旋磨术与切割球囊在冠状动脉支架再狭窄治疗中的作用

目的比较旋磨术与切割球囊及常规球囊对冠状动脉支架内再狭窄的疗效。方法将416例单支冠状动脉病变支架内再狭窄患者分别用旋磨术、切割球囊与常规球囊进行扩张治疗,在治疗即刻及6个月时再次行冠状动脉造影并进行定量分析。结果(1)介入治疗前各组间支架内再狭窄情况无明显区别。(2)旋磨后即刻所获得的冠状动脉支架内最小血管直径(MLD)最大(2.67±0.55mm,P<0.05),切割球囊与常规球囊治疗组差异无统计学意义(2.51±0.65mm比2.53±0.65mm,P>0.05)。(3)6个月后旋磨治疗组的冠状动脉支架内MLD最小(1.52±0.91mm,P<0.05),切割球囊组大于常规球囊治疗组,但差异无统计学意义(1.96±0.74mm比1.75±0.83mm,P>0.05)。旋磨术与切割球囊及常规球囊治疗组支架内血管直径狭窄率分别为54.78%,38.31%及46.50%。(4)旋磨治疗组后期血管丢失量最大(P<0.05),切割球囊组明显低于常规球囊治疗组(P<0.05)。结论旋磨术对冠状动脉支架内再狭窄即刻疗效显著,但远期疗效仍以经皮腔内冠状动脉成形术(PTCA)最佳。     

冠状动脉旋磨术联合不同球囊预处理在老年重度冠状动脉钙化介入治疗中的效果比较

目的 探讨冠状动脉旋磨术联合普通球囊和切割球囊预扩张在重度冠状动脉钙化介入治疗中的效果和安全性。方法 选取2018年1月～2020年12月宜宾市第二人民医院和宜宾市第三人民医院行介入治疗的重度冠状动脉钙化患者88例,采用随机数字法分为治疗1组44例(旋磨+普通球囊)和治疗2组44例(旋磨+切割球囊)。分别采用冠状动脉旋磨联合普通球囊和切割球囊进行预扩张,观察手术即刻成功率、并发症发生情况、血管内超声相关指标及术后12个月主要心脏不良事件发生率等。结果 治疗1组即刻成功率明显低于治疗2组,差异有统计学意义(81.8%vs 97.7%,P<0.05)。治疗2组术后最小管腔直径、最小管腔面积、获得管腔直径和获得管腔面积明显优于治疗1组[(1.35±0.12)mm vs(1.28±0.09)mm;(5.87±0.37)mm²vs(5.18±0.39)mm²;(0.40±0.04)mm vs(0.35±0.03)mm;(3.03±0.20)mm²vs(2.41±0.21)mm²,P<0.01]。结...     

冠状动脉旋磨术在冠心病钙化病变介入治疗中的应用

目的探讨冠状动脉旋磨术治疗冠状动脉钙化病变的安全性及有效性。方法回顾性分析12例行冠状动脉旋磨术结合冠状动脉球囊成形术和支架植入术的冠状动脉粥样硬化性心脏病(冠心病)患者的临床资料,着重分析手术方法、手术成功率、术后随访主要心血管事件(包括心源性死亡、心肌梗死、靶病变血运重建)的发生率。结果 12例患者共有16处钙化病变,有15处钙化病变行冠状动脉旋磨术,管腔狭窄由术前的87%±10%减少至42%±9%,结合冠状动脉球囊成形术,共植入18枚国产药物支架,手术成功率为93.75%(15/16)。1例因血管严重扭曲,球囊扩张后出现冠状动脉夹层,植入支架失败,建议行外科冠状动脉旁路移植术。术中均无主要并发症(包括心源性死亡、Q波心肌梗死、急诊冠状动脉旁路移植术)发生。所有患者随访(8.4±3.6)个月,有2例再发心绞痛,无主要心血管事件(包括心源性死亡、心肌梗死、靶病变血运重建)发生。5例患者复查冠状动脉造影,有1例出现支架内再狭窄30%。结论冠状动脉旋磨术联合球囊扩张和支架植入术治疗冠状动脉钙化病变可取得很高的手术成功率,是治疗钙化病变安全、有效的方法。     

