Lincoff A M, Topol E J, Chapekis A T, George B S, Candela R J, Muller D W, Zimmerman C A, Ellis S G
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195.
J Am Coll Cardiol. 1993 Mar 15;21(4):866-75. doi: 10.1016/0735-1097(93)90341-w.
A case-control analysis was performed to compare clinical outcome after intracoronary stenting with that after conventional therapy for abrupt vessel closure.
Previous studies have demonstrated that stenting after abrupt vessel closure results in marked angiographic improvement and preservation of coronary flow, leading to the anticipation of similar improvement in clinical outcome.
Sixty-one of 92 consecutive patients treated at two clinical sites by intracoronary stenting for abrupt vessel closure were matched, according to angiographic features of closure and estimated left ventricular mass threatened by ischemia, with patients treated conventionally during the 18 months before stent availability. In 33 pairs of matched patients, vessel closure was established; in 28 pairs, it was threatened (coronary dissection or worsening stenosis with preservation of normal anterograde flow). Baseline clinical and angiographic characteristics were comparable in the two matched groups. Patients with indeterminate mechanisms of total occlusion (31%) or dissections < 15 mm long (43%) predominated; patients with visible thrombus (8%) or dissections > 15 mm long (18%) were infrequently represented. Stents were successfully deployed in 60 of 61 patients at a median of 52 min (range 3 to 269) after the onset of closure.
When compared with conventional treatment, stenting resulted in less residual stenosis (26% vs. 49% diameter stenosis, p < 0.001), a greater likelihood of restoration of Thrombolysis in Myocardial Infarction (TIMI) grade 3 blood flow (97% vs. 72%, p < 0.001) and a reduction in the need for emergency bypass surgery (4.9% vs. 18%, p = 0.02). However, the incidence of Q wave myocardial infarction was nearly the same in the two groups (32% vs. 20%, respectively, p = NS). In the group with stenting, peak creatine kinase level and the frequency of Q wave infarction after established vessel closure increased with the time to stent placement (p = 0.001 and 0.054, respectively); the incidence of procedure-related Q wave infarction in patients who underwent stenting within 45 min of closure was very low (3.9%). In-hospital death occurred in 3.3% of patients in each treatment group. At a mean of 6.3 months of follow-up after hospital discharge, survival free from late cardiac death, myocardial infarction, bypass surgery or coronary angioplasty was 74.9% and 81.3% in the stent and the control treatment group, respectively (p = NS).
Although early treatment of established vessel closure by intracoronary stenting was associated with a low incidence of both myocardial infarction and emergency bypass surgery, the likelihood or severity of infarction was not reduced among those in whom stents were implanted later. Patients with threatened vessel closure could not be shown to benefit from stent treatment. These data provide preliminary indications for stent placement in the acute period to be validated in larger randomized studies.
进行一项病例对照分析，比较冠状动脉内支架置入术后与传统疗法治疗血管急性闭塞后的临床结局。
既往研究表明，血管急性闭塞后行支架置入术可使血管造影有显著改善并维持冠状动脉血流，从而预期临床结局也会有类似改善。
在两个临床中心接受冠状动脉内支架置入术治疗血管急性闭塞的92例连续患者中，根据闭塞的血管造影特征以及受缺血威胁的估计左心室质量，与在支架可用前18个月内接受传统治疗的患者进行匹配。在33对匹配患者中，血管闭塞已确定；在28对中，血管闭塞受到威胁（冠状动脉夹层或狭窄加重但前向血流正常）。两个匹配组的基线临床和血管造影特征具有可比性。完全闭塞机制不明（31%）或夹层长度<15mm（43%）的患者占多数；有可见血栓（8%）或夹层长度>15mm（18%）的患者很少。61例患者中有60例在闭塞发生后中位时间52分钟（范围3至269分钟）成功置入支架。
与传统治疗相比，支架置入术导致残余狭窄更少（直径狭窄26%对49%，p<0.001），恢复心肌梗死溶栓（TIMI）3级血流的可能性更大（97%对72%，p<0.001），急诊搭桥手术需求减少（4.9%对18%，p = 0.02）。然而，两组Q波心肌梗死的发生率几乎相同（分别为32%和20%，p = 无显著性差异）。在支架置入组中，血管闭塞确定后肌酸激酶峰值水平和Q波梗死频率随支架置入时间增加（分别为p = 0.001和0.054）；在闭塞后45分钟内接受支架置入术的患者中，与手术相关的Q波梗死发生率非常低（3.9%）。各治疗组住院死亡率均为3.3%。出院后平均随访6.3个月时，支架置入组和对照治疗组无晚期心源性死亡、心肌梗死、搭桥手术或冠状动脉成形术的生存率分别为74.9%和81.3%（p = 无显著性差异）。
尽管冠状动脉内支架置入术早期治疗已确定的血管闭塞与心肌梗死和急诊搭桥手术的低发生率相关，但后期置入支架的患者中梗死的可能性或严重程度并未降低。血管闭塞受到威胁的患者未显示从支架治疗中获益。这些数据为急性期支架置入提供了初步指征，有待在更大规模的随机研究中验证。
