Bifurkasyon Stentleme De In-Stent Restenozu ve Trombozu
Özet
Perkütan koroner girişim (PKG) uygulanan bifurkasyon lezyonlarında stent trombozu (ST) ve stent içi restenoz (ISR), hedef lezyona tekrarlayan revaskülarizasyonun en temel iki nedenidir. Stent trombozu, Akademik Araştırma Konsorsiyumu (ARC) tarafından kesinlik düzeyine ve oluş zamanına (erken, geç, çok geç) göre sınıflandırılmakta olup, bifurkasyon lezyonları ST için bağımsız bir risk faktörü teşkil etmektedir. ST hastalarına yaklaşımda acil primer koroner anjiyografi, intravasküler görüntüleme yöntemleri, seçilmiş vakalarda trombüs aspirasyonu ve non-kompliyan (NC) balonlarla yüksek basınçlı dilatasyonlar uygulanmaktadır. Stent içi restenoz (ISR) ise neointimal hiperplazi veya neoateroskleroz nedeniyle damar çapında %50'nin üzerinde darlık görülmesiyle tanımlanır. ISR yönetiminde intrakoroner görüntüleme (IVUS, OCT), scoring/cutting balonlarla lezyon hazırlığı, ilaç kaplı balonlar veya yeni nesil ilaç salınımlı stentler tercih edilmektedir. Farklı bifurkasyon teknikleri (provizyonel, DK-crush, culotte, TAP) kıyaslandığında; kompleks lezyonlarda DK-crush tekniğinin hedef lezyon revaskülarizasyonunu azaltmada üstün olduğu gösterilmiştir. Hem ST hem de ISR riskini azaltmada prosedür esnasında final kissing balon ve proksimal optimizasyon tekniğinin (POT) uygun şekilde yapılması kritik öneme sahiptir.
Stent thrombosis (ST) and in-stent restenosis (ISR) represent the two primary causes of target lesion revascularization following percutaneous coronary intervention (PCI) in bifurcation lesions. Stent thrombosis is classified by the Academic Research Consortium (ARC) based on certainty levels and timing (early, late, and very late), with bifurcation lesions serving as an independent risk factor for ST. The management of ST patients involves urgent primary coronary angiography, intravascular imaging, thrombus aspiration in selected cases, and high-pressure dilatation utilizing non-compliant (NC) balloons. In-stent restenosis (ISR) is defined as a reduction of over 50% in vessel diameter resulting from neointimal hyperplasia or neoatherosclerosis. Management strategies for ISR incorporate intracoronary imaging (IVUS, OCT), careful lesion preparation using scoring or cutting balloons, drug-coated balloons, or new-generation drug-eluting stents. Comparing various bifurcation techniques including provisional, DK-crush, culotte, and TAP; the DK-crush technique demonstrates clear superiority in reducing target lesion revascularization for complex lesions. Ultimately, the precise application of the final kissing balloon and proximal optimization technique (POT) during the procedure remains vital to mitigating long-term ST and ISR risks.
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