旋磨联合支架治疗老年患者冠状动脉严重钙化的临床特点分析

目的评估冠状动脉旋磨联合药物洗脱支架的临床疗效。方法回顾性分析因冠状动脉严重钙化行旋磨介入治疗的患者18例,分析手术即刻成功率、住院期间及心血管事件随访情况。结果 18例经造影证实为冠状动脉严重钙化,旋磨靶血管中左主干+左前降支2例(11.1%),左前降支13例(72.2%),左回旋支2例(11.1%),右冠状动脉1例(5.6%)。术中需主动脉球囊保护1例(5.6%),冠状动脉夹层2例(11.1%),慢血流1例(5.6%)。8例患者在血管内超声指导下进行,手术前后管腔最小直径、最小直径狭窄率、管腔有效面积分别为[(2.06±0.38)mmvs(4.00±0.76)mm,(73.26±7.02)%vs(16.25±5.18)%,(4.53±1.50)mm2 vs(12.54±6.19)mm2,P=0.000]。随访期间无心绞痛再发、急性心肌梗死、心源性猝死、靶血管再次血运重建事件发生。结论旋磨联合药物洗脱支架治疗严重钙化病变可以去除或减轻钙化斑块、增大管腔,提高严重钙化病变介入治疗成功率。     

冠状动脉内旋磨术联合支架术治疗严重钙化病变的疗效及随访研究

目的评价冠状动脉(冠脉)内旋磨术联合支架术治疗严重钙化病变的疗效及中期随访结果。方法对21例冠心病患者的严重钙化病变行冠脉内旋磨术及支架术治疗,6例患者在血管内超声的引导下进行,观察其治疗的即刻成功率及6个月的随访结果。结果行冠脉内旋磨术的21例患者,冠脉造影结果均为В2、C型严重钙化病变。旋磨头均成功通过了病变,15例(71.4%)病例仅选择1.25mm的旋磨头,3例(14.3%)病例仅选择1.5mm旋磨头,3例(14.3%)病例使用了2个旋磨头。全部病例均联合应用经皮冠脉血管成形术(PTCA),19例(90.5%)在旋磨术后置入支架。2例(9.5%)在术中发生冠脉痉挛;1例(4.8%)发生无血流现象;无冠脉穿孔、死亡、急性心肌梗死及急诊冠脉旁路移植术(CABG)。对15例患者进行了术后6个月的冠脉造影随访,有2例(13.3%)发生支架内再狭窄。结论冠脉内旋磨术联合支架术治疗严重钙化病变,去除钙化斑块增大管腔,提高了严重钙化病变的经皮冠脉介入治疗(PCI)成功率。     

旋磨术联合药物洗脱支架治疗老年冠状动脉钙化病变临床随访结果

目的旋磨术联合药物洗脱支架(DES)治疗老年冠状动脉钙化病变的安全性及有效性研究。方法回顾性分析在解放军总医院行冠状动脉旋磨术联合药物洗脱支架治疗的老年冠心病钙化病变患者143例。分析术中技术特点,术前术后造影和血管内超声资料、术中即刻并发症及患者院内和术后1年累积主要不良心脑血管事件(MACCE)发生率及影响因素。结果旋磨术联合DES治疗老年冠状动脉钙化病变手术成功率为97.2%,随访1年累积MACCE发生率为13.3%,左主干病变(HR:7.249,95%CI:1.501~35.459,P=0.014)、非计划性旋磨(HR:9.466,95%CI:2.219~40.375,P=0.002)、LVEF40%(HR:0.064,95%CI:0.011~0.385,P=0.003)、球囊后扩张(HR:0.232,95%CI:0.069~0.785,P=0.019)、支架后狭窄面积(HR:0.538,95%CI:0.374~0.774,P=0.001)。与支架置入前比较,支架置入术后狭窄直径显著增大,直径狭窄率显著减小,差异有统计学意义(P=0.000)。结论旋磨联合DES治疗老年冠状动脉钙化病变手术成功率高,长期随访临床效果较好。     

