血管内皮细胞的功能与支架置入后血管内皮化的关系

血管支架已被广泛应用于临床治疗心血管疾病,但由此产生的并发症也日益显露出来。支架置入后血管内皮功能异常,引发内皮层剥脱,导致血小板聚集、炎症反应、血管平滑肌细胞增殖迁移、细胞外基质形成等一系列病理反应,造成支架内再狭窄。本文从血管内皮细胞的功能与支架置入后血管内皮化的关系及支架涂层材料对支架置入后血管内皮化的影响作一综述。     

冠状动脉瘤的发病原因与治疗进展探讨(附2例报告)

正1临床资料患者1,男性,50岁,因冠心病、不稳定性心绞痛入院。高脂血症多年,无糖尿病、高血压病史。2007年10月冠状动脉造影结果显示,右冠状动脉中段瘤样扩张,瘤体近端伴有局限性狭窄85%。针对患者情况,于右冠状动脉中段置入GRAFT 3.0 mm×19 mm覆膜支架,覆盖瘤体;于右冠状动脉近段置入FIREBIRD 3.5 mm×29 mm支架,两支架少许重叠,观察其重复造影及血管内超声(IVUS)显示,结果满意。覆膜支架膨胀均匀,同时,观察其贴壁良好,支架内管腔直径可达3.2 mm;右冠状动脉近端支架膨胀均匀,支架内管腔直径3.5 mm。患者出院后采用常规双联抗血小板治疗,5个月     

冠状动脉介入术后支架内再狭窄的相关因素分析

目的分析冠状动脉介入术(PCI)后支架内再狭窄的相关因素。方法对198例PCI后患者进行回顾性队列分析。所选患者PCI术后1年复查冠脉造影,或者在PCI术后1年内因突发心血管事件再次行冠脉造影。按照置入支架处冠脉的再狭窄情况,分为再狭窄组64例和无再狭窄组134例。结果再狭窄组低密度脂蛋白(LDL-C)、尿酸、肌酐水平均高于无再狭窄组;高密度脂蛋白(HDL-C)、总胆红素水平均低于无再狭窄组;再狭窄组术前血管内径、置入支架直径低于无再狭窄组;再狭窄组置入支架长度高于无再狭窄组,差异均有统计学意义(P0.05)。总胆红素水平增高是减少再狭窄的保护性因素,差异有统计学意义(P0.05)。结论糖尿病、吸烟、LDL-C增高、高尿酸血症、支架内径3 mm、支架长度20 mm是导致PCI后再狭窄的危险因素,总胆红素水平增高是PCI后减少再狭窄的保护性因素。     

紫杉醇药物洗脱支架治疗冠状动脉弥漫长病变临床观察

目的评价紫杉醇药物洗脱支架（TAXUS）治疗冠状动脉长病变的临床效果。方法回顾分析本院接受TAXUS支架植入治疗冠状动脉长病变（≥20mm）患者51例（男38例，女13例），处理靶血管60支，其中12支病变〉35mm，置入两个支架重叠；48支为1个长支架覆盖病变。评价TAXUS的手术成功率，住院期间及随访期间的心绞痛、心肌梗死、猝死、再次血管重建的发生。结果手术即刻成功率100．0％，术后造影病变残余狭窄（5．6±4．1）％，住院期间无急性、亚急性血栓形成，无心肌梗死及死亡。临床随访6个月，46例患者心绞痛消失，5例症状减轻。7例6个月复查冠脉造影，无血管再狭窄。结论紫杉醇药物洗脱支架治疗冠状动脉长病变的疗效令人满意。     

