CN113331848A - 超低量对比剂在肾功能不全患者冠状动脉成像中的应用 - Google Patents
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Abstract
本发明公开了超低量对比剂在肾功能不全患者冠状动脉成像中的应用，属于影像学诊断药物应用领域，其中，对比剂为碘帕醇370，超低量为18ml，本发明有效的解决了一般可疑冠心病患者的冠状动脉成像与肾功能不全的患者的冠状动脉成像使用常规剂量(50‑70ml)造影剂易导致造影剂肾病的问题，特别是大大降低了对比剂对肾功能的影响，实现了特殊患者群体对冠心病的明确诊断及治疗。
Description
技术领域
本发明涉及对比剂在冠状动脉成像中的应用，具体涉及超低量对比剂在肾功能不全患者冠状动脉成像中的应用，属于影像学诊断药物应用领域。
背景技术
全世界有数百万人经常遭受心绞痛的折磨，甚至成为致残的疾病。对疑似冠状动脉疾病(CAD)患者进行明确诊断和预后正确管理，旨在改善及减少并发症。在冠心病诊断和治疗中，如何得到冠状动脉的影像非常关键和重要，只有清晰且精确的显示，才能利于医生进行观察和分析。迄今为止，基于二维成像的冠状动脉造影仍是诊断冠心病的“金标准”，造影图像序列能够展示心脏搏动时血管变形和心脏的供血功能等动态信息，然而这种影像学技术已经落后于临床需求。心脏血管是三维的，具有空间和时间的不均匀性，普通冠脉造影是三维空间到二维空间的投影成像，在这一过程中丢失了血管解剖结构丰富的空间立体信息，仅以某一个平面的血管狭窄度作为判断标准，存在较大偏差。此外，特别对于分叉处的血管结构，单一图像中容易出现重叠和缩短而影响观察，在这种情况下仅根据某个角度的投影很难得到清晰的分叉处血管线，医生只能通过有限的造影图像对病灶进行判断，主观性较强，影响了后继治疗干预质量。
虽然侵入性冠状动脉造影(CAG)仍然是诊断阻塞性CAD的金标准，但冠状动脉计算机断层扫描(CTA)已经成为一种可靠的非侵入性替代方法，具有排除阻塞性CAD的极佳准确性，它可对冠状动脉进行多角度的观察，能发现大于0.5cm的动脉粥样硬化斑块，并进行三维成像，提供冠状动脉的立体观感，使医生对病变冠脉具有一定的空间印象。CTA以回顾性心电门控间隔5％RR间期重建图像，选择质量好的断层图像重建2D和3D图像。读片时更多观察2D断层图像，因其提供更多解剖与相邻关系的信息，2D诊断后，与3D图像对照和验证，减少错误的几率。CTA使用多层面重组(MPR)、曲面重组(CPR)、最大密度投影(MIP)和容积再现(VR)等三维成像技术输出最后图像，各有特点，通常联合应用。然而，现有CTA的图像处理存在不少缺陷。首先，CTA的分辨率低于冠脉造影，假阳性率较高，严重钙化对CTA的准确度有显著影响，导致其阳性预测价值相对偏低(<80％)。
造影剂或对比剂是可以改变其中在医学成像中分析区域的方式的物质。特别地，它们能够改变器官、损伤或任意其他周围结构的反差，使得这种细节可见，否则它们难以检测或鉴别。
造影剂最初用于放射学或核磁共振诊断领域。根据应用领域的不同，这些衍生物呈现了结构特征，例如，就用作X-射线分析的造影剂的分子而言，存在一种或多种具有高原子数的原子(例如碘或钡)。
碘帕醇(N,N'-双[2-羟基-1-(羟基甲基)乙基]-5-[(2S)(2-羟基-1-氧代丙基)氨基]-2,4,6-三碘-1,3-苯二甲酰胺)(II)，其结构式如下：
碘帕醇是一种非离子型水溶性造影剂，由于含碘量高，使X射线衰减从而达到造影显像目的，适用于血管内注射用的X射线造影。临床上碘帕醇用于各种血管造影，如脑血管造影，心血管造影等。
然而，随之而来的是造影剂对人体健康所带来的影响，如造影剂肾病(CIN)，行冠状动脉CTA的肾功能受损患者存在造影剂诱导肾病的风险，极易引发并发症CIN，使得CIN成为一个越来越有争议的话题，因此，如何降低对比剂引发造影剂肾病(CIN)的风险，引起了人们的高度重视。
发明内容
有鉴于此，本发明提供了超低量对比剂在肾功能不全患者冠状动脉成像中的应用，解决了一般可疑冠心病患者的冠状动脉成像与肾功能不全的患者的冠状动脉成像使用常规剂量造影剂易导致造影剂肾病的问题，实现了特殊患者群体对冠心病的明确诊断及治疗。
