Levine G N, Chodos A P, Loscalzo J
Evans Department of Medicine, Boston University School of Medicine, Massachusetts, USA.
Clin Cardiol. 1995 Dec;18(12):693-703. doi: 10.1002/clc.4960181203.
Restenosis following angioplasty is an iatrogenic disease of increasing frequency. Restenosis may be defined in terms of either angiographic or clinical criteria. Definitions of angiographic restenosis have varied in different studies, accounting in part for the differences in reported restenosis rates. Most studies now define angiographic restenosis as either a > 50% loss of initial gain or an absolute lesion stenosis of > or = 50% at follow-up angiogram. Common clinical end points used in defining restenosis include recurrent angina, need for repeat revascularization, or myocardial infarction. Despite technical advances and multiple pharmacologic interventions, most studies have found that the incidence of angiographic restenosis remains in the range of 40%; in none of these studies, however, was complete angiographic follow-up obtained, and thus actual restenosis rates may be somewhat higher. In several studies, clinical restenosis has been found to occur in approximately 36-40% of patients. Thus, a minority of patients with angiographic restenosis have no clinical manifestations. Most patients who develop symptoms of restenosis develop these symptoms within the first 3 months after angioplasty. The presenting symptom in the majority of these patients is progressive exertional angina. Patients occasionally will present with unstable angina and only rarely with acute myocardial infarction. In patients who present with recurrent chest pain, several features have been found to be helpful in predicting whether they will have angiographic restenosis at follow-up angiography. Patients who present 1-6 months after angioplasty with typical anginal symptoms have a high likelihood of having angiographic restenosis. By contrast, patients who present more than 6 months after percutaneous transluminal coronary angioplasty with recurrent chest pain are more likely to have new, significant coronary lesions to account for their symptoms. Noninvasive testing in patients with clinical presentations suggestive of restenosis can, in general, add only modest information in predicting whether restenosis is indeed present. A negative exercise thallium test appears to have a high specificity in ruling out restenosis and may be helpful in patients who present with more atypical symptoms. Repeat angioplasty is the therapy most frequently utilized to treat restenosis, although coronary artery bypass surgery or medical therapy may be reasonable alternative therapies. Clinical success rates with repeat angioplasty are > 90%, and major complications are rare; however, restenosis will recur in a significant percentage of these patients. Some patients who develop such recurrent restenoses will ultimately benefit from a strategy of repeat angioplasties, although many will require surgical revascularization.
血管成形术后再狭窄是一种发病率不断上升的医源性疾病。再狭窄可根据血管造影或临床标准来定义。不同研究中血管造影再狭窄的定义各不相同，这在一定程度上解释了所报道的再狭窄率的差异。现在大多数研究将血管造影再狭窄定义为初始增益丧失>50%或随访血管造影时绝对病变狭窄≥50%。用于定义再狭窄的常见临床终点包括复发性心绞痛、再次血管重建的需求或心肌梗死。尽管技术取得了进步，并且有多种药物干预措施，但大多数研究发现血管造影再狭窄的发生率仍在40%左右；然而，在这些研究中均未获得完整的血管造影随访结果，因此实际的再狭窄率可能会略高一些。在几项研究中，发现临床再狭窄发生在约36% - 40%的患者中。因此，少数血管造影再狭窄的患者没有临床表现。大多数出现再狭窄症状的患者在血管成形术后的前3个月内出现这些症状。这些患者中的大多数出现的症状是进行性劳力性心绞痛。患者偶尔会出现不稳定型心绞痛，很少出现急性心肌梗死。在出现复发性胸痛的患者中，已发现有几个特征有助于预测他们在随访血管造影时是否会出现血管造影再狭窄。血管成形术后1 - 6个月出现典型心绞痛症状的患者很可能有血管造影再狭窄。相比之下，经皮腔内冠状动脉成形术后6个月以上出现复发性胸痛的患者更可能有新的、严重的冠状动脉病变来解释他们的症状。对于临床表现提示再狭窄的患者，一般来说，非侵入性检查在预测是否确实存在再狭窄方面只能提供有限的信息。运动铊试验阴性在排除再狭窄方面似乎具有较高的特异性，可能对出现更不典型症状的患者有帮助。重复血管成形术是治疗再狭窄最常用的方法，尽管冠状动脉旁路手术或药物治疗可能是合理的替代疗法。重复血管成形术的临床成功率>90%，主要并发症很少见；然而，这些患者中有相当比例会再次出现再狭窄。一些出现这种复发性再狭窄的患者最终将从重复血管成形术的策略中获益，尽管许多患者将需要手术血管重建。
