自发性冠状动脉夹层的临床特征及腔内影像学评估

Clinical feature and intravascular imaging of spontaneous coronary artery dissection

目的回顾性分析自发性冠状动脉夹层(spontaneous coronary artery dissection,SCAD)患者的发病特点和腔内影像学特征,探讨血管内超声(intravenous ultrasound,IVUS)和光学相干断层成像(optical coherence tomography,OCT)在其诊断和治疗中的应用价值。方法回顾性分析2012年8月至2018年3月南京市第一医院经IVUS或OCT确诊为SCAD的17例患者,借助SCAD冠状动脉造影分型对病变进行分类,分析不同类型SCAD患者影像学特点及临床随访事件。结果 17例SCAD患者中,临床表现为急性ST段抬高型心肌梗死7例(7/17),非ST段抬高型心肌梗死5例(5/17),不稳定型心绞痛5例(5/17)。冠状动脉造影病变累及左前降支14例(14/17),左回旋支2例(2/17),右冠状动脉1例(1/17)。SCAD分型示Ⅰ型2例(2/17),Ⅱ型10例(10/17),Ⅲ型5例(5/17)。17例患者中,10例(10/17)行IVUS检查,11例(11/17)行OCT检查,其中4例同时行IVUS和OCT检查。IVUS和OCT均能清晰显示撕裂的内膜片及分隔开的真腔和假腔。4例(4/17)患者接受经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI),13例(13/17)患者接受药物保守治疗。4例(4/17)患者1年后再次来院复查冠状动脉造影及IVUS,其中2例接受PCI的患者支架通畅,IVUS检查示支架贴壁良好;另2例接受药物治疗的患者IVUS检查示夹层消失。所有患者在随访期间未发生任何缺血事件。结论SCAD是临床少见的一类急性冠状动脉综合征,应用IVUS和OCT有助于准确评估SCAD,进而为SCAD治疗策略的选择提供一定依据。

Objective To explore and summarize the clinical and image features of spontaneous coronary artery dissection(SCAD)and to discuss the strategy on therapy for SCAD.Methods A total of17patients were diagnosed with SCAD from Aug2012to Feb2018,and SCAD was classifi ed according to the classification criterion of coronary artery dissection.The imagine features and clinical follow-up results of diff erent types SCAD were analyzed.Results Among the17patients,7were manifested as STEMI,5were manifested as NSTEMI and5were manifested as unstable angina.Dissection was most frequently located in the left anterior descending coronary artery(14/17),followed by circumflex coronary artery(2/17)and the right coronary artery(1/17).All the lesions were classifi ed into three types:type1(2/17),type2(10/17)and type3(5/17).IVUS was performed in10patients,and OCT was performed in11patients.The intimal fl ap and idetifi cation of the true lumen and false lumen could be achieved by both IVUS and OCT.Conservative therapy was given to13patients,and other4patients were treated by interventional therapy with stenting successfully to4lesions.Dissection was self-healed in two patients who were treated by conservative therapy at one year coronary angiography and IVUS follow-up.The stents were patent in the two patients who were treated by interventional therapy.All the patients were free of ischemic events during the followup.Conclusions SCAD was a rare disease with relatively good prognosis.IVUS and OCT could accurately evaluate the lesion,and play an important role in the diagnosis and treatment of SCAD.