影像科学与光化学  2019, Vol. 37 Issue (4): 349-355  DOI: 10.7517/issn.1674-0475.190505   PDF    
CT联合血清HCY、β2-M在下肢动脉狭窄闭塞性疾病中的诊断价值
何辉1, 沈洪晖2     
1. 上海市闵行区颛桥社区卫生服务中心, 上海 201108;
2. 上海市金山区中西医结合医院, 上海 201501
摘要: 本文对CT联合血清同型半胱氨酸(HCY)、β2-微球蛋白(β2-M)在下肢动脉狭窄闭塞性疾病中的诊断价值进行分析。选取上海市金山区中西医结合医院收治的120例疑似下肢动脉狭窄闭塞性疾病患者进行研究,选取同期健康体检者120例作为对照组,对患者进行CT检查、血清HCY和β2-M水平检查,并比较了CT诊断下肢动脉狭窄闭塞情况、两组患者血清HCY和β2-M水平,以明确CT、HCY、β2-M诊断价值及误诊率、漏诊率。结果显示,120例疑似患者中,CT检测出646节段病变血管,其中轻度狭窄155节段,中度狭窄257节段,重度狭窄143节段,血管完全闭塞91节段;研究组患者血清HCY、β2-M水平明显高于对照组,两组比较差异有统计学意义(P < 0.05);HCY的AUC为0.863,截断值>21.75(μmol/L),诊断敏感性为79.00%,特异性为80.00%,β2-M的AUC为0.837,截断值>2.98(μmol/mL),诊断敏感性为75.25%,特异性为65.21%;CT诊断阳性率为67.50%,HCY诊断阳性率为69.17%,β2-M诊断阳性率为67.50%,三者联合诊断阳性率为82.50%,联合诊断阳性率高于CT、HCY、β2-M单独诊断阳性率(P < 0.05);CT、HCY、β2-M单一检测对下肢动脉狭窄闭塞性疾病均有较高灵敏度、特异性及准确度,但三者联合诊断灵敏度、特异性及准确度最高,误诊率、漏诊率最低。本文证实了采用CT联合血清HCY、β2-M诊断下肢动脉狭窄闭塞性疾病诊断灵敏度、特异性及准确度高,误诊率、漏诊率低。
关键词: 下肢动脉狭窄闭塞性疾病    CT    同型半胱氨酸    β2-微球蛋白    
The Diagnostic Value of CT Combined with Serum HCY and β2-M in Arterial Stenosis and Occlusion of Lower Extremity
HE Hui1, SHEN Honghui2     
1. Zhunqiao Community Health Service Center, Minhang District, Shanghai 201108, P. R. China;
2. The Hospital of Integrated Traditional Chinese and Western Medicine, Jinshan District, Shanghai 201501, P. R. China
*Corresponding author: SHEN Honghui, E-mail: 13916682258@163.com
Abstract: In this paper, the diagnostic value of CT combined with serum homocysteine (HCY) and beta 2-microglobulin (beta 2-M) in lower extremity arterial stenosis and occlusive disease was analyzed. 120 patients with suspected lower extremity artery stenosis and occlusive disease were selected as the study group, and 120 healthy people in the same period were selected as the control group, CT examination, serum HCY and β2-M levels examination were performed. CT diagnosis of lower extremity arterial stenosis and occlusion, the serum HCY and β2-M levels were compared. In this paper, the diagnostic values of CT, HCY, and β2-M in two groups were analyzed, and the misdiagnosis rate and missed diagnosis rate were also analyzed. The results showed that, among 120 patients, 646 lesions were detected by CT, including 155 slight stenosis, 257 moderate stenosis, 143 severe stenosis, and 91 complete occlusion; the levels of serum HCY and β2-M in the study group were significantly higher than those in the control group, the difference between the two groups was statistically significant (P < 0.05). The AUC of HCY was 0.863, truncation value >21.75 (mol/L), diagnostic sensitivity was 79.00%, specificity was 80.00%, the AUC of β2-M was 0.837, truncation value >2.98 mol/mL, diagnostic sensitivity was 75.25%, specificity was 65.21%; the positive rate of CT diagnosis, HCY diagnosis, β2-M diagnosis, and three combined diagnosis were 67.50%, 69.17%, 67.50%, and 82.50%, respectively. The positive rate of combined diagnosis was higher than that of CT, HCY, and β2-M single diagnoses (P < 0.05); CT, HCY, and β2-M single diagnoses had high sensitivity, specificity, and accuracy for lower extremity artery stenosis and occlusion disease, but the combined diagnosis of the three had the highest sensitivity, specificity, and accuracy, and the misdiagnosis rate and missed diagnosis rate were the lowest.
Key words: lower extremity arterial stenosis and occlusive disease    CT    homocysteine    β2-microglobulin    

