Basso C, Ramondo A, Angelini A, Chioin R, Valente M, Thiene G
Divisione di Cardiologia, Università Degli Studi, Padova.
G Ital Cardiol. 1993 Nov;23(11):1079-90.
The coronary arteries from the hearts of 7 patients, 6 male and 1 female, age ranging from 39 to 69 years (mean 56), who died early or in the mid term from percutaneous transluminal coronary angioplasty (PTCA), were investigated by histology, immunohistochemistry and electron microscopy. Atherosclerotic coronary artery disease was present in all: single vessel disease in 2 and double vessel disease in 5. Indication to PTCA was stable angina in 1 patient, unstable angina in 2, postinfarction angina in 2 and acute myocardial infarction in the remaining 2. Thrombolysis was an associated procedure in 3 cases. Time interval between PTCA and death was less than 48 hours in 6, and 4 months in 1. Cause of death was myocardial infarction due to coronary occlusion complicating PTCA in 3 patients, and myocardial infarctions preceding PTCA in 4 patients. 9 coronary segments underwent dilatation: 5 in the anterior descending coronary artery, 3 in the right coronary artery and 1 in the left circumflex artery. Angiographically, the PTCA had been effective (decrease of stenosis > or = 40%) in 5 and failed in 4. Basically, the atherosclerotic plaques were eccentric in 3 and concentric in 6; the histotype was fibrotic in 4, atheromatous in 4 and fibro-atheromatous in 1. Only one case did not show any complication and the dilatation was effective as a consequence of plaque compression and stretching of the underlying tunica media. Complications observed in the other cases with early death consisted of: a) plaque cracks with intimal flaps and hematomas in all 6; b) laceration of the tunica media, even of the disease-free wall, with dissecting hematoma in 2; c) occlusive thrombosis in 3 and d) atheroembolism in 1. The 4 coronary segments, which appeared occluded angiographically soon after PTCA, were clinically interpreted as dissection in 3 and thrombosis in 1, whereas at histology the closing mechanism was an intimal hematoma with flap in 2, occlusive thrombosis in 1, and medio-adventitial dissecting hematoma with thrombosis in 1. Only ruptures of atheromatous plaques were complicated by thrombosis. The patient who died at 4 months exhibited a pattern of restenosis due to intimal smooth muscle cell proliferation. In conclusion, our postmortem study shows that PTCA may be associated with severe damage of the coronary artery consisting of plaque crack and laceration even of the disease-free wall, intimal and medial hematomas, thrombosis and atheroembolism.(ABSTRACT TRUNCATED AT 400 WORDS)
对7例患者（6例男性，1例女性，年龄39至69岁，平均56岁）的心脏冠状动脉进行了研究。这些患者均因经皮腔内冠状动脉成形术（PTCA）过早或中期死亡。研究采用了组织学、免疫组织化学和电子显微镜检查方法。所有患者均患有动脉粥样硬化性冠状动脉疾病：2例为单支血管病变，5例为双支血管病变。PTCA的适应证为：1例患者为稳定型心绞痛，2例为不稳定型心绞痛，2例为梗死后心绞痛，其余2例为急性心肌梗死。3例患者同时进行了溶栓治疗。PTCA与死亡之间的时间间隔，6例小于48小时，1例为4个月。3例患者的死亡原因是PTCA术后冠状动脉闭塞并发心肌梗死，4例患者是PTCA术前就存在心肌梗死。9个冠状动脉节段接受了扩张：5个在前降支冠状动脉，3个在右冠状动脉，1个在左旋支冠状动脉。血管造影显示，PTCA治疗有效的有5例（狭窄降低≥40%），无效的有4例。基本上，动脉粥样硬化斑块3例为偏心性，6例为同心性；组织学类型4例为纤维性，4例为粥样性，1例为纤维粥样性。只有1例未出现任何并发症，扩张有效是由于斑块受压和下层中膜伸展。其他早期死亡病例观察到的并发症包括：a）所有6例均有斑块破裂伴内膜瓣和血肿；b）2例中膜撕裂，甚至在无病变的血管壁，伴有夹层血肿；c）3例有闭塞性血栓形成；d）1例有动脉粥样硬化栓塞。PTCA术后血管造影很快显示闭塞的4个冠状动脉节段，临床诊断3例为夹层，1例为血栓形成，而组织学检查发现，闭塞机制2例为内膜血肿伴瓣形成，1例为闭塞性血栓形成，1例为中膜-外膜夹层血肿伴血栓形成。只有粥样斑块破裂并发血栓形成。4个月时死亡的患者表现为内膜平滑肌细胞增殖导致的再狭窄模式。总之，我们的尸检研究表明，PTCA可能与冠状动脉的严重损伤有关，包括斑块破裂甚至无病变血管壁的撕裂、内膜和中膜血肿、血栓形成和动脉粥样硬化栓塞。（摘要截选至400字）
