Bittl J A, Sanborn T A
Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115.
Circulation. 1992 Jul;86(1):71-80. doi: 10.1161/01.cir.86.1.71.
Excimer laser coronary angioplasty has been reported to be a promising treatment for complex coronary artery disease. The purpose of this study was to define the predictors of acute success and restenosis after this experimental intervention.
A cohort of 200 consecutive patients had a minimum of 6 months of follow-up evaluation after treatment of 215 coronary stenoses that were carefully selected for excimer laser coronary angioplasty. At the time of the initial procedure, the laser catheter alone produced a residual stenosis of less than or equal to 50% at 119 of 215 lesions (55.4%). For complete dilatation, 87.9% of the lesions required adjunctive balloon angioplasty. Clinical success was achieved in 183 of the 200 patients (91.5%), as indicated by a reduction by at least 20% of the narrowing of the vessel diameter, less than or equal to 50% residual stenosis, and no in-hospital complication. Complications included abrupt closure (5.0%), myocardial infarction (3.5%), bypass surgery (3.0%), perforation (2.0%), and death (0.0%). Logistic regression analysis showed that lesions at vessel bifurcations (success rate, 66%; adjusted odds ratio [OR] = 0.16; p = 0.002) or in tortuous vessels (success rate, 82%; OR = 0.48; p = 0.004) were associated with decreased clinical success. However, acceptable success rates were achieved in patients with lesions in saphenous vein grafts more than 3 years old (success rate, 94%; OR = 1.40; p = 0.75), in ostial lesions (success rate, 100%; OR = 3.36; p = 0.43), and in lesions longer than 10 mm (success rate, 93.5%; OR = 1.50; p = 0.39). Clinical follow-up was available in 197 of the 200 patients (98.5%) a mean of 5.9 +/- 1.9 months after angioplasty, at which time 31.0% of patients had developed symptoms or evidence of ischemia. No patient died during the study. Follow-up angiography was obtained in 83.1% of eligible patients after a mean [+/- SD] of 5.2 +/- 2.0 months. Angiographic restenosis, defined by greater than 50% stenosis, appeared at 78 of 164 lesions (47.6%). By logistic regression analysis, only lesions in saphenous vein grafts were associated with a decreased rate of restenosis (restenosis rate, 20%; OR = 0.18; p = 0.01).
This analysis, which defines the profile of risk for excimer laser angioplasty, provides a sound basis for rigorous comparison of adjunctive excimer laser with balloon angioplasty for ostial narrowings, long lesions, and saphenous vein graft stenoses.
据报道，准分子激光冠状动脉成形术是治疗复杂冠状动脉疾病的一种有前景的方法。本研究的目的是确定这种实验性干预后急性成功和再狭窄的预测因素。
连续200例患者在接受精心选择用于准分子激光冠状动脉成形术的215处冠状动脉狭窄治疗后，进行了至少6个月的随访评估。在初始手术时，仅激光导管在215处病变中的119处（55.4%）产生了小于或等于50%的残余狭窄。为实现完全扩张，87.9%的病变需要辅助球囊血管成形术。200例患者中有183例（91.5%）取得了临床成功，表现为血管直径狭窄至少降低20%、残余狭窄小于或等于50%且无院内并发症。并发症包括急性闭塞（5.0%）、心肌梗死（3.5%）、搭桥手术（3.0%）、穿孔（2.0%）和死亡（0.0%）。逻辑回归分析显示，血管分叉处的病变（成功率66%；调整优势比[OR]=0.16；p=0.002）或迂曲血管中的病变（成功率82%；OR=0.48；p=0.004）与临床成功率降低相关。然而，对于超过3年的大隐静脉移植血管病变患者（成功率94%；OR=1.40；p=0.75）、开口处病变患者（成功率100%；OR=3.36；p=0.43）以及长度超过10mm的病变患者（成功率93.5%；OR=1.50；p=0.39），均取得了可接受的成功率。200例患者中有197例（98.5%）进行了临床随访，平均随访时间为血管成形术后5.9±1.9个月，此时31.0%的患者出现了症状或缺血证据。研究期间无患者死亡。83.1%的符合条件患者在平均5.2±2.0个月后接受了随访血管造影。血管造影再狭窄定义为狭窄超过50%，在164处病变中的78处（47.6%）出现。通过逻辑回归分析，只有大隐静脉移植血管病变与再狭窄率降低相关（再狭窄率20%；OR=0.18；p=0.01）。
本分析确定了准分子激光血管成形术的风险特征，为严格比较辅助准分子激光与球囊血管成形术治疗开口处狭窄、长病变和大隐静脉移植血管狭窄提供了可靠依据。
