无保护左主干合并前降支慢性完全闭塞病变的介入治疗策略

Strategy of elective percutaneous coronary intervention on unprotected left main coronary artery disease complicated with chronic total occlusion lesions in left anterior descending

目的评价不宜接受冠状动脉旁路移植术的无保护左主干(unprotected left main coronary artery,ULM)病变合并左前降支(left anterior descending(coronary artery,LAD)慢性完全闭塞病变(chronic total occlusion,CTO)的经皮冠状动脉介入术(percutaneous coronary intervention,PCI)的效果。方法ULM合并CTO病变病人56例,行PCI,ULM狭窄在80%或以上25例(45%),其中累及直径超过2.5mm的冠状动脉回旋支(left circumflex coronary artery,LCX)14例(25%),先行ULM-LCX支架术,再行LAD-CTO病变支架术;LCX直径小于2.5mm或未累及LCX 11例(20%),先行ULM体部支架术。ULM狭窄在80%以下31例,其中累及较大LCX者18例,在LCX保护导丝或仅对LCX狭窄超过95%者行球囊扩张术的前提下,先行LAD-CTO支架术;小LCX或LCX未累及者则直接先行LAD-CTO支架术13例。结果即刻手术成功率ULM 100%,LAD-CTO98%(55/56)。ULM和LAD-CTO的55例成功病人住院期间出现非Q波心肌梗死2例,病例成功率95%(53/56)。病变成功的55例病人平均随访(41±25)个月,死亡3例(总病死率6%),其中心脏性死亡2例,食管癌1例;4例靶病变血运重建(其中2例CABG),主要不良心脏事件发生率13%。结论采取个体化策略用PCI治疗高危ULM合并LAD-CTO病变可获得较满意的即刻和长期临床疗效;应用PCI治疗CABG禁忌或高危的ULM合并LAD-CTO安全可行。

Objectives To investigate the safety and efficacy of percutaneous coronary intervention （PCI） in patients with unprotected left main （ULM） coronary arteries disease complicated with chronic total occlusion in left anterior descending （LAD-CTO） lesions who had CABG contraindications or at high surgical risk. Methods Fifty-six consecutive hospitalized patients between November 2001 and December 2007 who had PCI on ULM and LAD-CTO lesions were analyzed. Among them, 96% of the patients had CABG contraindications or at high surgical risk. （36 patients with Euroscore 〉 6 of high risk, accounting for 64%）. Two patients less than 40 years old did not accept CABG operation. Four PCI strategies were adopted according to the stenosis degree of LM and the diameter and involvement of left circumflex （LCX）. Results There were 25 patients with ULM equal to 80% stenosis or more, and 14 of them involved LCX lesions with diameter more than 2.5 mm were stented in their ULM-LCX lesions first, and then stented in LAD-CTO lesions. Eleven of them whose LCX diameter less than 2.5 mm were stented in the body of ULM first, and then in LAD-CTO lesions. There were 31 patients with ULM less than 80% stenosis, and 18 of them involved big LCX were stented in LAD- CTO lesion first, under LCX wire protection or only balloon dilation for LCX stenosis more than 95%. The remainder 13 patients with small LCX or LCX uninvolved were stented directly in their LAD-CTO lesions. The success rate on ULM lesions was 100% and on LAD-CTO lesions was 98%. Two patients who were succeed on both ULM and LAD-CTO lesions occurred with non-Q-wave MI in hospital, and the patient success rate was 95%（53/56）. Fifty-five patients who had procedure success were followed up for a mean of （41±25） months. At the end of the follow-up period, the incidence was 6% of all-cause mortality, and 13% （7/55） of major advise cardiac event, including 4% of cardiac mortality, 2% of MI, and 7% of target lesion revascularization （4% of CABG included）. Conclusions Coronary stenting on patients with ULM lesions complicated with LAD-CTO lesions can be performed safely in high-risk patients with acceptable immediate and long-term clinical follow-up outcome on the basis of individual therapeutic strategy at experienced center. It may be safe and feasible to apply this technique in selected patients with ULM lesion complicated with LAD-CTO coronary disease existing CABG contraindication or high risk.