冠状动脉支架内再狭窄相关因素研究

目的探讨冠状动脉内支架放置术后管腔再狭窄相关因素。方法选择行冠脉支架置入的冠状动脉疾病患者133例,按有无发生支架内再狭窄将患者分为再狭窄和无再狭窄2组,定期随访分析再狭窄发生的相关因素。结果再狭窄组糖尿病的发病率显著高于无再狭窄组(20.9%比9.1%,P<0.05);术后服用阿司匹林和他汀类药物的百分率显著低于无再狭窄组(70.3%比88.5%,54.6%比80.2%,P<0.05);治疗前病变血管直径<3 mm、置入支架数>1、复杂病变的发生率显著高于无再狭窄组(17.8%比5.8%,P<0.05;26.7%比8.0%,P<0.01;37.8%比19.3%,P<0.05);置入支架长度、充气时间亦>无再狭窄组[(22.5 mm比15 mm,P<0.01;(102.4±72.2)s比(76.3±58.4)s,P<0.05)],但病变发生部位、长度和充气压力2组差异无统计学意义(P>0.05)。结论冠状动脉支架内再狭窄发生与糖尿病、术后服用阿司匹林和他汀类药物、治疗前病变血管直径、置入支架长度、置入支架数、充气时间和复杂病变有关。     

25例冠状动脉支架内血栓患者临床分析

目的 探讨经皮冠状动脉介入治疗(PCI)术后支架内血栓患者的临床特点、影响因素及治疗效果.方法 回顾性分析本院心内科冠心病患者支架置入术(共3854例)后发生支架内血栓患者(25例)的临床特点、冠状动脉造影及治疗情况.结果 25例支架内血栓患者中急性心肌梗死25例(100%),多支血管病变22例(88%),合并大量吸烟史14例(56%),高脂血症13例(52%),高血压病11例(44%),糖尿病11例(44%).血栓靶血管累及左前降支16例,血栓靶血管为小血管(直径:＜2.5 mm)11例,长病变(＞20 mm)15例.18例患者经介入干预后血流达TIMI 3级;7例血流达TIMI 1-2级.25例患者均存活出院.结论 支架内血栓形成多发生于急性心肌梗死、多支血管病变、大量吸烟、前降支病变、小血管(直径＜2.5mm)、长病变(＞20 mm)、抗血小板治疗不充分等.急诊尽早再次介入治疗是治疗支架内血栓形成的首选治疗方案.     

25例冠状动脉支架内血栓患者临床分析

目的 探讨经皮冠状动脉介入治疗（PCI）术后支架内血栓患者的临床特点、影响因素及治疗效果.方法 回顾性分析本院心内科冠心病患者支架置入术（共3854例）后发生支架内血栓患者（25例）的临床特点、冠状动脉造影及治疗情况.结果 25例支架内血栓患者中急性心肌梗死25例（100%）,多支血管病变22例（88%）,合并大量吸烟史14例（56%）,高脂血症13例（52%）,高血压病11例（44%）,糖尿病11例（44%）.血栓靶血管累及左前降支16例,血栓靶血管为小血管（直径：＜2.5 mm）11例,长病变（＞20 mm）15例.18例患者经介入干预后血流达TIMI 3级;7例血流达TIMI 1-2级.25例患者均存活出院.结论 支架内血栓形成多发生于急性心肌梗死、多支血管病变、大量吸烟、前降支病变、小血管（直径＜2.5mm）、长病变（＞20 mm）、抗血小板治疗不充分等.急诊尽早再次介入治疗是治疗支架内血栓形成的首选治疗方案.     

雷帕霉素药物支架治疗冠状动脉心肌桥的疗效观察

目的探讨雷帕霉素药物支架治疗冠状动脉心肌桥的有效性。方法回顾分析经支架介入的18例心肌桥患者,8例置入Penta支架（普通支架组）,10例置入CypherTM支架（药物支架组）,对比两组患者即刻造影结果及随访结果。结果两组即刻造影成功率均为100%,在随访结果中,普通支架组心绞痛和支架内再狭窄发生率均为42.9%,药物支架组分别为20%和10%。结论对冠状动脉心肌桥患者,药物支架介入治疗安全有效,且可明显提高其远期疗效。     

