Department of Medicine, Division of Cardiology, Emory University School of Medicine, Emory Heart and Vascular Center, Atlanta, Georgia, USA.
Catheter Cardiovasc Interv. 2023 Nov;102(6):997-1003. doi: 10.1002/ccd.30855. Epub 2023 Oct 27.
The safety and efficacy of intravascular lithotripsy (IVL) for the treatment of calcified distal left main (LM) disease remains unclear, especially compared to rotational atherectomy (RA).
We retrospectively analyzed the baseline clinical, angiographic, intravascular ultrasound (IVUS) characteristics and procedural outcomes of 107 patients who underwent distal LM percutaneous coronary intervention (PCI) with IVL (with or without adjunct atherectomy) versus RA alone for plaque modification before stenting at a single center between 2020 and 2022.
A total of 50 patients underwent calcium modification with IVL with or without adjunct atherectomy and 57 with RA only. The mean age was 73 years and with a high prevalence of diabetes (58.9%), chronic kidney disease (42.1%), prior revascularization (coronary artery bypass graft surgery [36.4%] or prior PCI [32.7%]). Acute coronary syndrome was the primary indication for PCI in over 50% of the patients in both groups. Medina 1-1-1 LM bifurcation disease was identified in 64% and 60% of the IVL and RA groups (p = 0.64) respectively. Final minimum stent area in distal LM (>8.2 mm ), ostial LAD (>6.3 mm ) and ostial LCX (>5.0 mm ) were achieved in 96%, 85% and 89% of cases treated with IVL respectively and 93%, 93% and 100% of cases treated with RA respectively (LM p = 1.00; LAD p = 0.62; LCX; p = 1.00 for difference between the two groups). Procedural success (technical success without in-hospital major adverse events) was achieved in 98% of the IVL group and 86% of the RA-only group (p = 0.04). There were eight procedural complications (flow-limiting dissection, perforation, or slow/no-reflow) in the RA group compared to four in the IVL group (NS), and one patient in the RA required salvaged mechanical support compared to none in the IVL group.
Plaque modification with coronary IVL appears to be efficacious and safe for the treatment of severely calcified distal LM lesions compared to RA only. Larger randomized studies are needed to confirm these findings.
血管内碎石术（IVL）治疗钙化的左主干（LM）远段的安全性和疗效尚不清楚，尤其是与旋磨术（RA）相比。
我们回顾性分析了 2020 年至 2022 年期间在一家中心接受经皮冠状动脉介入治疗（PCI）的 107 例患者的基线临床、血管造影、血管内超声（IVUS）特征和手术结果，这些患者因斑块修饰而在支架置入前行 LM 远段 PCI，其中 50 例患者采用 IVL（伴或不伴辅助旋磨术）进行钙修饰，57 例患者仅采用 RA。
共 50 例患者采用 IVL 进行钙修饰，伴或不伴辅助旋磨术，57 例患者仅采用 RA。平均年龄为 73 岁，糖尿病（58.9%）、慢性肾脏病（42.1%）、既往血运重建（冠状动脉旁路移植术[36.4%]或既往 PCI[32.7%]）的患病率较高。两组中超过 50%的患者因急性冠脉综合征而接受 PCI。在 IVL 和 RA 组中，分别有 64%和 60%的患者存在 Medina 1-1-1 LM 分叉病变（p=0.64）。在接受 IVL 治疗的患者中，96%、85%和 89%的患者在 LM 远段（>8.2mm）、LAD 开口（>6.3mm）和 LCX 开口（>5.0mm）获得了最终最小支架面积，而接受 RA 治疗的患者中，分别有 93%、93%和 100%的患者获得了最终最小支架面积（LM p=1.00；LAD p=0.62；LCX p=1.00 为两组间差异）。IVL 组的手术成功率（无院内重大不良事件的技术成功）为 98%，RA 组为 86%（p=0.04）。RA 组有 8 例手术并发症（血流受限夹层、穿孔或慢/无复流），IVL 组有 4 例（无统计学差异），RA 组有 1 例患者需要挽救性机械支持，而 IVL 组无此类患者。
与单纯 RA 相比，冠状动脉 IVL 进行斑块修饰治疗严重钙化的 LM 远段病变似乎是有效且安全的。需要更大规模的随机研究来证实这些发现。
