Kuiper Karel K J, Salem Mohamed, Rotevatn Svein, Mills Joseph, Nordrehaug Jan Erik
Department of Heart Disease, Haukeland University Hospital, N-5021 Bergen, Norway.
Cardiovasc Revasc Med. 2007 Jan-Mar;8(1):9-14. doi: 10.1016/j.carrev.2006.10.001.
The deployment of drug-eluting stents (DES) to treat bare-metal stent restenosis [in-stent restenosis (ISR)] has become routine practice, with a consequential decline in the use of intracoronary brachytherapy (ICBT). However, there are concerns as to the long-term safety profile of DES, particularly in terms of late stent thrombosis. In addition, an appropriate treatment strategy for stenosis within DES has not been developed. The aim of this study was to examine the efficacy of best treatment with ICBT for ISR in patients at high risk for future recurrence.
Forty-seven consecutive patients with symptomatic ISR with at least one or more increased risk criteria for recurrence were treated with beta-radiation. The patients received best treatment based on avoidance of previously reported procedural risk factors for recurrence (incomplete stent apposition, dissection, geographical miss, and damage to the noninjured vessel segment), deferring ICBT when provisional stenting was performed. A beta-radiation dose of 20 Gy was used, and clopidogrel was prescribed for at least 6 months.
Treatment was successful for all patients without in-hospital complications. ICBT increased the total intervention procedure time by 15+/-10 min. ISR length was 25.4+/-11.5 mm. The angiographic minimal luminal diameter (MLD) was 2.24+/-0.43 mm after ICBT versus 0.75+/-0.58 mm at baseline (P<.05). On 9-month follow-up, the MLD was 1.93+/-0.48 mm (P<.05 vs. baseline). Binary restenosis was detected in six (13%) patients. At 29.7+/-9.3 months of follow-up, target lesion revascularization or target vessel (nonlesion) revascularization was performed in 17 (36%) patients. Only one patient suffered a myocardial infarction, and no deaths were observed.
The adoption of a best-practice protocol for the use of ICBT to treat ISR can result in a safe and effective clinical and angiographic outcome. Under these circumstances and with appropriate patient selection, ICBT may continue to be of value despite the popular use of DES.
药物洗脱支架（DES）用于治疗裸金属支架再狭窄（支架内再狭窄，ISR）已成为常规操作，冠状动脉内近距离放射治疗（ICBT）的使用相应减少。然而，人们对DES的长期安全性存在担忧，尤其是晚期支架血栓形成方面。此外，尚未制定针对DES内狭窄的合适治疗策略。本研究的目的是检验ICBT最佳治疗方案对未来复发高危患者ISR的疗效。
连续47例有症状的ISR患者，至少有一项或多项复发风险增加标准，接受了β射线放射治疗。患者接受基于避免先前报道的复发程序性危险因素（支架贴壁不全、夹层、边缘遗漏和未损伤血管段损伤）的最佳治疗，进行临时支架置入时推迟ICBT。使用20 Gy的β射线放射剂量，氯吡格雷至少服用6个月。
所有患者治疗成功，无院内并发症。ICBT使总干预操作时间增加15±10分钟。ISR长度为25.4±11.5毫米。ICBT后血管造影最小管腔直径（MLD）为2.24±0.43毫米，而基线时为0.75±0.58毫米（P<0.05）。在9个月随访时，MLD为1.93±0.48毫米（与基线相比P<0.05）。6例（13%）患者检测到二元再狭窄。在29.7±9.3个月随访时，17例（36%）患者进行了靶病变血运重建或靶血管（非病变）血运重建。仅1例患者发生心肌梗死，未观察到死亡病例。
采用ICBT治疗ISR的最佳实践方案可带来安全有效的临床和血管造影结果。在这种情况下，且选择合适的患者，尽管DES广泛使用，ICBT可能仍有价值。
