经远端桡动脉入路行冠状动脉介入治疗的学习曲线分析

王运涛; 王森虎; 王雨杰; 李紫旋; 齐淑媛; 王国忠; 王宇平; 张利彬; 王浩天; 郭金成

doi:10.16766/j.cnki.issn.1674-4152.003626

经远端桡动脉入路行冠状动脉介入治疗的学习曲线分析

doi: 10.16766/j.cnki.issn.1674-4152.003626

首都医科大学附属北京潞河医院心内科，北京 101100

基金项目:

首都卫生发展科研专项首发2022-2-7086

潞河医院青年孵育科研专项 LHYY2021-LC02

详细信息

通讯作者:
郭金成，E-mail: guojcmd@126.com

中图分类号: R543.3
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出版历程
- 收稿日期: 2024-02-11
- 网络出版日期: 2024-11-19

Learning curve of the distal radial access for coronary intervention

Department of Cardiology, Beijing Luhe Hospital, Capital Medical University, Beijing 101100, China

摘要

摘要: 目的探讨经远端桡动脉(DRA)行冠状动脉介入诊疗中操作数量与穿刺置管成功率的关系，并分析穿刺置管失败的危险因素。方法回顾性分析2021年1月—2022年12月北京潞河医院心内科单一术者经DRA入路行冠状动脉介入诊疗的患者1 000例，根据操作时间和先后顺序分为10组，每100例为一个阶段，主要研究终点为每100例患者的穿刺置管成功率，次要研究终点为每100例患者的一次性穿刺成功率和穿刺置管时间。采用logistic回归分析研究DRA穿刺置管失败的相关因素。结果 1 000例患者中，DRA穿刺置管成功率为92.3%。200例操作后，DRA的穿刺置管成功率可达93.0%以上(P=0.075)，一次性穿刺成功率从最初的74.0%增加至96.0%(P < 0.001)，穿刺置管中位时间从3.00 min减少到2.00 min(P < 0.001)。Logistic回归分析显示，DRA直径(P=0.020)与左侧入路(P=0.046)均为DRA穿刺置管失败的影响因素。结论 DRA路径需200例操作经验后穿刺置管成功率可达93.0%以上并维持稳定状态，小DRA直径和左侧入路是DRA穿刺置管失败的主要因素。
- 远端桡动脉 /
- 经皮冠状动脉介入治疗 /
- 学习曲线 /
- 穿刺置管成功率
Abstract: Objective To determine the correlation between operator experience in distal transradial coronary intervention (dTRI) and the successful cannulation rate of the distal radial artery (DRA), as well as to identify risk factors for puncture and cannulation failures. Methods From January 2021 to December 2022, 1 000 patients who underwent dTRI via DRA by a single interventionist in Beijing Luhe Hospital were retrospectively enrolled. These patients were chronologically ranked and divided into ten groups (100 cases each) according to operation time and order. The primary endpoint was the successful cannulation rate of DRA for every 100 cases, while the secondary endpoints were the success rate of one-time puncture catheterization and puncture catheterization time. Logistic regression analysis was carried out to identify predictors of unsuccessful DRA. Results A total of 1 000 patients were enrolled, with a successful DRA cannulation rate of 92.3%. After 200 cases, this rate stabilized at 93.0% (P=0.075). The first attempt DRA puncture success rate improved from 74.0% to 96.0%, while the median sheath cannulation time decreased from 3.00 min to 2.00 min (P < 0.001). Logistic regression analysis showed that a negative association between DRA diameter (P=0.020) and cannulation failure, and a positive association with left artery access (P=0.046). Conclusion Achieving over 93.0% success in DRA puncture and cannulation becomes consistent after 200 cases. Small DRA diameter and left-sided access are key predictors of failure.
- Distal radial artery /
- Percutaneous coronary intervention /
- Learning curve /
- The successful cannulation rate

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图 1 ACS患者dTRI穿刺置管成功率线图

Figure 1. The line chart of dTRI puncture catheterization success rate in ACS patients

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图 2 ACS患者dTRI一次性穿刺成功率线图

Figure 2. The line chart of the success rate of dTRI one-time puncture in ACS patients

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图 3 ACS患者dTRI穿刺置管时间散点图

Figure 3. The scatter plot of dTRI puncture catheterization time in ACS patients

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表 1 ACS患者dTRI穿刺置管成功组和失败组基线资料比较

Table 1. Comparison of baseline data between successful and failed dTRI puncture catheterization groups in patients with ACS

