无保护左主干病变应用药物洗脱支架介入治疗的预后及影响因素分析

目的:评价无保护左主干病变应用药物洗脱支架治疗的预后及影响因素。方法:2003-04至2008-06我院150例无保护左主干病变患者接受经皮冠状动脉介入治疗(PCI),平均年龄62.5±10.82(38～83)岁,根据病变是否累及左主干远端分叉分组,开口或体部病变为非分叉病变组(n=35),累及左主干远端或前降支、回旋支开口者为分叉病变组(n=115)。44例(29.33%,44/150)患者术中应用血管内超声指导,48例(32.43%,48/148)在平均(10.02±7.47)个月进行了冠状动脉造影复查。结果:术后存活的148例患者中125例(84.45%)随访成功,平均随访时间9.86±8.46(1～43)月,分叉病变组的再发心绞痛率(33.68%vs13.33%,P=0.0467)明显高于非分叉病变组,主要心脏不良事件(MACE)两组未见明显差异。对MACE单因素分析发现,血管内超声指导患者MACE的发生率明显低于无血管内超声指导患者(4.17%vs17.65%,P=0.0446)。影响再狭窄的因素分析显示双支架术的再狭窄率明显高于单支架术(64.29%vs10.71%,P=0.0011)。结论:经选择的无保护左主干病变,药物洗脱支架治疗是可行和安全的,可取得较好的近远期结果,经血管内超声指导MACE可明显减少。     

糖尿病合并分叉病变患者单双支架介入策略的比较

目的 探讨糖尿病合并冠状动脉分叉病变人群采用单双支架策略的预后差异.方法 回顾性研究了入选DK-Crush Ⅰ-Ⅳ系列试验的糖尿病合并冠状动脉真性分叉病变患者211例.其中,单支架策略组(PS组)119例,双支架策略组(DS组)92例,均使用了雷帕霉素洗脱支架.PS组于下述情况以“T”支架术式置入分支支架:(1)分支血管残余狭窄≥50％;(2)TIMI血流小于3级;(3)合并B型以上夹层.DS组采用DK-Crush技术56例(60.9％),“T”型支架置入技术26例(28.3％),Culotte技术置入10例(10.9％).无论DS组抑或PS组在支架置入后均强调完成分支高压后扩张和主、分支最终球囊对吻( FKI).主要研究终点为术后9个月内的主要不良心脏事件(MACE,包括心源性死亡、非致死性心肌梗死、再发心绞痛,再次靶血管重建),次要研究终点为9个月时血管造影主支和分支血管再狭窄.结果 9个月随访期内DS组与PS组的发生MACE分别为12例(13.0％)和14例(11.8％),两组间差异无统计学意义(x2=0.079,P＞0.05).随访血管造影主支再狭窄DS组与PS组分别为10例(10.9％)和12例(10.1％),组间比较无差异统计学意义(x2=0.034,P＞0.05),但分支再狭窄DS组18例(19.6％)显著低于PS组46例(38.7％)x2=8.948,P=0.003.结论 在糖尿病合并冠状动脉分叉病变患者中,单支架策略与双支架策略的9个月随访期的主要不良心脏事件无差异,但双支架策略显著减少了分支再狭窄.     

单支架和双支架策略治疗冠状动脉分叉病变的临床疗效评价

目的:探讨单支架与双支架置入治疗冠状动脉分叉病变的临床疗效。方法:回顾性分析2014年1月至2016年10月于解放军总医院就诊的455例行药物洗脱支架(DES)置入治疗冠状动脉分叉病变患者的临床资料。患者被分为单支架组(235例)和双支架组(220例)。观察比较两组病变分布情况,近端、远端及分支病变特征,支架置入,术式选择,术后即刻血流,临床不良事件率等。结果:两组患者的一般资料、冠脉造影显示的病变分布,近端、远端及分支病变特征均无显著差异,P均0.05。单支架组全部采用Cross-over技术,双支架组采用Crush术式(46.81%)、Culotte术式(37.73%)、T支架术式和V支架术式,以前两种为主。两组术后即刻主支、分支TIMI血流3级率均无显著差异,P均0.05。住院期间,双支架组非致死性心梗发生率显著高于单支架组(7.27%比2.98%),P=0.037。随访12个月,与单支架组比较,双支架组再狭窄率(5.53%比1.36%)显著降低,非致死性心梗(2.55%比6.82%)发生率显著升高,P=0.016,0.030。结论:单支架和双支架治疗冠状动脉分叉病变疗效无显著差异,双支架组再狭窄率显著降低,但非致死性心梗率显著升高。     

