Gómez-Hospital J A, Cequier A, Fernández-Nofrerías E, Mauri J, García del Blanco B, Iráculis E, Jara F, Esplugas E
Unidad de Hemodinámica y Cardiología Intervencionista, Ciutat Sanitària i Universitària de Bellvitge, L'Hospitalet de Llobregat, Barcelona.
Rev Esp Cardiol. 1999 Dec;52(12):1130-8.
In-stent restenosis is an increasing problem due to the frequent use of coronary stent as a form of percutaneous revascularization. The global incidence is near to 28%, and it is well document that a neointimal hyperplasia is its principal mechanism. The most commonly related factors for its appearance are diabetes mellitus, a longer length of the original lesion, a smaller diameter of the reference vessel, the left anterior descending artery location and a smaller luminal diameter at the end of the procedure. Due to a different long term evolution in-stent restenosis has been classified as focal or diffuse, according to the length of the restenotic lesion (focal < 10 mm and diffuse > or = 10 mm). Some strategies have been proven for its treatment, but no randomized-controlled trials have been published comparing these different treatments. In focal in-stent restenosis the practice of a conventional balloon angioplasty is associated with high initial clinical success with a favourable long term evolution (target lesion revascularization between 11-15%). But on the contrary, in diffuse in-stent restenosis, in spite of a high initial success rate, an elevated target lesion revascularization has been detected at the follow-up (up to 43%). Other proved such as atherectomy or excimer laser are associated with a significant procedural non-Q-wave infarction (near to 9%) and a long term target lesion revascularization during follow-up (23-31%). The implantation of an additional stent has been performed with low procedural complications and with a long term target lesion revascularization near to 27%. Patients treated with intracoronary radiation as a complementary technique seem to have a better long term evolution than those having had the other strategies alone. In conclusion, in-stent-restenosis is a new and progressively more frequent problem, requiring complex treatment and of which as been established. Comparative controlled studies need to be performed in order to determine the best treatment for this new entity.
由于冠状动脉支架作为经皮血管重建术的一种形式被频繁使用，支架内再狭窄问题日益突出。全球发病率接近28%，且有充分文献记载，新生内膜增生是其主要机制。其出现最常见的相关因素包括糖尿病、原发病变长度较长、参考血管直径较小、左前降支位置以及手术结束时管腔直径较小。由于支架内再狭窄的长期演变不同，根据再狭窄病变的长度（局灶性<10毫米，弥漫性>或 = 10毫米），已将其分为局灶性或弥漫性。已证实了一些治疗策略，但尚未发表比较这些不同治疗方法的随机对照试验。在局灶性支架内再狭窄中，传统球囊血管成形术的实施具有较高的初始临床成功率和良好的长期演变（靶病变血管重建率在11%-15%之间）。但相反，在弥漫性支架内再狭窄中，尽管初始成功率较高，但随访时发现靶病变血管重建率升高（高达43%）。其他已证实的方法，如旋切术或准分子激光，与显著的手术非Q波梗死（接近9%）以及随访期间的长期靶病变血管重建（23%-31%）相关。植入额外支架的手术并发症较低，长期靶病变血管重建率接近27%。作为辅助技术接受冠状动脉内放射治疗的患者似乎比仅采用其他策略的患者具有更好的长期演变。总之，支架内再狭窄是一个新的且日益常见的问题，需要复杂的治疗，对此已经有了一定认识。需要进行比较对照研究以确定针对这一新实体的最佳治疗方法。