下肢动脉狭窄闭塞性疾病是临床常见的下肢血管系统疾病,并随人口老龄化加剧,其发病率呈逐年上升趋势。临床主要特征为下肢动脉狭窄阻塞,一般由动脉粥样硬化引发,而随着斑块沉积增多,会加重患者血管狭窄,因此,早期诊断对改善患者预后显得极其重要[1, 2]。螺旋CT血管成像技术是在常规CT技术基础上发展而来,在下肢动脉狭窄闭塞性疾病诊断中有较高认可度[3]。同型半胱氨酸(homocysteine,HCY)是一种蛋氨酸代谢中间产物,有研究报道血清HCY升高可引起血管内皮损伤,参与下肢动脉粥样硬化等疾病的发生发展[4]。β2-微球蛋白(β2-M)是主要由淋巴细胞、多形核白细胞、血小板分泌的一种血清蛋白质,为白细胞抗原的一部分,在健康人群血清中较稳定,当动脉发生病变时,缺血、缺氧状态下可引起血清β2-M水平升高,与下肢动脉硬化闭塞疾病关系密切[5]。而关于CT联合血清HCY、β2-M诊断下肢动脉狭窄闭塞性疾病报道较少。因此,本研究旨在探讨CT联合血清HCY、β2-M在下肢动脉狭窄闭塞性疾病中的诊断价值。

1 资料与方法 1.1 一般资料

选取2016年1月~2018年1月上海市金山区中西医结合医院收治的120例疑似下肢动脉狭窄闭塞性疾病患者进行研究,选取同期健康体检者120例作为对照组。纳入标准:(1)经临床症状及影像学检查为疑似下肢动脉狭窄闭塞性疾病患者;(2)患者及家属对本研究知情,并签署知情同意书。排除标准:(1)合并凝血功能障碍性疾病者;(2)有血管造影禁忌症患者;(3)有碘剂过敏史患者;(4)合并下肢外伤、骨折等疾病;(5)合并糖尿病、类风湿性关节炎等慢性炎症疾病;(6)合并恶性肿瘤疾病;(7)精神异常患者。研究组男63例,女57例;年龄24~72岁,平均(50.75±5.31)岁;对照组男65例,女55例;年龄22~70岁,平均(49.13±5.67)岁,两组受试者性别、年龄等一般资料比较,差异无统计学意义(P>0.05)。

1.2 研究方法 1.2.1 CT扫描

采用Siemens Definition AS 64层CT扫描仪对120例下肢动脉狭窄闭塞性疾病患者进行CT检查,患者取仰卧位,足先进,扫描范围从足尖至腰间3椎体平面进行扫描,扫描参数:120 kV,120 mAs,螺距0.8,层厚0.9 mm,重建间隔0.7 mm,对比剂为碘海醇,肘静脉注入80 mL,流速3.0~5.0 mL/s。原始数据在工作站进行后处理,VR、MPR、MIP、CPR重建完整下肢动脉血管影像,观察血管全貌。

1.2.2 血清HCY、β2-M水平检测

采集所有受试者清晨空腹肘静脉血3~5 mL于离心管中,室温静置30 min,3000 r/min离心5 min,取上清,-80 ℃冻存待检。采用酶联免疫吸附法(ELISA)检测血清HCY水平,采用免疫比浊法检测血清β2-M水平。

1.3 统计学分析

采用SPSS 20.0统计软件处理实验数据,计量资料用均值±标准差(x±s)描述,采用t检验;计数资料用率描述,采用卡方检验。采用受试者工作特征曲线(ROC曲线)预测CT、HCY、β2-M对下肢动脉狭窄闭塞性疾病的诊断价值,当P<0.05时,认为差异有统计学意义。

2 结果 2.1 CT诊断下肢动脉狭窄闭塞情况

在120例患者中,用CT检测出646节段病变血管,详情见表 1

表 1 CT诊断下肢动脉狭窄闭塞情况 CT diagnosis of arterial stenosis and occlusion in lower extremities
2.2 典型病例

病例1,男,67岁,增强动脉期显示右侧股动脉重度狭窄(见图 1)。病例2,女性,60岁,增强动脉期显示左侧股动脉轻度狭窄(见图 2)。

图 1 右侧股动脉重度狭窄 Severe stenosis of the right femoral artery

图 2 左侧股动脉轻度狭窄 Mild stenosis of the left femoral artery
2.3 两组患者血清HCY、β2-M水平比较

研究组患者血清HCY、β2-M水平明显高于对照组,两组比较差异有统计学意义(P<0.05),见表 2

表 2 两组患者血清HCY、β2-M水平比较(x±s) Comparison of serum HCY and β2-M levels between two groups (x±s)
2.4 HCY、β2-M对下肢动脉狭窄闭塞性疾病的诊断价值

分别以下肢动脉狭窄闭塞性疾病患者血清中HCY、β2-M表达水平绘制的ROC曲线显示,HCY的AUC为0.863,截断值>21.75 μmol/L,诊断敏感性为79.00%,特异性为80.00%,95%的置信区间为0.791~0.918,约登指数为0.5775;β2-M的AUC为0.837,截断值>2.98 μmol/mL,诊断敏感性为75.25%,特异性为65.21%,95%的置信区间为0.761~0.896,约登指数为0.5255,见图 3