老年无保护左主干病变置人药物洗脱支架与行冠状动脉旁路移植术的预后比较

目的 对比老年无保护左主干病变患者置入药物洗脱支架(DES)和行冠状动脉旁路移植术(CABG)后2年的临床预后.方法 入选2004年1月至2006年6月因无保护左主干病变置入DES或行CABG的老年患者(≥70岁)共295例.随访2年,记录患者发生全因死亡、非致死性心肌梗死及靶病变血管重建的情况.结果 共206例患者行CABG,89例患者置入DES.随访2年的累积死亡率CABG组为10.2%,DES组为13.3%,两组之间差异无统计学意义(P=0.428).生存分析表明2年生存率CABG组为89.2%,DES组为86.4%,两组之间差异无统计学意义(P=0.668).2年心肌梗死发生率CABG组为10.1%,DES组为7.8%,两组之间差异无统计学意义(P=0.501).DES组2年内靶病变血管重建的发生率明显高于CABG组(13.5%比4.9%,P=0.015).多因素分析表明,年龄(HR:1.04,95% CI:1.01～1.09,P=0.024)、左心室功能不全(LVEF<30%)(HR:4.97,95%CI:1.22～24.85,P=0.018)以及2型糖尿病(HR:2.22,95%CI:1.31～4.86,P=0.001)均是死亡的独立危险因素.结论 对于≥170岁的老无保护左主干病变患者,行CABG和置入DES后2年的生存率相当,但置入DES的患者靶病变血管重建发生率明显高于行CABG的患者.     

85岁及以上老年冠心病患者经皮冠状动脉支架治疗的临床观察

目的 探讨85～94岁冠心病患者经皮冠状动脉支架治疗的疗效和预后.方法 回顾性分析90例85岁以上冠心病患者经皮冠状动脉支架治疗的临床和造影特点、住院期间和长期疗效.结果 90例中,21例应用金属裸支架(BMS),69例应用药物洗脱支架(DES).三支病变41例,2支病变21例,单支病变28例.手术成功率为94.4%,术前与术后TIMI-3级血流比例分别为72.2%和94.4%.手术相关并发症为15.6%,主要为冠脉夹层(11.1%).住院期间主要心血管不良事件(MACE)为7.8%,其中DES组住院期间MACE为5.8%,BMS组为14.3%.DES组出现2例严重出血.86例患者随访1年时,总的MACE为4.6%,其中DES组为6.0%,BMS组没有任何MACE.DES组出现]例脑卒中和1例严重出血.47例患者随访2年时,总的MACE为14.9%,其中DES组MACE为19.4%,BMS组无任何MACE.DES组1例发生严重出血,BMS组1例发生脑卒中.多因素COX回归分析表明,肌酐水平和高血压是影响长期预后的重要因素.结论 85岁以上冠心病患者经皮冠状动脉支架治疗手术成功牢较高,住院期间和长期的MACE事件发生率较低,并存高血压和严重.肾功能不全的患者MACE的发生率相对较高.     

按必要性支架植入术原则应用药物洗脱支架和药物涂层球囊治疗冠状动脉分叉病变的有效性和安全性

目的探究在治疗冠状动脉分叉病变时按必要性支架植入术原则,在主支植入药物洗脱支架(DES),分支应用药物涂层球囊(DCB)的有效性和安全性。方法该实验为前瞻性、单中心试验,57例有分叉病变患者。评估术后即刻效果,同时于术后9个月行冠脉造影检查,记录随访过程中不良心血管事件(MACE)的发生情况。结果所有病人均成功在主支植入DES,在分支应用DCB。术后9个月,晚期管腔丢失(LLL)主支为(0.27±0.38)mm,分支为(0.10±0.44)mm,MACE发生率为7.02%。其中1例死亡,2例发生心肌梗死,1例行靶病变血运重建(TLR)。结论按必要性支架植入术原则在主支植入DES,在分支应用紫杉醇涂层的药物球囊可考虑为治疗分叉病变安全、有效的新方法。     

