Zusammenfassung
Das Instent-Rezidiv (ISR) repräsentiert die wesentliche Limitation der koronaren Stentimplantation. Die Behandlung mittels einer erneuten Angioplastie ist zwar technisch einfach, jedoch mit einer sehr hohen Rate eines erneuten Rezidives verbunden. Die vaskuläre Brachytherapie (VBT) stellt derzeit die einzige Methode zur Reduktion der Restenoseneigung nach Angioplastie eines ISR dar, deren Effektivität in mehreren randomisierten Studien dargestellt worden ist. Der hierfür relevante Mechanismus ist die Inhibition der Neointimaformation, andere Effekte wie positives Remodelling im Stentsegment wurden jedoch ebenfalls vermutet. Genaue Analysen zu Ausmaß und Anteil der jeweiligen Mechanismen sowie zu deren früher Chronologie liegen nur in geringer Fallzahl vor. Das Ziel der vorliegenden Studie war daher, Ausmaß, Verteilung und Chronologie der Neointimaformation und des Remodellings der Zielläsion und des Referenzsegmentes nach Angioplastie und β-Radiotherapie von ISR mittels quantitativer Koronarangiographie (QCA) und intravaskulärem Ultraschall (IVUS) vor und nach VBT mit einer 40 oder 60 mm langen 90Sr/90Y-Strahlenquelle sowie beim Follow-up nach 3 oder 6 Monaten an 42 Patienten zu charakterisieren.
Der mittels QCA bestimmte akute Lumengewinn betrug 2,2±0,8 mm, der späte Lumenverlust nach 3 Monaten betrug 0,1±0,5 mm, nach 6 Monaten 0,4±0,7 mm. Durch die Angioplastie ließ sich die mit IVUS bestimmte Lumenfläche von 1,5±1,2 mm2 auf 7,9±1,9 mm2 erweitern. Das Ausmaß der Neointimaformation betrug nach 3 Monaten lediglich 0,2±1,0 mm2 (p=0,191), nach 6 Monaten jedoch 0,7±0,6 mm2 (p<0,001). Dies resultierte in einer Lumenfläche von 7,1±1,7 mm2. Die Stentdimensionen veränderten sich gegenüber postprozedural im zeitlichen Verlauf nicht. Die Lamina elastica externa-Fläche zeigt gegenüber postprozedural nach 3 Monaten eine signifikante Zunahme von 1,3±1,9 mm2 (p<0,001) und nach 6 Monaten eine weitere Zunahme um 0,7±2,9 mm2. Im Referenzsegment ließ sich im Langzeitverlauf ebenfalls ein positives Remodelling darstellen.
Zusammenfassend führt eine VBT von ISR im Beobachtungszeitraum von bis zu 6 Monaten nach der Indexprozedur zu einer absolut gesehen gering ausgeprägten Neointimaformation mit hauptsächlicher Ausprägung zwischen dem dritten und sechsten Monat. Daneben kommt es, vornehmlich in den ersten drei Monaten, zu einem signifikanten positiven Remodelling der Zielläsion. Beide beobachtete Effekte können zum Erhalt des Gefäßlumens beitragen.
Summary
In-stent restenosis (ISR) represents the major limitation of stent implantation. Treatment, although of relative technical ease, is unsatisfactory due to a high incidence of recurrent restenosis. Vascular brachytherapy (VBT) has emerged as a powerful adjunct therapeutic modality to treat ISR. Inhibition of neointima formation has been regarded as the relevant mechanism of action. Yet, positive remodelling has been suspected as another contributing factor. Since only very few precise analyses of the extent, distribution and time course of the respective mechanims exist, the goal of the present study was to describe the changes of the vessel geometry at the target lesion and at the reference site following angioplasty and VBT of ISR in 42 patients by means of quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS) before and after the index procedure and at the 3 and 6 month follow-up.
By QCA the acute lumen gain measured 2.2±0.8 mm, the late lumen loss at 3 months was 0.1±0.5 mm and at 6 months 0.4±0.7 mm. By IVUS luminal cross-sectional area increased from 1.5±1.2 mm2 to 7.9±1.9 mm2 (p<0.001). The intima hyperplasia cross-sectional area at 3 months was only 0.2±1.0 mm2 (p=0.191), but increased to 0.7±0.6 mm2 (p<0.001) at 6 months resulting in a lumen cross-sectional area of 7.1±1.7 mm2. Stent dimensions did not show any significant changes over time. The external elastic membrane cross-sectional area at 3 months increased by 1.3±1.9 mm2 (p<0.001), and showed a further increase by 0.7±2.9 mm2 at 6 months. Positive remodelling could be demonstrated also at the reference segment.
In conclusion the absolute amount of intima hyperplasia during a 6-month follow-up period after VBT of ISR is low and most pronounced between the third and sixth month. Besides this, predominantly within the first 3 months of follow-up, significant positive remodelling could be demonstrated at the target lesion and at the reference site. Both observed effects may contribute to the preservation of the vessel lumen.
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Diese Publikation enthält die Ergebnisse der Promotionsarbeit von Frau Andrea Zimmermann
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Zimmermann, A., Pöllinger, B., Rieber, J. et al. Early time course of neointima formation and vascular remodelling following percutaneous coronary intervention and vascular brachytherapy of in-stent restenotic lesions as assessed by intravascular ultrasound analysis. ZS Kardiologie 94, 239–246 (2005). https://doi.org/10.1007/s00392-005-0204-7
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DOI: https://doi.org/10.1007/s00392-005-0204-7