Schofer J, Rau T, Schlüter M, Mathey D G
Center for Cardiology Othmarschen, Hamburg, Germany.
J Am Coll Cardiol. 1997 Dec;30(7):1722-8. doi: 10.1016/s0735-1097(97)00367-7.
This study sought to elucidate the short-term efficacy and intermediate-term outcome of excimer laser recanalization of chronic coronary artery occlusions in patients in whom attempts at mechanical revascularization had failed.
Recanalization of chronic coronary occlusions with the use of a mechanical guide wire fails in 30% to 50% of cases, mostly because of inability to pass the wire through the lesion. The value of using excimer laser energy in this setting has not yet been determined.
The study group comprised 66 consecutive patients with 68 chronic coronary occlusions. Patients were eligible for inclusion in the study if a previous attempt at mechanical revascularization had failed and if their angiographic status was such that 1) the vessel segment distal to the occlusion could be visualized by way of collateral vessels, 2) the entry point of the occlusion was clearly outlined, and 3) not more than one anatomic bend was expected within the occlusion. Excimer laser energy was applied to the lesion through a 0.018-in. (0.046 cm) fiber-optic guide wire. Adjunctive balloon angioplasty and stenting were performed in all successfully treated patients but one.
Thirty-four occlusions (50%) in 32 patients (48%) could be crossed with the laser wire. Location and age of the occlusion had no adverse influence on the outcome of laser wire recanalization, nor did the presence of bridging collateral vessels, a major side branch at the site of the lesion or a blunt stump of the occlusion. An inverse relation was found between the success rate and the length of the occlusion, such that a 19% reduction of the success rate accompanied each 10-mm increment of the mean occlusion length. Thus, the success rate was 68% for lesions < or = 10 mm but only 25% for lesions > 30 to < or = 40 mm. The presence of a bend in the lesion exceeding 60 degrees was strongly related to procedural failure. During a median angiographic follow-up period of 18 weeks, restenosis > 50% (n = 6) or reocclusion (n = 4) was found in 10 of the 32 successfully treated patients, for an intermediate-term success rate of 33% (22 of 66). Clinical follow-up revealed improved anginal status in 21 patients (66%) after a median of 24 weeks. Major complications (death, myocardial infarction, emergency operation) were not encountered.
Successful recanalization of a chronic coronary occlusion by using currently available laser wires can be expected in 50% of selected patients in whom attempts at mechanical revascularization fail. Restenosis or reocclusion accounts for an overall 6-month success rate of 35%.
本研究旨在阐明准分子激光再通慢性冠状动脉闭塞病变的短期疗效和中期结果，这些患者的机械血运重建尝试已失败。
使用机械导丝再通慢性冠状动脉闭塞病变的成功率在30%至50%，主要原因是导丝无法通过病变部位。在此情况下使用准分子激光能量的价值尚未确定。
研究组包括66例连续患者，共68处慢性冠状动脉闭塞病变。若患者先前的机械血运重建尝试失败，且其血管造影情况满足以下条件，则符合纳入研究标准：1）闭塞远端血管段可通过侧支血管显影；2）闭塞入口点清晰；3）闭塞段预计不超过一个解剖学弯曲。通过0.018英寸（0.046厘米）光纤导丝向病变部位施加准分子激光能量。除1例成功治疗的患者外，所有患者均接受了辅助球囊血管成形术和支架置入术。
32例患者（48%）的34处闭塞病变（50%）可被激光导丝穿过。闭塞病变的位置和患者年龄对激光导丝再通结果无不良影响，病变部位的桥接侧支血管、主要分支或闭塞钝端的存在也无影响。成功率与闭塞长度呈反比关系，平均闭塞长度每增加10毫米，成功率降低19%。因此，长度≤10毫米的病变成功率为68%，而长度＞30至≤40毫米的病变成功率仅为25%。病变处存在超过60度的弯曲与手术失败密切相关。在血管造影中位随访期18周时，32例成功治疗患者中有10例出现＞50%的再狭窄（n = 6）或再闭塞（n = 4），中期成功率为33%（66例中的22例）。临床随访显示，中位随访24周后，21例患者（66%）的心绞痛症状改善。未发生主要并发症（死亡、心肌梗死、急诊手术）。
对于机械血运重建尝试失败的特定患者，使用现有激光导丝可使50%的慢性冠状动脉闭塞病变成功再通。再狭窄或再闭塞导致总体6个月成功率为35%。