急诊介入治疗急性心肌梗死患者分叉病变的疗效

目的研究急性心肌梗死(AMI)患者梗死相关血管(IRA)病变为分叉病变时,对急诊冠状动脉介入治疗(PCI)疗效的影响。方法对2004年1月至2008年6月本中心1209例发病在12 h内的AMI患者行急诊冠状动脉造影及PCI,其中急性ST段抬高型心肌梗死1037例,急性非ST段抬高型心肌梗死172例。梗死相关病变为分叉病变的患者(分叉病变组,BF)247例(20.4%),为非分叉病变的患者(非分叉病变组,NBF)962例(79.6%)。观察BF组患者的冠状动脉造影特点、急诊PCI的成功率及术后1年主要心血管事件(MACE)发生率。结果 BF组和NBF组患者年龄、性别、心功能Ⅲ-Ⅳ级、合并糖尿病、高血压、吸烟、高胆固醇血症、陈旧性心肌梗死病史比率无显著差异(P>0.05)。所有病变均植入药物洗脱支架(DES)。BF组IRA为左主干(LM)-前降支(LAD)/回旋支(LCX)16例(6.5%)、LAD/对角支(D)135例(54.7%)、LCX/钝缘支(OM)51例(20.6%)、右冠状动脉(RCA)远端分叉45例(18.2%)。其中220例(89.1%)只在主支植入支架,102例(41.3%)应用导丝保护边支。27例主支及边支均植入支架的病变中采用CruSh技术者8例,Culotte技术者15例,T支架技术者4例。BF组PCI成功239例(96.8%),NBF组PCI成功945例(98.2%),两组PCI成功率无显著差异(P=0.15)。两组术中均无死亡病例,术后住院期间BF组5例患者因急性或亚急性血栓形成而再次血运重建,9例患者死亡(3.6%),MACE发生率为5.7%;NBF组6例患者因急性或亚急性血栓形成而再次血运重建,27例患者死亡(2.8%),MACE发生率为3.4%。两组住院期间MACE发生率无显著差异(P=0.10)。术后1年随访BF组再次血运重建患者增加20例,死亡患者增加3例(死亡率4.9%),MACE发生率为15.0%(37/247);术后1年随访NBF组再次血运重建患者增加78例,死亡患者增加11例(死亡率4.0%)。MACE发生率为12.7%(122/962)。两组术后1年MACE发生率无显著差异(P=0.34)。结论 AMI患者IRA病变为分叉病变时,急诊PCI治疗有较高?     

药物洗脱支架血栓形成并发急性ST段抬高型心肌梗死的预后研究

目的 分析药物洗脱支架(DES)血栓形成引起急性ST段抬高型心肌梗死(STEMI)的临床和直接冠状动脉介入治疗(PCI)特征及预后.方法 31例因DES血栓形成引起STEMI(ST组)和93例由原发冠状动脉病变所致STEMI患者(对照组)接受直接PCI治疗.记录各例临床和PCI特征及1年随访结果.研究主要终点为院内及1年累积主要心脏不良事件(MACE),包括死亡、非致命性再梗死及靶血管再次血运重建(TVR).结果 与对照组比较,ST组年龄较大(69.9±11.4岁比63.7±13.6岁,P=0.01),糖尿病(41.9%比22.6%,P=0.04)和既往心肌梗死史(29.0%比11.8%,P=0.02)明显增多;直接PCI后冠状动脉TIMI 3级血流显著降低(45.2%比92.5%,P＜0.001).ST组院内死亡率(16.1%比3.2%,P=0.01)和MACE发生率(25.8%比7.5%,P:0.007)显著增高,术后1年总生存率及无MACE生存率显著降低(分别为77.4%比92.5%,P=0.016;59.4%比85.1%,P=0.001).结论 DES血栓形成引起STEMI患者即使接受直接PCI治疗,其院内死亡及MACE发生率仍显著高于由原发冠状动脉病变所致的心肌梗死患者.     

