- - 대상및방법 대상 방법 Korean Circulation J 2002;328:

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1 Original Articles Korean Circulation J 2002;328: 관동맥분지병변에서스텐트시술후분지폐쇄발생의예측인자 : 혈관내초음파연구 최소연 탁승제 김한수 염철훈 윤명호 유상용안성균 장혁재 황교승 신준한 최병일 Predictors of Side Branch Occlusion Immediately after Coronary Stenting an Intravascular Ultrasound Study So-Yeon Choi, MD, Seung-Jea Tahk, MD, Han-Soo Kim, MD, Zhe-Xun Lian, MD, Myeong-Ho Yoon, MD, Sang-Yong Yoo, MD, Sung-Gyun Ahn, MD, Hyuk-Jae Chang, MD, Gyo-Seung Hwang, MD, Joon-Han Shin, MD and Byung-Il William Choi, MD Department of Cardiology, Ajou University School of Medicine, Suwon, Korea ABSTRACT Background and ObjectivesPrevious studies have indicated that side branch occlusion SBO remains a significant problem in coronary bifurcation lesions during percutaneous intervention. Subjects and Methods To evaluate the predictors of SBO by intravascular ultrasound IVUS, 35 patients 28 males, mean age years were studied at their left anterior descending artery LAD-diagonal branch DB bifurcation lesions, prior to coronary intervention for the measurement of the following plaque characteristicstotal plaque area PA, PA of the branch-side semicircle, area stenosis AS of the LAD, the presence of bull s eye in the DB, the diameter of the vessel and the ostial lumen of the DB, and the LAD-DB angle. SBO was defined as a persistant reduction in the TIMI flow to 1 by the end of the procedure. ResultsThe PA of the branch-side semicircle, the vessel diameter and the ostial lumen diameter of the DB all significantly affected the SBO. The total PA and the AS of the LAD were not related to the SBO. Multivariate analysis identified that the PA of the branch-side semicircle was the only predictor of SBO odds ratio 3.2, 95 confidence interval 1.3 to 8.6, p ConclusionIt appears that the plaque distribution of LAD is a major determinant of SBO. These findings support the theory that the plaque shift snow plow effect may be the mechanism of the SBO following stenting. Korean Circulation J 2002;328: KEY WORDSUltrasonography, interventionalcoronary stenosisstents. 서 론 655

2 - - 대상및방법 대상 방법 Korean Circulation J 2002;328:

3 Fig. 1. Composite illustration demonstrating IVUS analysis for bifurcation lesion of LAD. Line A proximal portion of bifurcation lesion, Line B mid-portion of bifurcation lesion, Line C distal portion of bifurcation lesion, LAD left anterior descending artery, DB diagonal branch. Fig. 2. IVUS analysis at each portion of the bifurcation lesion. Line A, was perpendicular to the line B, passed the center of mother vessel and divided mother vessel into two semicircles (i.e.the side branch side and opposite side to side branch), Line B was connecting between two centers of LAD and DB, a ostial lumen diameter of DB, b DB vessel diameter, LAD left anterior descending artery, DB diagonal branch. 최대내경(maximal lumen diameter MaxLD), 최소내 좌전하행지의 중심과 대각지의 중심을 연결하는 선 경(minimal lumen diameter MinLD), 최대경화반두 (Fig. 2, line B)에 수직이면서 좌전하행지의 중심을 지 께(maximal plaque thickness MaxPT), 최소경화반 나는 선(Fig. 2, line A)을 이용하여 좌전하행지를 두 두께(minimal plaque thickness MinPT)를 측정하였 반원으로 양분하고 반원 중 분지측에 존재하는 반원을 분 으며, 내경대칭지수(lumen symmetry index LSI)는 지측 반원, 그리고 반대편의 다른 반원은 반분지측 반원 최소내경과 최대내경의 비로 경화반편재지수(plaque ec- 으로 정의하였고 분지측 반원에 존재하는 경화반의 면적 centric index PEI)는 최소경화반두께와 최대경화반두 인 분지측경화반면적을 구하였다. 께의 비로 구하였다. 모지의 경화반 특성은 경화반의 구성에 따른 분류를 이 657

