긴 관상동맥 병변에 대한 제1세대 및 2세대 약물용출 스텐트 중첩시술 후 2년간 임상 경과의 비교
Comparison of Clinical Outcomes after Implantation of First- and Second-Generation Overlapping Drug-Eluting Stents to Treat Diffuse Long Coronary Lesions
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목적: 긴 관상동맥 질환은 경피적 관상동맥 중재술의 발전에도 불구하고 높은 재협착률과 좋지 않은 임상결과를 보이고 있다. 약물용출 스텐트를 중첩하여 시술하는 경우에 중첩되어 있는 부분에는 약물용출이 두 배로 늘어나고 스텐트에 부착되어 있는 중합체에 따른 염증 반응이나 재내피화 지연이 주요 심장사건에 영향을 미치는 것으로 알려져 있다. 하지만 미만성 병변에 대한 약물용출 스텐트 중첩 시술 후 장기적 임상 경과에 대한 연구가 부족한 실정이어서 이에 대한장기적 임상 경과를 알아보고자 하였다. 방법: 대상자는 2006년 1월부터 2012년 7월까지 전남대학교병원 심혈관센터에서 긴 관상동맥 병변에 대하여 약물용출스텐트 중첩 시술 후 2년간 임상적 추적 관찰이 이루어진 환자 364예(63.3 ± 10.6세, 남 = 270예)를 대상으로 하였다. 이환자 중에서 1세대 약물용출 스텐트 시술 받은 환자를 I군(n = 183, 62.3 ± 10.4세, 남 = 136예), 2세대 약물용출 스텐트 시술 받은 환자를 II군(n = 181, 64.3 ± 10.7세, 남 = 134예)으로분류하여 임상경과 및 주요 심장사건 예측인자를 분석하였다. 긴 관상동맥 병변은 30 mm 이상 병변 혈관을 대상으로비교하였고, 재협착은 관상동맥 내경이 50% 이상 협착된 경우로 정의하였다. 결과: 기본적 임상 특성에서 양군 간에 차이가 없었다. 임상 진단명으로 안정형 협심증은 I군에서 II군보다 많았고(23.5% vs. 10.5%, p < 0.001), ST분절 비상승 심근경색증은 I군보다II군에서 많았다(20.2% vs. 30.4%, p = 0.026). 미국심장학회(ACC/AHA) 병변 분류에서 I군에서 II군보다 B2형 이상의 복잡 병변이 많았다(58.5% vs. 26.5%, p < 0.001). 주요 심장사건중에서 표적 병변 재개통률(21.9% vs. 2.2%, p < 0.001)은 I군에서 II군보다 통계적으로 유의하게 높았다. 주요 심장사건에미치는 예측인자를 파악하기 위하여 다변량 분석(multivariate analysis)을 한 결과, 패크리탁셀 용출 스텐트(PES) (HR, 5.168; 95% CI, 2.515-10.617; p < 0.001), 45% 미만의 좌심실 구혈률(HR, 3.586; 95% CI, 1.839-6.990; p < 0.001), 당뇨병(HR, 2.984; 95% CI, 1.605-5.548; p < 0.001)이 유의한 예측인자이었다. 결론: 긴 관상동맥 병변에 약물용출 스텐트 중첩 시술 후2년간 임상 결과, 2세대 약물용출 스텐트 중첩 시술은 1세대약물용출 스텐트 중첩 시술보다 양호한 결과를 보였다. 약물용출 스텐트 중첩 시술 후 PES, 좌심실 기능저하 및 당뇨병이 표적 병변 재개통률에 대한 발생 예측인자이었다.
Abstract
Background/Aims: Despite improved revascularization techniques, the clinical outcomes of patients with diffuse coronary artery lesions after percutaneous coronary intervention are unsatisfactory. However, few studies have compared the efficacy of first- and second-generation drug-eluting stents (DES) in patients with diffuse long coronary artery lesions. Methods: Between January 2006 and July 2012, 364 patients who were treated with DES for long coronary artery stenosis (> 30 mm) were enrolled in this study and assigned to either Group I (first-generation DES, 62.3 ± 10.4 years, 136 males, n = 183) or Group II (second-generation DES, 64.3 ± 10.7 years, 134 males, n = 181). The incidence of major adverse cardiac events (MACE) was compared between the two groups over 2 years of follow-up, and predictive factors associated with MACE were evaluated through a multivariate analysis. Results: Although several coronary angiographic characteristics were different between the two groups, most demographic and baseline clinical variables were the same. The cumulative incidence of MACE was significantly higher in Group I than in Group II (25.7 vs. 6.6%; p < 0.001), mainly due to reduced target lesion revascularization (21.9 vs. 2.2%; p < 0.001). According to the results of the multivariate analysis, the use of a paclitaxel-eluting stent (PES) (hazard ratio [HR], 5.168; 95% confidence interval [CI], 2.515-10.617; p < 0.001), decreased left ventricular function (≤ 45%; HR, 3.586; 95% CI, 1.839-6.990; p < 0.001), and diabetes mellitus (HR, 2.984; 95% CI, 1.605-5.548; p < 0.001) were independent contributors to MACE. Conclusions: For patients with diffuse long coronary artery stenosis, the use of second-generation DES improved the clinical outcome compared with first-generation DES. In addition, the use of a PES, left ventricular dysfunction, and diabetes were predictors of MACE after overlapping stenting.
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