药物支架和裸支架治疗急性ST段抬高心肌梗死患者的随访研究

Objective To evaluate the effects of drug-eluting stents (DES) versus bare-metal stents (BMS) on clinical outcomes in patients with acute ST-segment elevation myocardial infarction (ASTEMI) receiving primary percutaneous coronary intervention (PPCI). Methods The 217patients with ASTEMI receiving PPCI from Jan. 2005 to Dec. 2007 were enrolled in this study. And they were divided into two groups: DES group (n=92) and BMS group (n=125). The baseline characteristics including age, gender, angiographic characteristics, stents characteristics, Killip classification, cardiac troponin I(CTnI)levels, left ventricular ejection fraction(LVEF), hemoglobin levels, hypertension, diabetes, hyperlipidemia, obesity and smoking of the two groups were collected.Clinical follow-up end point were major adverse cardiac event(MACE)including death, acute myocardial infarction, stent thrombosis and stent restenosis. Clinical follow-up duration was(16.8±11.3) months (6-38 months). Results The average age (years), rate of Killip classification (class 2, 3, 4), average diameter (mm) of stent were significantly higher in BMS group than in DES group(64.6±11.9 vs. 61.2±11.8, t=2.09, P=0.037;25.9% vs. 12.2%, χ2=5.53, P=0.019;3.07±0.38 vs. 2.91±0. 40, t=2.78, P=0.006). And the average LVEF (%) was significantly lower in BMS group than in DES group (55.4±11.9 vs. 60.3±12.8, t= -2.57, P=0.011). The average length (mm) of stent, rate of stent post dilatation and diabetes were significantly higher in DES group than inBMSgroup (32.8±16.2 vs. 26.2±11.2, t=-3.54, P=0.001;45.7% vs. 21.6%, χ2=13.85, P=0. 000;28.2% vs. 16.0%, χ2=4.77, P=0.030). MACE occurred in 36 patients during clinical follow-up, 6 in DES group and 30 in BMS group. Incidence of MACE was significantly lower in DES group than in BMS group(6.5% vs. 24.0%, χ2=11.70, P＜0.01). Conclusions Using DES in ASTEMI patients is safe and may improve clinical outcomes by reducing incidence of MACE compared with BMS.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.     

Drug-eluting stents in patients on chronic hemodialysis: Paclitaxel-eluting stents vs. limus-eluting stents

BackgroundPatients requiring chronic hemodialysis (HD) are at high risk for restenosis after percutaneous coronary intervention (PCI) with bare metal stents. Outcome data on drug-eluting stent (DES) implantation in HD patients are limited and suggest superiority of paclitaxel-eluting stents (PES) over limus-eluting stents (LES).MethodsIn total, 218 consecutive patients were prospectively enrolled. A comparison of post-PCI outcomes up to 2 years was carried out between patients receiving PES (n = 62) and LES (n = 156; SES n = 112, EES n = 44). The primary end point was 2-year major adverse cardiac events [MACE; death, Q-wave myocardial infarction and target lesion revascularization (TLR)].ResultsBaseline characteristics were comparable. The overall prevalence of diabetes mellitus was 71%. On clinical follow-up to 2 years, MACE rates were similar [PES 32/51 (62.7%) vs. LES 77/132 (58.3%), p = 0.59]; however, clinically-driven revascularization occurred more than twice as frequently in LES patients: TLR [PES 4/36 (11.1%) vs. LES 24/93 (25.8%), p = 0.07] and target vessel revascularization [5/37 (13.5%) vs. 33/96 (34.4%), p = 0.02]. Given that overall mortality was nominally higher for PES patients [31/50 (62.0%) vs. 61/127 (48.0%), p = 0.09], a competing outcome analysis was implemented for TLR against mortality, which demonstrated that the trend for increased TLR with LES was no longer apparent (p = 0.282). On multivariable adjustment, only diabetes mellitus was independently associated with TLR (use of PES was not).ConclusionsPatients on chronic HD experience high rates of clinically driven TLR despite DES implantation. Use of PES does not demonstrate a significant advantage over LES in this population.     

