Akut Koroner Sendromda Bifurkasyon Lezyonlarına Girişim
Özet
Akut koroner sendrom (AKS) seyrinde görülen koroner bifurkasyon lezyonları, perkütan koroner girişimlerde (PKG) düşük işlem başarısı, yüksek restenoz ve stent trombozu riskleri nedeniyle klinik bir zorluk teşkil etmektedir. Güncel Avrupa Kardiyoloji Derneği (ESC) ve Avrupa Bifurkasyon Kulübü (EBC) kılavuzları, bu lezyonların tedavisinde ilk yaklaşım olarak kademeli provizyonel yan dal stentlemesini önermektedir. Ancak DEFINITION kriterlerine göre karmaşık bifurkasyon sınıfına giren lezyonlarda, özellikle büyük bir yan dalın varlığında planlı çift stent stratejilerinin (örneğin DK-crush veya nano-crush) uygulanması, hedef lezyon başarısızlığını (TLF) ve uzun dönem kardiyak ölüm oranlarını azaltmada provizyonel yaklaşıma üstünlük gösterebilmektedir. AKS ve ST yükselmeli miyokard infarktüsü (STEMI) hastalarında zaman kısıtlılığı, trombüs yükü ve kontrast nefropatisi riskleri nedeniyle bifurkasyon stratejileri daha uzun işlem ve floroskopi sürelerine yol açar. Bu süreçte stent malpozisyonunu ve deformasyonunu önlemek adına proksimal optimizasyon tekniği (POT) ve eş zamanlı kissing balon (FKI) kombinasyonlarının uygulanması hayati önem taşımaktadır. İntravasküler ultrason (IVUS) ve optik bilgisayarlı tomografi (OCT) gibi görüntüleme yöntemleri tedaviyi optimize etse de, akut fazda kullanımı sınırlıdır. Sonuç olarak, AKS durumunda bifurkasyon lezyonlarının yönetimi; lezyon morfolojisi, anatomik özellikler ve operatörün tecrübesine göre hasta bazlı olarak şekillendirilmelidir.
Coronary bifurcation lesions encountered during acute coronary syndrome (ACS) present a significant clinical challenge in percutaneous coronary interventions (PCI) due to lower procedural success, higher restenosis, and stent thrombosis rates. Current European Society of Cardiology (ESC) and European Bifurcation Club (EBC) guidelines recommend stepwise provisional side-branch stenting as the default strategy for most lesions. However, according to the DEFINITION criteria, complex bifurcation lesions with a significant side branch may benefit from an upfront two-stent strategy (such as DK-crush or nano-crush), which has been shown to reduce target lesion failure (TLF) and cardiac mortality compared to the provisional approach. Managing bifurcation lesions in ACS and ST-elevation myocardial infarction (STEMI) patients involves technical difficulties, high thrombus burden, and increased contrast volume, leading to longer procedural and fluoroscopy times. To mitigate stent deformation and malposition, the routine utilization of the proximal optimization technique (POT) combined with final kissing balloon inflation (FKI) is strongly emphasized. Although intravascular imaging modalities like IVUS and OCT provide crucial structural data to guide revascularization, their use in the acute phase remains limited. Consequently, a patient-tailored approach balancing lesion morphology, anatomical features, and operator experience is essential for optimal outcomes.
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