Bauters C, Passart F, Lablanche J M, McFadden E P, Hamon M, Bertrand M E
Service de Cardiologie B et Hémodynamique, Hôpital Cardiologique, Lille, France.
Eur Heart J. 1996 Nov;17(11):1671-7. doi: 10.1093/oxfordjournals.eurheartj.a014750.
We hypothesized that percutaneous transluminal coronary angioplasty performed on coronary stenoses that have demonstrated rapid angiographic progression would be associated with a high risk of restenosis.
High rates of restenosis have been documented after percutaneous transluminal coronary angioplasty of unstable lesions and of lesions that recur rapidly after a successful initial angioplasty. This suggests that the "activity' of the plaque at the time of angioplasty may be an important factor determining the risk of restenosis.
In our institution we recommend angiographic follow-up for all patients with successful percutaneous transluminal coronary angioplasty. In this way we identified 86 consecutive patients who, at the time of angiographic follow-up had not developed restenosis at the dilated site, but required a further percutaneous transluminal coronary angioplasty at a different site. (which was successful). Based on quantitative angiographic measurements, 45 of these lesions (rapidly progressive lesions) had significantly increased in severity in the interval between the two angiograms (7.7 +/- 3.3 months) while 41 (stable lesions) had not. Rapid progression was defined as a > 0.4 mm decrease in minimal lumen diameter between initial angiography and percutaneous transluminal coronary angioplasty. All 86 patients had further angiographic follow-up 6 months later.
Baseline clinical and angiographic variables were similar in both groups except that a higher proportion of patients in the rapid progression group had unstable angina (20% vs 5%; P < 0.05). Late loss during follow-up did not differ statistically between groups (0.31 mm) and minimal lumen diameter at follow-up was also similar (stable lesion group = 1.40 +/- 0.48 mm; rapidly progressive lesion group = 1.30 +/- 0.59 mm). The loss index (late loss divided by acute gain) was also similar in both groups (0.45 +/- 0.52 in the stable lesion group, 0.37 +/- 0.76 in the rapidly progressive lesion group). A strong correlation between acute gain and late loss was observed in the stable lesion group (r = 0.61; P < 0.0001); by contrast, there was no relationship between these two variables in the rapidly progressive lesion group (r = 0.20; P = 0.19).
Percutaneous transluminal coronary angioplasty in patients with unstable angina or with early recurrence after a first percutaneous transluminal coronary angioplasty is associated with an increased risk of restenosis. By contrast, this study shows that angiographic instability, as evidenced by rapid stenosis progression, has no deleterious effect on the occurrence of restenosis. Percutaneous transluminal coronary angioplasty thus appears as a reasonable therapeutic option for coronary stenoses that have demonstrated rapid angiographic progression in the months prior to the procedure.
我们推测，对已显示出快速血管造影进展的冠状动脉狭窄进行经皮腔内冠状动脉成形术（PTCA）会与高再狭窄风险相关。
在对不稳定病变以及首次成功血管成形术后迅速复发的病变进行经皮腔内冠状动脉成形术后，已记录到高再狭窄率。这表明血管成形术时斑块的“活性”可能是决定再狭窄风险的一个重要因素。
在我们机构，我们建议对所有成功进行经皮腔内冠状动脉成形术的患者进行血管造影随访。通过这种方式，我们确定了86例连续患者，这些患者在血管造影随访时，扩张部位未发生再狭窄，但需要在不同部位进一步进行经皮腔内冠状动脉成形术（且手术成功）。基于定量血管造影测量，在这两个血管造影检查之间的间隔期（7.7±3.3个月），这些病变中有45个（快速进展性病变）严重程度显著增加，而41个（稳定病变）则没有。快速进展定义为初始血管造影与经皮腔内冠状动脉成形术之间最小管腔直径减小>0.4mm。所有86例患者在6个月后进一步进行了血管造影随访。
两组的基线临床和血管造影变量相似，只是快速进展组中不稳定型心绞痛患者的比例更高（20%对5%；P<0.05）。随访期间的晚期管腔丢失在两组之间无统计学差异（0.31mm），随访时的最小管腔直径也相似（稳定病变组=1.40±0.48mm；快速进展性病变组=1.30±0.59mm）。两组的丢失指数（晚期管腔丢失除以急性管腔获得）也相似（稳定病变组为0.45±0.52，快速进展性病变组为0.37±0.76）。在稳定病变组中观察到急性管腔获得与晚期管腔丢失之间有很强的相关性（r=0.61；P<0.0001）；相比之下，在快速进展性病变组中这两个变量之间没有关系（r=0.20；P=0.19）。
不稳定型心绞痛患者或首次经皮腔内冠状动脉成形术后早期复发患者进行经皮腔内冠状动脉成形术与再狭窄风险增加相关。相比之下，本研究表明，如快速狭窄进展所证明的血管造影不稳定性对再狭窄的发生没有有害影响。因此，对于在手术前几个月已显示出快速血管造影进展的冠状动脉狭窄，经皮腔内冠状动脉成形术似乎是一种合理的治疗选择。