为了实现上述目的，本发明采用如下技术方案：
超低量对比剂在肾功能不全患者冠状动脉成像中的应用，具体的，对比剂为碘帕醇370，对于BMI值(身体质量指数)为18-26，HR(心率)<60次/分的患者，行18ml碘帕醇370。
给药后观察右心房对比剂染色，根据对比剂染色浓度及心率进行冠状动脉CTA扫描成像，给药后6-9s开始扫描，延迟8.9s，冠脉扫描时间0.3-0.8s。
临床相关性：随着多层螺旋CT(multi-slice spiral CT，MSCT)技术的发展，CT血管成像(CT angiography，CTA)的临床应用越来越广泛，对比剂剂量的控制一直是困扰研究者的关键问题，特别是肾功能不全的患者；revolutionCT宽探测器及快速扫描使得当前临床采用18ml对比剂扫描检查方案，根据患者心率的个体差异，个性化确定触发扫描时间在保障图像质量及满足诊断的前提下降低对比剂剂量成为可能性。
本发明的有益效果在于，本发明有效的解决了一般可疑冠心病患者的冠状动脉成像与肾功能不全的患者的冠状动脉成像使用常规剂量(50-70ml)造影剂易导致造影剂肾病的问题，特别是大大降低了对比剂对肾功能的影响，实现了特殊患者群体对冠心病的明确诊断及治疗。
附图说明
图1为本发明实施例18ml对比剂量行冠状动脉扫描结果图。
具体实施方式
下面将结合本发明实施例中的附图，对本发明实施例中的技术方案进行清楚、完整地描述，显然，所描述的实施例仅仅是本发明一部分实施例，而不是全部的实施例。基于本发明中的实施例，本领域普通技术人员在没有做出创造性劳动前提下所获得的所有其他实施例，都属于本发明保护的范围。
实施例
顺序选取2017.02.01至2017.10.01于聊城市人民医院CT室行冠状动脉CTA检查住院患者107例，患者要求年龄小于75周岁，血压90/60mmHg-140/90mmHg，BMI值为18-26，心率<60次/分，其中所选取患者中包含肾功能不全患者14例。
根据心率快慢行18ml对比剂碘帕醇370以冠状动脉CTA扫描成像，肉眼观察右心房对比剂染色，根据对比剂染色浓度及心率进行扫描，打药后6-9s开始扫描，延迟8.9s，冠脉扫描时间0.3-0.8s。
用18ml对比剂量行冠状动脉扫描，结果如图1所示，图1中，A：升主动脉CT值311.2HU；B：左冠状动脉(LAD)CT值292.1HU；C：右冠状动脉(RCA)CT值294.9HU；D：回旋动脉(LCX)CT值291.3HU,均达到诊断要求。
统计右冠状动脉、前降支动脉及回旋支动脉CT值，结果如表1。
表1冠状动脉扫描结果
对107例患者冠脉CTA图像质量进行客观评分(不能满足诊断为1分；图像质量尚可为2分；图像质量基本满意为3分；图像质量良好满足诊断为4分；图像质量优质为5分)，记录测量值，结果如表2。综合评估扫描图像质量，并统计总辐射剂量。
表2 CTA图像质量评分
分析14例肾功能不全患者冠脉CTA前及检查后24小时、72小时尿素氮、肌酐、尿酸、肾小球滤过率、胱抑素C及尿蛋白指标变化，评估18ml低对比剂量对肾功能影响，结果如表3。
表3肾功能不全患者冠脉CTA前及检查后指标变化
*检查后24小时和冠脉CTA检查前比较
#检查后74小时和冠脉CTA检查前比较
由上可知，冠状动脉三支主要冠脉血管CT值在245.0HU～304.8HU之间，主观图像质量评分≥3分占91.6％，基本能满足冠状动脉CTA结果诊断，受射线照射总剂量50.17-202.58mGy·cm，14例肾功能不全的患者，冠状动脉扫描前后肾脏功能变化没有统计学意义(P>0.05)。
因此，根据心率快慢行18ml低对比剂量冠状动脉脉CTA扫描，可基本满足冠脉CTA成像质量及临床诊断，并降低肾功能不全患者造影剂肾损害发生风险。
Claims (1)
1.超低量对比剂在肾功能不全患者冠状动脉成像中的应用，其特征在于，所述对比剂为碘帕醇370，所述超低量为18ml。
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