关于拓宽直接冠状动脉支架植入术适应证的探讨

Investigation on the indication of coronary stenting without predilatation

目的 :探讨放宽直接支架术的“经典适应证”同时如何保持高成功率和低并发症发生率。方法 :对 2 16例冠心病病人 2 2 5支靶血管上 2 35处靶病变不预扩张 ,直接植入冠状动脉支架 ,病人平均冠心病病史 38± 12 .7个月 ,平均年龄 5 7 5± 11 2岁 ,年龄范围 31～ 79岁。包括不稳定心绞痛、AMI并心源性休克、充血性心力衰竭、多支病变或单支多处病变者。狭窄程度 6 0 %～ 99% ,靶血管直径 2 5～ 4 0mm ,B2 及C型复杂病变占 39 1%。排除重度钙化、>38mm长、>12 0°弯曲及完全闭塞病变。应用了 11种管状支架 (占 74 1% )、组件式支架 (占 2 5 5 % )及自膨胀支架 (0 4% )。结果 :直接支架术占该中心全部支架术总数的 2 1 4% ,应用比例从 1997年的 8 2 %增至 2 0 0 0年的 31 1% ,复杂病变占 39 1%。技术成功率 99 6 % ,手术成功率 10 0 % ,无并发症。术后近期及远期疗效理想。结论 :在当前冠状动脉支架已明显改进的基础上可适当拓宽直接支架术的临床和病变适应证。保持高成功率和低并发症发生率的关键 ,一是遵循学习曲线规律 ,二是排除重度钙化、高度弯曲和过长的病变。

Objective:To investigate the indication of direct coronary stenting without predilatation meanwhile maintain high success rate and low complication.Methods:Two hundred and sixteen coronary heart disease patients with stable angina,unstable angina,acute myocardial infarction with or without cardiogenic shock,multivessel or tandem lesions,chronic heart failure,age 57.5±11.2(31～79)years,average duration of symptoms for 38±12.7 month were included.The percentages of stenosis were 60%～90%,diameters of target vessel were 2.5 mm～4.0 mm and type B\-2 or C complex lesions were 31.9%.Lesions with severe calcification,diffuse lesion>38 mm,lesion tortuosity>120° and total occlusion were excluded.235 stents were implanted directly with 11 kinds of slotted-tube stents(74 1%),tube-coil stents(25.5%)and selfexpanding stents(0.4%).Results:21.4% of our stenting from 1997 to 2000 were direct stenting which increased from 8.2% in 1997 to 31.3% in 2000,in which 39.1% were complex lessions.Technical success was 99.6% and procedure success was 100%,with no complication and satisfied immediate and long term effects.Conclusion:The clinical and lesion indications for direct stenting can be broadened on the basis of currently improved stents.The key points to maintain high success rate and low complication are to adhere to the interventional learning curve and to exclude severe calcification,significant tortuosity and /or diffuse long lesion.