不同手术入路对冠心病患者短期内两次应用对比剂诱导的急性肾损伤的影响

Impact of femoral or radial approach on acute renal injury induced by repeated contrast medium in patients with coronary heart disease

目的探讨短期内2次行冠状动脉介入手术、使用对比剂的冠心病患者,不同手术入路对每次术后对比剂诱导的急性肾损伤(CI-AKI)发生的影响。方法本研究为回顾性分析,入选2010年1月至2015年1月就诊于北部战区总医院心内科的冠心病患者,筛选其中30 d内2次行介入手术(包括冠状动脉造影术及经皮冠状动脉介入治疗)、接触对比剂且具有完整随访资料的患者322例。按介入手术入路分为:桡动脉组(2次介入手术入路均为桡动脉,n=235)和股动脉组(2次介入手术入路均为股动脉,n=87)。所有纳入患者均分别于术后48、72 h检测血肌酐(SCr)值。终点事件为CI-AKI,定义为排除其他病因的前提下,患者应用对比剂72 h内肾功能发生损害,SCr水平较术前升高>0.5 mg/dl(44.2μmol/L)或相对比例[(术后SCr-术前SCr)/术前SCr×100%]>25%。比较两组患者的临床特点及每次术后CI-AKI发生率,采用多因素logistic回归分析短期内2次行介入手术、使用对比剂的冠心病患者,术后发生CI-AKI的危险因素。结果股动脉组中吸烟、有经皮冠状动脉介入治疗(PCI)史及STEMI患者比例及纤维蛋白原、空腹血糖、肌钙蛋白T水平高于桡动脉组(P均<0.05)。股动脉组患者的手术间隔时间长于桡动脉组(P=0.001)。股动脉组患者第1次术后CI-AKI发生率高于桡动脉组,但差异无统计学意义[18.6%(16/87)比11.9%(28/235),P=0.133]。第2次术后两组的CI-AKI发生率差异无统计学意义(P>0.05)。多因素logistic回归分析结果显示,对于短期内2次行介入治疗手术的冠心病患者,介入手术入路并不是术后发生CI-AKI的独立危险因素(P均>0.05);STEMI(OR=2.854,95%CI 1.100~7.404,P=0.031)、利尿剂(OR=4.002,95%CI 1.470~10.893,P=0.007)是第1次术后CI-AKI发生的独立危险因素。结论短期内2次行冠状动脉介入手术、应用对比剂的冠心病患者,CI-AKI发生风险与介入手术入路无相关性。

Objective To investigate the effects of femoral approach versus radial approach on the incidence of contrast-induced acute kidney injury(CI-AKI)in patients with coronary heart disease,who received twice contrast agents within a short interval.Methods A total of 322 patients with coronary heart disease,who admitted to the General Hospital of Northern Theater Command from January 2010 to January 2015,were included in this retrospective analysis.All patients exposed to contrast agents twice within 30 days.The patients were divided into two groups according to the approach of interventional operation:radial artery group(n=235)and femoral artery group(n=87).Serum creatinine(SCr)values were detected at 48 and 72 hours post procedure.Endpoint events were CI-AKI,which was defined as SCr increased>0.5 mg/dl(44.2μmol/L)or relative ratio((postoperative SCr-preoperative SCr)/preoperative SCr×100%>25%)within 72 hours after contrast agent use after excluding other causes.Clinical characteristics and the incidence of CI-AKI were compared between the two groups,multivariate logistic regression analysis was used to detect the risk factors of postoperative CI-AKI in these patients.Results The proportion of smoking,PCI history,STEMI patients and levels of fibrinogen,fasting blood glucose,troponin T was significantly higher in femoral artery group than in radial artery group(all P<0.05).The interval between two procedure sessions was significantly longer in the femoral artery group than in the radial artery group(P=0.001).The incidence of CI-AKI tended to be higher in femoral artery group than in radial artery group after the first operation(18.6%(16/87)vs.11.9%(28/235),P=0.133).CI-AKI incidence after the second operation was similar between the two groups(P>0.05).Multivariate logistic regression analysis showed that interventional approach was not an independent risk factor for postoperative CI-AKI in patients with coronary heart disease undergoing interventional procedures twice within 30 days(P>0.05);STEMI(OR=2.854,95%CI 1.100-7.404,P=0.031)and diuretics use(OR=4.002,95%CI 1.470-10.893,P=0.007)were independent risk factors for CI-AKI after the first operation.Conclusion There is no correlation between the risk of CI-AKI and interventional approaches in patients with coronary heart disease who undergo interventional surgery twice within 30 days.