冠状动脉分叉病变介入治疗中分支血管的变化规律
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摘要
有报道分叉病变可占介入治疗病变的16%。随着介入治疗技术的发展,介入治疗适应症的放宽,分叉病变所占的比例可能不断增加。然而,同非分叉病变相比,其成功率低,并发症率高,再狭窄率高,远期疗效远远不如非分叉病变。
分叉病变治疗中主要是分支问题,分支闭塞发生的危险因素是什么?药物支架表面的多聚物涂层及药物会不会对分支有影响?本文入选2001年1月至2004年10月间于我院心内科置入冠状动脉支架并进行造影随访的236例患者,分析其置入支架前后及随访时造影资料。重点分析支架横过的分支血管的变化。根据支架的不同,分为BMS、taxus DES和cypher DES三组。分别对各组分支开口及血流情况等的变化进行分析比较,可见支架术后分支血管的闭塞率在cypher药物支架组为9.09%,taxus药物支架组为10.50%,BMS组为9.31%;闭塞的分支大部分会自行再通,在cypher组是76.47%,taxus组为63.16%,BMS为74.07%,三组支架组间没有明显差异;分支开口狭窄和起始部位有病变是分支闭塞的独立危险因素;支架内再狭窄、病变类型及分支情况等都不会影响闭塞分支的再通。
那些比较大的分支,如果闭塞会引起一些急性并发症,如急性心肌梗死等,故对于那些较大的分支(直径>2.2mm)经常会采取一定的治疗措施如球囊扩张和支架置入术等,但什么样的治疗措施是最好的呢?本文对被主支支架横过、直径大于2mm且开口狭窄>50%的73例患者的90支分支血管根据采取的治疗方法不同分成分支血管支架置入、球囊扩张和分支未处理3组,对临床症状及分支血管病变等的改变进行比较。结果发现支架置入组术后即刻分支开口狭窄程度最低10.00±21.21%,未处理组狭窄程度最高76.21±20.59%;随访时分支开口狭窄程度没有明显差别,三组患者分别为53.37±41.41%、46.43±32.49%和68.39±26.27%。但是主支药物支架置入组随访时分支开口狭窄程度在各治疗组分别为37.00±37.78%、27.50±23.15%和63.10±28.85%,三组间有统计学差异,然而三组患者随
It has been reported that the bifurcation lesion treatment in all percutaneous coronary intervention accouted for up to 16%. This percentage can greatly increase with the emerging of drug eluting stents which will expand indications. But comparing with the non-bifurcation lesions, the bifurcation lesion treatment has the lower success rate, higher complication rate, higher restenosis rate and the poorer remote clinical outcomes.The most important problem in the bifurcation treatment is the problem of side branch. What kind of side branches should be protected? What are the risk factors of side branch occlusion? Some studies have been performed on these topics after bare metal stenting. But it was unclear whether the side branch occlusion rate would be higher for the polymer coated on the surface of the drug eluting stents. In this study, we assessed the angiograms and medical records of two hundred and thirty-six patients who had stent implantation and follow-up angiograms. Any side branches covered by the stents was evaluated. The results shows side branch occlusion occurred in 9.09% in cypher DES group , 10.50% in taxus DES group and 9.31% in BMS group. Spontaneous recanalization was observed in 76.47% in cypher DES, 63.16% in taxus stent group and 74.07% in BMS. The side branches with ostial stenosis before stenting and origining from the lesion of the parent vessel are at the risk of occlusion.Large side branch occlusion may result in significant clinical syndromes such as AMI. So the jailed large side branches usally be stented or treated with balloon. This study included 73 patients with side branches jailed by main branch stents. Three different methods used to treat these branches: (1) stenting at the ostium of the side branch; (2) angioplasty across the metallic structure; (3) no treatment. The stented group had the most favorable immediate angiographic results, but during follow up there was no significant difference among three
分叉病变治疗中主要是分支问题,分支闭塞发生的危险因素是什么?药物支架表面的多聚物涂层及药物会不会对分支有影响?本文入选2001年1月至2004年10月间于我院心内科置入冠状动脉支架并进行造影随访的236例患者,分析其置入支架前后及随访时造影资料。重点分析支架横过的分支血管的变化。根据支架的不同,分为BMS、taxus DES和cypher DES三组。分别对各组分支开口及血流情况等的变化进行分析比较,可见支架术后分支血管的闭塞率在cypher药物支架组为9.09%,taxus药物支架组为10.50%,BMS组为9.31%;闭塞的分支大部分会自行再通,在cypher组是76.47%,taxus组为63.16%,BMS为74.07%,三组支架组间没有明显差异;分支开口狭窄和起始部位有病变是分支闭塞的独立危险因素;支架内再狭窄、病变类型及分支情况等都不会影响闭塞分支的再通。
