血管内超声动态观察左主干分叉病变行单支架术中最终对吻技术对分叉解剖结构的影响

The impact of final kissing balloon inflation on anatomical structure in single-stent technique strategy for left-main bifurcation lesion:a serial IVUS study

目的:探讨在单支架横跨支架术式治疗左主干分叉病变中,使用血管内超声(IVUS)动态观察最终对吻技术对分叉区域解剖结构的影响。方法:前瞻性入组36例左主干分叉病变且行单支架横跨术式,所有患者在术前分别从前降支(run1)、回旋支(run2)回拉IVUS,支架释放后从前降支回拉IVUS(run3),最终对吻后分别从前降支(run4)、回旋支(run5)回拉IVUS;分析患者的临床特征、造影资料和IVUS数据。结果:患者年龄(63.8±12.1)岁,左主干真性分叉病变占22.2%。相较于术前IVUS(run2),最终对吻术后的IVUS(run5)发现回旋支开口处管腔面积[(7.30±3.08)mm^(2) vs(.6.37±2.66)mm^(2),P<0.05]和血管面积[(13.10±3.27)mm^(2) vs.(12.47±2.93)mm^(2),P=0.012]均明显减小,而斑块面积差异无统计学意义[(5.80±2.02)mm^(2) vs.(6.10±2.09)mm^(2),P=0.128];回旋支开口处管腔面积变化与血管面积变化相关(r=0.787,P<0.001),而与斑块面积变化不相关(r=0.187,P=0.276)。相较于支架释放后IVUS(run3),最终对吻术后的IVUS(run4)发现多边形区域面积[(9.80±2.09)mm^(2) vs.(11.48±2.65)mm^(2),P<0.05]、左主干远端面积[(9.91±1.73)mm^(2) vs.(11.85±2.38)mm^(2),P<0.05]和左主干最小支架内面积[(9.61±1.53)mm^(2) vs(.11.34±2.33)mm^(2),P<0.05]均明显增加,支架贴壁不良现象减少(83.3%vs.61.1%,P=0.035),但是伴随支架不对称指数增加,多边形区域(1.23±0.14 vs.1.33±0.12,P<0.05);左主干远端(1.18±0.09 vs.1.25±0.10,P<0.05);左主干最小管腔面积处(1.17±0.09 vs.1.24±0.10,P<0.05)。结论:在左主干分叉病变行单支架横跨支架术中,最终对吻后回旋支开口面积明显减小,与嵴移位相关;最终对吻增加左主干及多边形区域支架内面积,减少支架贴壁不良现象,但是会增加支架不对称指数。

Objective:To investigate the impact of final kissing balloon inflation(FKBI)on anatomical structure in single-stent crossover technique for left main artery bifurcation lesions with serial intravascular ultrasound(IVUS)imaging.Methods:Totally,36 patients with left main artery bifurcation lesions were prospectively enrolled,and treated with single-stent crossover strategy.Serial IVUS pullback examinations were performed,including the runs of pre-intervention from both left anterior descending artery(LAD,run1)and left circumflex artery(LCX,run2),the run of post-stenting from LAD(run3),and the runs of post-FKBI from both LAD(run4)and LCX(run5).Results:The mean age of these patients was(63.8±12.1)years old,with left main true bifurcation lesion accounting for 22.2%.Compared with IVUS imaging of pre-intervention(run2),the ostium area of LCX was significantly decreased after FKBI[run5,(7.30±3.08)mm^(2) vs.(6.37±2.66)mm^(2),P<0.001],as well as vessel area[(13.10±3.27)mm^(2) vs.(12.47±2.93)mm^(2),P=0.012],however,there was no significant changes in plaque area[(5.80±2.02)mm^(2) vs.(6.10±2.09)mm^(2),P=0.128].The change in lumen area within the LCX ostium was positively correlated with the change in EEM area(r=0.787,P<0.05),but not with plaque area(r=0.187,P=0.276).Compared with IVUS imaging of post-stenting(run3),FKBI(run4)significantly increased the area at the site of polygon of confluence[POC,(9.80±2.09)mm^(2) vs.(11.48±2.65)mm^(2),P<0.05],distal left main[(9.91±1.73)mm^(2) vs.(11.85±2.38)mm^(2),P<0.05]and the minimal lumen area(MLA)of the left main[(9.61±1.53)mm^(2) vs.(11.34±2.33)mm^(2),P<0.05],decreased stent malapposition phenomena(83.3%vs.61.1%,P=0.035),but increased the stent asymmetry index significantly(POC:1.23±0.14 vs.1.33±0.12,P<0.05;Distal LM:1.18±0.09 vs.1.25±0.10,P<0.05;MLA:1.17±0.09 vs.1.24±0.10,P<0.05).Conclusion:Our analysis showed that carina shift,instead of plaque shift,was the main mechanism of LCX ostium compromise after FKBI in single-stent crossover technique for left-main bifurcation lesions.FKBI increased the stent area of the left main and POC,and decreased stent malapposition phenomena,at the cost of increasing stent symmetric index.