4 A Fig. 3. Illustration demonstrating IVUS analysis for LAD/DB angle. The LAD/DB angle was calculated as a function of LAD/DB angle arc tan /2. LADleft anterior descending artery, DBdiagonal branch, Aimage at the proximal portion of bifurcation lesion, Bimage at level of 2 mm distal to the proximal portion of bifurcation lesion, distance between the center of LAD and that of DB at the level of the image B. B - - 통계분석 Table 1. Baseline characteristics of patients with side branches covered by stents without SBO n29 with SBO n6 Age yr Men Diabetes mellitus Hypertension Total cholesterol Smoking Diagnosis Stable angina Unstable angina MI EF % EF 40% Data presented are meansd or number % of patients. SBOside branch occlusion, MImyocardial infarction, EFejection fraction on echocardiogram Korean Circulation J 2002;328: p

5 결 임상적인특징 관동맥혈관조영술소견 Table 2. Baseline angiographic and procedural characteristics 과 without SBO n29 with SBO n6 Vessel disease VD VD VD Infarct related artery Type of lesion Subtype a Pre-Stent MinLD mm %DS % Post-Stent MinLD mm %DS % Stent size mm Stent size/reference Data presented are meansd or number % of patients. SBOside branch occlusion, VDvessel disease, MinLDminimal lumen diameter, %DSpercent of diameter stenosis p 혈관내초음파검사결과 659

6 Table 3. IVUS predictors of mother vessel of side branch occlusion Proximal portion without SBO n29 with SBO n6 p MinLD mm LA mm VA mm %AS % Total PA mm PA of branch-side semicircle mm Plaque burden % Mid portion MinLD mm LA mm VA mm %AS % Total PA mm PA of branch-side semicircle mm Plaque burden % Distal portion MinLD mm LA mm VA mm %AS % Total PA mm PA of branch-side semicircle mm Plaque burden % Data presented are meansd. SBOside branch occlusion, MinLDminimal lumen diameter, LAlumen area, VAvessel area, %ASpercent of area stenosis, PAplaque area Fig. 4. Comparison of the PA of branch-side semicirde betwer Non-SBO group and SBO group. of SBO group had a significantly larger plaque area of branchside semicircle compared with patients of Non-SBO group. SBOside branch occlusion, PAplaque area, NSnot significant. 분지폐쇄의예측인자 660 Table 4. IVUS findings of mother vessel Plaque characteristics without SBO n29 with SBO n6 Soft Hard PEI LSI Data presented are meansd or number % of patients. SBOside branch occlusion, PEIplaque eccentricity index, LSIlumen symmetricity index Korean Circulation J 2002;328: p

7 Table 5. IVUS findings of side branch Table 6. Multivariate analysis of predictor for side branch occlusion 고 분지완전폐쇄의예측인자 without SBO n29 Odds ratio 95% CI p DB diameter DB ostial diameter Bull's eye sign PA of branch-side semicircle DBdiagonal branch, PAplaque area 찰 with SBO n6 DB diameter mm DB ostial diameter mm LAD/DB angle Bull's eye sign Data presented are meansd or number % of patients. SBOside branch occlusion, DBdiagonal branch, LADleft anterior descending artery Fig. 5. Comparison of the vessel diameter and the ostial lumen diameter of DB betneen Non-SBO group and SBO group. of SBO group had significantly smaller vessel diameter and ostial lumind diameter compared with patients of Non-SBO group. SBOside branch occlusion, DBdiagonal branch. p 분지완전폐쇄의기전 661

8 본연구의주요결과및의의 분지의혈관내초음파검사 Fig. 6. Case 1 who had relatively small plaque area of sidebranch side before intervention, showed a redistribution of plaque to opposite side of DB after stenting of LAD. In case 2 who had relatively large plaque area of sidebranch side before intervention, the plaque shift to side branch side resulting occlusion of diagonal branch was observed after stenting. SBOside branch occlusion, VAvessel area, LAlumen area, PAplaque area, SPAside-branch side plaque area, PBplaque burden. 662 Korean Circulation J 2002;328:

