Radke P W, Klues H G, Haager P K, Hoffmann R, Kastrau F, Reffelmann T, Janssens U, vom Dahl J, Hanrath P
Medical Clinic I, RWTH University Hospital, Aachen, Germany.
J Am Coll Cardiol. 1999 Jul;34(1):33-9. doi: 10.1016/s0735-1097(99)00151-5.
This quantitative angiographic and intravascular ultrasound study determined the mechanisms of acute lumen enlargement and recurrent restenosis after rotational atherectomy (RA) with adjunct percutaneous transluminal coronary angioplasty in the treatment of diffuse in-stent restenosis (ISR).
In-stent restenosis remains a significant clinical problem for which optimal treatment is under debate. Rotational atherectomy has become an alternative therapeutic approach for the treatment of diffuse ISR based on the concept of "tissue-debulking."
Rotational atherectomy with adjunct angioplasty of ISR was used in 45 patients with diffuse lesions. Quantitative coronary angiographic (QCA) analysis and sequential intravascular ultrasound (IVUS) measurements were performed in all patients. Forty patients (89%) underwent angiographic six-month follow-up.
Rotational atherectomy lead to a decrease in maximal area of stenosis from 80+/-32% before intervention to 54+/-21% after RA (p < 0.0001) as a result of a significant decrease in intimal hyperplasia cross-sectional area (CSA). The minimal lumen diameter after RA remained 15+/-4% smaller than the burr diameter used, indicating acute neointimal recoil. Additional angioplasty led to a further decrease in area of stenosis to 38+/-12% due to a significant increase in stent CSA. At six-month angiographic follow-up, recurrent restenosis rate was 45%. Lesion and stent length, preinterventional diameter stenosis and amount of acute neointimal recoil were associated with a higher rate of recurrent restenosis.
Rotational atherectomy of ISR leads to acute lumen gain by effective plaque removal. Adjunct angioplasty results in additional lumen gain by further stent expansion and tissue extrusion. Stent and lesion length, severity of ISR and acute neointimal recoil are predictors of recurrent restenosis.
本定量血管造影和血管内超声研究确定了在治疗弥漫性支架内再狭窄（ISR）时，旋磨术（RA）联合经皮冠状动脉腔内血管成形术（PTCA）后急性管腔扩大和再发再狭窄的机制。
支架内再狭窄仍然是一个重大临床问题，其最佳治疗方法仍存在争议。基于“组织减容”概念，旋磨术已成为治疗弥漫性ISR的一种替代治疗方法。
对45例有弥漫性病变的患者采用旋磨术联合ISR血管成形术。对所有患者进行定量冠状动脉造影（QCA）分析和连续血管内超声（IVUS）测量。40例患者（89%）接受了6个月的血管造影随访。
旋磨术使最大狭窄面积从干预前的80±32%降至RA术后的54±21%（p<0.0001），这是由于内膜增生横截面积（CSA）显著减小。RA术后最小管腔直径仍比所用磨头直径小15±4%，表明存在急性内膜回缩。额外的血管成形术使狭窄面积进一步降至38±12%，这是由于支架CSA显著增加。在6个月的血管造影随访中，再发再狭窄率为45%。病变和支架长度、干预前直径狭窄以及急性内膜回缩量与再发再狭窄率较高相关。
ISR的旋磨术通过有效去除斑块导致急性管腔增加。联合血管成形术通过进一步扩张支架和挤压组织导致额外的管腔增加。支架和病变长度、ISR严重程度以及急性内膜回缩是再发再狭窄的预测因素。
