Hofmann R, Kerschner K, Grund M, Leisch F
I. Medizinische Abteilung mit Kardiologie, Allgemeines Krankenhaus Linz, Krankenhausstrasse 9, A-4020 Linz, Osterreich.
Z Kardiol. 1999 Oct;88(10):788-94. doi: 10.1007/s003920050353.
Coronary surgery is at this point of time the standard therapy of unprotected left main coronary artery stenosis. Coronary angioplasty (PTCA) is performed only in bail out situations. The number of publications of successful percutaneous intervention in unprotected left main coronary stenosis is increasing because of increasing use of stents and ticlopidine to avoid stent-thrombosis. From 9/96 to 7/98, 13 patients with unprotected left main coronary stenosis were treated with stents. All of them were accepted by the heart surgeon for bypass surgery but were not considered to be optimal candidates due to advanced age of more than 80 years (n = 5), significant co-morbidity (n = 2) or diffuse diseased peripheral coronary segments (n = 6). Mean age of patients was 74 +/- 10 years, 9 were male, and all patients presented with angina III-IV (CCS). Mean ejection fraction was 55 +/- 15%. Localization of stenoses were classified as ostial (n = 5), middle (n = 3), and bifurcational (n = 6). One patient had stenoses both in the ostium and in the bifurcation. In all cases a PTCA of the culprit stenosis was performed prior to stent implantation. The mean diameter of the stents used was 3.3 +/- 0.3 mm and the mean length was 11 +/- 4 mm. In 6 patients a PTCA of either left anterior descendens (LAD) or right coronary artery was performed in the same session. In 4 of these patients it was followed by a stent implantation. All procedures were performed with surgical stand-by, an intraaortal balloon pump was available, but was not uses prophylactically. Stent implantation could be performed successfully in 12 out of the 13 patients (success rate 92%). In bifurcational stenoses stents were positioned with the proximal end in the left main and the distal end in the LAD. Significant injury or occlusion of the circumflex artery was not observed. In one patient with bifurcational stenosis with severe calcification it was not possible to cross the lesion with an accurate sized balloon. Trying to cross with a smaller balloon (2.5 mm) resulted in dissection of the left main coronary artery which could not be reopened again by catheter technique. This patient was transferred to the operating room under conditions of cardiopulmonary resuscitation and a bypass surgery was performed. He was dismissed from the hospital with no evidence of perioperative myocardial infarction. The mean time for follow-up was 12 +/- 7 months, all patients are still alive. In 6 patients an angiography was performed during follow-up because of suspicion of recurrent ischemia. Two patients out of these 6 had restenoses in the left main coronary artery which were re-dilated (17%). Another 2 patients had stenoses in other coronary segments and were also dilated. Thus, stenting of left main coronary artery stenoses is feasible, however, with acceptable risks and could be considered in selected patients as an alternative to coronary artery surgery.
目前，冠状动脉手术是无保护左主干冠状动脉狭窄的标准治疗方法。仅在紧急情况下才进行冠状动脉血管成形术（PTCA）。由于越来越多地使用支架和噻氯匹定以避免支架血栓形成，关于无保护左主干冠状动脉狭窄成功进行经皮介入治疗的出版物数量正在增加。从1996年9月至1998年7月，13例无保护左主干冠状动脉狭窄患者接受了支架治疗。他们所有人都被心脏外科医生接受进行搭桥手术，但由于年龄超过80岁（n = 5）、严重合并症（n = 2）或弥漫性病变的外周冠状动脉节段（n = 6），不被认为是最佳候选者。患者的平均年龄为74±10岁，9例为男性，所有患者均表现为Ⅲ - Ⅳ级心绞痛（加拿大心血管学会分级）。平均射血分数为55±15%。狭窄部位分类为开口处（n = 5）、中段（n = 3）和分叉处（n = 6）。1例患者在开口处和分叉处均有狭窄。在所有病例中，在植入支架之前均对罪犯病变进行了PTCA。所用支架的平均直径为3.3±0.3mm，平均长度为11±4mm。6例患者在同一会诊中对左前降支（LAD）或右冠状动脉进行了PTCA。其中4例患者随后进行了支架植入。所有手术均在有外科备用的情况下进行，有主动脉内球囊泵可用，但未预防性使用。13例患者中有12例成功进行了支架植入（成功率92%）。在分叉处狭窄中，支架近端置于左主干，远端置于LAD。未观察到回旋支动脉有明显损伤或闭塞。1例患有严重钙化的分叉处狭窄患者，无法用合适尺寸的球囊穿过病变。试图用较小的球囊（2.5mm）穿过导致左主干冠状动脉夹层，无法通过导管技术再次开通。该患者在心肺复苏条件下被转至手术室并进行了搭桥手术。他出院时没有围手术期心肌梗死的证据。平均随访时间为12±7个月，所有患者仍存活。6例患者因怀疑复发性缺血在随访期间进行了血管造影。这6例患者中有2例左主干冠状动脉出现再狭窄并进行了再次扩张（17%）。另外2例患者在其他冠状动脉节段出现狭窄，也进行了扩张。因此，无保护左主干冠状动脉狭窄的支架置入术是可行的，然而，风险可接受，对于选定的患者可作为冠状动脉手术的替代方法考虑。
