血管内超声指导对于冠状动脉真性分叉病变介入治疗长期预后的影响

目的研究血管内超声（intravascular ultrasound，IVUS）指导对于冠状动脉真性分叉病变植入药物洗脱支架（drug eluting stent，DES）长期预后的影响。方法通过分析2005年10月至2010年3月DK—Crush系列随机对照研究入选735例原位冠状动脉真性分叉病变植入DES患者，应用倾向评分匹配临床和造影特征，165例IVUS指导和165例冠状动脉造影指导患者纳入研究，比较两组患者的长期预后。结果两组临床基线资料和造影特征比较，差异无统计学意义（P〉0．05）。IVUS指导组更常见选择双支架策略（P=0．007），IVUS指导组主支血管（MV）和分支血管（SB）的最大支架直径和支架总长度以及分支血管支架个数显著超过常规造影指导组；介入治疗后QCA分析显示，IVUS指导组分支血管参考血管直径（RVD）和即刻获得以及主支血管近端和分支血管最小管腔直径（MLD）显著超过造影指导组。12个月随访发现两组心脏死亡、靶病变重建（TLR）和主要心血管事件（MACE）比较，差异无统计学意义（P〉0．05）。然而，IVUS指导组晚期支架内血栓和急性心肌梗死发生率显著低于造影指导组，差异有统计学意义（0．6％ vs.4．8％。P=0．04；1．8％ vs.6．7％，P=0．03）。结论IVUS指导冠状动脉真性分叉病变植入DES可以显著减低晚期支架内血栓和由此引起急性sT段抬高心肌梗死发生率而改善长期预后。

Impact of intravascular ultrasound guidance on long-term clinical outcomes of drug eluting stent implantation for coronary true bifurcation lesions

Objectives To investigate the impact of intravascular ultrasound （IVUS） guidance on long-term clinical outcomes of drug eluting stent （DES） implantation for coronary true bifurcation lesions. Methods The DK-Crush randomized controlled trials listed 735 patients with de novo coronary true bifurcation lesions who underwent DES implantation between October 2005 and March 2010. By using propensity score matching with clinical and angiographic characteristics, 165 patients with IVUS guidance and 165 patients with angiographic guidance were enrolled. The long-term clinical outcomes were compared between the 2 groups. Results Baseline clinical and angiographic characteristics were well matched and showed no significant differences between the 2 groups （P〉0.05）. Compared to angiographic guidance group, two-stent technique was more frequently adopted in the IVUS guidance group （P=0.007）. Maximal stent diameters and total stent lengths at both the main vessel （MV） and the side branch （SB）, stent number at SB were significantly larger in IVUS guidance group. In quantitative coronary angiography analysis, reference vessel diameters （RVD） and acute gain at SB, minimal lumen diameters （MLDs） at both proximal MV and SB were significantly greater in IVUS guidance group after stenting. During 12-month follow-up, the incidences of cardiac death, target lesion revascularization （TLR） and major adverse cardiac events （MACEs） were not significantly different between the 2 groups （P〉0.05）. However, the incidence rates of late stent thrombosis and myocardial infarction （MI） were significantly lower in the IVUS guidance group compared to the angiographie guidance group （0.6% vs. 4.8%, P=0.04; 1.8% vs. 6.7%, P=0.03）. Conclusions IVUS guidance during DES implantation at true bifurcation lesions can be helpful to improve long-term clinical outcomes by reducing late stent thrombosis, with a resultant reduction in ST-elevation MI.