【作者】 张璐；

【导师】 刘红波；

【作者基本信息】 中国医科大学 ， 公共卫生（专业学位）， 2019， 硕士

【摘要】 目的:股浅动脉闭塞是常见的下肢动脉粥样硬化性疾病之一,随着下肢动脉栓塞疾病的发病率和死亡率逐渐增加,股浅动脉闭塞疾病患者也逐年增加。临床将血管腔内治疗作为一线治疗方式。然而即使作为首选治疗方式,与其他治疗手段一样,由于各种原因,某些患者在治疗后的短期或长期内可能会出现治疗后再次不通畅的情况,这反而降低了该患者的生存质量,缩短了其生存时间;同时腔内治疗及随后相关的医疗费用也相对较高。因此,如果临床医生可以在手术前对这类患者的腔内治疗术后的通畅情况进行预估,从而根据预估结果选择进行腔内治疗或其他保守治疗,可以有目的提高患者生存质量,减少经济损失。因此,利用容易获得的病史和生化指标,构建一个综合的简易可推广的临床风险预测评价的测量工具,对于优化成本和提早预测和识别高危的股浅动脉术后再次闭塞病例具有重要价值。方法:采用t检验和秩和检验对符合正态性和不符合正态分析的变量进行描述,结果以均数?标准差或中位数(最小值-最大值)表示。本研究中股浅动脉闭塞患者腔内治疗结局短期危险评分体系的构建和长期危险评分体系的构建步骤一致。首先采用单因素Logistic回归分析进行单因素的筛选。随后以筛选的单因素的各变量赋值结果为自变量,术后一个月或十二个月通畅与否为应变量,使用Logistic逐步回归进行因素筛选。为获得稳定合理的危险因素的影响程度,采用10-fold cross-validation和Logistic逐步回归进行模型拟合。以危险评分标准和患者各指标的结果计算其在术后一个月或十二个月发生闭塞的危险评分。依据回归系数?和OR值构建危险评分体系。最后根据ROC曲线及其曲线下面积进行危险评分体系的评价,并以危险分数不同的截断点将腔内治疗的不通畅结局划分成高危险和低危险。结果:1.本研究入选383例患者,平均年龄72.2岁,患者最小年龄43.1岁,最大年龄94.9岁;男性患者256例,女性患者127例,男性患者平均70.7岁,女性患者平均75.3岁;吸烟患者210人(54.8%),平均BMI为23.5。2.患者平均跛行距离为136.4米,踝肱指数(ABI)为0.37,平均栓塞狭窄程度为82.2%。3.随访一个月的患者平均年龄72.4岁,有男性患者211人,女性患者109人,吸烟患者占53.4%。在腔内治疗一个月后,80.4%(259例)患者股浅动脉保持通畅;患者的平均跛行距离为823.2米,平均值ABI为0.79。4.随访十二月时,平均年龄72.1岁,男性139人,女性74人,吸烟患者占52.1%;患者通畅率为47.9%(103人);平均跛行距离为460.6米,平均ABI为0.67。5.股浅动脉闭塞患者腔内治疗短期结局的影响因素为:ABI,糖尿病史和甘油三酯;长期结局的影响因素为:糖尿病史,甘油三酯,空腹血糖,栓塞情况和吸烟。6.股浅动脉闭塞患者腔内治疗短期结局危险评分公式为:危险评分=6×ABI+1×糖尿病史+3×甘油三酯;长期结局危险评分公式为:危险评分=2×糖尿病史+5×甘油三酯+8×空腹血糖+2×栓塞情况+吸烟。结论:1.ABI,糖尿病史和甘油三酯是股浅动脉闭塞患者腔内治疗短期结局的影响因素;糖尿病史,甘油三酯,空腹血糖,栓塞情况和吸烟为长期结局的影响因素。2.股浅动脉闭塞患者腔内治疗短期结局危险评分为:危险评分=6×ABI+1×糖尿病史+3×甘油三酯;长期结局危险评分为:危险评分=2×糖尿病史+5×甘油三酯+8×空腹血糖+2×栓塞情况+吸烟。3.股浅动脉闭塞患者腔内治疗短期结局危险评分体系和长期结局危险评分体系具有良好预测能力,建议在临床实际工作中作为手术指征的辅助指标。更多还原

