Автореферат и диссертация по медицине (14.00.06) на тему:Прогноз, профилактика и лечение осложнений транслюминальных коронарных вмешательств у больных ишемической болезнью сердца
- Ученая степень
- доктора медицинских наук
- ВАК РФ
- 14.00.06
Оглавление диссертации Першуков, Игорь Викторович :: 2004 :: Москва
Список сокращений.
Введение.
Глава 1. Обзор литературы.
1.1 Развитие ЧТКВ в лечении ишемической болезни сердца.
1.2 Механизм ЧТКВ.
1.3 Непосредственные и ближайшие результаты ЧТКВ.
1.4 Отдаленные результаты ЧТКВ.
1.5 Рестеноз после коронарного стентирования.
Введение диссертации по теме "Кардиология", Першуков, Игорь Викторович, автореферат
Чрезкожные транслюминальные коронарные вмешательства (ЧТКВ) применяются в клинической практике с конца 70-х годов XX века. Проведенные ранее исследования показали высокую эффективность ЧТКВ в лечении стенозирующих поражений коронарных артерий у больных ИБС [9]. Малая травматичность, отсутствие наркоза, снижение затрат и другие преимущества позволили ЧТКВ опередить операции аортокоронарного шунтирования и другие методы прямой реваскуляризации миокарда [509]. В США и многих странах Европы соотношение ЧТКВ и операций АКШ составляет 1.5-2:1 [6,9,52]. Количество ЧТКВ в развитых странах продолжает увеличиваться.
Широкое распространение ЧТКВ выявило отрицательные стороны их применения. Наиболее грозными острыми осложнениями ЧТКВ оказались выраженная диссекция сосуда, его полная окклюзия и дистальная эмболизация. В начале применения ЧТКВ окклюзия возникала в 5-7% случаев, приводя зачастую к инфаркту миокарда и летальному исходу [152]. К настоящему времени в разных лабораториях острые фатальные и нефатальные осложнения ЧТКВ отмечаются в 1-2% случаев [623]. Но анализ причин осложнений, как правило, затруднен, поскольку во многих российских катетерных лабораториях пока выполняется не более 400 вмешательств в год и статистика 5-10 ежегодных осложнений не позволяет делать каких-либо достоверных выводов [5].
В отдаленном периоде повторное сужение сосуда (рестеноз) стало «Ахиллесовой пятой» баллонных методов лечения. На первых порах рестеноз развивался в 30-60% случаев в течение 6 месяцев после ЧТКВ [111]. После внедрения в 90-х годах коронарных стентов частота рестеноза снизилась на 10-20% [83]. Но повторное сужение внутри стента оказалось процессом, отличающимся по своей морфологии от рестеноза после обычной баллонной дилатации, и потребовало новых подходов к его профилактике и лечению [88].
