약물용출 스텐트를 이용한 관상동맥중재술 후 재협착의 독립적 예측인자에 관한 연구 : MDCT calcium-scoring 시행 환자 대상으로
The Study on the Independent Predictive Factor of Restenosis after Percutaneous Coronary Intervention used Drug-Eluting Stent : Case on MDCT Calcium-Scoring Implementation Patient
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본 연구에서는 약물용출성 스텐트 삽입 후 재협착에 관한 독립적 인자를 확인하고 MDCT로 측정된 calcium score가 재협착 발생의 예측인자로써 가능성을 알아보고자 하였다. 2006년 5월부터 2009년 5월까지 전남대학교병원에서 MDCT상 관상동맥 협착이 발견되어 약물 용출 스텐트를 삽입 받은 환자 1,131명 중 추적검사로 관상동맥조영술을 시행되었던 178명(남자 159명, 여자 19명, 평균연령 61.7, 연령분포 51~71세), 190개소 병변을 대상으로 하였으며 재협착 여부에 따라 두 군(비협착군 133병변, 재협착군 57병변)으로 나누어 비교․분석하였다. 그 결과 임상진단명은 진구성 심근경색이 비협착군 3예(2.3%), 재협착군 5예(8.8%)로 유의한 차이가 있었으며(p=0.040), 급성 심근경색증, 불안정 협심증, 안정 협심증의 유병률은 차이가 없었다. 관상동맥 조영술 소견에서 병변 혈관의 위치는 재협착군에서 좌주간지 병변이 더 많았다(0.8% vs. 5.3%, p=0.047). 스텐트 직경은 재협착군에서 유의하게 작았으며(3.3±0.4mm vs. 3.1±0.3mm, p=0.004), 스텐트 길이는 양군 간에 차이가 없었다. 관상동맥 조영술 상 혈관의 초기 협착 정도는 재협착군에서 더 심했으며(86.1±11.4% vs. 91.5±9.2%, p=0.001), 복잡 병변(B2/C형)은 양 군간에 차이가 없었다. 연령은 재협착군에서 더 높았고(60.2±9.9세 vs. 65.8±9.0세, p=0.0001), 흡연력과 고지혈증은 비협착군에서(42.1% vs. 19.3%, p=0.003, 23.3% vs. 8.8%, p=0.019), 그리고 당뇨병은 재협착군에서 많았다(21.8% vs. 52.6%, p=0.0001). 심초음파로 측정한 좌심실 구혈률은 양 군 간에 유의한 차이는 없었다. 전체 MDCT coronary artery calcium scoring는 비협착군 371.2±500.8, 재협착군 389.3±458.3로 차이가 없었고, 목표혈관과 좌주간지, 좌전하행지, 좌회선지 및 우관상동맥 각각의 calcium score 역시 양군 간 차이가 없었다. 다 변량 로지스틱 회귀분석에서 좌주간지 병변(OR=168.0, 95% CI=7.83-3,604.3, p=0.001), 남성(OR=36.5, 95% CI=5.89-2,226.9, p=0.0001), 당뇨병의 존재(OR=2.62, 95% CI=1.071~6.450, p=0.035)가 약물용출성 스텐트 삽입 후 재협착 발생에 대한 독립적인 예측인자이었다. 따라서 관상동맥 협착에 대해 약물용출 스텐트를 삽입 받은 환자에서 스텐트 내 재협착의 발생은 좌주간지 병변, 남성, 당뇨병의 존재와 관련이 있었으나, MDCT로 측정된 calcium score는 재협착 발생에 대한 독립적인 예측인자로써 기능은 없었다.
Abstract
We sought to confirm an independent factor about in-stent restenosis (ISR) in the patients who underwent drug-eluting stent (DES) and know a possibility as a predictor of measured coronary artery calcium score by MDCT. A total of 178 patients (159 men, 61.7±10.0 years of age) with 190 coronary artery lesions were included in this study out of 1,131 patients who underwent percutaneous coronary intervention (PCI) with DES implantation for significant stenosis on MDCT at Chonnam National University Hospital between May 2006 and May 2009. All lesions were divided into two groups with the presence of ISR : group I (re ISR, N=57) and group II (no ISR, N=133). Compared to group II, group I was more likely to be older (65.8±9.0 vs. 60.2±9.9 years, p=0.0001), diabetic (21.8% vs. 52.6%, p=0.0001), have old myocardial infarction (8.8% vs. 2.3%, p=0.040), left main stem disease (5.3% vs. 0.8%, p=0.047), and smaller stent size (3.1±0.3mm vs. 3.3±0.4mm, p=0.004). Group II was more likely to be smokers (19.3% vs. 42.1%, p=0.003), have dyslipidemia (8.8% vs. 23.3%, p=0.019). Left ventricular ejection fraction, lesion complexity, and stent length were not different between the two groups. Total CAC score was 389.3±458.3 in group I and 371.2±500.8 in group II (p=0.185). No statistical difference was observed between the groups in CAC score in the culprit vessel, left main stem, left anterior descending artery, left circumflex artery, and right coronary artery. On multivariate logistic regression analysis, left main stem disease (OR=168.0, 95% CI=7.83-3,604.3, p=0.001), male sex (OR=36.5, 95% CI=5.89-2,226.9, p=0.0001), and the presence of diabetes (OR=2.62, 95% CI=1.071-6.450, p=0.035) were independent predictors of ISR after DES implantation. In patients who underwent DES implantation for significant coronary stenosis on MDCT, ISR was associated with left main stem disease, male sex, and the presence of diabetes. However, CAC score by MDCT was not a predictor of ISR in this study population.
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