背景:关于RA最佳时机的证据很少,尽管据报道,计划外手术的围手术期并发症增加。
目的:比较严重钙化冠状动脉病变患者计划和非计划使用旋磨斑块切除术(RA)的斑块修饰。
方法:使用倾向评分方法分析了2008年至2020年间计划(416例患者的448条血管中的562个病变)和非计划(403例患者的435条血管中的490个病变)RA的手术和1年随访数据。主要复合终点为靶病变失效(TLF),定义为心血管死亡(CVD),靶血管心肌梗死(TVMI),或靶病变血运重建(TLR)。
结果:两组血管造影成功率>99%。计划RA的透视时间和造影剂体积显着降低(p<0.001)。围手术期并发症,包括慢血流,冠状动脉夹层,MI发生在计划后的4.8%,以及计划外RA后的5.7%。TLF发生在计划后的18.5%,计划外RA后占14.7%。TLF的加权子分布风险比显示计划RA的1年不良结果(sHR1.62[1.07-2.45],p=0.023),这是由TLR驱动的(sHR2.01[1.18-3.46],p=0.011),但不是通过CVD,或TVMI。在全因死亡率方面没有观察到差异。
结论:与计划性RA相比,计划性RA与良好的预后相关。因此,RA可以安全地保留用于通过常规手段证明无法治疗的病变。需要进行随机和前瞻性试验,以评估未来旋转粥样斑块切除术作为救助策略的主要使用。
BACKGROUND: Evidence on the optimal timing of RA is scarce, although increased periprocedural complications for unplanned procedures have been reported.
OBJECTIVE: To compare planned versus unplanned use of rotational atherectomy (RA) for plaque modification in patients with severely calcified coronary lesions.
METHODS: Procedural and 1-year follow-up data of planned (n = 562 lesions in 448 vessels of 416 patients) and unplanned (n = 490 lesions in 435 vessels of 403 patients) RA between 2008 and 2020 were analyzed using the propensity score methods. The primary composite endpoint was target lesion failure (TLF), defined as cardiovascular death (CVD), target vessel myocardial infarction (TVMI), or target lesion revascularization (TLR).
RESULTS: Angiographic success was > 99% in both groups. Fluoroscopy time and contrast volume were significantly lower in planned RA (p < 0.001). Periprocedural complications including slow-flow, coronary dissection, and MI occurred in 4.8% after planned, and in 5.7% after unplanned RA. TLF occurred in 18.5% after planned, and in 14.7% after unplanned RA. Weighted subdistribution hazard ratios for TLFs revealed an unfavorable 1-year outcome for planned RA (sHR 1.62 [1.07-2.45], p = 0.023), which was driven by TLR (sHR 2.01 [1.18-3.46], p = 0.011), but not by CVD, or TVMI. No differences were observed in all-cause mortality.
CONCLUSIONS: Unplanned RA was associated with favorable outcome when compared to planned RA. Thus, RA can safely be reserved for lesions that prove untreatable by conventional means. Randomized and prospective trials are needed to evaluate a predominant use of rotational atherectomy as a bailout strategy in the future.