До настоящего времени не создано абсолютно эффективного метода профилактики рестеноза после баллонной ангиопластики и коронарного стентирования. Распространению локальной радиации или «брахитерапии», достоверно уменьшающей на 30-60% частоту рестеноза и применяемой для первичной и вторичной профилактики, препятствует сложность доставки и хранения радиоактивных инструментов [660,707,711,712]. Покрытые антирестенотическими препаратами (сиролимус и таксол) стенты достоверно снижают частоту повторных сужений в популяции с 15-45% до 4-8% [405,470,631]. Но стоимость покрытых лекарственными препаратами стентов выше непокрытых устройств в 2,5-3 раза, что значительно увеличивает затраты, и пока не позволяет широко применять покрытые стенты. К тому же развитие подострого тромбоза и внезапной смерти в течение нескольких месяцев после имплантации покрытого стента за последний год стало проблемой на пути применения покрытых стентов в реальной клинической практике. Потому многие инвазивные кардиологи продолжают имплантировать непокрытые стенты, а в случае развития рестеноза внутри стента проводят обычную баллонную ангиопластику, получая повторное сужение в 20-80% случаев [450]. В то же время применение экстракционных методов, в частности эксимерной лазерной ангиопластики, перед баллонной дилатацией или повторным стентированием рестеноза внутри стента позволило снизить частоту осложнений [230]. К сожалению, отдаленные результаты лазерной ангиопластики при рестенозе внутри стента пока мало изучены. Также считают [587], что повторное стентирование при рестенозе внутри стента может улучшить непосредственный результат, но до настоящего времени в литературе немного данных о повторном рестенозировании в стенте и эффективности такого лечения поражений внутри стента. Целью исследования является выявление факторов, связанных с развитием ближайших и отдаленных осложнений ЧТКВ, а также сравнительная оценка эффективности и безопасности различных транслюминальных методов лечения и вторичной профилактики рестеноза в стенте. Задачи исследования:
1. Изучить частоту внезапного закрытия сосуда во время и после транслюминальных коронарных вмешательств, выявить клинические, ангиографические и процедурные факторы, связанные с развитием внезапного закрытия сосуда;
2. Проанализировать отдаленные до 6 месяцев результаты коронарного стентирования, выявить клинические, ангиографические и процедурные факторы, влияющие на развитие диффузной и агрессивной форм рестеноза внутри стента;
3. Сравнить непосредственные и госпитальные результаты баллонной ангиопластики и лазерной ангиопластики в лечении рестеноза внутри стента;
4. Проанализировать отдаленные до 6 месяцев исходы баллонной ангиопластики и лазерной ангиопластики у больных с рестенозом внутри стента;
5. Оценить непосредственные и госпитальные результаты повторного коронарного стентирования у больных с рестенозом внутри стента;
6. Изучить отдаленные до 6 месяцев исходы повторного коронарного стентирования у больных с рестенозом внутри стента;
7. Сопоставить безопасность и эффективность баллонной, лазерной ангиопластики и повторного коронарного рестентирования в лечении рестеноза внутри стента по госпитальным данным и результатам отдаленных наблюдений.
Научная новизна:
Впервые из репрезентативной выборки 10439 больных с ИБС, перенесших чрезкожное транслюминальное коронарное вмешательство, выделены 885 пациентов, у которых случалось наиболее грозное острое осложнение - внезапное закрытие сосуда, выявлены клинические, ангиографические и процедурные факторы, значимо связанные в реальной клинической практике с развитием внезапной окклюзии.
В группе 456 больных, перенесших коронарное стентирование без острых осложнений, установлены значимые признаки, связанные с развитием диффузной и агрессивной форм рестеноза в стенте.
У 190 больных с рестенозом в стенте проведена сравнительная оценка трех наиболее распространенных эндоваскулярных методов лечения рестеноза: баллонной ангиопластики, лазерной ангиопластики и повторного коронарного стентирования. Результаты лечения рестеноза в стенте прослежены на протяжении более 6 месяцев. Практическая значимость:
Показано, что плановое коронарное стентирование является единственным процедурным фактором, значимо снижающим риск внезапного закрытия сосуда в ходе ЧТКВ.
Являясь наиболее часто применяемым методом ЧТКВ, коронарное стентирование приводит к рестенозу, причем среди больных с рестенозом внутри стента у 63% процесс рестеноза является диффузным и превышает
10 мм. Наиболее часто рестеноз в стенте развивается у женщин и больных сахарным диабетом. При лечении РВС непосредственный успех ТБКА, ЭЛКА и коронарного стентирования был сопоставимым: 98.3%, 98.5% и 100% соответственно.
Несмотря на большую сложность в выполнении повторного стентирования при РВС, его отдаленный исход оказался благоприятнее исхода после ЭЛКА (выживаемость без сердечно-сосудистых осложнений за 8 месяцев - 84% против 62.3%) и лучше исхода после ТБКА (выживаемость без сердечно-сосудистых осложнений - 53.6%). Поэтому повторное коронарное стентирование является методом выбора среди ЧТКВ у пациентов с РВС.
