Sawhney Neil, Moses Jeffrey W, Leon Martin B, Kuntz Richard E, Popma Jeffrey J, Bachinsky William, Bass Theodore, DeMaio Samuel, Fry Edward, Holmes David R, Teirstein Paul S
Division of Cardiology, Scripps Clinic, San Diego, Calif 92037, USA.
Circulation. 2004 Jul 27;110(4):374-9. doi: 10.1161/01.CIR.0000136580.34604.B8. Epub 2004 Jul 12.
Revascularization strategies often hinge on the presence and degree of left anterior descending coronary artery (LAD) stenosis. A decision for bypass surgery is often based on the durability of surgical LAD revascularization compared with percutaneous approaches. By decreasing restenosis, drug-eluting stents may have reduced the "reintervention gap" between surgery and percutaneous intervention, making the percutaneous route preferable.
Of the 1101 patients in the SIRIUS trial, 459 with an LAD stenosis were randomized to percutaneous intervention with either sirolimus-eluting or bare-metal stents. Baseline demographic, clinical, and angiographic data were obtained. Patients had 1-year clinical and 8-month angiographic follow-up. Baseline characteristics were similar in both groups. The majority of lesions were tubular type B lesions (69.7%) with a mean diameter of 2.73 mm and a mean length of 14.0 mm. The binary in-stent restenosis rate was 2% for the sirolimus stent group and 41.6% for the bare-metal arm (relative risk, 0.05; 95% CI, 0.02 to 0.1; P<0.001). One-year major adverse events (defined as cardiac death, Q-wave and non-Q-wave myocardial infarction, or target vessel revascularization) was decreased 59% in the sirolimus-stent group (9.8% versus 24.9%; relative risk, 0.39; 95% CI, 0.26 to 0.61; P<0.001). Subgroup analysis of 135 patients with proximal LAD lesions showed similar benefits. In-stent restenosis was 0 in the proximal LAD sirolimus-eluting group (n=67), compared with 38% in the bare-metal arm (n=68), and major adverse events demonstrated a similar trend, with a 50% decrease compared with control patients (10.4% versus 20.6%, P=NS).
Sirolimus-eluting stents significantly decrease revascularization rates in LAD lesions. At 1 year, sirolimus-eluting stent revascularization rates are comparable to historic single vessel bypass surgery revascularization rates.
血运重建策略通常取决于左前降支冠状动脉（LAD）狭窄的存在及程度。与经皮介入治疗相比，外科搭桥手术的决策通常基于外科LAD血运重建的持久性。通过降低再狭窄率，药物洗脱支架可能缩小了手术与经皮介入治疗之间的“再次干预差距”，使得经皮介入途径更具优势。
在西罗莫司洗脱支架治疗冠状动脉狭窄的随机对照研究（SIRIUS试验）的1101例患者中，459例LAD狭窄患者被随机分配接受西罗莫司洗脱支架或裸金属支架的经皮介入治疗。收集基线人口统计学、临床和血管造影数据。患者接受为期1年的临床随访和8个月的血管造影随访。两组的基线特征相似。大多数病变为B型管状病变（69.7%），平均直径2.73mm，平均长度14.0mm。西罗莫司洗脱支架组的支架内再狭窄二元率为2%，裸金属支架组为41.6%（相对风险，0.05；95%可信区间，0.02至0.1；P<0.001）。西罗莫司洗脱支架组1年主要不良事件（定义为心源性死亡、Q波和非Q波心肌梗死或靶血管血运重建）减少了59%（9.8%对24.9%；相对风险，0.39；95%可信区间，0.26至0.61；P<0.001）。对135例LAD近端病变患者的亚组分析显示了类似的获益。LAD近端西罗莫司洗脱支架组（n=67）的支架内再狭窄率为0，而裸金属支架组（n=68）为38%，主要不良事件也显示出类似趋势，与对照组相比降低了50%（10.4%对20.6%，P=无统计学意义）。
西罗莫司洗脱支架显著降低LAD病变的血运重建率。在1年时，西罗莫司洗脱支架的血运重建率与既往单支血管搭桥手术的血运重建率相当。
