Schalcher C, Sütsch G, Amann F W
Department of Internal Medicine, University Hospital, Zurich.
Schweiz Med Wochenschr. 1999 Nov 13;129(45):1679-96.
Coronary artery stenting has definitely been proven to improve results of percutaneous revascularisation in a large number of patients. Stenting reduces restenosis in large vessels above 3 mm diameter. Stenting has not solved the problem of restenosis but in spite of the inevitable in-stent restenosis due to neointimal proliferation seems to yield better long-term results than conventional PTCA. Adjunctive pharmacological treatment with aspirin and clopidogrel in combination with improved stent deployment techniques has reduced the incidence of subacute stent thrombosis. GP IIb/IIIa inhibition is a promising mean for the reduction of procedure related ischaemic events and complications not only with stent implantation but also with conventional PTCA. Other new devices may further influence the treatment choices of stenting versus conventional PTCA in the future. Novel approaches such as brachytherapy and molecular genetic approaches to reduce in-stent restenosis are currently being investigated but to date no conclusions can be drawn as to their future place in clinical practice. From a mechanistic standpoint it seems obvious to give all our efforts to protect patients with coronary atherosclerosis from loss of myocardium either with coronary artery bypass grafting or percutaneous revascularisation. As both approaches are palliative in nature, it may be useful to attempt percutaneous revascularisation in patients amenable to this therapy and thus obviate or delay the need for definitive revascularisation by coronary artery bypass grafting. At the end of this discussion we would like to remind that medical therapy for coronary artery disease is of utmost importance as all revascularisation procedures do not influence the underlying disease. Besides symptomatic relief of angina, treatment of heart failure, and other beneficial strategies to improve endothelial function, medical therapy with lipid lowering compounds together with risk factor control offers the possibility to delay progression of coronary artery disease.
冠状动脉支架置入术已明确被证实可改善大量患者经皮血管重建的效果。支架置入可减少直径大于3毫米大血管的再狭窄。支架置入术虽未解决再狭窄问题，但尽管因内膜增生不可避免会出现支架内再狭窄，其长期效果似乎优于传统经皮冠状动脉腔内血管成形术（PTCA）。阿司匹林和氯吡格雷联合辅助药物治疗，再加上改进的支架置入技术，已降低了亚急性支架血栓形成的发生率。糖蛋白IIb/IIIa抑制剂不仅在支架植入时，而且在传统PTCA时，都是减少与手术相关缺血事件和并发症的一种有前景的方法。其他新装置未来可能会进一步影响支架置入术与传统PTCA治疗选择。目前正在研究诸如近距离放射疗法和分子遗传学方法等新型方法以减少支架内再狭窄，但迄今为止，关于它们在临床实践中的未来地位尚无定论。从机制角度看，显然我们应全力以赴通过冠状动脉旁路移植术或经皮血管重建术保护冠状动脉粥样硬化患者的心肌不发生损失。由于这两种方法本质上都是姑息性的，对于适合这种治疗的患者尝试经皮血管重建术可能有用，从而避免或推迟冠状动脉旁路移植术进行确定性血管重建的必要性。在本次讨论结束时，我们想提醒，冠状动脉疾病的药物治疗至关重要，因为所有血管重建手术都不会影响潜在疾病。除了缓解心绞痛症状、治疗心力衰竭以及其他改善内皮功能的有益策略外，使用降脂化合物进行药物治疗并控制危险因素有可能延缓冠状动脉疾病的进展。