覆膜血管支架治疗Stanford B型主动脉夹层的临床分析（附16例报道）

目的 探讨利用覆膜血管支架行腔内修复术治疗Stanford B型主动脉夹层的疗效.方法 对本院经CT增强扫描或磁共振确诊Stanford B型主动脉夹层16例患者,切开右或左侧股动脉,经股动脉将覆盖支架置于降中动脉夹层裂口处,支架自膨胀张开使人造血管覆盖支架固定于裂口附近的主动脉壁上将裂口封闭并阻断血流进入假腔,置入后重复造影检查.结果 支架置入全部成功,术后即时造影14例无内漏,2例轻度内漏.患者无支架移位与远端脏器缺血.术后半年复查CT增强扫描,16例均示支架段内假腔消失,血栓形成.2例轻度内漏均消失.结论 覆膜支架腔内修复术是治疗Stanford B型主动脉夹层的有效方法,具有创伤小、并发症少、安全性高等优点,近期疗效满意.但远期效果有待进一步观察.     

置入药物洗脱支架患者短期停用抗血小板治疗的安全性

背景 置入药物洗脱支架（DES）的患者在接受外科手术时常要中断抗血小板治疗。然而，中断抗血小板治疗是发生晚期支架内血栓形成（LST）的一个重要危险因素。本研究目的是确定短期停止抗血小板治疗安全性。     

表面磁性膜支架植入后对血管壁炎症反应的影响

目的研究表面磁性膜医用316L不锈钢支架对血管壁炎症反应的影响。方法通过动物体内支架植入,采用蛋白免疫印迹（Western blotting）技术对两支架血管壁炎症因子细胞间黏附分子1（ICAM-1）、白介素6（IL-6）的蛋白合成情况进行分析。结果表面磁性膜支架与普通裸支架相比可以抑制ICAM-1和IL-6蛋白合成从而发挥抑制血管壁炎症反应的作用,且效应至少可以维持3个月。结论该发现可能是其抗血管再狭窄的机制之一。     

Platelet and coagulation functions during triphasic oestrogen-progestogen treatment

The purpose of this investigation was the longitudinal evaluation of the hemostatic system before and after 1, 3, and 6 months of treatment with a triphasic oestrogen-progestogen combination. No changes of circulating platelet aggregates, as an index of in vivo platelet aggregability, and of megathrombocytes, an indirect evaluation of accelerated thrombocytopoiesis, were observed. A very slight, but significant, increase of Fibrinopeptide A (FPA), a reliable index of thrombin formation, was found only after 1 month of treatment; after 3 and 6 months, the increase of FPA was not homogeneous and not significant. Antithrombin III activity (AT III) showed no modifications after the first month; after 3 months AT III increased to a small extent, and after 6 months it was similar to basal values. Our findings indicate that the triphasic combination does not modify platelet functions and induces a low-degree activation of coagulation counteracted by an increased activity of the physiological inhibitors of blood clotting.     

Angiographic and histologic changes in artery, vein and portal vein after placement of bare or covered Z-stent; an experimental study in dogs

The aim of this study was to examine stenosis in the aorta, portal vein (PV), and inferior vena cava (IVC) after bare and covered Z-stent placement. Eight beagles underwent bare (n=4) or polytetrafluoroethylene (PTFE) covered (n=4) Z-stent placement in the aorta, PV, and IVC. Angiography was performed 1 and 3 weeks later to evaluate stenosis. The animals were sacrificed after 3 weeks for histopathologic examination. Angiographic findings revealed that stenosis in the bare stent group tended to be smaller than in the covered stent group in 3 vessels and stenosis tended to be smaller in the order of the aorta, PV and IVC in either group. In both groups, stenosis in the PV and IVC was mainly caused by organized thrombus. In addition, in the covered stent group, the space between the cover and native vessel wall (subgraft space) was formed and filled with neointima in every vessel. Preventing thrombus formation in the PV and IVC after bare and covered stent placement and reducing the subgraft space in the aorta after covered stent placement are important for minimizing stenosis.     

