Assoziation zwischen Progression unbehandelter Koronarstenosen und In-Stent-Restenosierung

Hintergrund und Fragestellung: Die Progression der koronaren Herzkrankheit (KHK) wird nur unvollständig verstanden. Dies gilt für native Stenosen wie für In-Stent-Restenosen (ISR) als Extremform akzelerierter Arteriosklerose. Fragestellung der vorliegenden angiographischen Studie war, ob Restenosierung nach Stentim-plantation mit der Progression unbehandelter Läsionen assoziiert ist.

Patienten und Methodik: Insgesamt 179 höhergradige native Koronarstenosen (mittlerer Stenosegrad 68±16 %) von 131 Patienten wurden mittels Stentimplantation behandelt; zusätzliche 101 mäßig- bis mittelgradige Läsionen (Stenosegrad > 30 %) wurden so belassen. 6±2 Monate später erfolgte eine quantitative koronarangiographische Evaluierung der Koronarien hinsichtlich ISR (Stenosegrad > 50 %), koronarer Progression (Zunahme des Stenosegrades um > 20 %) bzw. Regression (Abnahme um > 20 %). Angiographische, prozedurale und klinische Charakteristika wurden auf eine Assoziation zu ISR, Progression und/oder Regression untersucht.

Ergebnisse: In 70 der 179 (39 %) behandelten Zielstenosen wurde eine ISR nachgewiesen. Prädiktiv für ISR waren Diabetes mellitus (p = 0,04) sowie die kumulative Dauer der Inflationen (p = 0,01) als prozeduraler Parameter. Signifikante Progression wurde in zehn der 101 (10 %) primär unbehandelten Läsionen nachgewiesen. Progression bei vormalig angiographisch normalem Segment oder Regression waren nicht zu beobachten. Die Progression nativer Plaques war in neun Fällen mit Auftreten einer ISR und nur in einem Fall mit deren Fehlen assoziiert (p = 0,01). Prädiktiv für Plaqueprogression waren Nikotinabusus (p = 0,02), nicht jedoch Medikation und prozedurale bzw. angiographische Parameter.

Folgerungen: Die Befunde der vorliegenden Pilotstudie zeigen die Restenosierung nach Stentimplantation der Zielstenose mit der Progression anderer primärer unbehandelter Läsionen assoziiert und legen damit gemeinsame systemische Pathomechanismen für beide Arterioskleroseformen nahe. Bei Nachweis einer ISR sollte grundsätzlich auch die Darstellung vormals unbehandelter Koronarien erfolgen, insbesondere wenn vorbestehende Plaques bekannt sind.

Background and objectives: Progression of coronaryartery di-sease is only incompletely understood regarding de-novo stenoses as well as in-stent restenoses (ISR) indicative of acce-lerated atherosclerosis. The objective of the present angiographic study was to prove an association between target lesion ISR and progression of primarily untreated coronary lesions.

Patients and methods: A total of 179 high-grade native coronary stenoses (mean diameter stenosis 68±16 %) of 131 patients were treated by stent implantation. Additional 101 lesions remained untreated because of their moderate to intermediate diameter stenoses (>30 %). Quantitative coronary angiographic analysis was performed 6±2 months later to evaluate ISR (diameter stenosis > 50 %), coronary progression (>20 % increase in diameter stenosis) and regression (>20 % decrease), respectively. Angiographic, procedural and clinical characteristics were assessed for a possible association with ISR and/or coronary progression and regression, respectively.

Results: ISR was seen in 70 of 179 (39 %) stented target lesions. Presence of diabetes mellitus (p = 0.04) and cumulative duration of inflations (p = 0.01) as procedural determinant were predictive for ISR. Significant progression was found in ten of 101 (10 %) primarily untreated lesions. Progression of previously normal segments or regression were not seen. Progression of native plaques was associated with ISR presence in nine cases and with ISR absence in only one case (p = 0.01). Of note, smoking (p = 0.02) turned out to be predictive for plaque progression, whereas medication and procedural/angiographic parameters were not.

Conclusions: The findings of the present pilot study demonstrate target lesion ISR associated with progression of other primarily untreated lesions and thereby suggest that both atherosclerosis types share common systemic pathogenetic mechanisms. With presence of ISR, coronary angiography should also include primarily untreated arteries, especially in case of preexisting plaques.

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