血管内超声与冠状动脉造影引导药物洗脱支架植入治疗慢性完全闭塞性病变:5年随访结果

目的:探讨血管内超声(IVUS)引导药物洗脱支架(DES)植入治疗慢性完全闭塞性病变(CTO)的远期疗效。方法:将230例成功开通CTO病变的患者按1∶1随机分组为IVUS引导组和冠状动脉造影(CAG)引导组。主要研究终点为术后5年时主要不良心血管事件(MACE),包括全因死亡、心肌梗死、靶血管血运重建(TVR)和支架内血栓(ST)。结果:230例患者中,219例成功完成5年临床随访,其中IVUS引导组109例,CAG引导组110例。2组间临床特征和CAG特征没有统计学差异。219例患者术后5年时共发生88例MACE(40.18%),其中IVUS引导组38例(34.9%),略低于CAG引导组的50例(45.5%),但没有统计学差异(P=0.110)。2组间全因死亡、心源性死亡、心肌梗死、TVR、靶病变血运重建(TLR)没有统计学差异。IVUS引导组ST发生率为1.8%,CAG引导组为8.2%,有显著统计学差异(P=0.032)。结论:对于CTO病变,相比于CAG引导,IVUS引导DES植入可以降低远期ST风险,也有降低MACE的趋势。     

应用药物球囊与药物洗脱支架治疗左主干再狭窄分叉病变的对比研究

目的对比应用药物球囊(DCB)血管成形术与再次植入药物洗脱支架(DES)治疗左主干再狭窄分叉病变对患者的长期影响。方法回顾性纳入2014年10月—2018年10月在天津市胸科医院因左主干再狭窄分叉病变行介入治疗的患者48例,其中DCB组24例,DES组24例,术前、术后均行冠状动脉造影定量分析,39例(81.3%)患者18个月随访再次行冠状动脉造影及冠状动脉造影定量分析,并对临床终点事件进行长期随访。结果基线资料分析表明,与DES组相比,DCB组非ST段抬高型心肌梗死或ST段抬高型心肌梗死患者比例相似(8.3%比25.0%,P=0.25);具有较高的低密度脂蛋白胆固醇水平[(92.9±35.1) mg/dL比(78.0±30.7) mg/dL,P=0.07],以及更多的双层支架病例(25.0%比4.2%,P=0.05),但均未达统计学意义。PCI后18个月冠状动脉造影定量分析随访,与DES组相比,DCB组晚期管腔丢失差异无显著性[(1.06±1.10) mm比(0.84±1.15) mm,P=0.62],靶病变最小管腔直径差异无显著性[(1.68±0.96) mm比(2.06±1.21) mm,P=0.37]。中位随访时间868天,主要不良心血管事件累计发生率DCB组为25.0%,DES组为29.2%,差异无统计学意义(P=0.75)。结论 DCB和DES在左主干再狭窄分叉病变患者中表现出相似的长期临床结局。     

One-year clinical outcomes of protected and unprotected left main coronary artery stenting.

AIMS: To evaluate outcomes for left main coronary artery (LMCA) stenting and compare results between protected (left coronary grafted) and unprotected LMCA stenting in the current bare-metal stent era. METHODS: We reviewed outcomes among 142 consecutive patients who underwent protected or unprotected LMCA stenting since 1997. All-cause mortality, myocardial infarction (MI), target-lesion revascularization (TLR), and the combined major adverse clinical event (MACE) rates at one year were computed. RESULTS: Ninety-nine patients (70%) underwent protected and 43 patients (30%) underwent unprotected LMCA stenting. In the unprotected group, 86% were considered poor surgical candidates. Survival at one year was 88% for all patients, TLR 20%, and MACE 32%. At one year, survival was reduced in the unprotected group (72% vs. 95%, P<0.001) and MACE was increased in the unprotected patients (49% vs. 25%, P=0.005). CONCLUSIONS: In the current era, stenting for both protected and unprotected LMCA disease is still associated with high long-term mortality and MACE rates. Stenting for unprotected LMCA disease in a high-risk population should only be considered in the absence of other revascularization options. Further studies are needed to evaluate the role of stenting for unprotected LMCA disease.     