冠状动脉旋磨术及经皮冠状动脉成形术在复杂病变介入治疗中的应用

目的　探讨冠状动脉旋磨术 (Rotational atherectomy)及经皮腔内冠状动脉成形术 (Percutaneous translum i-nal coronary angioplasty PTCA)治疗复杂冠脉病变的临床效果。方法　对 15例患者的 2 0处病变行冠脉旋磨术及经皮腔内冠状动脉成形术 (PTCA)治疗 ,部分病例并在血管内超声指导下进行 ,观察其治疗的即刻成功率及并发症率。结果　 15例施行冠状动脉旋磨术的患者 ,旋磨头均成功地通过了病变 ,平均狭窄程度由 88.30 %± 7.5 4 %降至15 .6 0 %± 10 .75 %。其中 6 0 .0 0 %的病例选择了 1.5 mm的旋磨头 ,13.33%的病例使用了 2个旋磨头。全部病例均联合应用了 PTCA,13例在行旋磨术后置入冠脉内支架 (余下 2例为支架内再狭窄病例 )。 1例患者术中发生较严重的冠状动脉痉挛 ,经冠状动脉内给予硝酸甘油后缓解 ;2处 (10 .0 0 % )病变出现了 B型以上的内膜撕裂 ,出现缓慢血流现象发生率为 3.8%。无急诊冠状动脉搭桥及死亡病例。结论　冠状动脉旋磨术及 PTCA可选择性用于复杂冠状动脉病变 ,尤其是严重钙化病变 ,小血管长节段病变     

斑块旋磨术联合药物洗脱支架置入术治疗冠状动脉弥漫性严重钙化病变的近期效果分析

目的探讨斑块旋磨术联合药物洗脱支架置入术治疗冠状动脉弥漫性严重钙化病变的手术安全性和近期效果。方法回顾性分析2011年1月1日至2016年5月31日在北京大学人民医院因冠状动脉严重钙化病变行斑块旋磨术联合药物洗脱支架置入术的109例冠心病患者,共114处病变,其中28例患者在术中行血管内超声检查。按钙化病变的长度分为弥漫性钙化病变组(钙化病变长度≥25 mm,68例、72处病变)和局限性钙化病变组(钙化病变长度25 mm,41例、42处病变)。分析两组患者病变及手术特点、手术成功率、并发症及住院期间主要不良心血管事件(MACE,包括心源性死亡、非致死性心肌梗死和支架内血栓形成)的发生情况。结果弥漫性钙化病变组钙化病变长度[(38.2±11.0)mm比(15.0±4.9)mm,P0.001]、旋磨次数[(6.17±1.61)次比(4.02±1.20)次,P0.001)]、置入支架数[(2.31±0.78)枚比(1.60±0.70)枚,P0.001]显著大于局限性钙化病变组,差异有统计学意义;与局限性钙化病变组相比,弥漫性钙化病变组手术即刻成功率(98.5%比100%,P=0.453)、并发症发生率(41.2%比34.1%,P=0.673)、住院期间MACE发生率(41.2%比31.7%,P=0.484)相当,差异均无统计学意义。结论注意手术操作的规范性、采取恰当的措施预防和处理术中并发症,可以安全地对冠状动脉弥漫性严重钙化病变进行斑块旋磨术并置入药物洗脱支架,手术即刻成功率及近期效果满意。     

冠脉旋磨术在冠状动脉钙化病变患者PCI治疗中的应用价值

目的:研究冠脉旋磨术(CRA)在冠状动脉钙化(CAC)病变患者经皮冠状动脉介入(PCI)治疗中的应用价值。方法:2016年6月~2016年12月于我院治疗,且需行PCI治疗的CAC病变患者104例被随机分为旋磨治疗组(52例,接受CRA)和球囊扩张组(52例,接受球囊扩张术),比较两组介入治疗指标、术中并发症发生率及随访1年内主要心血管不良事件(MACE)发生率。结果:两组术前最小管腔直径无显著差异(P=0.304)。与球囊扩张组比较,旋磨治疗组手术时间[(96.29±7.15)min比(72.96±5.76)min]、对比剂用量[(113.25±14.54)ml比(83.27±13.18)ml]、放射线暴露时间[(12.74±1.58)min比(9.07±1.26)min]、术中并发症发生率(26.92%比5.77%)显著降低,支架置入数量[(1.75±0.28)枚比(2.27±0.35)枚]、术后最小管腔直径[(3.15±0.53)mm比(4.31±0.86)mm]、病变残余狭窄<10%率(65.38%比94.23%)、手术即刻成功率(76.92%比98.08%)均显著升高(P均<0.01)。随访期间,旋磨治疗组MACE发生率显著低于球囊扩张组(13.46%比38.46%),P=0.004。结论:CRA能显著提高CAC病变患者PCI治疗手术成功率,降低术中并发症发生率,改善患者预后。     

