颈动脉支架置入术后再灌注损伤的列线图预测模型构建

Construction of nomogram model to predict reperfusion injury after carotid artery stenting

目的 分析颈动脉狭窄所致缺血性卒中患者行颈动脉支架置入术后发生再灌注损伤的影响因素,构建颈动脉支架置入术后再灌注损伤的列线图预测模型,探讨其预测价值。方法 2016年12月—2021年5月南阳市中心医院诊治颈动脉狭窄所致缺血性卒中患者310例,均行颈动脉支架置入术,术后发生再灌注损伤36例为再灌注损伤组,未发生再灌注损伤274例为非再灌注损伤组。比较2组体质量指数(BMI)、合并症(高血压、糖尿病、冠心病)、吸烟史、饮酒史、颈动脉狭窄部位、狭窄程度、侧支循环情况及入院时血清总胆固醇(TC)、三酰甘油(TG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、S-100β、神经元特异性烯醇化酶(NSE)水平;采用多因素logistic回归分析颈动脉支架置入术后发生再灌注损伤的危险因素;根据危险因素,应用R软件4.0“rms”包构建颈动脉支架置入术后发生再灌注损伤的列线图模型,采用C指数、校准曲线评价模型性能,采用决策曲线评估模型的净收益。结果 (1)再灌注损伤组高血压(83.33%)、冠心病(27.78%)、侧支循环不良(47.22%)、颈动脉重度狭窄(25.00%)比率及血清S-100β[(88.36±4.52)ng/L]、NSE[(10.80±1.36)μg/L]水平均高于非再灌注损伤组[65.33%、6.93%、17.15%、5.11%、(82.90±4.08)ng/L、(9.55±1.06)μg/L](P<0.05),性别比例、年龄、BMI、吸烟史、饮酒史、糖尿病、颈动脉狭窄部位及血清TC、TG、LDL-C、HDL-C水平与非再灌注损伤组比较差异均无统计学意义(P>0.05)。(2)冠心病(OR=8.033,95%CI:4.326~25.663,P<0.001)、侧支循环不良(OR=3.686,95%CI:1.121~12.118,P=0.032)、颈动脉重度狭窄(OR=7.087,95%CI:1.636~30.697,P=0.009)、S-100β≥84.9 ng/L(OR=15.448,95%CI:3.976~60.016,P<0.001)是颈动脉支架置入术后发生再灌注损伤的危险因素。(3)内部验证结果显示构建的列线图模型C指数为0.766(95%CI:0.719~0.786),校准曲线与理想曲线基本接近,具有较好的一致性;决策曲线远离横纵坐标,预测颈动脉支架置入术后再灌注损伤的风险阈值>0.03。结论 有冠心病、侧支循环不良、颈动脉重度狭窄、血清S-100β≥84.9 ng/L是颈动脉狭窄所致缺血性卒中患者颈动脉支架置入术后发生再灌注损伤的危险因素,构建的列线图模型可有效预测颈动脉支架置入术后再灌注损伤的发生风险。

Objective To analyze the influencing factors of reperfusion injury after carotid artery stenting in patients with ischemic stroke caused by carotid artery stenosis,to construct a nomogram model of reperfusion injury after carotid artery stenting,and to intestigate its predictive value.Methods From December 2016 to May 2021,310 patients with ischemic stroke underwent carotid artery stenting in Nanyang Central Hospital,among whom 36 patients developed postoperative reperfusion injury(reperfusion injury group)and 274 patients developed no reperfusion injury(non-reperfusion injury group).The body mass index(BMI),comorbidities(hypertension,diabetes,coronary heart disease),smoking habits,alcohol consumptions,carotid artery stenosis site and degree,collateral circulation,and serum levels of total cholesterol(TC),triglyceride(TG),high-density lipoprotein cholesterol(HDL-C),low-density lipoprotein cholesterol(LDL-C),S-1oop,and neuron-specific enolase(NSE)on admission were compared between two groups.The risk factors of reperfusion injury after carotid artery stenting were analyzed by multivariate logistic regression,and the R software 4.0 was used to analyze the results of reperfusion injury according to the risk factors.Based on the risk factors,R language software 4.0"rms"package was used to construct a nomogram model of reperfusion injury after carotid artery stenting in ischemic stroke patients,the performance of the model was evaluated by C index and calibration curve,and the net benefit of the model was assessed by decision curve.Results(1)The rates of hypertension,coronary heart disease,poor collateral circulation and severe carotid artery stenosis,and the levels of serum S-10op and NSE were higher in reperfusion injurygroup[83.33%,27.78%,47.22%,25.00%,(88.36±4.52)ng/L,(10.80±1.36)μg/L]than those in non-reperfusion injurygroup[65.33%,6.93%,17.15%,5.11%,(82.90±4.08)ng/L,(9.55±1.06)μg/L](P<0.05),and there were no significant differences in the gender ratio,age,smoking habits,alcohol consumptions,diabetes mellitus,carotid artery stenosis site,serum levels of TC,TG,LDL-C and HDL-C levels between two groups(P>0.05).(2)Coronary heart disease(OR=8.033,95%CI:4.326-25.663,P<0.001),poor collateral circulation(OR=3.686,95%CI:1.121-12.118,P=0.032),severe carotid artery stenosis(OR=7.087,95%CI:1.636-30.697,P=0.009),and S-100β≥84.9 ng/L(OR=15.448,95%CI:3.976-60.016,P<0.001)were the risk factors of reperfusion injury after carotid artery stenting in patients with ischemic stroke.(3)The results of internal validation showed that the C index of the constructed nomogram model was 0.766(95%CI:0.719-0.786),and the calibration curve was basically close to the ideal curve with a good agreement;the decision curve was far away from the horizontal and vertical coordinates,and the risk threshold for predicting reperfusion injury after carotid artery stenting was>0.03.Conclusion Coronary artery disease,poor collateral circulation,severe carotid artery stenosis,and S-10op level≥84.9 ng/L are the risk factors of reperfusion injury after carotid artery stenting in patients with ischemic stroke caused by carotid artery stenosis,and the nomogram model can effectively predict the risk of reperfusion injury.