Bramucci E, Angoli L, Merlini P A, Barberis P, Laudisa M L, Colombi E, Poli A, Kubica J, Ardissino D
Division of Cardiology, IRCCS, Policlinico San Matteo, Pavia, Italy.
J Am Coll Cardiol. 1998 Dec;32(7):1855-60. doi: 10.1016/s0735-1097(98)00485-9.
This prospective case-control study evaluated the acute and long-term results of stent implantation preceded by debulking of the plaque by means of directional coronary atherectomy.
In comparison with balloon angioplasty, intracoronary stenting produces a larger luminal diameter, maintains artery patency and reduces the incidence of restenosis. Optimal stent deployment is a pivotal factor for achieving the best results, but the bulk of the atherosclerotic plaque opposes stent expansion and may limit the success of the procedure. Debulking of the plaque may provide a better milieu for optimal stent deployment.
Directional coronary atherectomy followed by a single Palmaz-Schatz stent implantation was attempted in 100 patients. The successes, complications and angiographic results of the combined procedure were evaluated both acutely and during follow-up. Matched patients undergoing successful Palmaz-Schatz stent implantation alone during the same period served as controls.
Atherectomy followed by stent implantation was performed in 94 patients with 98 lesions; periprocedural complications were observed in four cases. The stenosis diameter decreased from 76+/-9% at baseline to 30+/-13% after atherectomy (p < 0.0001), and 5+/-9% after stent implantation (p < 0.0001); it increased to 27+/-15% at 6-month angiography (p < 0.0001). During the 14+/-10 months of follow-up, none of the patients died or experienced myocardial infarction, but three patients underwent target lesion revascularization. The patients undergoing stent implantation alone achieved smaller acute gains, tended to have a higher late lumen loss, had a higher restenosis rate (30.5% vs. 6.8%, p < 0.0001) and showed a greater incidence of clinical events during follow-up (p < 0.0001).
Debulking atherosclerotic lesions by means of directional coronary atherectomy before stent implantation is a safe procedure with a high success rate and a low incidence of restenosis at follow-up.
本前瞻性病例对照研究评估了通过定向冠状动脉斑块旋切术对斑块进行减容后再植入支架的急性和长期效果。
与球囊血管成形术相比，冠状动脉内支架植入可产生更大的管腔直径，维持动脉通畅并降低再狭窄发生率。最佳的支架置入是取得最佳效果的关键因素，但大量的动脉粥样硬化斑块会阻碍支架扩张，并可能限制手术的成功率。斑块减容可为最佳的支架置入提供更好的环境。
对100例患者尝试进行定向冠状动脉斑块旋切术，随后植入单个Palmaz-Schatz支架。对联合手术的成功率、并发症及血管造影结果进行了急性和随访期评估。同期单纯成功植入Palmaz-Schatz支架的匹配患者作为对照。
94例患者的98处病变接受了斑块旋切术后再植入支架；4例观察到围手术期并发症。狭窄直径从基线时的76±9%降至斑块旋切术后的30±13%（p<0.0001），支架植入后为5±9%（p<0.0001）；在6个月血管造影时增至27±15%（p<0.0001）。在14±10个月的随访期间，无患者死亡或发生心肌梗死，但3例患者接受了靶病变血管重建。单纯接受支架植入的患者急性管腔增加较小，晚期管腔丢失倾向更高，再狭窄率更高（30.5%对6.8%，p<0.0001），且随访期间临床事件发生率更高（p<0.0001）。
在支架植入前通过定向冠状动脉斑块旋切术对动脉粥样硬化病变进行减容是一种安全的手术，成功率高，随访期再狭窄发生率低。
