Boehrer J D, Ellis S G, Pieper K, Holmes D R, Keeler G P, Debowey D, Chapekis A T, Leya F, Mooney M R, Gottlieb R S
Department of Cardiology and Center for Thrombosis and Vascular Biology, Cleveland Clinic Foundation, Ohio, USA.
J Am Coll Cardiol. 1995 May;25(6):1380-6. doi: 10.1016/0735-1097(95)00008-r.
We hypothesized that atherectomy would be superior to balloon angioplasty for ostial and nonostial left anterior descending coronary artery lesions.
Balloon angioplasty of ostial coronary artery lesions has been associated with a lower procedural success rate and a higher rate of complications and of restenosis than angioplasty of nonostial stenoses. Directional coronary atherectomy has been proposed as an alternative therapy for ostial lesions.
In the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I), 1,012 patients were randomized to undergo either procedure; 563 patients had proximal left anterior descending coronary artery lesions, of which 74 were ostial. We compared balloon angioplasty with directional atherectomy for early and 6-month results for ostial as well as nonostial proximal left anterior descending coronary artery lesions.
Directional atherectomy led to an initially higher gain in minimal lumen diameter for ostial lesions (1.13 vs. 0.56 mm, respectively, p < 0.001) but a higher rate of adjudicated non-Q wave myocardial infarction (24% vs. 13%, respectively, p < 0.001) than balloon angioplasty and no improvement in restenosis rates (48% vs. 46%, respectively). In the nonostial proximal left anterior descending coronary artery lesions, angiographic restenosis was reduced (51% vs. 66%, p = 0.012), but this was also associated with a higher rate of periprocedural myocardial infarction (8% vs. 2%, p = 0.008 by site and 24% vs. 8%, p < 0.001 by adjudication) and no difference in the need for subsequent coronary artery bypass surgery (7.3% vs. 8.4%, respectively) or repeat percutaneous coronary intervention (24% vs. 26%, respectively).
For ostial left anterior descending coronary artery stenoses, both procedures yielded similar rates of initial success and restenosis, but atherectomy was associated with more non-Q wave myocardial infarction. In this trial the predominant angiographic benefit (increased early gain and less angiographic restenosis) of atherectomy for the left anterior descending coronary artery was in proximal nonostial lesions. However, the tradeoffs for this angiographic advantage were more in-hospital myocardial infarctions and no decrease in clinical restenosis.
我们推测，对于左前降支冠状动脉开口处及非开口处病变，旋切术优于球囊血管成形术。
与非开口处狭窄的血管成形术相比，冠状动脉开口处病变的球囊血管成形术手术成功率较低，并发症和再狭窄发生率较高。冠状动脉定向旋切术已被提议作为开口处病变的替代治疗方法。
在冠状动脉血管成形术与旋切术试验（CAVEAT-I）中，1012例患者被随机分配接受其中一种手术；563例患者有左前降支冠状动脉近端病变，其中74例为开口处病变。我们比较了球囊血管成形术与定向旋切术治疗开口处以及非开口处左前降支冠状动脉近端病变的早期和6个月结果。
对于开口处病变，定向旋切术最初使最小管腔直径增加更多（分别为1.13 mm和0.56 mm，p<0.001），但与球囊血管成形术相比，判定的非Q波心肌梗死发生率更高（分别为24%和13%，p<0.001），再狭窄率无改善（分别为48%和46%）。在非开口处左前降支冠状动脉近端病变中，血管造影再狭窄减少（51%对66%，p = 0.012），但这也与围手术期心肌梗死发生率较高有关（按部位分别为8%对2%，p = 0.008；按判定分别为24%对8%，p<0.001），后续冠状动脉搭桥手术的需求无差异（分别为7.3%和8.4%），重复经皮冠状动脉介入治疗的需求也无差异（分别为24%和26%）。
对于左前降支冠状动脉开口处狭窄，两种手术的初始成功率和再狭窄率相似，但旋切术与更多的非Q波心肌梗死相关。在本试验中，旋切术对左前降支冠状动脉的主要血管造影益处（早期增益增加和血管造影再狭窄减少）在于近端非开口处病变。然而，这种血管造影优势的权衡是更多的院内心肌梗死，且临床再狭窄无减少。