冠状动脉血管内超声对严重钙化病变斑块旋磨术终点判断的评价研究

目的评价冠状动脉血管内超声(IVUS)对严重钙化病变斑块旋磨术终点的影响。方法回顾性分析2016年8月至2021年2月于北京大学人民医院行IVUS指导下冠状动脉斑块旋磨术治疗的54例患者。根据初次旋磨治疗后是否强化预处理方案(包括升级旋磨头或使用棘突/切割球囊进行扩张)或直接采用半顺应性/非顺应性球囊扩张进行分组,强化组11例,非强化组43例。比较两组患者临床资料、病变特点、手术情况及腔内影像学结果等情况。结果两组患者性别、年龄、既往病史(高血压病、糖尿病、高脂血症、心肌梗死、经皮冠状动脉介入治疗及冠状动脉旁路移植术)、左心室射血分数(LVEF)、估算的肾小球滤过率(eGFR)、旋磨靶血管、三支病变情况、旋磨头/血管直径比值、半顺应性或非顺应性球囊平均直径及最大扩张压力、手术时间、对比剂用量、X线辐射剂量、手术成功率等方面比较,差异均无统计学意义(均P0.05)。强化组患者旋磨头数量明显多于非强化组[2(1,2)个比1(1,1)个,P0.001],病变钙化弧度明显高于非强化组[(357.3±9.0)°比(339.1±41.7)°,P=0.011],差异均有统计学意义;而两组在钙化长度、钙化结节、旋磨后出现多重反射、最小支架面积及支架膨胀率等方面的差异均无统计学意义(均P0.05)。结论 IVUS提示钙化弧度为360°或接近360°的严重钙化病变需要更加积极的强化预处理策略,包括升级旋磨头或旋磨后使用棘突/切割球囊进行扩张;对于旋磨治疗后出现多重反射者需要给予更多关注。     

Feasibility of intravascular ultrasound studies: Predictors of imaging success before coronary interventions

Background: Intravascular ultrasound (IVUS) is currently used to study lesions during transcatheter coronary therapy. However, before dilation some lesions cannot be reached or crossed with the imaging catheter. Hypothesis: This study seeks to elucidate which factors determine the feasibility of IVUS examination before coronary interventions. Methods: Accordingly, 100 consecutive patients undergoing IVUS examination before coronary angioplasty were prospectively studied. The clinical and angiographic characteristics of 77 patients with a successful IVUS study (Group A) were compared with those of 23 patients in whom IVUS was attempted but the target lesion could not be interrogated (Group B). The echogenic characteristics of the target lesion [before (n = 77) or after intervention (in 18 patients in Group B)] were also studied. Results: Patients in Group B were significantly older (62 ± 7 vs. 57 ± 10 years, p < 0.05) and more frequently had stable angina [8 (35%) vs. 9 (11%), p < 0.05]. The distribution of lesions within the coronary tree and angiographic lesion characteristics including length, eccentricity, calcification, bend location, and the American College of Cardiology/American Heart Association classification were similar in both groups. However, proximal tortuosities (>45° at end diastole) were more frequently found in Group B [20 (87%) vs. 47 (61%), p < 0.05]. In addition, by quantitative angiography, patients in Group B had smaller arteries (reference diameter 2.8 ± 0.4 vs. 3.1 ± 0.4 mm, p < 0.05) and more severe lesions (minimal lumen diameter 0.46 ± 0.24 vs. 0.65 ± 0.34 mm, p < 0.05). On IVUS, calcified lesions were more frequently visualized in Group B (61 vs. 38%, p < 0.05). On multivariate analysis, catheter size, baseline minimal lumen diameter, angiographic proximal tortuosities, and lesion calcification on imaging were independent predictors of the feasibility of IVUS studies. Conclusions: Unsuccessful IVUS studies before intervention occur more frequently (1) in vessels with proximal tortuosities or severe lumen narrowing, (2) in lesions that are calcified on IVUS, and (3) when large imaging catheters are used.     

