Original Articles Korean Circulation J 1998;28 6 : 항혈소판요법을이용한관동맥내 Stent 삽입술의조기결과 손지원 김영준 손민수 오세진 안태훈 최인석 신익균 Initial Results after Implantation

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1 Original Articles Korean Circulation J 1998;286: 항혈소판요법을이용한관동맥내 Stent 삽입술의조기결과 손지원 김영준 손민수 오세진 안태훈 최인석 신익균 Initial Results after Implantation of Coronary Artery Stents with Antiplatelet Agents Ji-Won Son, MD, Yeong-Jun Kim, MD, Min-Soo Son, MD, Se-Jin Oh, MD, Tae-Hoon Ahn, MD, In-Suk Choi, MD and Iak-Kyun Shin, MD Division of Cardiology, Heart Center, Gachon Medical College, Gil Medical Center, Inchon, Korea ABSTRACT BackgoundThe placement of stents in coronary arteries has been shown to reduce acute closure and restenosis in comparison to balloon angioplasty. However, clinical use of intracoronary stents is impeded by the subacute stent thrombosis and hemorrhagic complications associated with the anticoagulant regimen. Its known that the complete stent deployment with high pressure inflation and new antiplatelet agents are effective in reduction of subacute thrombosis and hemorrhage. So we evaluated initial results success and complication rate after high pressure-stent deployment with new anticoagulation protocol. MethodsOne hundred and ninety one patients with 201 lesions were treated with 231 stents of various types. The high pressure balloon inflation and antiplatelets agents were used in all cases. Final high pressure balloon inflation guided by IVUS were performed in 23 consecutive cases with incomplete stent deployment according to angiographic findings. Results1 The indications of stenting n210 were De novo in %, bailout procedure in 57 27%, suboptimal result after PTCA in 19 8%, and restenosis after PTCA in 14 6%. The location of lesions were LAD in 101, RCA in 67, circumflex in 28, ramus intermedius in 3, and LMT artery in 2 lesions. Angiographic morphologic characteristics were type A in 2, type B in 158 B157, B2101, and type C in 22 lesions. 2 The angiographic and clinical success rate was 96% 192/201 and 92% 186/201 respectively. 3 In angiographic analysis, the baseline average reference vessel dirmeter was mm. Baseline minimum lumen diametermld was mm, with baseline percent diameter stenosis of %. The final stent diameter was mm, with mean final percent stenosis of The mean MLD after stenting was significantly increased p The mean MLD within stent increased 14%, from mm at the nominal balloon inflationinflation pressure7 atm to mm at high pressure balloon inflation inflation pressure12atm p The length of lesions in GR cook, GR, and Micro stents were significantly longer than ones in PS, Cordis, Wiktor, Nir p In intravascular ultrasound analysis, the mean lumen CSA at the tightest point within stent increased 11%, from mm 2 at the intial intravascular ultrasound to mm 2 at the final intravascular ultrasound p The procedural andpostprocedural complications were 2 acute closures associated with AMI and emergent CABG, 1 subacute closure which was revascularized by bail out stenting, 5 major hemorrhage requiring transfusion associated with 1 CVA and 2 metabolic acidosis induced by acute renal failure, and 5 939

2 death. ConclusionThe high pressure stent deployment procedure and new anticoagulation protocol associating tidopidine and aspirin without coumadin or prolonged heparin infusion allow us to obtain an acceptably low subacute thrombosis or bleeding complication rate. These results are encouraging and allow a wide use of coronary stenting. Korean Circulation J 1998;286: KEY WORDSStent Antiplatelets High pressure inflation. 서론 대상환자 연구및방법 사용한 stent 종류및삽입방법 Table 1. Clinical and angiographic chracteristics of patients n191, 201 lesions Age year 6010 Sex M/F 152/29 Clinical diagnosis n191 Stable angina 42 Unsable angina 56 Myocardial infarction 93 acute/old 48/45 Indication De novo % Bail out precedure 57 27% AMI 40 Suboptimal result 19 8% Restenosis 14 6% Single VD/Multi VD 171/30 Location LAD/RCA/LCX/RI/LMT 101/67/28/3/2 Lesion morphology* A/B1/B2/C 21/57/101/22 VDVessel disease LADLeft anterior descending RCARight coronary artery LCXLeft circumflex LMTLeft main trunk RIRamus intermedius *AHA/ACC classification 940 Korean Circulation J 1998;286:

3 혈관조영결과분석 혈관내초음파의시술방법및정량적분석 통계분석 결과 941

29 는 GR Ⅰ, Ⅱ와 Micro Ⅱ stent가 상대적으로 길었으 DS (%) 82.86±8.64 0.63±8.25** Length of P-S stent 11.68±4.62 며(p<0.001), stent 삽입후 nominal balloon inflation 시의 최소혈관내경(mininial lumiml diameter)이 2.91 3.33±0.