The impact of IVUS guided bare metal stent implantation for non-small vessel

Previous studies have shown larger target vessel or greater stent area contribute to reduced restenosis rate. Thus, intravascular ultrasound (IVUS)-guided bare metal stent (BMS) implantation for selected lesions might achieve drug-eluting stent-like outcomes. The aim was to examine the long-term outcomes of BMS using IVUS-guided optimization. METHODS: Consecutive 103 coronary artery lesions suitable for IVUS were enrolled. Using IVUS, final stent balloon size selected was 90 percent of media-to-media diameter at the lesion or distal reference. The balloon size was listed as follows: group A (3.0-3.5 mm, n = 15), group B (3.5-3.75 mm, n = 64), and group C (3.75-4.5 mm, n = 24). RESULTS: At post-intervention, average stent area increased by the balloon size (A: 7.2 +/- 1.4 mm2, B: 8.9 +/- 1.5 mm2, and C: 12.1 +/- 2.0 mm2, respectively p < 0.001). At 6 month follow up, the average lumen area increased by balloon size (A: 4.1 +/- 1.7 mm2, B: 5.7 +/- 1.2 mm2, and C: 8.1 +/- 2.0 mm2, respectively p < 0.001). Accordingly, group B and C revealed lower restenosis, compared to group A (A: 46.7%, B: 10.9%, C: 8.3%, A vs B: p = 0.001; C vs A: p = 0.015). Moreover, target lesion revascularization was less in group B and C than group A (A 26.6%, B 3.1%, C 0%, A vs B: p = 0.011; C vs A: p = 0.017). CONCLUSIONS: For non-small vessels, IVUS-guided BMS implantation showed less restenosis and target lesion revascularization compared to small vessels, mainly due to larger initial gain. These study results suggest that IVUS-guided optimal BMS implantation for selected lesions might result in favorable long-term outcomes similar to those seen using drug-eluting stents. For a decade, coronary stenting has become a standard therapy for coronary artery disease due to favorable long-term outcomes and simple treatment procedure. Furthermore, for the last two years, drug-eluting stents (DES), releasing antiproliferative agents from bare metal backbone, revealed the restenosis rates less than half of those seen using conventional bare metal stents (BMS). While target lesions especially suitable for DES continue to be identified, earlier BMS studies showed that larger target vessel or greater stent area contributed to less restenosis. Thus, optimal IVUS-guided BMS implantation for selected lesions might achieve DES-like long-term outcomes. This study was designed to examine the long-term outcomes of BMS with intravascular ultrasound (IVUS)-guided optimization, using coronary angiography and IVUS data.     

颅内外动脉支架术前后脑CT灌注评价

目的：CTP在评估颅内外动脉支架植入术前后脑血流动力学变化中的价值。方法对15例颅内外动脉狭窄患者支架植入术前后行灌注扫描,术前后相对灌注值进行统计分析。结果狭窄血管供血区术后rTTP比术前降低,有统计学意义（P<0.05）,狭窄血管非供血区术前后rTTP及狭窄血管供血区和非供血区术前后rCBV、rCBF、rMTT均无统计学差异（P>0.05）。结论CTP可较好评估颅内外动脉支架植入术前后脑血流动力学变化,以rTTP较敏感。     

The effect of carotid stenting on rheological parameters, free radical production and platelet aggregation

INTRODUCTION: Carotid artery stenting has become a possible treatment of significant carotid stenosis. The risk of stent occlusion and restenosis might be increased by abnormal rheological conditions amplified platelet aggregation and free radical production during the operation. AIMS: The aim of this study was to assess the changes of the rheologic parameters, platelet aggregation, and oxidative stress after endovascular treatment of carotid stenosis. METHODS: 18 patients (11 men, ages 68 +/- 9 years and 7 women, ages 62 +/- 8 years) suffering from significant carotid stenosis and treated with carotid endovascular intervention were examined. Alteration in hemorrheological parameters as well as epinephrine-, ADP-, and collagen-induced platelet aggregation were evaluated. Oxidative stress was characterized by the determination of catalase activity. The measurements were carried out directly before and after the procedure and 1, 2, 5 days and 1 month following the intervention. Preceding the operation the patients were administered a maximum dose (300 mg) of clopidogrel. RESULTS: The hematocrit, the plasma fibrinogen concentration (Pfc) and whole blood-, and plasma viscosity (Wbv and Pv) decreased significantly immediately after stenting ( p < 0.001). By the fifth day following the intervention the Pfc, Wdv, Pv, red blood cell (Rbc) aggregation and ADP-induced platelet aggregation increased significantly ( p < 0.0001) compared to values measured after the procedure. At 1 month follow-up these parameters, excepting Wbv, decreased significantly compared to measurements made on the 5th day. On the other hand, catalase activity showed significant elevation by the end of the first month. CONCLUSION: Hemorrheological parameters and platelet aggregation showed specific changes following carotid stenting. Abnormal changes of the rheological conditions and increasing platelet activation are the most pronounced in the first week following stenting, which may lead to the stent's early occlusion. Oxidative stress production returned to baseline levels only by the end of the first month.     