那些比较大的分支,如果闭塞会引起一些急性并发症,如急性心肌梗死等,故对于那些较大的分支(直径>2.2mm)经常会采取一定的治疗措施如球囊扩张和支架置入术等,但什么样的治疗措施是最好的呢?本文对被主支支架横过、直径大于2mm且开口狭窄>50%的73例患者的90支分支血管根据采取的治疗方法不同分成分支血管支架置入、球囊扩张和分支未处理3组,对临床症状及分支血管病变等的改变进行比较。结果发现支架置入组术后即刻分支开口狭窄程度最低10.00±21.21%,未处理组狭窄程度最高76.21±20.59%;随访时分支开口狭窄程度没有明显差别,三组患者分别为53.37±41.41%、46.43±32.49%和68.39±26.27%。但是主支药物支架置入组随访时分支开口狭窄程度在各治疗组分别为37.00±37.78%、27.50±23.15%和63.10±28.85%,三组间有统计学差异,然而三组患者随
It has been reported that the bifurcation lesion treatment in all percutaneous coronary intervention accouted for up to 16%. This percentage can greatly increase with the emerging of drug eluting stents which will expand indications. But comparing with the non-bifurcation lesions, the bifurcation lesion treatment has the lower success rate, higher complication rate, higher restenosis rate and the poorer remote clinical outcomes.The most important problem in the bifurcation treatment is the problem of side branch. What kind of side branches should be protected? What are the risk factors of side branch occlusion? Some studies have been performed on these topics after bare metal stenting. But it was unclear whether the side branch occlusion rate would be higher for the polymer coated on the surface of the drug eluting stents. In this study, we assessed the angiograms and medical records of two hundred and thirty-six patients who had stent implantation and follow-up angiograms. Any side branches covered by the stents was evaluated. The results shows side branch occlusion occurred in 9.09% in cypher DES group , 10.50% in taxus DES group and 9.31% in BMS group. Spontaneous recanalization was observed in 76.47% in cypher DES, 63.16% in taxus stent group and 74.07% in BMS. The side branches with ostial stenosis before stenting and origining from the lesion of the parent vessel are at the risk of occlusion.Large side branch occlusion may result in significant clinical syndromes such as AMI. So the jailed large side branches usally be stented or treated with balloon. This study included 73 patients with side branches jailed by main branch stents. Three different methods used to treat these branches: (1) stenting at the ostium of the side branch; (2) angioplasty across the metallic structure; (3) no treatment. The stented group had the most favorable immediate angiographic results, but during follow up there was no significant difference among three
引文
1 Renkin J, Wijns W, Hanet C, et al. Angioplasty of coronary bifurcation stenosis. Cathet Cardiovase Diagn 1991; 22: 167-73.
2 Savian RD, Freed M. The Marmual of Interventional Cardiology. 3nd ed, Birmingham, Michigan: Phusieian's Press 2001; 141-156
3 Lefevre T, Louvard Y, Morice MC, et al. Stenting of bifurcation lesions: a rational approach. J Interv Cardiol, 2001; 14(6): 573-585
4 Ishiki R, Ham K, Ikari Y, et al. Patency of intermediate size side branches after Palmaz-Schatz stent implantation. Jpn Heart J 1997; 38: 191-197
5 Cutlip DE, Leon MB, Ho KK, et al. Acute and ninemonth clinical outcomes
2 Savian RD, Freed M. The Marmual of Interventional Cardiology. 3nd ed, Birmingham, Michigan: Phusieian's Press 2001; 141-156
3 Lefevre T, Louvard Y, Morice MC, et al. Stenting of bifurcation lesions: a rational approach. J Interv Cardiol, 2001; 14(6): 573-585
4 Ishiki R, Ham K, Ikari Y, et al. Patency of intermediate size side branches after Palmaz-Schatz stent implantation. Jpn Heart J 1997; 38: 191-197
5 Cutlip DE, Leon MB, Ho KK, et al. Acute and ninemonth clinical outcomes