Percutaneous Coronary Intervention for Distal Unprotected Left Main Coronary Artery Stenoses-The Inadequacy of Selective Debulking Strategy

遠端非保護性左主幹狹窄經皮冠狀動脈介入治療－選擇性減容術之不足

鄭正一(Cheng-I Cheng) ； 方志元(Chih-Yuan Fang) ； 謝元凱(Yuan-Kai Hsieh) ； 陳建仁(Chien-Jen Chen) ； 楊正旭(Cheng-Hsu Yang) ； 葉漢根(Hon-Kan Yip) ； 陳勉成(Mien-Cheng Chen) ； 傳懋洋(Morgan Fu) ； 吳炯仁(Chiung-Jen Wu)

《Acta Cardiologica Sinica》 23卷4期 (2007/12) Pp. 234-246

摘要

目的　比較遠端非保護性左主幹冠狀動脈(distal unprotected left main coronary artery)狹窄之病人以單純藥物塗層支架(drug-eluting stent)（第一組，49位病人）或傳統金屬支架(bare metal stent)（第二組，29位病人）植入的非減容治療方式(non-debulking)與先由左前降支往左主幹實行選擇性方向性粥狀硬塊切除術(directional atherectomy)(DCA)再植入傳統金屬支架（第三組，11位病人）的減容(debulking)治療方式其預後差別。
方法　本研究收納89位接受冠狀動脈介入治療(percutaneous coronary intervention)之非保護性左主幹狹窄病患去回溯分析其再阻塞(restenosis)，標的病灶再治療(target lesion revascularization)次主要心血管不良反應(major adverse cardiac event)之發生率。
結果　第三組之病人於整體左主幹區段有最高之再狹窄率(75%)（主要發生於左迴旋支開口處），而第一組病人於左主幹本身之再阻塞率只有2.6%。腎功能不全（血中肌酐酸＞1.4mg/dl）為整體左主幹區段再狹窄之獨立危險因子（危險度：7.704，p=0.047），而植入藥物塗層支架能減少整體左主幹區段再狹窄（危險度：0.189，p＝0.0022）。第一組比第三組兩年標的病灶再治療今生率明顯較低（19.3%比49.5%；p=0.011），而第一組比第二組並無顯著差異。
結論　本研究顯示對於遠端非保護性左主幹狹窄病人，以選擇性方向性粥狀硬塊切除術由左前降支往左主幹選擇性減容再加上植入傳統金屬血管支架的治療，與單純拉入藥物塗層或傳統金屬支架之非減容治療方式比較，並無更佳的預後。雖然植入藥物塗層支架能降低左主幹本身外狹窄，且與傳統金屬支架比較，病人之標的病灶再治療與主要心血管不良反應較少，但因病人數少而無統計差異。

關鍵字

左主幹冠狀動脈狹窄 ； 經皮冠狀動脈介入治療 ； 減容治療

並列摘要

Objectives & background: to compare the outcomes of percutaneous coronary intervention (PCI) using a non-debulking strategy with implantation of either drug-eluting stent (DES) (group Ⅰ; n=49) or hate metal stent (BMS) (Group Ⅱ: n=29) to a selective debulking strategy with directional atherectomy (DCA) before BMS implantation (Group Ⅲ; n=11) for distal unprotected left main coronary artery (ULMCA) stenosis.
Methods: This study reviewed the outcomes of 89 consecutive patients who underwent PCI for distal ULMCA stenoses. Restenosis rate, target-lesion revascularization (TLR), and major adverse cardiovascular events (MACE) were analyzed.
Results: Group Ⅲ displayed the highest overall restenosis rate (75.0%), primarily involving the ostium of the left circumflex artery, while restenosis was observed at the ULMCA per se in 2.6% of patients in Group Ⅰ. Renal insufficiency (serum creatinine＞1.4mg/dl) was an independent risk factor predicting overall restenosis (OR: 7.704; p=0.047), and implantation of DES associated with lower restenosis rate (OR: 0.189; p=0.002). Cumulative TLR rate at two years was significantly lower in Group Ⅰ than Group Ⅲ (19.3% vs. 49.5%; p=0.011), but Groups Ⅰ and Ⅱ(25.4%) did not differ significantly.
Conclusion: This investigation demonstrated that the debulking strategy with selective DCA from left anterior descending artery to ULMCA before BMS implantation did not achieve better clinical outcomes titan a non-debulking strategy with implantation of either BMS or DES. Implantation of DES resulted in significant reduction of restenosis at ULMCA per se. DES had numerically lower TLR anti MACE than those of BMS, which was statistically insignificant due to the small case number.

並列關鍵字

Left main coronary disease ； Percutaneous coronary intervention ； Debulking