冠状动脉旋磨术在高危钙化病变中应用的单中心经验

Application of rotational atherectomy in treating high-risk calcified coronary lesions: single center experience

目的 总结冠状动脉旋磨术在高危冠状动脉钙化病变中应用的经验,分析该技术治疗高危钙化病变患者的安全性及近、远期预后。方法 回顾分析2010年1月至2014年12月接受冠状动脉旋磨术结合支架植入术治疗患者130例,其中符合高危复杂钙化病变患者23例。分析术前术后冠状动脉DSA造影资料及临床信息,评估介入术并发症和主要心脑血管不良事件发生率。结果 23例患者26处钙化病变均接受冠状动脉旋磨术,其中15处（57.7%）、7处（26.9%）、4处（15.4%）病变分别以初始直径1.25 mm、1.5 mm、1.75 mm磨头开始旋磨。23处病变（88.5%）成功旋磨并顺利植入支架,即刻效果满意,无并发症;3处（11.5%）病变未植入支架,原因分别为血管太细、血管穿孔和支架内再狭窄,仅作旋磨术。术中发生冠状动脉夹层1处（3.8%）,支架植入后边支闭塞2处（7.7%）,血管穿孔1处（3.8%）,无复流2处（7.7%）及支架内残余狭窄1例（3.8%）。住院期间无死亡事件发生,发生支架植入术后心肌梗死3例（13.0%）,对比剂肾病2例（8.7%）。术后1年随访发现5例（21.7%）心绞痛症状再发,其中2例经造影证实与支架内再狭窄有关。21例获随访4-60个月,平均（25.5±10.7）个月,结果 4例病死,2例再行血管重建术。结论 冠状动脉旋磨术治疗高危钙化病变安全、有效,术中根据病变特点遵循“磨头更小、推进更慢、分段旋磨”的原则,手术成功率高,并发症发生率低,术后主要心脑血管不良事件发生率低。

Objective To summarize the application experience of coronary rotational atherectomy （CRA） in treating high-risk calcified coronary lesions, and to evaluate the safety, short-term and long-term outcomes of CRA for the treatment of high-risk calcified lesions. Methods The clinical data of 130 patients, who received CRA combined with stent implantation during the period from February 2010 to December 2014, were retrospectively analyzed. Among the 130 patients, high-risk complex calcified lesion was found in 23 patients. Preoperative and postoperative coronary DSA findings and clinical data were analyzed, and procedure- related complications and incidence of major cardiovascular adverse events were evaluated. Results A total of 26 calcified coronary lesions were found in 23 patients, and CRA was employed for all the 26 lesions. The performing of CRA for 15（57.7%）, 7（26.9%） and 4（15.4%） lesions was started with the use of initial diameter of 1.25 mm, 1.5 mm and 1.75 mm grinding head respectively. Successful rotation and smooth stent implantation were accomplished for 23 lesions （88.5%）, and satisfactory instant effect was obtained with no complications. For the remaining 3 lesions only CRA was carried out without adopting stent implantation because the coronary artery was too thin or was perforated, or in-stem restenosis occurred. During hospitalization, no death occurred, 3 patients （13%） developed myocardial infarction after stent implantation, and 2 patients （8.7%） developed contrast-induced nephropathy. Follow-up examination after one year of treatment showed that symptomatic recurrence of angina pectoris was seen in 5 patients （21.7%）, and angiography revealed that in 2 patients the angina pectoris was related to in-stent restenosis. Twenty-one patients were followed up for 4-60 months with a mean of （25.5±10.7） months, and during follow-up period 4 patients died and 2 patients received vascular reconstruction. Conclusion For the treatment of high-risk calcified coronary lesions, CRA is safe and effective. Referring to the characteristics of the pathological changes and following the ＂smaller grinding head, slowly advancing and segmental rotation＂ principle will ensure a higher surgical success rate and a lower complication rate; the incidence of postoperative adverse cardiovascular and cerebrovascular events is lower.