4 A B Fig. 1. Coronary angiographic finding. A pre-stenting B poststenting+high pressure balloon inflation ±0.35 mm였으며 stent전 최소혈관내경이 0.58±0.29 Table 2. Quantitative angiographic measurements mm에서 stent후 3.37±0.29 mm로 증가하였고, stent Pre Post 전 diameter stenosis가 82.86±8.64%로 stent후 RD (mm) 0.63±8.25%로 감소하였다(p<0.0001). 병변의 길이 MLD (mm) 0.58±0.29 는 GR Ⅰ, Ⅱ와 Micro Ⅱ stent가 상대적으로 길었으 DS (%) 82.86± ±8.25** Length of P-S stent 11.68±4.62 며(p<0.001), stent 삽입후 nominal balloon inflation 시의 최소혈관내경(mininial lumiml diameter)이 ±0.35 lesion (mm) G-R stent 3.37±0.29** Cook GRII 20.12±8.60* VS P-S 32.62±4.52** ±0.39 min에서 고압풍선술 실시후 최소혈관내경이 Micro II 3.37±0.29 min로 증가하였다(p<0.001)(Table 2). Wiktor 10.11±0.28 NIR 9.87±0.11 4) IVUS에 의한 stent 삽입후의 고압풍선술 전후를 측정한 결과 혈관단면적(cross sectional area)가 ±2.4 mm 2에서 9.4±2.1 mm 으로 유의하게 증가하 였다(p<0.001)(Fig. 2, Table 3). 5) 시술중 합병증으로 2예에서 관동맥 급성폐쇄을 경험하였는데, 이는 stent 원위부의 혈관해리에 기인했 Final nominal balloon size (mm) 3.71±0.37 Balloon/artery ratio 1.11±0.08 Maximal pressure (atm) 16.33±1.64 Stent recoil (%) P-S stent 8.27±3.84 G-R stent 9.26±4.11 MLD after nominal balloon 으며, 급성심근경색증이 발현되어 응급 bypass 수술을 inflation (mm)(at 7 atm) 실시하였으나 사망하였다(Table 4). MLD after maximal balloon 6) 30일 이내의 시술후 합병증으로 1예에서 관동맥 아급성폐쇄가 있어 응급 관동맥 풍선술 및 stent 시술 을 하여 성공적으로 재관류 시켰고, 급성심근경색증 환 ±3.56** 2.91±0.39* 3.37±0.29 inflation (mm) RD Reference diameter MLD Minimal luminal diameter DS Diameter stenosis * p<0.001 ** p< p-s Palmaz-Schatz G-R Gianturco-Robin Korean Circulation J 1998;28(6):

Intravascular ultrasound measurements of stented sitesn23 고 Initial IVUS 안 Final IVUS Lumen

5 A B Fig. 2. IVUS image after stent implantation. Awith nominal balloon inflation 68 atm B. with high pressure balloon inflation 12 atm Table 3. Intravascular ultrasound measurements of stented sitesn23 고 Initial IVUS 안 Final IVUS Lumen area mm * Minor diameter mm * Major diameter mm * Minor/major diameter *p

6 Table 4. Intraprocedural and postprocedural within 30 dayscomplications Intraprocedural complications Postprocedural complications within 30 days n % n % n % Clinical follow up Myocardial infarction Coronary bypass Stent thrombosis Emergency intervention Death Vascular complication Per-patient events n191 patients Total 944 Korean Circulation J 1998;286:

7 요약 연구배경 : 대상및방법 : 결과 : 결론 : 중심단어 REFERENCES 1) Serruys PW, de Jaegere P, Kiemeneij F, et al. A comparison of balloon expandable stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med ) Fischman DL, Leon MB, Baim D, et al. A randomized comparision of coronary stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med ) Colombo A, Hall P, Nakamura S, et al. Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation ) Fajadet J, Jenny D, Guagliumi G, et al. Does the indi- 945

8 cation for coronary stenting influence clinical results? J Am Coll Cardiol ) Fishman DL, Savage MP, Leon MB, et al. Angiographic predictors of subacute thrombosis following coronary artery stenting. Circulation 1991; ) Kimura T, Nosaka H, Yokoi H, et al. Emergency coronary stenting for abrupt closure and dissection after balloon angioplasty. J Am Coll Cardiol ) Haude M, Erbel R, Straub U, et al. Short and long-term results after intracoronary stenting in human coronary arteries Monocentre experience with the balloon expandable Palmaz-Schatz Stent. Br Heart J ) Schatz RA, Baim DS, Leon MB, et al. Clinical experience with the Palmaz-Schatz coronary stent Initial results of a multicenter study. Circulation ) Serruys PW, de Jaegere P, Kiemeneij F, et al. For the Benestent Study Group A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med ) Sutton JM, Ellis SG, Roubin GS, et al. For the Gianturco-Roubin Intracoronary Stent Investigator Group. Major clinical events after coronary stenting. The multicenter registry of acute and elective Gianturco-Roubin stent placement. Circulation ) Fajadet J, Marco J, Cassagneau B, et al. Emergency coronary stenting for acute dissection during PTCA. J Am Coll Cardiol A. 12) Doucet S, Fajadet J, Cassagneau B, et al. Early thrombotic occlusion following coronary Palmaz-Schatz stent implantation Frequency and clinical or angiographic predictors. Eur Heart J ) Morice MC. Advances in post stenting medication protocol. J Invasive Cardiol Vol A. 14) Gold HK, Gimple LW, et al. Pharmacodynamic study of Fab 2 fragments of murine monoclonal antibody 7E3 directed against human platelet glycoprotein b/a in patients with unstable angina pectoris. J Clin Invest ) Erbel R, Swars H, Hofner G, et al. Reduction of subacute thrombotic stent occlusion by improved anticoagulation monitoring. Circulation ) Barragan P, Sainsous J, Silvestri M, et al. Ticlopidine and subcutaneous heparin as an alternative regimen following coronary stenting catheter. Cardiovascular Diagn ) Gregorini L, Marco J, Fajadet J, et al. Reduction of hemostasis activation with a new anticoagulation protocol during PTCA and stent implantation. J Invasive Cardiol vol 7n A. 18) Carvalho H, Fajadet J, Jordan C, et al. A lower rate of complications after Gianturco-Roubin coronary stenting using a new antiplatelet and anticoagulant protocol. Circulation ) Jordan C, Carvalho H, Fajadet J, et al. Reduction of subacute thrombosis rate after coronary stenting using a new anticoagulant protocol. Circulation ) Goldberg SL, Colombo A, Nakamura S, et al. The benefit of intracoronary ultrasound in the deployment of Palmaz- Schatz stents. J Am Coll Cardiol 1994; ) Nakamura S, Colombo A, Gaglione S, et al. Intracoronary ultrasound observation during stent inplantation. Circulation ) Karrillon GJ, Morice MC, Benveniste EB, et al. Intracoronary stent implantation without ultrasound guidance and with replacement of conventional anticoagulation by antiplatelet therapy 30-day clinical outcome of the french multicenter registry. Circulation ) Nakamura S, Hall P, Gaglione A, et al. High pressure assisted coronary stent implantation accomplished without intravascular ultrasound guidance and subsequent anticoagulation. J Am Coll Cardiol ) Russo RJ, Nicosia A, Teirstein PS for the AVID investigator. Angiography versus intravascular ultrasounddirected stent placement abstract. J Am Coll Cardiol A. 25) Moussa I, Di Mario C, Tobis J, et al. The differential predictive value of various intravascular ultrasound criteria of subacute stent thrombosis abstract. Circulation ) Albiero R, Hall P, Itoh A, Blengino S, et al. Results of a consecutive series of patients receiving only antiplatelet therapy after optimized stent implantation Comparison of aspirin alone versus combined ticlopidine and aspirin therapy. Circulation Korean Circulation J 1998;286:

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