项目	总数(n=1 000)	成功组(n=923)	失败组(n=77)	统计量	P值
年龄(x±s，岁)	61.2±12.9	61.1±12.9	63.1±13.8	-1.318^a	0.188
性别[例(%)]				11.869^b	0.001
男性	790(79.0)	741(80.3)	49(63.6)
女性	210(21.0)	182(19.7)	28(36.4)
身高(x±s，cm)	167.1±9.5	167.3±9.6	165.3±8.1	1.704^a	0.089
体重[M(P₂₅, P₇₅)，kg]	73.0(65.0, 80.0)	73.0(65.0, 80.0)	75.0(65.0, 82.5)	-0.642^c	0.526
BMI[M(P₂₅, P₇₅)]	25.9(23.7, 28.4)	25.8(23.5, 28.4)	26.8(24.5, 29.4)	-2.377^c	0.017
危险因素[例(%)]
高血压	628(62.8)	580(62.8)	48(62.3)	0.008^b	0.930
糖尿病	322(32.2)	296(32.1)	26(33.8)	0.094^b	0.759
高脂血症	387(38.7)	357(38.7)	30(39.0)	0.002^b	0.961
当前吸烟	460(46.0)	437(47.3)	23(29.9)	8.738^b	0.003
慢性肾功能不全	29(2.9)	24(2.6)	5(6.5)	3.826^b	0.065
心房颤动	60(6.0)	52(5.6)	8(10.4)	2.069^b	0.126
脑卒中	111(11.1)	101(10.9)	10(13.0)	0.301^b	0.583
既往PRA[例(%)]	231(23.1)	210(22.8)	21(27.3)	0.818^b	0.366
既往DRA[例(%)]	58(5.8)	57(6.2)	1(1.3)	2.266^b	0.121
既往PCI[例(%)]	259(25.9)	241(26.1)	18(23.4)	0.277^b	0.599
射血分数(x±s，%)	64.1±9.8	64.1±9.9	64.3±8.8	-0.193^a	0.847
右侧入路[例(%)]	985(98.5)	912(98.8)	73(94.8)	5.237^b	0.023
诊断[例(%)]
UAP/NSTEMI	506(50.6)	464(50.3)	42(54.5)	0.520^b	0.471
STEMI	456(45.6)	424(45.9)	32(41.6)	0.549^b	0.459
其他	38(3.8)	35(3.8)	3(3.9)	< 0.001^b	0.999
操作[例(%)]
CAG	142(14.2)	131(14.2)	11(14.3)	0.001^b	0.982
PCI	858(85.8)	792(85.8)	66(85.7)	0.001^b	0.982
DRA直径(x±s，mm)	2.3±0.4	2.3±0.4	2.0±0.4	5.409^a	< 0.001
PRA直径(x±s，mm)	3.0±0.5	3.0±0.5	2.7±0.4	5.280^a	< 0.001
注：^a为t值，^b为χ²值，^c为Z值。CAG为冠状动脉造影(coronary angiography)；PCI为经皮冠状动脉介入治疗(percutaneous coronary intervention)；UAP为不稳定型心绞痛(unstable angina pectoris)；NSTEMI为非ST段抬高型心肌梗死(non ST-segment elevation myocardial infarction)；STEMI为ST段抬高型心肌梗死(ST-segment elevation myocardial infarction)。

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表 2 变量赋值情况

Table 2. Variable assignment

变量	赋值方法
性别	男性=0，女性=1
身高	以实际值赋值
BMI	以实际值赋值
当前吸烟	无=0，有=1
慢性肾功能不全	无=0，有=1
入路方式	右侧=0，左侧=1
DRA直径	以实际值赋值
PRA直径	以实际值赋值

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表 3 ACS患者远端桡动脉穿刺置管失败的多因素logistic回归分析

Table 3. Multivariate logistic regression analysis of failed distal radial artery puncture catheterization in ACS patients

变量	B	SE	Waldχ²	P值	OR值	95% CI
女性	0.310	0.367	0.717	0.397	1.364	0.665~2.797
身高	0.006	0.019	0.088	0.767	1.006	0.968~1.044
BMI	< 0.001	0.003	0.010	0.921	1.000	0.994~1.005
当前吸烟	-0.404	0.285	2.006	0.157	0.667	0.381~1.168
慢性肾功能不全	0.667	0.541	1.523	0.217	1.948	0.675~5.621
左侧入路	1.262	0.633	3.972	0.046	3.533	1.021~12.224
DRA直径	-1.053	0.451	5.451	0.020	0.349	0.144~0.844
PRA直径	-0.475	0.415	1.306	0.253	0.622	0.276~1.404

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表 4 ACS患者DRA和PRA入路术后并发症发生情况比较

Table 4. Comparison of postoperative complications between DRA and PRA approaches in ACS patients

项目	例数	止血时间 [M(P₂₅, P₇₅), h]	PRAO [例(%)]	DRAO [例(%)]	血肿 [例(%)]	EASY≥Ⅱ血肿 [例(%)]	假性动脉瘤 [例(%)]	动静脉瘘 [例(%)]	手指麻木 [例(%)]
DRA	923	3.27(3.00, 3.72)	19(2.1)^b	37(4.0)	73(7.9)	16(1.8)	2(0.2)	1(0.1)	10(1.1)
PRA	66	6.19(5.65, 6.64)	6(9.1)^c	3(4.6)	6(9.1)	1(1.5)	0	0	1(1.5)
统计量		-10.445^a	12.363^d	0.046^d	0.117^d	0.017^d	0.143^d	0.072^d	0.104^d
P值		< 0.001	0.005	0.745	0.734	0.999	0.999	0.999	0.534
注: ^a为Z值, ^d为χ²值。^b为与同组DRAO发生率比较，差异有统计学意义(2.1% vs. 4.0%, χ²=5.967，P=0.015);^c为与同组DRAO发生率比较差异无统计学意义(9.1% vs. 4.6%, χ²=1.093，P=0.296)。

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