Department of Cardiology and the Department of Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, Korea.
Circ Cardiovasc Interv. 2011 Dec 1;4(6):562-9. doi: 10.1161/CIRCINTERVENTIONS.111.964643. Epub 2011 Nov 1.
We assessed the optimal intravascular ultrasound (IVUS) stent area to predict angiographic in-stent restenosis (ISR) after sirolimus-eluting stent implantation for unprotected left main coronary artery (LM) disease.
A total of 403 patients treated with single- or 2-stent strategies (crushing and T-stent) had immediate poststenting IVUS and 9-month follow-up angiography. Poststenting minimal stent area (MSA) was measured in each of 4 segments: ostial left anterior descending (LAD), ostial left circumflex (LCX) polygon of confluence (POC, confluence zone of LAD and LCX), and proximal LM above the POC. Overall, 46 (11.4%) showed angiographic restenosis at 9 months: 3 of 67 (4.5%) nonbifurcation lesions treated with a single-stent, 14 of 222 (6.3%) bifurcation lesions treated with single-stent crossover, and 29 of 114 (25.4%) of bifurcation lesions treated with 2 stents. The MSA cutoffs that best predicted ISR on a segmental basis were 5.0 mm(2) (ostial LCX ISR), 6.3 mm(2) (ostial LAD ISR), 7.2 mm(2) (ISR within the POC), and 8.2 mm(2) (ISR within the LM above the POC). Using these criteria, 133 (33.8%) had underexpansion of at least 1 segment. Angiographic ISR (at any location) was more frequent in lesions with underexpansion of at least 1 segment versus lesions with no underexpansion (24.1% versus 5.4%, P<0.001). Two-year major adverse coronary event-free survival rate was significantly lower in patients with underexpansion of at least 1 segment versus lesions with no underexpansion (90±3% versus 98±1%, log-rank P<0.001), and poststenting underexpansion was an independent predictor for major adverse cardiac events (adjusted hazard ratio, 5.56; 95% confidence interval, 1.99-15.49; P=0.001).
With these criteria, IVUS optimization during LMCA stenting procedures may improve clinical outcomes.
我们评估了血管内超声（IVUS）支架面积的最佳值，以预测无保护左主干冠状动脉（LMCA）病变行西罗莫司洗脱支架置入术后的血管造影内支架再狭窄（ISR）。
共 403 例患者采用单支架或 2 支架策略（挤压和 T 支架）进行治疗，支架置入后即刻行 IVUS 检查，9 个月时行血管造影随访。在 4 个节段测量支架置入后最小支架面积（MSA）：左前降支（LAD）开口、左回旋支（LCX）开口的多边形汇合处（POC，LAD 和 LCX 的汇合区），以及 POC 上方的近端 LMCA。总的来说，9 个月时共有 46 例（11.4%）出现血管造影再狭窄：单支架治疗的 67 例非分叉病变中有 3 例（4.5%），单支架交叉的 222 例分叉病变中有 14 例（6.3%），2 支架治疗的 114 例分叉病变中有 29 例（25.4%）。基于节段的 ISR 最佳预测的 MSA 截断值为 5.0 mm²（LCX 开口 ISR）、6.3 mm²（LAD 开口 ISR）、7.2 mm²（POC 内 ISR）和 8.2 mm²（POC 上方 LMCA 内 ISR）。根据这些标准，133 例（33.8%）至少有 1 个节段支架扩张不足。与无支架扩张不足的病变相比，至少有 1 个节段支架扩张不足的病变发生血管造影 ISR（任何部位）的频率更高（24.1%比 5.4%，P<0.001）。与无支架扩张不足的病变相比，至少有 1 个节段支架扩张不足的患者 2 年主要不良心脏事件无复发生存率显著降低（90±3%比 98±1%，log-rank P<0.001），支架置入后支架扩张不足是主要不良心脏事件的独立预测因素（校正危险比，5.56；95%置信区间，1.99-15.49；P=0.001）。
根据这些标准，LMCA 支架置入术中的 IVUS 优化可能会改善临床结果。