Changes in hematologic and hemostatic parameters after transjugular intrahepatic portosystemic shunt (TIPS) implantation

BACKGROUND: The pathogenesis of thrombocyte- and leukopenia associated with liver cirrhosis is far from being understood. Hypersplenism is considered to play a major role in this hematologic complication. The effect of transjugular intrahepatic portosystemic shunt (TIPS) implantation--a more recent technique in portal decompression--on platelet count is controversial in the literature. One of the main problems related to TIPS is the frequent occurrence of shunt malfunctions. There have been no reports on consistent clinical or biochemical parameters being able to predict the occlusive and rebleeding episodes after TIPS implantation. AIM AND METHOD: Platelet counts, white blood cell counts and different haemostatic data (prothrombin time, activated partial thromboplastin time and fibrinogen level) of the 24 patients undergoing TIPS placement were analyzed retrospectively prior to the procedure, after one month, after 3 months and 3 monthly thereafter for 18 months. RESULTS: The portal pressure gradient decreasing below the desired 12 mmHg after TIPS placement seems to be the only factor, which can result in moderate but significant increase in platelet counts. There was no significant alteration in white blood cell counts during the follow-up period. The different haemostatic parameters scattered in a wide range, no real tendency was demonstrable. Patients in whom recurrent variceal bleeding occurred, the platelet count at the 3rd month was significantly lower compared to the basal platelet count. The decrease in the platelet count preceded shunt malfunction detected with color-Doppler or the appearance of the clinical symptoms. CONCLUSION: Monitoring platelet count may be of prognostic interest in the assessment of the shunt function and the risk of imminent variceal rebleedings during the follow-up period.     

肝细胞色素P450系统基因多态性对下肢动脉硬化闭塞症支架术后患者服用氯吡格雷的远期疗效影响

目的探讨肝细胞色素P450系统CYP2C19基因多态性在下肢动脉硬化闭塞症(atherosclerosis obliterans, ASO)患者中的分布规律,及其与氯吡格雷治疗下肢ASO支架术后患者远期疗效的相关性。 方法选取2011年1月至2012年12月在复旦大学附属中山医院血管外科行支架植入手术的下肢ASO患者50例,按泛大西洋学会联盟 (Trans-Atlantic Inter- Society Consensus,TASC) II分级A~C,采用测序法检测影响氯吡格雷代谢活性基因 (CYP2C19*2, *3, *17) 的单核苷酸多态性分布。采用多普勒超声和周围血管检查随访12个月,对疑难病例用X光、CT血管造影共同评价患者支架内狭窄程度,以分析年龄、身体质量指数、性别、糖尿病、高血压、脑梗、冠心病、吸烟史等因素对支架术后患者临床预后的影响。 结果50例下肢ASO支架术后患者中,CYP2C19*2、*3等位基因突变频率分别为48.0% (24/50)、6.0% (3/50)。CYP2C19快代谢型(*1/*1)、中代谢型(*1/*2、*1/*3)、慢代谢型 (*2/*2、*2/*3) 的比例分别为48.0% (24例)、44.0% (22例)、8.0% (4例)。50例下肢ASO支架术后服用氯吡格雷患者经12个月随访,CYP2C19代谢型和吸烟史所预示终点事件发生的风险比 (Hazard ratio,HR)分别为2.688,95%CI 1.366~5.288,P=0.004;HR 2.430,95%CI 1.024~5.765,P=0.044。经Kaplan-Meier生存分析,12个月中携带1个丧失功能型(loss-of- function,LOF)、2个LOF、不携带LOF等位基因的下肢ASO患者间发生缺血性事件的差异有统计学意义 (P=0.007)。但CYP2C19*2和*3对下肢ASO患者缺血性事件影响的差异无统计学意义 (P=0.05)。 结论CYP2C19基因多态性对服用氯吡格雷治疗下肢ASO 患者远期疗效有影响,携带LOF等位基因可能增加缺血事件发生的风险。但由于本研究病例数少,需扩大样本量予以进一步验证。     