靶病变浅表性钙化对经皮冠状动脉介入治疗的影响

目的探讨冠状动脉靶病变浅表性钙化对介入操作及疗效的影响。方法连续收集61例冠心病患者（61处靶病变）,根据血管内超声（IVUS）检测冠脉靶病变钙化情况分为浅表性钙化组和非浅表性钙化组,对比两组之间介入操作特点、经皮冠脉介入治疗（PCI）术后临床及影像学特征。结果浅表性钙化29例,非浅表性钙化32例。浅表性钙化组面积狭窄率大于非浅表性钙化组[（75．70±7．11）％VS（68．78±5．56）％,P=0．019];前者术后支架对称性及支架膨胀指数明显小于后者[（0．85±0．06）US（O．90±0．02）,P=0．016;（0．68±0．14）w（0．82±0．10）,P=0．021]。浅表性钙化组术后最小支架直径[（2．51±0．43）w（2．76±0．29）mm]、最小支架面积[（5．86±1．82）VS（6．73±1．40）miTl气相对管腔获得[（1．26±0．68）坩（1．37±0．72）]趋于小于非浅表性钙化组,但差异未发现统计学意义。两组术中术后并发症差异无统计学意义。所有患者无院内主要不良心脏事件发生。结论冠状动脉靶病变浅表性钙化可能较非浅表性钙化对支架的充分扩张及对称性影响更大。     

Mechanism of cutting balloon angioplasty for in-stent restenosis: an intravascular ultrasound study.

We investigated by intravascular ultrasound (IVUS) the mechanism of action of cutting balloon (CB) angioplasty in patients with in-stent restenosis. Seventy-one consecutive restenotic lesions of 66 patients were studied by quantitative coronary angiography (QCA) and IVUS before, immediately after, and, in 20 cases, at 24-hr time interval after CB. CB was selected according to 1:1 CB-to-stent ratio and inflated at 8 atm for 60-90 sec. Both IVUS planar and volumetric (Simpson's rule, 25 patients) analysis were carried out. IVUS measurements included external elastic membrane area (EEMA), stent area (SA), minimal lumen area (MLA), and restenosis area (RA). Following CB, QCA analysis showed increase of minimal lumen diameter (1.17 +/- 0.46 vs. 2.45 +/- 0.51 mm; P < 0.0001) and decrease of diameter stenosis (64% +/- 13% vs. 21% +/- 9%; P < 0.0001). IVUS measurements showed a significant increase of MLA (2.18 +/- 0.80 vs. 7.31 +/- 1.8 mm(2); P < 0.0001), SA (9.62 +/- 2.6 vs. 10.7 +/- 2.75 mm(2); P < 0.0001), and EEMA (17.27 +/- 5 vs. 18.1 +/- 5 mm(2); P < 0.0001) and a decrease of RA (7.43 +/- 2.63 vs. 3.45 +/- 1.39 mm(2); P < 0.0001). No significant change was observed in the original plaque + media area (7.65 +/- 3 vs. 7.38 +/- 2.9 mm(2); P = NS). Thus, of the total lumen enlargement (5.13 +/- 1.85 mm(2)), 23% was the result of increase in mean SA, whereas 77% was the result of a decrease in mean RA. These changes were associated with a 5% increase in EEMA. IVUS volumetric changes paralleled planar variations. Angiographic and IVUS changes were well maintained at 24 hr. CB enlarges coronary lumen mainly by in-stent tissue reduction associated with a moderate degree of additional stent expansion. Favorable QCA and IVUS acute results are maintained at 24 hr.     

Restenosis rate after intravascular ultrasound-guided coronary stent implantation