Airway stents in children

Airway obstruction in children is a rare, but difficult clinical problem, with no clear agreement on optimal therapeutic approach. Stenting of the airway has been used successfully in adults, and is an attractive alternative in children. Fundamental differences of pediatric compared to adult use include the benign nature of most stenoses, the narrow and soft airways of children, the required long-term tolerance and adaptation to growth. These differences may significantly alter the therapeutic balance, calling into question the precise role stents play in the treatment of airway obstruction in children. Stent placement can be technically demanding but is not exceedingly difficult. Experience is necessary to select the proper size and type of stent. Metal stents usually achieve airway patency and clinical improvement in the majority of cases, while this is less frequently the case with silicone stents. Some complications such as granulation and secretion retention seem to occur in most children after stent implantation. Unfortunately, severe complications including death have been reported in a significant proportion of children. Stent related mortality can be estimated at 12.9% from published data, but these include complication centered reports. The initial euphoria for airway stents in children has largely abated and most authors agree that they should only be employed in circumstances with no good alternatives. It is crucial that all surgical and medical alternatives are considered and the decision to place a stent is not made because other options are overlooked or not available locally. Stent use in a palliative setting has also been reported and is probably reasonable. Stents will only allow limited adaptation for the growth of pediatric airways by balloon dilatation. All metal stents should be considered as potentially permanent, and removal sometimes may only be possible through a surgical and sometimes risky approach.     

Enteral stents

Obstruction of the digestive tract is a frequent cause of morbidity in patients with gastrointestinal malignancies. The role of palliative stenting in the management of these patients has expanded in recent years to include the esophagus, the gastroduodenal region, and the colon. Stent placement also serves as an adjunct to definitive surgical therapy for obstructing colonic lesions, as endoscopic decompression facilitates formal bowel cleansing and subsequent single-stage elective surgery. Stenting has also expanded into the realm of benign esophageal disease, with limited data demonstrating the use of an SEPS for benign strictures and anastomotic leaks. Endoscopic capabilities are likely to expand with the advent of innovative stenting devices and techniques.     

Meta-analysis comparing drug-eluting stents with bare metal stents

We performed a meta-analysis of 10 randomized trials of 5,066 patients with 6 to 12 months of follow-up. The summary risk differences excluded any major differences between the 2 types of stents for death (0.12%, 95% confidence interval [CI] -0.34% to 0.58%, p = 0.60) and overall myocardial infarction (0.04%, 95% CI -0.72% to 0.81%, p = 0.91). There was a modest increase in the risk of Q-wave myocardial infarction with drug-eluting stents (0.36%, 95% CI -0.04% to 0.77%, p = 0.080) but no difference in non-Q-wave myocardial infarction (-0.26%, 95% CI -0.95% to 0.43%, p = 0.47). The trend for increased risk of Q-wave myocardial infarction was seen for paclitaxel and sirolimus stents (risk differences 0.28% and 0.58%, respectively). Drug-eluting stents also had a nonsignificant trend for higher risk of thrombosis (0.29%, 95% CI -0.08% to 0.66%, p = 0.13). We conclude that sirolimus- and paclitaxel-eluting stents are equivalent to bare-metal stents in terms of mortality and overall myocardial infarction risk for the first year of follow-up; the meta-analysis excludes with considerable confidence the presence of large, clinically relevant differences for these outcomes.     

Intravascular stents

Intravascular stents have been developed to address acute arterial closure and restenosis, the major limitations of percutaneous transluminal coronary angioplasty (PTCA). Metallic stents in human clinical trials have shown efficacy in treating acute closure and, in selected patients, lowering the restenosis rate. This review delineates the characteristics of the ideal stent and examines ongoing clinical trials that are evaluating various stent prototypes. Developmental stents that use radiopaque and bioabsorbable materials are presented. The potential role for intravascular stents as vehicles for localized drug delivery and gene therapy is discussed.