Автореферат и диссертация по медицине (14.00.44) на тему:Результаты ангиопластики и коронарного шунтирования у больных с множественным поражением коронарных артерий
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Оглавление диссертации Меркулов, Евгений Владимирович :: 2006 :: Москва
ВВЕДЕНИЕ.
Глава 1. ОБЗОР ЛИТЕРАТУРЫ.
1.1 Развитие методов хирургического лечения атеросклероза коронарных артерий.
1.2 Развитие методов катетерного лечения атеросклероза коронарных артерий.
1.3 Сравнение современных подходов к хирургическому и катетерному лечению миогососудистого поражения коронарных артерий.
Глава 2. МАТЕРИАЛ И МЕТОДЫ ИССЛЕДОВАНИЯ.
2.1 Характеристика материала исследования.
2.2 Методы обследования и лечения.
2.3 Техники катетерной и хирургической реваскуляризации.
2.4 Методы статистического анализа.
Глава 3. РЕЗУЛЬТАТЫ СОБСТВЕННЫХ ИССЛЕДОВАНИЙ.
3.1 Госпитальные результаты реваскуляризации больных с многососудистым поражением.
3.2 Отдаленные результаты реваскуляризации больных с многососудистым поражением.
3.3 Результаты катетерного лечения больных с коронарным атеросклерозом после операции трансплантации сердца.
Введение диссертации по теме "Сердечно-сосудистая хирургия", Меркулов, Евгений Владимирович, автореферат
Актуальность исследования.
В настоящее время помимо медикаментозной терапии больных ИБС с множественними поражениями коронарных артерий прочные позиции заняли различные методы реваскуляризации миокарда: аортокоронарное шунтирование, малоинвазивное шунтирование, эндоваскулярные методы (транслюминальная баллонная коронарная ангиопластика, атерэктомия, стентирование). Каждый из них обладает как преимуществами, так и недостатками. Коронарная баллонная ангиопластика является органосохраняющим, малотравматичным методом, выполнимым при многососудистых поражениях, позволяющим рано активизировать больных после вмешательства. Но в месте баллонированного стеноза и имплантированного стента в 15-30% (R.Shatz, 1994, C.R.Holmes, 1998) формируется рестеноз, что требует повторного вмешательства. Аортокоронарное шунтирование позволяет в течение длительного времени обеспечить нормальную перфузию миокарда через венозные и артериальные шунты. Однако, по данным различных авторов, в первый год после операции АКШ наблюдается окклюзия 15-20% венозных шунтов, а в каждый последующий год дополнительно закрываются от 1% до 4% шунтов(С.J.White, 1998), и может возникнуть необходимость в повторной операции, которая сопряжена с большим риском, чем первичное вмешательство. Проведенные ранее исследования не позволяют однозначно выбрать предпочтительный метод лечения. В связи с этим требуется проведение дополнительных исследований, результаты которых дадут возможность объективно сравнить коронарную ангиопластику и коронарное шунтирование по ближайшим и отдаленным результатам.
Поэтому сравнение ближайших и долгосрочных результатов разных техник реваскуляризации многососудистого поражения коронарных артерий является актуальным в настоящее время.
Целью исследования: является оценка ближайших и отдаленных (до 3 лет) результатов эндоваскулярной (ТБКА и стентирование) и хирургической реваскуляризации (АКШ-МКШ) многососудистого поражения коронарных артерий, а также возможностей эндоваскулярного лечения больных с атеросклеротическим поражением коронарных артерий после операции трансплантации сердца.
Задачи исследования:
1. Оценить непосредственные ангиографические результаты и исходы ангиопластики и стентирования, провести сравнение с госпитальными результатами операции аортокоронарного и маммарокоронарного шунтирования у больных с многососудистым поражением коронарных артерий.
2. Сопоставить отдаленные до 3-х лет исходы эндоваскулярного и хирургического лечения больных с многососудистым поражением коронарных артерий, проанализировать структуру осложнений после проведенного лечения.
3. Оценить роль сахарного диабета и других неблагоприятных факторов в исходах эндоваскулярного и хирургического лечения.
4. Проанализировать возможности катетерного лечения больных с атеросклеротическим поражением после операции трансплантации сердца.