【Abstract】 Objective: Superficial femoral artery(SFA)occlusion disease is one of the common peripheral artery diseases(PAD).Due to the increased morbidity and mortality of PAD,patients with SFA occlusion disease are also increasing yearly.Endovascular treatment,compared with exercise treatment,medication treatment,percutaneous transluminal angioplasty,is the primary treatment in the clinical area,because of its simple operation,mini-wound,and lower requirements of the surgical condition.However,even it was treated as the preferred treatment,like other treatments,patients may experience occlusion again after treatment,which will reduce the quality of life or survival time.In addition,the cost of endovascular treatment and the cost of subsequent related medical treatment are also relatively high.Therefore,if the surgeon can estimate the patency rate after endovascular treatment of such patients before surgery,they can decide from endovascular treatment or other conservative treatments according to the predicted results.Bad results will be purposefully avoided.A comprehensive and easily accessible clinical risk prediction tool plays an important role in identifying high-risk cases of SFA occlusion patients,which will also optimize the medical expense.Methods: In the statistical description,T-test and rank-sum test were used to describe the variables that conform to the normality and do not.The results were expressed as mean standard deviation,and the categorical variables are expressed as the median(minimum-maximum Express).In this study,the construction of the short-term risk scoring system for endovascular treatment outcomes in SFA occlusion patients was consistent with the construction of the long-term risk scoring system.Effect factors were screened by Logistic regression analysis,which was used as independent variables.Subsequently,choosing the patency of one month and twelve months were treated as a dependent variable,and the Logistic stepwise regression was used to screen the factors,respectively.Then,to obtain reasonable risk factors,10-fold cross-validation and Logistic stepwise regression were used to fit the model.A risk score of one month or twelve months were calculated by using the risk score criteria and the results of each patient’s index,respectively.A hazard scoring system was constructed based on the regression coefficients ? and OR values.Finally,according to the ROC curve and the area under the curve,the risk scoring system was evaluated that dividing into high risk and low risk with cutoff points with different risk scores.Results: 1.A total of 383 patients met the enrollment criteria.The minimum age was 43.1 years,the maximum age was 94.9 years,and the average age was 72.2 years.Additionally,256 of them were male patients,127 of them were female patients,male patients’ age was 70.7 and female was 75.3.Besides,the number of smoking patients were 210(54.8%),with an average BMI of 23.5.2.All patients’ average distance of claudication was 136.4 meters,the ankle index(ABI)was 0.37,and the average embolization stenosis was 82.2% before the endovascular treatment.3.The average age of patients who were followed up for one-month was 72.4 years old,with 211 male patients,109 female patients,and 53.4% smoking patients.80.4%(259)patients’ superficial femoral artery(SFA)remained unobstructed after endovascular treatment with 823.2 m average claudication distance and 0.79 mean ABI.4.Follow-up at 12 months,the average age was 72.1 years,139 of them were men and 74 of them were women with 48.4% of smokers.The patency rate of SFA was 47.9%(103 patients),the average claudication distance was 460.6 m,and the average ABI was 0.67 at that time.5.The factors of short-term outcomes in patients with SFA occlusion disease including ABI,the history of diabetes and triglycerides.Similarly,factors of long-term outcomes including the history of diabetes,triglycerides,fasting blood-glucose,embolism degree,and smoking.6.The short-term outcome risk score formula for endovascular treatment of patients with SFA occlusion disease is: risk score = 6 × ABI + 1 × diabetes history + 3 × triglycerides and the long-term outcome risk score formula is: risk score = 2 × history of diabetes + 5 × triglycerides +8 × fasting blood glucose + 2 × embolism + smoking.Conclusion: 1.ABI,the history of diabetes and triglycerides affect SFA occlusion patients’ endovascular treatment results in short-term and embolism,history of diabetes,triglycerides,fasting blood glucose,smoking effect that in long-term.2.The short-term outcome risk score for patients with SFA occlusion is 6 × ABI + 1 × diabetes history + 3 × triglycerides and the long-term outcome risk score is 2 × diabetes history + 5 × triglyceride+8 × fasting blood glucose + 2 × embolization + smoking.3.These two predictor models both have great predictive ability,which can be used as auxiliary indicators before endovascular treatment for SFA occlusion patients.更多还原