图 3 下肢动脉狭窄闭塞性疾病患者血清中HCY和β2-M的ROC曲线 ROC curve of serum HCY and β2-M in patients with lower extremity arterial stenosis and occlusive disease
2.5 CT、HCY、β2-M诊断结果

120例患者经金标准确诊101例,排除19例; CT诊断阳性率为67.50%;HCY诊断阳性率为69.17%;β2-M诊断阳性率为67.50%;三者联合诊断阳性率为82.50%。联合诊断阳性率高于CT、HCY和β2-M单独诊断阳性率(P<0.05),见表 3

表 3 CT、HCY、β2-M诊断结果 Diagnostic results of CT, HCY and β2-M
2.6 CT、HCY、β2-M对下肢动脉狭窄闭塞性疾病的诊断价值

CT、HCY、β2-M单一检测对下肢动脉狭窄闭塞性疾病均有较高灵敏度、特异性及准确度,但三者联合诊断灵敏度、特异性及准确度最高,误诊率、漏诊率最低,见表 4

表 4 CT、HCY、β2-M对下肢动脉狭窄闭塞性疾病诊断价值 Diagnostic value of CT, HCY and β2-M in lower extremity arterial stenosis and occlusion
3 讨论

下肢动脉狭窄闭塞性疾病的致病因素较多,可能与高血压、冠心病、糖尿病等疾病关系密切[6]。下肢动脉狭窄闭塞性疾病临床表现为下肢疼痛异常、进行性跛行,若治疗不当或不及时可导致截肢,对患者身心健康带来不利影响,并严重影响患者生活质量[7]。因此,对下肢动脉狭窄闭塞性疾病进行早期诊断,可尽早干预病情,以改善转归。

目前临床诊断多以彩色多普勒超声造影检查结果作为“金标准”,然而彩色多普勒超声技术有操作者依赖性,且加压超声可造成患者血管损伤[8]。随着螺旋CT技术不断改进,其诊断优势越来越明显,对患者无创伤性,仅需在体表静脉注入对比剂,即可双下肢动脉同时成像,避免对患者血管造成损伤,同时有较高的空间与时间分辨率,具有可直观病变部位血管直径大小、狭窄程度等优势[9]。本研究结果显示,120患者中CT检测出646节段病变血管,其中轻度狭窄155节段,中度狭窄257节段,重度狭窄143节段,血管完全闭塞91节段,与司昌革等[10]研究基本相似,提示CT检测对下肢动脉狭窄闭塞性疾病病变情况直观性强。血清HCY是一种含硫氨基酸,在正常情况下,血清HCY处于生成与清除平衡状态,当机体出现血管损伤时,血清HCY水平可明显升高,HCY还能促进白介素-8、单核细胞趋化蛋白-1等促炎因子分泌,加剧血管炎症,同时血清HCY升高还可增加引起血管损伤活性氧产生,进一步提高患者下肢动脉狭窄闭塞性疾病发生率[11]。β2-M作为血清蛋白质,广泛存在与体液及血液中,在正常机体内的血清浓度相对稳定,与性别、年龄无关,而在肢体缺血、缺氧状态下,机体神经内分泌调节系统可自动调节增加血淋巴细胞数量,淋巴细胞活性增强,促使分泌大量β2-M,造成血清β2-M水平升高[12, 13]。本研究结果显示,研究组患者血清HCY、β2-M水平明显高于对照组,HCY的AUC为0.863,诊断敏感性为79.00%,特异性为80.00%,β2-M的AUC为0.837,诊断敏感性为75.25%,特异性为65.21%,与冀景刚等[14]和刘海勇等[15]研究结果基本相似,提示血清HCY、β2-M在下肢动脉狭窄闭塞性疾病中高表达,并具有较高诊断敏感性和特异性,临床诊断价值较高。进一步分析显示,CT诊断阳性率为67.50%,HCY诊断阳性率为69.17%,β2-M诊断阳性率为67.50%,三者联合诊断阳性率为82.50%,联合诊断阳性率高于CT、HCY、β2-M单独诊断阳性率。CT、HCY、β2-M单一检测对下肢动脉狭窄闭塞性疾病均有较高灵敏度、特异性及准确度,但三者联合诊断灵敏度、特异性及准确度最高,误诊率、漏诊率最低,与张韬等[16]及徐志富等[17]研究结果一致。

综上所述,本研究通过采用CT联合血清HCY、β2-M诊断下肢动脉狭窄闭塞性疾病,结果显示患者血清HCY、β2-M水平升高,三者联合诊断下肢动脉狭窄闭塞性疾病的灵敏度、特异性及准确度高,误诊率、漏诊率低,对下肢动脉狭窄闭塞性疾病诊断具有较高临床价值。由于本研究所选样本量有限,可能造成研究结果出现一定误差,在之后研究中会逐步增加样本量,进一步验证其联合诊断价值。

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