预扩张支架术和直接支架术治疗老年冠心病患者比较观察

Comparison between predilation stenting and direct stenting in the treatment of aged patients with coronary heart disease

目的 比较采用充分预扩张支架术、有限预扩张支架术和直接支架术治疗老年冠心病患者的优缺点及远期疗效。方法 选择具有如下特点的病例进入观察:①临床诊断不稳定型心绞痛(UAP)或非ST段抬高性心肌梗死(NSTEMI)。②年龄≥65岁。③无糖尿病史。④冠状动脉(冠脉)病变狭窄程度≥75％但≤95％,长度≤30mm,参考直径≥3.0mm,成角≤45°。⑤透视下病变钙化程度中度以下。对人选病例的病变随机分为3组:①充分预扩张支架组,采用与病变参考血管直径1:1的球囊充分预扩张后置入支架。②有限预扩张支架组,采用比病变参考血管直径小30％左右的球囊作有限预扩张后置入支架。③直接支架组,不经过预扩张直接置入支架。全组病例术后常规服用噻氯匹定4周,联合应用β-阻滞剂、钙拮抗剂、血管紧张素转换酶抑制剂和他汀类降脂药物。每半年随访症状和心电图,对有胸痛症状和缺血检查结果者复查冠脉造影。结果 共入选198例患者(263个病变),男/女为122/76,年龄(72±11)岁。3组病变分组情况及介入治疗结果:①充分预扩张支架组,87个病变(63例),支架全部放置成功,支架直径(3.3±0.7)mm,长度(2.68±0.7)mm,预扩张后33个病变(37.9％)出现夹层,其中11个(33.3％)需采用长支架或补放支架处理。②有限预扩张支架组88个病变(69例),支架全部放?

Objective To evaluate the efficacy of optimal predilation stenting, suboptimal predilation stenting and direct stenting in the treatment of aged patients with acute coronary syndrome. Methods Patients with following characteristics were enrolled into the study: ①unstable angina pectoris or non ST elevation myocardial infarction; ②older than 65 years; ③without diabetes mellitus; ④target coronary lesion was stenosis of 75-95% , ≤30mm in length, ≥3.0mm in reference vessel diameter, ≤45° angulation and moderate calcification. The patients were randomized into following groups: ①stenting with complete predilation (SCP group): stent was implanted in lesion site after complete predilation with 1: 1 balloon to reference vessel diameter; ②stenting with incomplete predilation (SIP group) : stem was implanted in lesion site after incomplete predilation with a balloon 20-30% smaller than reference vessel diameter; ③stenting without predilation (SWP group): stent was implanted in lesion site without predilation. Ticlopidine was used for 4 weeks. Other medications such as β-blocker, calcium antagonist agent, ACEI and statins were continued. Clinical presentation and ECG were followed up semiannually. Repeated coronary angiography was conducted selectively for patients with reccurrent chest pain or myocardial ischemia attack. Results One hundred and ninety-eight patients (263 target lesions) with mean age of 72 ± 11 were enrolled. In SCP group, 87 lesions (63 patients) were stented successfully. In this group 33 major dissections (33.3%) were treated with bail-out stenting. In SIP group, 88 stents were implanted in 69 patients with 9 minor dissections. In SWP group, 88 target lesions were successfully stented in 66 patients. During follow-up of (15.2 ± 5.3) months, there was no case of death and myocardial infarction. Twelve patients (6.2%) received coronary angiography due to chest pain and myocardial ischemia. Of them, 5 cases (4 in SCP and 1 in SIP) had target lesion restenosis, three cases had aggravation of non-target lesion and 4 cases kept coronary artery patent. Conclusions ①In aged patients with non-occluded target coronary lesion, stenting with and without complete and incomplete predilation had the equal success rate. ②Complete predilation had high dissection rate, bail-out stenting rate and long-term restenosis rate. Direct stenting had shortest procedure time, lowest cost and less restenosis rate.③It is not advocated to attempt complete predilation to obtain 'stent-like' balloon dilation effect in aged. ④Stenting after imcomplete predilation can be used as regular procedure in old patients with coronary disease.