Original Articles Korean Circulation J 2002;328:655-665 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 56 11 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, p0.015. 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;328:655-665 KEY WORDSUltrasonography, interventionalcoronary stenosisstents. 서 론 655
- - 대상및방법 대상 방법 656 - - Korean Circulation J 2002;328:655-665
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
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 - 658 Table 1. Baseline characteristics of patients with side branches covered by stents without SBO n29 with SBO n6 Age yr 05510 06213 0.124 Men 23 79 5 83 0.656 Diabetes mellitus 04 14 3 50 0.079 Hypertension 13 45 3 50 0.582 Total cholesterol 19044 19412 0.691 Smoking 22 76 3 50 0.213 Diagnosis 0.818 Stable angina 07 24 1 17 Unstable angina 13 45 2 33 MI 09 31 3 50 EF % 06214 06113 0.867 EF 40% 02 07 0 00 0.682 Data presented are meansd or number % of patients. SBOside branch occlusion, MImyocardial infarction, EFejection fraction on echocardiogram Korean Circulation J 2002;328:655-665 p
결 임상적인특징 관동맥혈관조영술소견 Table 2. Baseline angiographic and procedural characteristics 과 without SBO n29 with SBO n6 Vessel disease 0.749 1VD 21 72 5 83 2VD 06 21 1 17 3VD 02 07 0 00 Infarct related artery 09 31 3 50 0.329 Type of lesion 0.213 1 14 45 3 30 2 08 26 3 50 3 07 23 0 00 Subtype a 17 59 5 83 0.257 Pre-Stent MinLD mm 01.00.4 01.100.4 0.807 %DS % 69.49.5 68.812.4 0.904 Post-Stent MinLD mm 03.10.4 03.400.3 0.179 %DS % 08.66.0 08.404.6 0.947 Stent size mm 03.40.3 03.400.4 0.697 Stent size/reference 0.990.0 0.9600.1 0.315 Data presented are meansd or number % of patients. SBOside branch occlusion, VDvessel disease, MinLDminimal lumen diameter, %DSpercent of diameter stenosis p 혈관내초음파검사결과 659
Table 3. IVUS predictors of mother vessel of side branch occlusion Proximal portion without SBO n29 with SBO n6 p MinLD mm 02.200.6 02.200.4 0.989 LA mm 2 05.302.2 04.701.7 0.526 VA mm 2 15.503.3 16.603.4 0.476 %AS % 80.421.1 84.807.4 0.386 Total PA mm 2 10.303.3 11.902.6 0.247 PA of branch-side semicircle mm 2 04.501.6 07.402.3 0.001 Plaque burden % 65.413.1 72.108.7 0.242 Mid portion MinLD mm 02.100.6 02.300.3 0.317 LA mm 2 04.602.1 05.101.3 0.577 VA mm 2 12.902.9 14.002.2 0.384 %AS % 61.415.9 58.606.7 0.854 Total PA mm 2 08.302.9 08.903.0 0.650 PA of branch-side semicircle mm 2 02.701.1 04.701.8 0.001 Plaque burden % 64.114.9 62.514.7 0.804 Distal portion MinLD mm 02.000.5 02.400.6 0.163 LA mm 2 04.301.9 04.200.8 0.900 VA mm 2 11.902.9 12.204.3 0.875 %AS % 58.817.7 55.627.8 0.722 Total PA mm 2 07.603.1 07.903.9 0.827 PA of branch-side semicircle mm 2 03.101.4 05.102.3 0.010 Plaque burden % 62.915.3 58.526.4 0.575 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 06 21 1 17 0.656 Hard 23 79 5 38 0.413 PEI 0.20.1 0.30.1 0.129 LSI 0.80.1 0.80.1 0.624 Data presented are meansd or number % of patients. SBOside branch occlusion, PEIplaque eccentricity index, LSIlumen symmetricity index Korean Circulation J 2002;328:655-665 p
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 0.0 0.002.4 0.082 DB ostial diameter 0.7 0.009.6 0.154 Bull's eye sign 2.9 0.333.5 0.217 PA of branch-side semicircle 3.2 1.308.6 0.015 DBdiagonal branch, PAplaque area 찰 with SBO n6 DB diameter mm 02.60.4 02.10.5 0.015 DB ostial diameter mm 02.50.4 02.00.5 0.018 LAD/DB angle 57.47.7 58.74.9 0.679 Bull's eye sign 6 21 2 33 0.420 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
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;328:655-665
임상적응용 본연구의제한점 - 요약 배경및목적 : 방법 : 결과 : 663
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