Comparison of single‐ versus two‐stent techniques in treatment of unprotected left main coronary bifurcation disease

Background : This study sought to compare 3‐year outcomes of single‐ versus two‐stent techniques in patients with distal unprotected left main coronary artery (LMCA) disease treated with drug‐eluting stents (DES). Methods and Results : A total of 392 patients with distal unprotected LMCA disease who underwent DES implantation with single‐ (n = 234) or two‐ (n = 158) stent techniques were evaluated. The primary end point was major adverse cardiac events (MACE), defined as the composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). The two‐stent group was more likely to have extensive coronary artery stenosis. After adjustment with weighted Cox model using the inverse probability of treatment weighting, the 3‐year risk of death was similar in the single‐ and two‐stent groups (hazard ratio [HR], 0.77, 95% confidence interval [CI], 0.28–2.13, P = 0.62). However, the 3‐year risks of MI (HR, 0.38, 95% CI, 0.19–0.78, P = 0.008), TLR (HR, 0.16, 95% CI, 0.05–0.57, P = 0.005), and MACE (HR, 0.89, 95% CI, 0.22–0.67, P = 0.0007) were significantly lower in the single‐stent group. Conclusion : Compared with the two‐stent technique, the single‐stent technique showed more favorable long‐term clinical outcomes in patients with distal unprotected LMCA disease who received DES. © 2011 Wiley‐Liss, Inc.     

Comparison of simple and complex stenting techniques in the treatment of unprotected left main coronary artery bifurcation stenosis

We assessed the safety and feasibility of various stenting techniques using the sirolimus-eluting stent (SES) in the treatment of unprotected left main coronary artery (LMCA) bifurcation stenoses. One hundred sixteen patients with unprotected LMCA bifurcation stenoses underwent SES implantation. A simple stenting technique (simple group, n = 67) across the left circumflex artery (LCx) and a complex technique (complex group) comprising "kissing" stenting (n = 24) or a "crush" (n = 25) technique were used. Baseline clinical and angiographic characteristics were similar for the 2 groups, except for more multivessel involvement and narrower LCxs in the complex group. The procedural success rate was 100%. Angiographic restenosis rate at 6 months was lower in the simple group (5.3%) than in the complex group (24.4%, p = 0.024). In the complex group, restenosis rates were similar for the kissing (25.0%) and crush (23.8%) techniques (p = 1.0). There were no incidents of death or myocardial infarction during follow-up (median 18.6 months). Target lesion revascularization was performed in 6 patients only in the complex group (0% vs 12.2%, p = 0.005). At 18 months, survival rates without target lesion revascularization were 100 +/- 0% in the simple group and 85.7 +/- 5.6% in the complex group (p = 0.004). In conclusion, SES implantation for unprotected LMCA bifurcation stenoses appears to be safe and effective. Compared with the complex stenting technique, the simple technique was technically easier and appeared to be more effective in improving long-term outcomes in patients with normal LCxs.     

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。     

Long-term effect of stenting in unprotected left main coronary artery disease in the elderly

Objective To evaluate the feasibility, safety and efficacy of percutaneous stent implantation for treating left main coronary artery (LMCA) stenosis. Methods Consecutive patients with unprotected left main coronary artery disease treated by stent-based percutaneous intervention (PCI) at 6 medical centers in China were enrolled. Procedural data and clinical outcomes were obtained from all patients. Results From January 2001 to December 2004, 138 patients (79 males and 59 females; mean age: 69.7±5.8 years) underwent PCI for LMCA stenosis. Bare metal stents (BMS) were implanted in 51 patients with non-bifurcational lesions and in 5 patients with bifurcational lesions from January of 2001 to June of 2003 (BMS group);. drug eluting stents (DES) were used unselectively to cover both bifurcational and non-bifurcational lesions in 86 patients from July of 2003 to December of 2004 (DES group). Procedural success rate of the 138 cases was 98% (135/138). One patient (0.7%) with bifurcation lesion who was treated with DES died from severe heart failure 2 weeks after the procedure. During a mean follow up period of 21.3±5.6 months, one patient died from renal failure, one from sudden cardiac death, 4 underwent target lesion revascularization (TLR) in the BMS group, which all occurred in patients with bifurcational lesions; whereas in the DES group no deaths occurred and only one patient with bifurcational lesion had TLR. Conclusions (1) PCI is feasible and relatively safe to treat unprotected left main coronary artery disease in elderly patients at medical centers with experienced professionals. (2) BMS and DES have similar immediate and long-term efficacy in the treatment of ostium and shaft lesions of the LMCA. (3) DES are strongly suggested in the therapy of distal bifurcation lesion of unprotected LMCA.     

