Moussa I, Moses J, Colombo A
Lenox Hill Heart and Vascular Institute, Department of Interventional Cardiology, 130 E. 77th Street, 9th Floor, New York, NY 10021, USA.
Curr Interv Cardiol Rep. 2000 Feb;2(1):20-26.
Coronary stents have improved the short- and long-term outcomes of patients undergoing catheter-based coronary interventions. However, the use of these devices in complex coronary lesions has also created an incessant form of in-stent restenosis that still defies treatment. Plaque burden has been consistently and reproducibly recognized as an important factor that may incite neointimal proliferation after stent implantation. Prospective nonrandomized experience has shown that plaque removal prior to stent implantation using directional atherectomy is a promising approach to reduce restenosis in selected patients. However, the proof of concept awaits the results of the randomized trials. Ultimately, the clinical use (safety and efficacy) of this approach will depend on 1) further improvements on the current directional atherectomy device to make it user friendly; 2) minimizing the incidence of non-Q-wave myocardial infarction with selective use of IIb-IIIa platelet receptor antagonists or distal protection devices; and 3) targeting patients at high risk for restenosis in whom efficient debulking is feasible. This would include patients who have noncalcified lesions in vessels greater than 2.75 mm but less than 3.5 mm in diameter that require a long stent or multiple stents, aorto-ostial lesions, bifurcational lesions, and chronic total occlusions.
冠状动脉支架改善了接受导管介入冠状动脉治疗患者的短期和长期预后。然而，在复杂冠状动脉病变中使用这些装置也产生了一种持续存在的支架内再狭窄形式，至今仍难以治疗。斑块负荷一直被一致且可重复地认为是支架植入后可能引发新生内膜增生的一个重要因素。前瞻性非随机研究经验表明，在支架植入前使用定向旋切术去除斑块是一种有前景的方法，可减少特定患者的再狭窄。然而，这一概念的验证有待随机试验的结果。最终，这种方法的临床应用（安全性和有效性）将取决于：1）对当前定向旋切装置进行进一步改进，使其便于使用；2）通过选择性使用IIb-IIIa血小板受体拮抗剂或远端保护装置，将非Q波心肌梗死的发生率降至最低；3）针对再狭窄高危且可行有效减容的患者。这将包括那些血管直径大于2.75 mm但小于3.5 mm、需要长支架或多个支架的非钙化病变患者、主动脉开口病变患者、分叉病变患者以及慢性完全闭塞患者。