This study was designed to test the hypothesis that patients fulfilling intravascular ultrasound (IVUS) criteria for optimal coronary stent implantation show a reduction in the restenosis rate at 6 months. IVUS guidance for stent dilation may be associated with faciliated stent implantation and an increased acute luminal gain, but it has not yet been determined, whether and to what extent this procedure is associated with a reduction in the restenosis rate. IVUS-guided optimization of Palmaz-Schatz stent placement was performed in 125 consecutive patients, 64 of whom fulfilled IVUS-criteria for optimal stent placement. Another 125 patients served as the non-IVUS control group. In 107 patients (86%) of the non-IVUS control group and 105 patients (84 %) of the IVUS group, angiographic follow-up was performed. The IVUS group of patients revealed a significantly lower restenosis rate of 20.9% as compared with 29.9% in the control group (P = 0.033). Patients that met IVUS criteria for optimal stent placement had a larger minimal lumen diameter immediately after stent implantation (3.13 ± 0.44 vs. 2.95 ± 0.47 mm; P = 0.045) and at 6-month follow-up (2.23 ± 0.78 vs. 1.87 ± 0.76 mm; P = 0.019) as well as a significantly lower restenosis rate (13.5% vs. 28.3%; P = 0.038) as compared with patients that did not fulfil these criteria. Our data suggest that patients fulfilling IVUS criteria for optimal stent placement demonstrate a reduced risk for the development of restenosis. Thus, IVUS investigation identifies factors predictive of restenosis after coronary stent placement. Cathet. Cardiovasc. Diagn. 44:380–386, 1998. © 1998 Wiley-Liss, Inc.     

Stepwise intravascular ultrasound (IVUS) guidance of high-pressure coronary stenting does not result in an improved acute or long-term outcome: A randomized comparison to “final-look” IVUS assessment

The objective of this study was to evaluate the potential benefit of stepwise intravascular ultrasound (IVUS)-guided coronary stent deployment compared to angiographic stent implantation with final IVUS assessment only. Acute procedural success and 6-month angiographic follow-up were compared in both groups. Intravascular ultrasound was performed using a 20- or 30-MHz mechanically rotated catheter in 85 patients who were prospectively randomized to group A (n = 42; IVUS-guided) and group B (n = 43; angiography + final IVUS assessment). There was no difference in the number of stents implanted (1.5 ± 0.9 stents/lesion in group A and 1.3 ± 0.6 stents/lesion in group B), the duration of the procedure, or the amount of contrast medium used. Defined criteria of optimal stent deployment (stent apposition, stent symmetry, complete coverage of dissections, >90% in-stent lumen area/reference lumen area) were achieved in 54.2% in group A and 56.6% in group B (NS). Angiographic follow-up was 87.1% at 6 ± 2 months, and clinical follow-up was 100% at 8 ± 1 months. There was no significant difference in restenosis rate (33.3% vs. 34.9%) applying a binary >50% diameter stenosis criterion for both groups. There was no significant difference in minimal in-stent lumen area at both baseline (7.91 ± 2.64 mm² vs. 7.76 ± 2.21 mm²) and follow-up (5.84 ± 2 mm² vs. 5.52 ± 1.87 mm²). With regard to immediate procedural lumen gain and rate of restenosis, multiple IVUS examinations during the procedure showed no advantage compared to final IVUS assessment only. Cathet. Cardiovasc. Intervent. 46:135–141, 1999. © 1999 Wiley-Liss, Inc.     

中重度冠状动脉钙化对介入治疗即刻疗效的影响

目的观察中重度冠状动脉钙化对冠状动脉介入治疗即刻疗效的影响。方法连续收集84例冠心病患者(84处靶病变),在冠状动脉支架置入术前后,通过血管内超声分析冠状动脉斑块特征、评估支架置入情况,并收集临床资料及介入操作相关信息,根据结果分为无钙化组36例和中重度钙化组48例,所有钙化病变均给予充分预扩张,并在血管内超声指导下视情况给予后扩张处理,对比2组PCI前后临床及影像学特征。结果 PCI后中重度钙化组置入支架直径、术后最小支架直径、最小支架横截面积、即刻管腔获得及相对管腔获得均小于无钙化组(P<0.05),PCI前中重度钙化组单支病变、靶病变B1型、斑块偏心指数、远端参考外弹力膜面积及管腔面积小于无钙化组(P<0.05,P<0.01)。而2组支架对称性、膨胀指数、手术并发症、院内主要不良心血管事件发生率比较,差异无统计学意义(P>0.05);2组术前最小管腔截面积、斑块负荷、管腔面积狭窄率、重构指数、病变长度差异无统计学意义(P>0.05)。结论血管内超声指导下给予充分预扩张及非顺应性高压球囊后扩张处理后,中重度钙化仍然影响PCI术后即刻管腔获得,但最终管腔面积基本理想。     

Hyperemic coronary flow after optimized intravascular ultrasound-guided balloon angioplasty and stent implantation

OBJECTIVES

This study evaluated the acute physiological gain of adjunctive intravascular ultrasound (IVUS) guided balloon angioplasty and stent implantation.

