Moussa I, Moses J, Colombo A
Lenox Hill Heart and Vascular Institute, NY, USA.
Semin Interv Cardiol. 2000 Dec;5(4):217-25. doi: 10.1053/siic.2000.0138.
Coronary stents have improved the short and long-term outcomes of selected 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 recognized as an important factor that may incite neo-intimal proliferation after stent implantation. Prospective non-randomized 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 utility of this approach will depend upon: (1) further improvements on the current directional atherectomy device; (2) minimizing the incidence of non-Q-wave myocardial infarction with selective use of IIb-IIIa platelet receptor antagonists or distal protection devices; (3) targeting patients at high risk for restenosis in whom efficient debulking is feasible such as non-calcified lesions in vessels >2.75 mm and <3.5 mm in diameter that require long 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的特定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器械也引发了一种持续存在的支架内再狭窄形式，目前仍难以治疗。斑块负荷被认为是支架植入后可能引发新生内膜增殖的一个重要因素。前瞻性非随机研究表明，在支架植入前使用定向旋切术去除斑块是减少特定患者再狭窄的一种有前景的方法。然而，这一概念的验证有待随机试验的结果。最终，这种方法的临床实用性将取决于：（1）对当前定向旋切器械的进一步改进；（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）针对再狭窄高危患者，对其进行有效减容是可行的，如直径>2.75 mm且<3.5 mm、需要长支架的血管中的非钙化病变、主动脉开口病变、分叉病变和慢性完全闭塞病变。
