Strauss B H, Natarajan M K, Batchelor W B, Yardley D E, Bittl J A, Sanborn T A, Power J A, Watson L E, Moothart R, Tcheng J E
Division of Cardiology, St Michael's Hospital, University of Toronto, Ontario, Canada.
Circulation. 1995 Aug 1;92(3):348-56. doi: 10.1161/01.cir.92.3.348.
Percutaneous excimer laser coronary angioplasty (PELCA) has been approved for treatment of diseased saphenous vein bypass grafts. However, detailed and complete quantitative angiographic analysis of immediate procedural and late follow-up results has not been performed.
PELCA using the CVX-300 excimer laser system was performed in 125 bypass lesions (mean graft age, 96 +/- 53 months; range, 2 to 240 months) in 106 consecutive patients at eight centers. Quantitative analyses of the procedural and follow-up angiograms were done with the Cardiac Measurement System. Stand-alone PELCA was done in 21 lesions (17%). Lesions were located at the ostium (20%), body (67%), or distal anastomosis (13%). The graft reference diameter was 3.26 +/- 0.79 mm (mean +/- SD). Minimal lumen diameter increased from 1.09 +/- 0.52 mm before treatment to 1.61 +/- 0.69 mm after laser and 2.18 +/- 0.63 mm after adjunctive balloon dilation (P < .001) but had declined at follow-up to 1.40 +/- 1.17 mm. Dissections were evident in 45% of lesions after laser treatment (types A and B, 27%; types C through F, 18%), including 7% occlusions. Angiographic success (< or = 50% diameter stenosis [% DS]) was 54% after laser and 91% after adjunctive PTCA, with an overall clinical success rate of 89%. In-hospital complications were death, 0.9%; myocardial infarction (Q-wave and non-Q-wave), 4.5%; and bypass surgery, 0.9%. Independent predictors of % DS after laser were reference diameter, lesion length, and minimal lumen diameter before laser. At angiographic follow-up in 83% of eligible patients, the restenosis rate per lesion (DS > 50%) was 52%, including 23 occlusions (24%). The only independent predictor of increased % DS at follow-up was lesion symmetry. Logistic regression indicated that smaller reference diameter was an independent predictor of late occlusion. Overall 1-year mortality was 8.6%. Actuarial event-free survival (freedom from death, myocardial infarction, bypass surgery, or target vessel percutaneous transluminal coronary angioplasty) was 48.2% at 1 year.
Excimer laser angioplasty with adjunctive balloon angioplasty can be safely and successfully performed in diseased, old saphenous vein bypass graft lesions considered at high risk for reintervention. The extent of laser ablation remains limited by the diameter and effectiveness of the catheters. Late restenosis and, in particular, total occlusion mitigate the early benefits of the procedure. Other approaches such as the routine use of additional anticoagulation (eg, warfarin) should be considered to reduce the risk of late occlusions and restenosis after laser angioplasty of bypass grafts.
经皮准分子激光冠状动脉成形术（PELCA）已被批准用于治疗病变的大隐静脉旁路移植血管。然而，尚未对手术即刻及后期随访结果进行详细而全面的定量血管造影分析。
在八个中心对106例连续患者的125个旁路病变（平均移植血管年龄为96±53个月；范围为2至240个月）进行了使用CVX - 300准分子激光系统的PELCA。使用心脏测量系统对手术及随访血管造影进行定量分析。21个病变（17%）仅行PELCA。病变位于开口处（20%）、血管体部（67%）或远端吻合口（13%）。移植血管参考直径为3.26±0.79mm（平均值±标准差）。最小管腔直径从治疗前的1.09±0.52mm增加到激光治疗后的1.61±0.69mm以及辅助球囊扩张后的2.18±0.63mm（P<0.001），但在随访时降至1.40±1.17mm。激光治疗后45%的病变出现夹层（A和B型，27%；C至F型，18%），包括7%的闭塞。激光治疗后血管造影成功（直径狭窄率[DS]≤50%）为54%，辅助PTCA后为91%，总体临床成功率为89%。院内并发症包括死亡0.9%；心肌梗死（Q波和非Q波）4.5%；再次旁路手术0.9%。激光治疗后DS的独立预测因素为参考直径、病变长度和激光治疗前的最小管腔直径。在83%符合条件的患者进行血管造影随访时，每个病变的再狭窄率（DS>50%）为52%，包括23个闭塞（24%）。随访时DS增加的唯一独立预测因素为病变对称性。逻辑回归表明较小的参考直径是晚期闭塞的独立预测因素。总体1年死亡率为8.6%。1年时无事件生存（免于死亡、心肌梗死、旁路手术或靶血管经皮冠状动脉腔内血管成形术）的精算生存率为48.2%。
对于被认为再次干预风险高的病变、陈旧的大隐静脉旁路移植血管病变，准分子激光血管成形术联合辅助球囊血管成形术可安全、成功地进行。激光消融的程度仍受导管直径和有效性的限制。晚期再狭窄，尤其是完全闭塞减轻了该手术的早期益处。应考虑其他方法，如常规使用额外的抗凝治疗（如华法林）以降低旁路移植血管激光血管成形术后晚期闭塞和再狭窄的风险。