BACKGROUND

Recent studies indicate safe coronary luminal enlargement and “stent-like” long-term outcomes using upsized balloons guided by IVUS.

METHODS

After angiographically guided balloon angioplasty in 20 patients with 1-vessel disease and normal left ventricular function, IVUS was performed to determine the size of the adjunctive balloon using the mean of the maximal luminal diameter and the maximal diameter of the external elastic membrane measured in the adjacent proximal and distal reference segments. Serial adenosine-induced hyperemic blood flow velocity measurements were performed using a 0.014″ Doppler guide wire to determine the physiological lumen obstruction after standard balloon angioplasty, followed by IVUS-guided balloon angioplasty and stent implantation.

RESULTS

Upsized balloon angioplasty (increase balloon size: 0.98 ± 0.26 mm; balloon:artery ratio 1.35 ± 0.21) resulted in an additional increase of arterial dimensions: minimal lumen diameter (MLD) 2.18 ± 0.38 mm to 2.73 ± 0.51 mm; percent diameter stenosis (%DS) 34 ± 13% to 19 ± 22%; IVUS assessed minimal lumen area (MLA) 7.53 ± 1.55 mm² to 10.24 ± 2.22 mm² (all p < 0.0001). Major dissections (≥ type C) did not occur. Hyperemic blood flow velocity increased from 49.8 ± 20.1 cm/s to 59.1 ± 22.9 cm/s (p < 0.05) after IVUS-guided balloon angioplasty. Adjunctive stent implantation resulted in a further increase of MLD to 3.84 ± 0.51 mm, %DS to −9 ± 21% and MLA to 13.39 ± 1.80 mm² (all p < 0.0001), while hyperemic blood flow velocity remained unchanged (61.2 ± 24.7 cm/s, p = 0.7).

CONCLUSIONS

Upsized IVUS-guided balloon angioplasty increases arterial coronary dimensions and the distal hyperemic blood flow velocity. Adjunctive stent implantation does not yield a further gain in the hyperemic blood flow velocity, indicating the absence of a functional residual lumen obstruction after IVUS-guided balloon angioplasty. This may explain a similar clinical outcome reported after those coronary interventions.     

Cutting-balloon angioplasty before drug-eluting stent implantation for the treatment of severely calcified coronary lesions

Background Severely calcified coronary lesions respond poorly to balloon angioplasty, resulting in incomplete and asymmetrical stent expansion. Therefore, adequate plaque modification prior to drug-eluting stent （DES） implantation is the key for calcified lesion treat- ment. This study was to evaluate the safety and efficacy of cutting balloon angioplasty for severely calcified coronary lesions. Methods Ninety-two consecutive patients with severely calcified lesions （defined as calcium arc 〉 180% calcium length ratio 〉 0.5） treated with bal- loon dilatation before DES implantation were randomly divided into two groups based on the balloon type： 45 patients in the conventional balloon angioplasty （BA） group and 47 patients in the cutting balloon angioplasty （CB） group. Seven cases in BA group did not satisfactorily achieve dilatation and were transferred into the CB group. Intravascular ultrasound （IVUS） was performed before balloon dilatation and after stent implantation to obtain qualitative and quantitative lesion characteristics and evaluate the stent, including minimum lumen cross-sectional area （CSA）, calcified arc and length, minimum stent CSA, stent apposition, stent symmetry, stent expansion, vessel dissection, and branch vessel jail. In-hospital, 1-month, and 6-month major adverse cardiac events （MACE） were reported. Results There were no statistical differences in clinical characteristics between the two groups, including calcium arc （222.2° ± 22.2° vs. 235.0° ± 22.1 °, p=0.570）, calcium length ratio （0.67 ± 0.06 vs. 0.77± 0.05, P = 0.130）, and minimum lumen CSA before PCI （2.59 ±0.08 mm2 vs. 2.52 ± 0.08 mm2, P = 0.550）. After stent implantation, the final minimum stent CSA （6.26 ± 0.40 mm2 vs. 5.03 ± 0.33 mm2; P = 0.031） and acute lumen gain （3.74 ±0.38 mm2 w. 2.44 ± 0.29 mm2, P = 0.015） were significantly larger ila the CB group than that of the BA group. There were not statis tically differences in stent expansion, stent symmetry, incomplete stent apposition, vessel dissection and branch vessel jail between two groups. The 30-day and 6-month MACE rates were also not different. Conclusions Cutting balloon angioplasty before DES implantation in severely calcified lesions appears to be more efficacies including significantly larger final stent CSA and larger acute lumen gain, without increasing complications during operations and the MACE rate in 6-month.     