甲、乙型肝炎联合疫苗在儿童中0、6月程序接种的安全性和免疫原性研究

目的 观察和评价在儿童中接种2剂倍尔来福~(TM)甲、乙型肝炎(分别简称为甲肝、乙肝)联合疫苗的安全性及免疫原性.方法 本研究以江苏省常州市116名1～10岁完成乙肝疫苗全程免疫同时无甲肝疫苗接种史的抗甲肝病毒抗体(anti-hepatitis A virus,抗-HAV)阴性儿童为研究对象,按0、6个月程序接种甲、乙肝联合疫苗(倍尔来福~(TM)).每剂疫苗0.5 ml,含HAV抗原250 U和乙肝表面抗原5μg.观察接种疫苗后72 h内局部反应和全身反应,检测免疫后1、6、7个月的血清抗-HAV阳转率、乙肝病毒表面抗体(抗-HBs)保护率及抗体滴度.结果 倍尔来福~(TM)接种后局部和全身不良反应发生率分别为12.1%(14/116)和6.0%(7/116),其中局部不良反应以注射部位红、肿、硬结为主,占6.9%(8/116)～11.2%(13/116),全身不良反应发生率为6.0%(7/116),以发热为主.免疫后1、6、7个月,抗.HAV阳转率为92.9%(92/99)～100.0%(101/101),抗体几何平均滴度(GMT)为47.0～2762.3 mIU/ml;疫苗免疫前抗-HBs阳性保护率为86.1%(87/101),免疫后1个月达到100.0%(101/101),免疫后1、6、7个月抗-HBs GMT为894.3～3314.3 mlU/ml.结论 倍尔来福~(TM)甲、乙肝联合疫苗2剂接种程序在乙肝基础免疫儿童中应用具有良好的安全性和免疫原性.     

Treatment of large, esophageal perforations and mediastinitis with a covered, removable metallic endoprosthesis and mediastinal drainage

The application of covered metallic stents in the treatment of benign strictures and perforations is still in the early stages, because their removal is difficult and may cause tissue proliferation. The therapeutic effect and the efficiency of a new method for the extraction of a removable metallic stent were examined in three patients treated for oesophageal perforation. Two of the three patients were dilated with a balloon catheter because of corrosive oesophageal stenosis, and the oesophagus was perforated. In one patient mediastinal drainage, and jejunostomy and in the other primary suturing and drainage were performed. Sepsis and mediastinitis developed due to the oesophageal perforation and the fistula caused by the mediastinal drain in the first patient, and the insufficiency of the suture in the second patient. The oesophageal defects were sealed on day 8 and 10 after the perforation, and surgery by a covered stent. In the third patient, the oesophageal rupture caused by the dilatation and the attempt to stent a malignant obstruction was sealed with a covered stent within 2 hours. Parenteral nutrition and broad-spectrum antibiotic therapy were started. Three days after the interventions, swallowing tests with water-soluble contrast medium (Gastrografin) did not reveal any extravasations. Feeding via a nasogastric tube, and later oral feeding was started. After transient mediastinal drainage, the stents were removed on day 35 and 74 after implantation. Both openings healed completely. Restenoses above the stents were dilated again. The rupture of the malignant oesophagus in the third patient, following early, permanent stenting, healed without drainage and with no complications. Even with mediastinitis and concomitant sepsis, large oesophageal perforations can be treated successfully with removable, covered metallic stents and adequate mediastinal drainage.