Staged correction of coronary blood flow in patients with coronary heart disease and multi-vascular lesion after stenting of a clinically- dependent artery for acute coronary syndrome

Introduction

Diseases of the circulatory system are the leading cause of mortality in the world [1]. Coronary heart disease (CHD), particularly acute coronary syndrome (ACS) have a maximum share index of mortality in a group of diseases of the circulatory system. [2]

Until today, the debate continues as to the place of percutaneous coronary intervention in myocardial revascularization (PCI) in patients with coronary artery disease [3]. PCI significantly improves the outcome for patients with ACS [4], but is less clear [5] in place of stable coronary artery disease PCI.

The results showed that drug-eluting stents generation 2 shows similar results with CABG in the late period [6].

Are used today in practice stents with a drug coating generation 3 [7], but the data on the results of their application is extremely scarce.

Objective: to compare the long-term results phasic correction of coronary blood flow in patients with coronary artery disease and multivessel stenting clinical-related artery (CRA) on the ACS, which was performed complete revascularization CABG or PCI.

Materials and methods: a total of 250 patients were included with CAD and multivessel disease. The first stage - CRA stenting for health due to ACS. The second stage was carried out within 90 days from the date the PCI CRA - full functional CABG revascularization (CABG group) or PCI 3 using stents coated with drug generation and biodegradable polymer (group PCI).

For PCI applied 3-generation drug-eluting stents and sirolimus bioresorbable polymer "Calypso" producer of "Angioline", Russia.

Diameter implantable stents determined the reference diameter of the distal coronary artery, the length - the need artery portion overlap at least 5 mm distal edge of atherosclerotic plaques in both directions.

PCI was conducted by a standard procedure: predilatation performed, stent implantation and, if necessary, postdilatatsiya using high pressure ballons.

When performed bifurcation lesion side branch protection conductor.

1-stent strategy stenting is preferred, however, in the event of pain, slowing the flow speed is compromised side branch ostium - held "kissingdilation" and, while maintaining the above complications - stenting of side branches.

Criteria for successful PCI: bloodstream TIMI III, residual stenosis of less than 10%, the disappearance of subjective and objective symptoms of acute myocardial ischemia after intervention; and it was successful in 100% of cases in both groups.

Before performing PCI CRA patients received a loading dose of clopidogrel and then administered acetylsalicylic acid, clopidogrel, beta-blockers, statins and angiotensin-converting enzyme.

CABG performed by a single method - laying on mammary shunt anterior descending artery and vein grafts in other arteries when indicated in cardiopulmonary bypass, normothermia, cold blood cardioplegia.

CABG group consisted of 121 patients who underwent complete myocardial revascularization was performed by CABG.

129 patients included in the PCI group, revascularization of coronary arteries was performed by PCI.

Exclusion criteria were age less than 18 and more than 80 years prior to PCI or CABG, the lack of adherence to drug therapy, contraindications to antiplatelet agents, the presence of severe comorbidity, limiting the survival of patients, inability to perform full functional revascularization, the severity of coronary lesions on Syntax scale less 22 points and more than 33 points, defeated the trunk of the left coronary artery.

Long-term results were evaluated at the outpatient stage after the stage 2 on a quarterly basis within 24 months. Endpoints surveillance - cardiovascular death, myocardial infarction, acute ischemic stroke, repeat revascularization and combined point MACCE.

Statistical analysis was performed using Statistica software version 13.3 (TIBCO SoftwareInc., 2017, http ://statistica. io). Results are presented as mean and standard deviation (M+SD) for a normal distribution, the median with interquartile scale of 25% and 75% percentiles for an asymmetric distribution. Type of distribution of quantitative variables was evaluated by the Kolmogorov - Smirnov adjusted Lillieforsa. When comparing quantitative data, the U-Mann-Whitney criterion with corrected continuity was applied. To compare the qualitative variables used two-sided Fisher criterion. The ratio of the chances of developing large vascular events and the return of angina clinic was calculated using four-floor tables. Statistically significant differences between groups were considered at p <0.05.

Results. Statistical differences in the clinical and demographic and operational characteristics did not (Table 1, Table 2). Between the groups, except the frequency of generalized atherosclerosis, and quantity of smoking patients who were more common in the group of PCI, as well as myocardial infarction, myocardial earlier - significantly more in the CABG group

Table 1 CLINICAL CHARACTERISTICS OF PATIENTS

Table 2 ANGIOGRAPHIC AND OPERATIONAL PATIENT CHARACTERISTICS

Frequencies of myocardial infarction, revascularization, angina return clinics and MACCE were higher in the PCI (Table. 3).

Table 3 THE RESULTS OF THE STUDY

Discussion. Of optimal tactics of myocardial revascularization in patients with multivessel coronary artery disease with intermediate severity on a scale Syntax after stenting CRA about the ACS is a complex issue [8].

Often the "heart team" takes a less than optimal solution of the complete myocardial revascularization by PCI, the absolute majority of these patients in hospitals are unable to perform CABG. Choice is explained by the lack of clear and unambiguous algorithms are treated the recommendations of [9.10], as well as the attractiveness of PCI due to the small number of complications, minimally invasive, there is no need for rehabilitation in the postoperative period, short-term hospitalization.

According to the studies and long-term results CABG PCI with stents with drug coating 2 generation in patients with stable coronary artery disease [11,12], did not differ from CABG except repeated revascularization. Research method selection complete myocardial revascularization (CABG or PCI) in patients after successful stenting of the CRA on the ACS with intermediate severity of coronary lesions in, we did not find the available literature.

Our data - a higher rate of non-fatal myocardial infarction, repeat revascularization, and angina clinic return MACCE in the PCI group talk about the need for greater performance of CABG in patients of this group.

Conclusion

In patients with coronary artery disease and multivessel coronary artery intermediate severity on a scale of Syntax, underwent successful stenting clinical-related artery for an acute coronary syndrome, the incidence of non-fatal myocardial infarction, repeat revascularization, return clinical signs of angina, as well as the combined point MACCE significantly higher in the group of percutaneous coronary interventions.

The authors declare no conflict of interest.

ischemic heart coronary infarction

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