Intravascular Imaging to Guide Lithotripsy in Concentric and Eccentric Calcific Coronary Lesions

BackgroundCalcified coronary lesions still represent a challenge for coronary angioplasty, with sub-optimal acute PCI results causing more frequent late stent failure.PurposeThe study aimed at the evaluation of the immediate procedural outcome in a real-world consecutive population of a selective use of lithotripsy based on the intravascular imaging assessment with IVUS or OCT.Methods and resultsThirty-one calcified stenoses (28 patients) out of a total of 455 lesions (370 patients) treated between November 2018 and May 2019 received IVL under intravascular imaging guidance. The majority of the IVL lesions had angiographically severe calcifications and were selected after intravascular imaging. A smaller group was identified by poor expansion after high-pressure balloon dilatation, in one case despite preliminary small burr Rotablation. After IVL, when OCT was performed calcium fractures were observed in 71% of cases. After OCT/IVUS guided stent optimization a satisfactory lumen enlargement (minimal stent area 7.09 ± 2.77 mm²) was observed with good stent expansion (residual area stenosis<20% in 29 lesions, 93.5%) Peri-procedural complications were limited to one dissection at the distal edge requiring an additional stent and 3 peri-procedural myocardial infarctions. There were no periprocedural coronary perforations or pericardial effusions, and no in-hospital or 30 days stent thrombosis.When patients were divided into two subgroups according to a calcium arc ≤180° (Group A: 10 lesions, calcium arc 140 ± 24°; Group B: 21 lesions, calcium arc 289 ± 53°), at OCT Group B presented also a higher number of calcium fractures post IVL than group A (group A: 38% vs group B: 92%, p = 0.03). The in-stent minimum lumen diameter (MSD), the in stent minimal lumen area (MSA) and the acute gain, however, were similar between the two groups (acute gain group A: 1.22 ± 0.29 mm; group B: 1.31 ± 0.52 mm, p = 0.63).ConclusionsA standardized algorithm applying intravascular imaging guidance of IVL facilitated second generation DES expansion delivers excellent immediate lumen expansion and patient outcome, both in concentric and eccentric calcifications.     

经皮切割球囊成形术治疗支架内再狭窄的研究

目的　研究切割球囊成形术对治疗支架内再狭窄的即刻和 6个月内随访效果。方法　 6 9例支架内再狭窄患者随机分配到切割球囊组 (38例 )和普通球囊治疗组 (31例 )。球囊扩张前及扩张后即刻在定量冠状动脉造影和冠状动脉内超声下 ,测定相关参数。观察随访 6个月内临床改善及冠状动脉造影结果。研究终点包括出现心肌梗死 ,需要冠状动脉搭桥或再介入治疗。结果　两组的手术成功率均为 10 0 %。切割球囊组 1例患者扩张后在支架的远端出现夹层。平均随访 (6 .7± 2 .3)个月。切割球囊组于术后 3和 6个月时的再狭窄率显著低于普通球囊组(15 %∶38%及 18%∶4 2 % ,P <0 .0 0 1)。扩张后即刻血管直径获得值在切割球囊组和普通球囊组分别为 (1.72±0 .5 2 )mm和 (1.15± 0 .5 4 )mm ,随访 3个月及随访终点时切割球囊组的血管直径晚期丢失分别为 (0 .2 6± 0 .0 5 )mm(3个月 )及 (0 .38± 0 .0 6 )mm ,同时的普通球囊组丢失值分别为 (0 .78± 0 .19)mm(3个月 )及 (0 .89± 0 .16 )mm。结论　切割球囊成形术治疗老年冠心病患者支架内狭窄效果可靠 ,安全 ,容易操作 ,再狭窄率低