Elective stenting of unprotected left main coronary artery stenosis: effect of debulking before stenting and intravascular ultrasound guidance

OBJECTIVES: We sought to evaluate: 1) the long-term outcomes of 127 selected patients receiving unprotected left main coronary artery (LMCA) stenting; and 2) the impact of the debulking procedure before stenting and intravascular ultrasound (IVUS) guidance on their clinical outcomes. BACKGROUND: The long-term safety of stenting of unprotected LMCA stenoses has not been established yet. METHODS: A total of 127 consecutive patients with unprotected LMCA stenosis and normal left ventricular function were treated by elective stenting. The long-term outcomes were evaluated between two groups: IVUS guidance (n = 77) vs. angiographic guidance (n = 50); and debulking plus stenting (debulking/stenting; n = 40) vs. stenting only (n = 87). RESULTS: Angiographic restenosis was documented in 19 (19%) of 100 patients. The lumen diameter after stenting was significantly larger in IVUS-guided group (p = 0.003). The angiographic restenosis rate was significantly lower in the debulking/stenting group (8.3% vs. 25%, p = 0.034). The reference artery size was the only independent predictor of angiographic restenosis. During follow-up (25.5 +/- 16.7 months), there were four deaths, but no nonfatal myocardial infarctions occurred. The survival rate was 97.0 +/- 1.7% at two years. CONCLUSIONS: These data suggest that stenting of unprotected LMCA stenosis might be associated with a favorable long-term outcome in selected patients. Guidance with IVUS may optimize the immediate results, and debulking before stenting seems to be effective in reducing the restenosis rate. However, we need a large-scale, randomized study.     

Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation

OBJECTIVES: This study was designed to compare the clinical and angiographic outcomes of sirolimus-eluting stent (SES) and bare metal stent (BMS) implantation for unprotected left main coronary artery (LMCA) stenosis. BACKGROUND: The safety and effectiveness of SES implantation for unprotected LMCA stenosis have not been ascertained. METHODS: Elective SES implantation for de novo unprotected LMCA stenosis was performed in 102 consecutive patients with preserved left ventricular function from March 2003 to March 2004. Data from this group were compared to those from 121 patients treated with BMS during the preceding two years. RESULTS: Compared to the BMS group, the SES group received more direct stenting, had fewer debulking atherectomies, had a greater number of stents, had more segments stented, and underwent more bifurcation stenting. The procedural success rate was 100% for both groups. There were no incidents of death, stent thrombosis, Q-wave myocardial infarction (MI), or emergent bypass surgery during hospitalization in either group. Despite less acute gain (2.06 +/- 0.56 mm vs. 2.73 +/- 0.73 mm, p < 0.001) in the SES group, SES patients showed a lower late lumen loss (0.05 +/- 0.57 mm vs. 1.27 +/- 0.90 mm, p < 0.001) and a lower six-month angiographic restenosis rate (7.0% vs. 30.3%, p < 0.001) versus the BMS group. At 12 months, the rate of freedom from death, MI, and target lesion revascularization was 98.0 +/- 1.4% in the SES group and 81.4 +/- 3.7% in the BMS group (p = 0.0003). CONCLUSIONS: Sirolimus-eluting stent implantation for unprotected LMCA stenosis appears safe with regard to acute and midterm complications and is more effective in preventing restenosis compared to BMS implantation.     

Optimal final lumen area and predictors of target lesion revascularization after stent implantation in small coronary arteries