Заключение диссертационного исследования на тему "Прогноз, профилактика и лечение осложнений транслюминальных коронарных вмешательств у больных ишемической болезнью сердца"
выводы.
У больных, перенесших чрезкожное транслюминальное коронарное вмешательство, в госпитальном периоде возникает внезапное закрытие сосуда в 4-16% в зависимости от ряда факторов и их комбинаций. Частота внезапного закрытия сосуда наиболее значимо коррелирует с исходными рентгеноморфологическими характеристиками поражения: эксцентричностью, изъязвлением, кальцинозом, тромбозом бляшки, извитостью артерии, а также с курением.
Риск внезапного закрытия увеличивается при неотложных коронарных вмешательствах: у больных с нестабильной стенокардией (ОШ=2.13), с острым инфарктом миокарда (ОШ=2.76), особенно осложненным кардиогенным шоком (0111=4.31). Риск внезапного закрытия сосуда меньше при плановом стентировании (0111=0.43) и больше при неотложном стентировании (0111=1.45), обычной баллонной ангиопластике (ОШ=1.66) и реолитической тромбэкстракции (0111=1.95).
Прогноз осложнений после транслюминального коронарного вмешательства у больных ишемической болезнью сердца зависит от рентгеноморфологического типа поражения коронарного русла, опыта оперирующего врача и характера проводимой антиагрегантной терапии.
5. Непосредственный успех коронарного стентирования составляет 9699% по сравнению с 84-92% после обычной баллонной ангиопластики. В течение полугода рестеноз развивается у 25-40% больных после коронарного стентирования по сравнению с 35-50% рестеноза после обычной баллонной ангиопластики.
6. По характеру поражения рестеноз внутри стента в 37%) является локальным, а в 63% - диффузным, в том числе у 18% приводит к полной окклюзии просвета артерии.
7. Диффузный и агрессивный рестеноз внутри стента чаще развиваются у больных сахарным диабетом и женщин.
8. Рентгеноморфологическими предпосылками для диффузного рестеноза внутри стента являются малый минимальный диаметр сосуда и малый должный диаметр сосуда, а для агрессивного рестеноза в стенте -больший минимальный диаметр сосуда и малая длина исходного поражения.
9. Имплантация проволочного стента приводит чаще к диффузному и агрессивному рестенозу внутри стента.
10. Непосредственный положительный результат лечения рестеноза внутри стента при выполнении только баллонной ангиопластики составляет 98.3%, при комбинации лазерной и баллонной ангиопластики - 98.5%, а при повторном стентировании - 100%.
11. Частота госпитальных осложнений после лечения рестеноза внутри стента при баллонной ангиопластике составляет 8.6%, при комбинации лазерной и баллонной ангиопластики 3.0%, а при повторном стентировании 5.0%.
12. Через 6 месяцев кумулятивная частота сердечно-сосудистых осложнений была минимальной после повторного стентирования рестеноза внутри стента - 18%, после комбинации баллонной и лазерной ангиопластики составила 37% и максимальна после обычной баллонной ангиопластики - 46%.
13. Сравнение госпитальных и отдаленных результатов трех эндоваскулярных методов воздействия на рестеноз внутри стента показало, что наиболее эффективным и безопасным методом является повторное коронарное стентирование («стент в стент»).
14. Прогноз осложнений после эндоваскулярного лечения рестеноза внутри стента зависит от рентгеноморфологического типа поражения в стенте и выбранного эндоваскулярного метода воздействия на рестеноз.
ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ.
1. У больных ИБС при планирования инвазивного вмешательства для уменьшения риска внезапного закрытия сосуда методом выбора является коронарное стентирование.
2. Для первичной профилактики рестеноза внутри стента оптимально выполнять процедуру стентирования при большем должном диаметре сосуда и применять по возможности короткие матричные стенты.
3. При лечении рестеноза внутри стента повторное стентирование является методом выбора. Баллонную ангиопластику и лазерную ангиопластику целесообразно выполнять при исходных технических сложностях для имплантации второго стента.
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