成角近段旋磨对严重钙化成角冠状动脉病变的治疗价值

The Therapeutic Value of Proximal Angular Rotational Atherectomy in Patients With Severe Calcified Angulated Coronary Artery Disease

目的:在严重钙化成角冠状动脉(冠脉)病变患者中,对比成角近段旋磨和全程旋磨的手术成功率、术中并发症及临床预后,评估成角近段旋磨对该类病变的治疗价值。方法:连续纳入我院2017年1月至2019年12月接受冠脉旋磨介入治疗且冠脉均存在严重钙化伴成角(≥45°)的患者共245例,依据旋磨手术策略分为全程旋磨组(n=179)和成角近段旋磨组(n=66)。比较两组手术成功率和术中并发症发生率,观察两组患者的临床转归,观察终点包括院内和1年主要不良心血管事件(MACE,包括心原性死亡、靶血管再次血运重建、支架内血栓)发生率。结果:成角近段旋磨组的手术成功率为97.0%,2例(3.0%)患者因术中球囊无法扩张而最终转换为全程旋磨;全程旋磨组的手术成功率为99.4%,1例(0.6%)患者因冠脉穿孔导致手术失败而行急诊冠脉旁路移植术。全程旋磨组发生旋磨头嵌顿和心包填塞各2例(1.1%)、冠脉穿孔4例(2.2%),而成角近段旋磨组未出现这些严重并发症;两组术中慢血流/无复流的发生率差异无统计学意义(P>0.05),但全程旋磨组术中冠脉夹层的发生率显著高于成角近段旋磨组(43.6%vs.19.7%,P<0.05)。两组的院内总MACE发生率相当,但全程旋磨组1年MACE发生率明显高于成角近段旋磨组(27.4%vs.13.6%,P<0.05)。结论:对于严重钙化伴成角的冠脉病变,成角近段旋磨联合球囊扩张的手术成功率和临床转归与全程旋磨相似,而术中并发症尤其严重并发症的发生风险明显低于后者,说明仅采用成角近段旋磨治疗此类病变是安全和有效的。

Objectives:To investigate whether there is any difference in the success rate,intraoperative complications and clinical prognosis between the rotational atherectomy treatment in the proximal segment of the angulation and in the whole process in patients with severe calcified angulated coronary artery disease,so as to evaluate the value of proximal angular rotational atherectomy in the treatment of these lesions.Methods:A total of 245 patients with severe coronary artery calcification and angulation(≥45°)who received interventional treatment with coronary rotational atherectomy were enrolled in our hospital from January 2017 to December 2019,and were divided into the whole process rotational atherectomy group(n=179)and the calcified angulated proximal rotational atherectomy group(n=66)according to the rotational atherectomy strategy.The incidence of complications and the success rate of operation were compared between the two groups.Clinical outcomes in both groups were observed,including the incidence of major adverse cardiovascular events(MACEs,were defined as cardiac death,revascularization of target vessels,stent thrombosis)in hospital and in one year.Results:The success rate was 97.0%in the angulated proximal segment rotational atherectomy group and 2 cases(3.0%)were converted to the whole rotational atherectomy group because the balloon could not expand during the operation.The success rate was 99.4%in the whole process rotational atherectomy group and 1 patient(0.6%)underwent emergency surgical coronary bypass graft due to due to coronary artery perforation.Two cases(1.1%)of cardiac tamponade,2 cases(1.1%)of entrapped rotablator burr,and 4 cases(2.2%)of coronary artery perforation occurred in the whole rotational atherectomy group,but these serious complications were not found in the angulated proximal segment rotational atherectomy group.There was no significant difference in the incidence of intraoperative slow flow/no reflow between the two groups(P>0.05),but the incidence of intraoperative coronary artery dissection was significantly higher in the whole process rotational atherectomy group than in the angulated proximal segment rotational atherectomy group(43.6%vs.19.7%,P<0.05).Total in-hospital MACEs were comparable between the two groups,but the one-year MACEs was significantly higher in the whole process rotational atherectomy group than in the angulated proximal segment rotational atherectomy group(27.4%vs.13.6%,P<0.05).Conclusions:For patients with severe coronary artery calcification and angulation,the procedural success rate and clinical outcome of the angulated proximal segment rotational atherectomy combined with balloon dilation are comparable to that of the whole process of rotational atherectomy,and associated with lower risk of intraoperative complications,especially serious complications,as compared with the whole process of rotational atherectomy option.Our results suggest that patients with severe coronary artery calcification and angulation could be effectively and safely treated with the angulated proximal segment rotational atherectomy combined with balloon dilation strategy.