Repetto Alessandra, Ferlini Marco, Ferrario Maurizio, Angoli Luigi, Bramucci Ezio
Division of Cardiology, IRCCS Policlinico San Matteo, Pavia, Italy.
Ital Heart J. 2005 Jun;6(6):494-7.
The original aim of atherectomy was to reduce restenosis by means of aggressive plaque debulking, and the failure of large randomized trials to show any advantage of atherectomy over balloon angioplasty restricted its wider application. However, single-center registries in which aggressive debulking was performed by experienced operators have reported favorable results in terms of reduced restenosis and improved clinical outcomes when atherectomy was performed before stenting. Plaque debulking reduces the potential for plaque shift and facilitates subsequent high-pressure stent expansion, smoothes the internal vessel surface, scaffolds intimal flaps, and prevents elastic recoil. It has also been demonstrated that atherectomy can play a role in the treatment of complex lesions (ostial left anterior descending coronary artery lesions, left main lesions, and bifurcations), in which plaque shift may compromise the result of the procedure. New-generation devices have shown that atherectomy can be safely and effectively used to treat even relatively small vessels. In the current era of drug-eluting stents characterized by a considerable reduction in restenosis rates, optimal stent geometry and final luminal diameter are still important predictors of restenosis. Given the possible role of plaque shifting at the edges of a stent in causing restenosis, debulking could be added to the local drug effect in complex lesions.
斑块旋切术最初的目的是通过积极的斑块减容来降低再狭窄率，而大型随机试验未能显示出斑块旋切术相对于球囊血管成形术有任何优势，这限制了其更广泛的应用。然而，由经验丰富的术者进行积极减容的单中心注册研究报告称，在支架置入前进行斑块旋切术时，在降低再狭窄率和改善临床结局方面取得了良好效果。斑块减容可降低斑块移位的可能性，并有助于随后的高压支架扩张，使血管内表面光滑，支撑内膜瓣，并防止弹性回缩。也有研究表明，斑块旋切术可在复杂病变（左前降支冠状动脉开口病变、左主干病变和分叉病变）的治疗中发挥作用，在这些病变中，斑块移位可能会影响手术效果。新一代设备表明，斑块旋切术甚至可安全有效地用于治疗相对较小的血管。在当前再狭窄率显著降低的药物洗脱支架时代，最佳的支架几何形状和最终管腔直径仍是再狭窄的重要预测因素。考虑到支架边缘的斑块移位在导致再狭窄方面可能发挥的作用，在复杂病变中，减容可增强局部药物效果。
