双对吻挤压术与即兴支架置入术治疗冠状动脉分叉病变的对比研究★

背景：多种分叉病变的治疗焦点仍然在于最佳置入方法是单支架置入还是双支架置入。 目的：比较双对吻挤压与即兴支架置入治疗冠状动脉分叉病变的疗效和安全性。 设计、时间及地点：非随机对照前瞻性试验，于2006-08/2007-04于南京市第一医院完成。 对象：入选62例真性分叉病变需行经皮冠状动脉介入治疗的急性冠状动脉综合征患者(目测分支血管直径> 2.0 mm) 。其中32例患者接受即兴支架置入治疗，30例患者接受双对吻挤压技术治疗。 方法：主支血管及分支血管所置入支架均选用雷帕霉素药物洗脱支架。即兴支架组主支常规置入支架，如果球囊对吻后分支仍然有大于50%残余狭窄或有影响前向血流的夹层出现则根据术者经验采取T支架、Culotte支架或Reverse crush支架术。双对吻挤压组按常规置入支架。 主要观察指标：比较两组患者支架置入后即刻及置入后6~9个月的冠状动脉造影结果。随访终点为1年内主要不良心脏事件。 结果：两组患者基线特征具有可比性（P > 0.05）。冠状动脉造影测得支架置入后即刻双对吻挤压组分支血管开口部位最小管腔直径明显大于即兴支架组(P < 0.01),同时双对吻挤压组残余狭窄度显著小于即兴支架组(P < 0.01)。6~9个月造影随访结束,双对吻挤压组分支血管最小管腔直径显著大于即兴支架组(P < 0.01), 残余狭窄度小于即兴支架组(P < 0.01)。即兴支架组晚期管径丢失较双对吻挤压组有增高趋势，但差异无显著性(P > 0.05)。住院期间两组均无主要不良心脏事件，1年随访期间双对吻挤压组发生1例主要不良心脏事件, 即兴支架组发生4例主要不良心脏事件(P > 0.05)。 结论：双对吻挤压与即兴支架置入治疗冠状动脉真性分叉病变均有良好的疗效及安全性。由于双对吻挤压可以有效降低分支血管再狭窄率及主要不良心脏事件的发生率，故具有潜在优势。

Study on DK crush versus provisional stenting technique for treatment of coronary artery bifurcation lesions

BACKGROUND: Whether single or double stent implantation is the optimal stenting strategy in coronary artery bifurcation lesions is unknown. OBJECTIVE: To compare the efficacy and safety of DK crush (DK) versus provisional stenting technique (PT) for the treatment of coronary artery bifurcation lesions. DESIGN, TIME AND SETTING: Non-randomized, controlled and prospective experiment was performed at the Nanjing First Hospital between August 2006 and April 2007. PARTICIPANTS: Sixty-two patients with true coronary bifurcation lesions (branch diameter > 2.0 mm by visual estimation) were enrolled. Thirty-two patients were treated by PT and the other patients undergoing DK. METHODS: Only Rapamycin eluting-stents were allowed to be implanted. T stent, Culotte stent or Reverse crush stent could be used if there was still more than 50% residual stenosis or dissection that could affect blood flow in PT group following routine implantation. DK group only underwent routine stent implantation. MAIN OUTCOME MEASURES: Quantifying coronary angiography dada were analyzed before and immediately after percutaneous coronary intervention as well as at 6-9 months follow-up. Major adverse cardiovascular events were recorded by telephone call after 1 year. RESULTS: There were no significant differences between two groups in terms of baseline characteristics (P > 0.05). Patients in the DK group compared with those in the PT group were characterized by larger minimum lumen diameter at branch ostium (P < 0.01) and smaller residual stenosis (P < 0.01). At 6-9 months follow-up, no statistically significant differences were identified in minimum lumen diameter (P < 0.01), residual stenosis (P < 0.01) and late lumen loss in main vessel, but it tented to be higher in PT group compared with DK group (P > 0.05). There were no major adverse cardiovascular events developed during hospitalization in both groups. At 1 year follow-up, 1 major adverse cardiovascular event occurred in DK group and 4 developed in PT group (P > 0.05). CONCLUSION: Both DK crush and provisional stenting techniques are effective and safe for the treatment of coronary bifurcation lesions. But DK crush shows superior over provisional stenting because it can effectively reduce incidence of restenosis and major adverse cardiovascular events.