Научная новизна:
Впервые в отечественной практике проведено сравнение 3-х летних результатов. эндоваскулярного и хирургического лечения ИБС. На репрезентативной группе больных ИБС с многососудистым поражением выполнено одноцентровое сравнительное изучение эффективности и безопасности различных методик реваскуляризации миокарда, что позволяет прогнозировать результаты лечения и улучшить качество оперативной помощи. Доказано, что к трем годам после реваскуляризации бессимптомными остается большее количество пациентов после КШ, чем после 4KB, различие связано с более частыми повторными реваскуляризациями в группе 4KB. Выявлено, что развитие осложнений (рестеноз, повторные 4KB и КШ) после реваскуляризации в определенной степени связано с наличием у больного сахарного диабета. Его значение максимально велико для больных после 4KB. Анализ результатов чрезкожных реваскуляризаций у больных после трансплантации сердца показал, что баллонная ангиопластика дает стойкий положительный эффект.
Практическая значимость:
Полученные данные исследования позволяют прогнозировать результаты лечения у больных с множественным поражением коронарного русла. Коронарное шунтирование и эндоваскулярное лечение позволяют эффективно и безопасно провести реваскуляризацию миокарда при стенозирующих поражениях различной морфологии с минимальным риском развития осложнений. К преимуществам эндоваскулярного лечения можно отнести малотравматичность и сокращение времени пребывания пациента в стационаре. Тем не менее, в отдаленном периоде (до 3-х лет) после эндоваскулярного лечения многососудистых поражений необходимость в повторной реваскуляризации выше, чем у прооперированных больных, что необходимо учитывать при планировании тактики лечения.
Анализ результатов эндоваскулярных вмешательств у больных, перенесших операцию трансплантации сердца, позволяет рекомендовать проведение коронарной ангиопластики в связи с развитием атеросклеротических изменений в донорских коронарных артериях, так как она не отличается по технике и ближайшим результатам от ангиопластики в нативных артериях.
Заключение диссертационного исследования на тему "Результаты ангиопластики и коронарного шунтирования у больных с множественным поражением коронарных артерий"
выводы.
1. В сопоставимых группах сравнения полная анатомическая и функциональная реваскуляризация достижима у 71% больных с многососудистым поражением при чрескожных коронарных вмешательствах и у 87% больных при операции коронарного шунтирования.
2. Основные госпитальные осложнения (ИМ, смерть, повторные вмешательства) после реваскуляризации миокарда не имеют значимых различий между КШ и 4KB и составляют (без учета сохраняющейся стенокардии) 3% и 2% соответственно.
3. Совокупность наступления всех сердечно-сосудистых осложнений за 6 месяцев наблюдения после КШ отмечается в 24%, что значимо реже (р<0,05), чем 41% осложнений после 4KB.
4. Единственным значимым (р<0,05) отличием в сроке 6 месяцев между группами КШ и 4KB является частота повторных реваскуляризаций, составляя 7% и 22% соответственно.
5. Бессимптомное течение ИБС к 3 годам после операции\вмешательства отмечено в группе 4KB у 44% пациентов, а в группе КШ- у 56% пациентов (р<0,05). Различие связано, в основном, с более частыми повторными реваскуляризациями в группе 4KB.
6. Развитие осложнений (рестеноз, повторные 4KB и КШ) после реваскуляризации связано с наличием у больного сахарного диабета. Его значение максимально велико для больных, перенесших 4KB.
7. При чрескожных реваскуляризациях у больных после трансплантации сердца баллонная ангиопластика дает стойкий положительный эффект от 6 месяцев до 2 лет, но выраженное ремоделирование коронарных артерий провоцируется аутоиммунными процессами и приводит к быстрому прогрессированию атеросклероза в других, нелеченных сегментах артерий.
ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ.
1. У больных ИБС с многососудистым поражением для лечения стенозирующего коронарного атеросклероза возможно применение как хирургического, так и эндоваскулярного метода. Выбор метода реваскуляризации у пациентов без сахарного диабета и с сохранной функцией левого желудочка может определяться лечащим врачом с учетом рекомендаций оператора и предпочтения пациента, информированного об отдаленных перспективах.
2. Для пациентов с ишемической болезнью сердца и сахарным диабетом предпочтительно выполнение операции коронарного шунтирования с обязательным использованием внутренней грудной артерии в качестве шунта. Она обеспечивает максимальную выживаемость без сердечно-сосудистых осложнений у данных больных. in
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