9 임상적응용 본연구의제한점 - 요약 배경및목적 : 방법 : 결과 : 663

10 결론 : 중심단어 REFERENCES 1) Meier B, Gruentzig AR, King SB 3rd, Douglas JS, Jr Hollman J, Ischinger T, Aueron F, Galan K. Risk of side branch occlusion during coronary angioplasty. Am J Cardiol ) Vetrovec GW, Cowley MJ, Wolfgang TC, Ducey KC. Effects of percutaneous transluminal coronary angioplsty on lesion-associated branches. Am Heart J ) Boxt LM, Meyerovitz MF, Taus RH, Ganz P, Friedman PL, Levin DC. Side branch occlusion complicating percutaneous transluminal coronary angioplasty. Radiology ) Arora RR, Raymond RE, Dimas AP, Bhadwar K, Simpfendorfer C. Side branch occlusion during coronary angioplasty incidence, angiographic characteristics, and 664 outcome. Cathet Cardiovasc Diagn ) Fischman DL, Savage MP, Leon MB, Schartz RA, Ellis S, Cleman MW, Hirshfeld JW, Teirstein P, Bailey S, Walker CM, Goldberg S. Fate of lesion-related side branches after coronary artery stenting. J Am Coll Cardiol ) Aliabadi D, Tilli FV, Bowers TR, Benzuly KH, Safian RD, Goldstein JA, Grines CL, O Neill WW. Incidende and angiograhic predictors of side branch occlusion following high-pressure intracoronary stenting. Am J Cardiol ) Kim KH, Jeong MH, Kim NH, Kim SH, Kim JW, Cho JH, Ahn YK, Cho JG, Park JC, Kang JC. Long-term clinical and angiographic outcomes of side branch occlusion after coronary stenting. Korean Circulation J ) Morimoto S, Hiramitsu S, Yamada K, Uemura A, Kubo N, Mizuno Y. Lesions in side branches of arteries having undergone percutaneous transluminal angioplasty a histopathologic stydy. Am Heart J ) Safian RD, Schreiber TL, Baim DS. Specific indications for directional coroanry atherectomy origin left anterior discending coronary artery and bifurcation lesions. Am J Cardiol E-41E. 10) Ormiston JA, Webster MW, Ruygrok PN, Stewart JT, White HD, Scott DS. Stent deformation following simulated side-branch dilatation a comparison of five stent designs. Catheter Cardiovasc Interv ) Safian RD. Bifurcation lesions. In Safian RD, Freed MS, editor. The manual of interventional cardiology. 3rd ed. Michigan Physicians Press2001. p ) di Mario C, Grge G, Peters R, Kearney P, Pinto F, Hausmann D, von Birgelen C, Colombo A, Mudra H, Roelandt J, Erbel R. Clinical application and image interpretation in intracoronary ultrasound. Eur Heart J ) Metz JA, Yock PG, Fitzgerald PJ. Intravascular ultrasound basic interpretation. Cariol Clinic ) Kimura BJ, Russo RJ, Bhargava V, McDaniel MB, Peterson KL, DeMaria AN. Atheroma morphology and distribution in proximal left anterior descending coronary artery in vivo observations. J Am Coll Cardiol ) Mallus MT, Kutryk MJ, Prati F, von Birgelen C, de Feyter PJ, Roelandt JR, Serruys PW. Extent and distribution of atherosclerotic plaque in relation to major coronary side-branches an intravascular ultrasound study in vivo. G Ital Caardiol ) Tsutsui H, Yamagishi M, Uematsu M, Suyama K, Nakatani S, Yasumura Y, Asanuma T, Miyatake K. Intravascular ultrasound evaluation of plaque distribution at curved coronary segments. Am J Cardiol ) Lefevre T, Louvard Y, Morice MC, Dumas P, Loubeyre C, Benslimane A, Premchand RK, Guillard N, Piechaud JF. Stenting of bifurcation lesions classification, treatments and results. Catheter Cardiovasc Interv ) al Suwaidi J, Berger PB, Rihal CS, Garratt KN, Bell MR, Ting HH, Bresnahan JF, Grill DE, Holmes DR Jr. Immediate and long-term outcome of intrracoronary stent implantation for true bifurcation lesions. J Am Coll Cardiol ) Oesterle SN. Coronary interventions at a crossroads the bifurcation stenosis. J Am Coll Cardiol Korean Circulation J 2002;328:

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서론 대상및방법 대상환자 관상동맥조영술소견 551

서론 대상및방법 대상환자 관상동맥조영술소견 551 Original Articles Korean Circulation J 1999;296:550-559 관상동맥중재술후제 2 차재협착에관여하는인자 김성희 1 정명호 1,2 김준우 1 조장현 1 김남호 1 박우석 1 최명자 1 김인수 1 안영근 1,2 조정관 1,2 박종춘 1,2 강정채 1,2 Risk Factors for the Second Restenosis