Brück M, Ludwig J, Flachskampf F A, Daniel W G
Medizinische Klinik II und Poliklinik Universität Erlangen-Nürnberg Ostliche Stadtmauerstr. 29 91054 Erlangen, Germany.
Z Kardiol. 2002 Jan;91(1):16-23. doi: 10.1007/s392-002-8367-9.
Treatment of degenerated vein grafts is a large, growing portion of interventional procedures. Because the operative risk of repeat bypass surgery is substantially increased, percutaneous transluminal coronary angioplasty has been accepted as a less invasive treatment in symptomatic patients with significant stenoses of vein grafts. Stent placement has been established in the randomized SAVED trial as a safe and efficient treatment strategy of degenerated saphenous vein grafts, enhancing acute success, reducing the incidence of subsequent angiographic restenosis, and improving event-free survival. Despite coronary stents and new technological innovations like directional and transluminal extraction atherectomy distal embolization is still a frequent occurrence, with a reported incidence of 10-15% associated with an increased in-hospital mortality. Blockade of the platelet surface glycoprotein IIb/IIIa receptors has been convincingly demonstrated to reduce the ischemic complications of angioplasty in native coronary arteries. In degenerated vein grafts the efficacy of glycoprotein IIb/IIIa inhibitors in reducing distal embolization is uncertain. Major clinical events could not be reduced by glycoprotein IIb/IIIa antagonists administered periprocedurally. But prospective randomized trials are lacking. Protection devices could reduce the incidence of distal embolization during interventions in degenerated saphenous vein grafts. The relative role of these devices compared to pharmacologic interventions will require careful assessment in future clinical trials.
退化静脉移植物的治疗是介入手术中一个庞大且不断增长的部分。由于再次搭桥手术的手术风险大幅增加，经皮腔内冠状动脉成形术已被视为对有症状且静脉移植物存在明显狭窄的患者的一种侵入性较小的治疗方法。在随机化的SAVED试验中，支架置入已被确立为退化大隐静脉移植物的一种安全有效的治疗策略，可提高急性成功率、降低后续血管造影再狭窄的发生率并改善无事件生存率。尽管有冠状动脉支架以及诸如定向和腔内旋切斑块切除术等新技术创新，但远端栓塞仍然频繁发生，报道的发生率为10% - 15%，且与住院死亡率增加相关。血小板表面糖蛋白IIb/IIIa受体的阻断已被确凿证明可减少原位冠状动脉成形术的缺血并发症。在退化静脉移植物中，糖蛋白IIb/IIIa抑制剂在减少远端栓塞方面的疗效尚不确定。围手术期给予糖蛋白IIb/IIIa拮抗剂并不能降低主要临床事件的发生率。但缺乏前瞻性随机试验。保护装置可降低退化大隐静脉移植物介入治疗期间远端栓塞的发生率。与药物干预相比，这些装置的相对作用将需要在未来的临床试验中进行仔细评估。
