血管内超声指导与单独血管造影指导相比，可改善行经皮冠状动脉介入治疗的无保护左主干患者的预后。
Intravascular Ultrasound Guidance Is Associated With Better Outcome in Patients Undergoing Unprotected Left Main Coronary Artery Stenting Compared With Angiography Guidance Alone.
机构信息
From the Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Sweden (P.A., S.K., M.A.M., M.G., S.K., D.E.); Department of Medical Sciences, Uppsala University, Sweden (S.J., B.L.); Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, and Unit of Medicine, Capio St Görans Sjukhus, Stockholm, Sweden (J.J.); Department of Cardiology, Faculty of Health, Örebro University, Sweden (O.F.); Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden (O.A., E.O.); University and Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., E.O.); Department of Cardiology, Umeå University Hospital, Heart Centre, Sweden (J.N.); and Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden (J.P.).
出版信息
Circ Cardiovasc Interv. 2017 May;10(5). doi: 10.1161/CIRCINTERVENTIONS.116.004813.
BACKGROUND
Small observational studies have indicated better outcome with intravascular ultrasound (IVUS) guidance when performing unprotected left main coronary artery (LMCA) percutaneous coronary intervention (PCI), but the overall picture remains inconclusive and warrants further investigation. We studied the impact of IVUS guidance on outcome in patients undergoing unprotected LMCA PCI in a Swedish nationwide observational study.
METHODS AND RESULTS
Patients who underwent unprotected LMCA PCI between 2005 and 2014 because of stable coronary artery disease or acute coronary syndrome were included from the nationwide SCAAR (Swedish Coronary Angiography and Angioplasty Registry). Of 2468 patients, IVUS guidance was used in 621 (25.2%). The IVUS group was younger (median age, 70 versus 75 years) and had fewer comorbidities but more complex lesions. IVUS was associated with larger stent diameters (median, 4 mm versus 3.5 mm). After adjusting for potential confounders, IVUS was associated with significantly lower occurrence of the primary composite end point of all-cause mortality, restenosis, or definite stent thrombosis (hazard ratio, 0.65; 95% confidence interval, 0.50-0.84) and all-cause mortality alone (hazard ratio, 0.62; 95% confidence interval, 0.47-0.82). In 340 propensity score-matched pairs, IVUS was also associated with significantly lower occurrence of the primary end point (hazard ratio, 0.54; 95% confidence interval, 0.37-0.80).
CONCLUSIONS
IVUS was associated with an independent and significant outcome benefit when performing unprotected LMCA PCI. Potential mediators of this benefit include larger and more appropriately sized stents, perhaps translating into lower risk of subsequent stent thrombosis. Although residual confounding cannot be ruled out, our findings indicate a possible hazard when performing unprotected LMCA PCI without IVUS guidance.
背景
小型观察性研究表明，在进行无保护左主干冠状动脉（LMCA）经皮冠状动脉介入治疗（PCI）时，血管内超声（IVUS）指导可获得更好的结果，但总体情况仍不确定，需要进一步研究。我们在一项瑞典全国性观察性研究中研究了 IVUS 指导对接受无保护 LMCA PCI 患者结局的影响。
方法和结果
该研究纳入了 2005 年至 2014 年期间因稳定型冠状动脉疾病或急性冠状动脉综合征而接受无保护 LMCA PCI 的全国性 SCAAR（瑞典冠状动脉血管造影和血管成形术登记处）患者。在 2468 例患者中，621 例（25.2%）接受了 IVUS 指导。IVUS 组患者年龄较小（中位数年龄为 70 岁 vs 75 岁），合并症较少，但病变更复杂。IVUS 与更大的支架直径相关（中位数为 4 毫米 vs 3.5 毫米）。调整潜在混杂因素后，IVUS 与主要复合终点（全因死亡率、再狭窄或明确支架血栓形成）和全因死亡率的发生显著降低相关（风险比为 0.65；95%置信区间为 0.50-0.84）。在 340 对倾向评分匹配的患者中，IVUS 也与主要终点的发生显著降低相关（风险比为 0.54；95%置信区间为 0.37-0.80）。
结论
在进行无保护 LMCA PCI 时，IVUS 与独立且显著的结局获益相关。这种获益的潜在介导因素包括更大和更合适的支架，这可能降低随后发生支架血栓形成的风险。尽管不能排除残余混杂因素，但我们的研究结果表明，在没有 IVUS 指导的情况下进行无保护 LMCA PCI 可能存在风险。
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