有效性  

Safety and efficacy of excimer laser ablation combined with drug-coated balloon for treating complex femoropopliteal in-stent restenosis

作　　者：徐展 张天华[1] 陈波[1] 姜维良[1] XU Zhan;ZHANG Tianhua;CHEN Bo;JIANG Weiliang(Department of Vascular Surgery,the Second Affiliated Hospital of Harbin Medical University,Harbin 150000,China)

机构地区：[1]哈尔滨医科大学附属第二医院血管外科,黑龙江哈尔滨150000

出　　处：《中国普通外科杂志》2024年第12期2011-2022,共12页China Journal of General Surgery

摘　　要：背景与目的:支架植入术和球囊血管成形术(POBA)仍是股腘动脉支架再狭窄的主要治疗方式,该术式具有良好的短期通畅率,但是由于支架对血管内膜的持续刺激,使得支架内极易发生再次狭窄。随着腔内血管技术的发展,准分子激光消蚀术(ELA)联合药物涂层球囊(DCB)的应用为血管内支架再狭窄的治疗提供了新的手段。因此,本研究探讨ELA联合DCB治疗复杂股腘动脉支架再狭窄的安全性和有效性。方法:回顾性分析2020年6月—2022年6月期间接受介入手术治疗的股腘动脉支架再狭窄69例患者临床资料,其中,27例患者接受ELA联合DCB治疗(ELA+DCB组),42例患者接受POBA联合DCB治疗(POBA+DCB组)。比较两组患者的相关临床指标。结果:两组患者术前基线资料差异均无统计学意义(均P>0.05)。69例患者手术入路均真腔开通,ELA+DCB组和POBA+DCB组手术成功率分别为92.6%(25/27)和90.5%(38/42),差异无统计学意义(P>0.05);两组术中各项不良事件发生率差异均无统计学意义(均P>0.05)。Logistic风险回归分析结果显示,靶病变血栓是ELA联合DCB术中远端栓塞的独立危险因素(HR=24.695,95%CI=1.061~574.904,P=0.046)。两组患者术后即刻及术后1、6个月的踝肱指数(ABI)差异无统计学意义(均P>0.05),但ELA+DCB组术后12、18、24个月ABI优于POBA+DCB组(均P<0.05)。两组术后全因死亡与截肢率差异无统计学意义(均P>0.05);Kaplan-Meier分析结果显示,ELA+POBA组2年免于靶病变血运重建率(81.5%vs.57.1%,P=0.044)和2年血管通畅率(77.8%vs.52.4%,P=0.031)优于POBA+DCB组。ROC曲线分析显示,术中激光导管直径/参考血管直径(TD/RVD)预测ELA联合DCB术后2年血管通畅率的截断值为0.47(AUC=0.825,95%CI=0.619~1.000),特异度为66.7%;Cox风险回归分析结果显示,术后抗凝抗血小板治疗(HR=0.033,95%CI=0.002~0.661,P=0.026)、膝下动脉开通数(≥2)(HR=0.022,95%CI=0.001~0.808,P=0.038)、TD/RVD≥0.47(HR=0.002,95%CI=0.000~0.403,P=0.Background and Aims:Stenting and plain old balloon angioplasty(POBA)remain the primary treatments for femoropopliteal in-stent restenosis(ISR).These approaches demonstrate good short-term patency;however,ISR frequently recurs due to continuous stimulation of the vascular intima by the stent.With advancements in endovascular technology,excimer laser ablation(ELA)combined with drug-coated balloons(DCB)offers a novel strategy for treating ISR.This study investigated the safety and efficacy of ELA combined with DCB for complex femoropopliteal ISR.Methods:The clinical data of 69 patients with femoropopliteal ISR treated with interventional procedures between June 2020 and June 2022 were retrospectively analyzed.Among them,27 patients underwent ELA combined with DCB treatment(ELA+DCB group),and 42 patients underwent POBA combined with DCB treatment(POBA+DCB group).Relevant clinical variables were compared between the two groups:Results:No significant differences were observed in baseline characteristics between the two groups(all P>0.05).True lumen re-entry was achieved in all 69 patients.The procedural success rates for the ELA+DCB and POBA+DCB groups were 92.6%(25/27)and 90.5%(38/42),respectively,with no statistically significant difference(P>0.05).Intraoperative adverse events were comparable between groups(all P>0.05).Logistic regression analysis indicated that thrombus in the target lesion was an independent risk factor for distal embolization during ELA+DCB(HR=24.695,95%CI-1.061-574.904,P=0.046).Ankle-brachial index(ABI)values immediately after the procedure and at 1 and 6 months postoperatively showed no significant differences between the two groups(all P>0.05).However,the ELA+DCB group demonstrated superior ABI outcomes at 12,18,and 24 months postoperatively(all P<0.05).There were no significant differences in all-cause mortality or amputation rates postoperatively(both P>0.05).Kaplan-Meier analysis showed that the ELA+DCB group had higher 2-year freedom from target lesion revascularization(81.5%vs.57.1%,P=0.0

关 键 词：移植物闭塞 血管 激光 准分子 消融技术 药物涂层球囊 

分 类 号：R654.3[医药卫生—外科学]