Despite similar early clinical events, patients who undergo treatment of small vessels are at an increased risk for target lesion revascularization (TLR) after coronary artery stenting. We sought to determine predictors of TLR after stent implantation in small coronary arteries. We identified 423 consecutive patients who underwent intravascular ultrasound (IVUS)-guided small vessel stenting procedures in 465 coronary lesions with an angiographic reference vessel diameter of <2.75 mm. Patients were divided into 2 groups based on a final IVUS lumen area of < or =6.0 mm2 (n=345 lesions, group I) and >6.0 mm2 (n=115, group II). Baseline patient characteristics and in-hospital outcomes were similar between the 2 groups, except for a higher rate of restenotic lesions in group I and bifurcation lesions in group II. Group I had higher TLR rates at 1 year compared with group II patients (39% vs 26%, p = 0.02). The TLR rate appeared to decrease with greater stent expansion, especially at >90% of the reference vessel area, as assessed by IVUS. By multivariate analysis, an IVUS final stent area of < or =6 mm2, diabetes, absence of prior myocardial infarction, and history of intervention were independent predictors of 1-year TLR in this population. Final stent area of >6.0 mm2 and greater stent expansion were associated with a decrease in TLR. Therefore, there does not appear to be any "downside" to aggressive stent implantation strategies in small vessels. In contrast, IVUS allows maximization of final lumen dimensions to minimize clinical restenosis.     

Drug‐eluting stents in bifurcation lesions: To stent one branch or both?

OBJECTIVES: The objective of this study was to compare two techniques to treat bifurcation lesions: a single drug-eluting stent (DES) implanted in the main branch combined with balloon dilatation for the side branch vs. stenting of both branches (double stent). BACKGROUND: Percutaneous coronary intervention in coronary bifurcation lesions remains challenging. Although DES reduce restenosis in lesions, the double stent procedure has not shown clear advantages over a single stent with balloon dilation. METHODS: Fifty-three symptomatic patients with true bifurcation lesions were treated using either the double stent technique (n = 25) or one stent in the parent vessel plus balloon angioplasty of the side branch (n = 28). Procedural results and major adverse cardiac event rates (MACE: cardiac death, myocardial infarction, target vessel revascularization (TVR)) were compared. RESULTS: Angiographic procedural success (residual stenosis <30% in both branches) was 75% in the single stent group and 100% in the double stent group (P = 0.01). All differences were due to residual stenosis of the side branch. Clinical follow-up (6-18 months) was available for all patients; 90.5% of patients had a coronary angiography or nuclear stress test. Three patients (11%) in the single stent group and two (8%) in the double stent group had ischemia-driven TVR (P = NS). Asymptomatic angiographic restenosis (>50% diameter stenosis) in the ostium of the side branch was seen in two patients in the double-stent group. At 6 months, MACE-free was comparable between groups (89.3% vs. 88%, P = 0.7). CONCLUSIONS: When treating bifurcation lesions with sirolimus-eluting stents, restenosis following a single stent procedure is comparable to stenting both parent and side branch vessels. Thus, stenting the main-branch lesion, coupled with balloon angioplasty in the side branch, produces a high success rate and good clinical outcomes at 6 months.     

Percutaneous coronary intervention versus coronary artery bypass graft surgery for the treatment of unprotected left main coronary artery stenosis: in-hospital and one year outcome after emergent and elective treatments

This study attempts to compare the risks and benefits of provisional stenting with drug eluting stents and bypass surgery for left main coronary artery (LMCA) stenosis. Recent improvements in interventional technologies have increased interest in percutaneous treatment of LMCA stenosis. However, application of percutaneous techniques to LMCA has been sporadic and controversial. In-hospital and one year outcomes of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) cases were compared. From September, 2003 to June, 2005, a total of 59 consecutive patients with de novo unprotected LMCA stenosis were treated with either CABG or PCI. Twenty patients received non-intravascular ultrasound-guided PCI with a stent in the LMCA. Thirty-nine patients underwent CABG. At 30-day follow-up, the major adverse cardiac and cerebrovascular event (MACE) rates of mortality, myocardial infarction, cerebral vascular accident, and target vessel revascularization were 25.6% in the CABG group and 5% in the PCI group (P=0.054). At one year follow-up, the MACE rates were 33.3% in the CABG group and 5% in the PCI group. One year MACE for the CABG group significantly differed from that of the PCI group (P=0.015). The odds ratio (OR) of one year MACE-free survival was 0.75 (P<0.001) in the CABG group versus the PCI group. Further analysis demonstrated there was a significant difference in in-hospital MACE and one year MACE between the elective CABG group and elective PCI group (P=0.045). However, there was no significant difference between the emergent CABG group and emergent PCI group (P=1.000 for in-hospital MACE; P=0.486 for one year MACE). PCI on unprotected LM offers an alternative option in patients with high surgical risk and appropriate lesion morphology.