支架骨架的厚度对小血管病变支架内再狭窄的影响

小血管病变(<3.0mm)已公认为是支架置入术后再狭窄的独立预测因素。支架置入过程中造成的管壁损伤是造成术后再狭窄的重要原因。近期的一项研究显示采用薄壁支架可明显降低参照血管直径>2.8mm患者术后的造影再狭窄率和临床再狭窄率。该文对支架厚度是否会影响小血管内支架置入术后的再狭窄率作一     

血管内超声引导冠脉支架植入的应用进展

血管内超声 (IVUS)是近十年来发展起来的一项介入影像学新技术 ,在冠心病的诊断和治疗方面有很重要的应用价值 ,其引导冠脉支架植入 ,可获得尽可能大的管腔直径 ,降低支架术后再狭窄率的发生。本文综述IVUS在引导冠脉支架植入的作用及进展     

西罗莫司洗脱支架对支架植入再狭窄的预防作用

采用多中心、双盲、随机对照试验,评价西罗莫司洗脱支架（sirolimus BX Velocity eluting stent）的安全性和疗效,西罗莫司诱导对细胞增殖G1后期的抑制作用。     

微小RNA对血管平滑肌细胞的调控作用以及与支架内再狭窄的联系

血管平滑肌细胞(Vascular Smooth Muscle Cells,VSMCS)的增殖、迁移及凋亡与支架内再狭窄(In-Stent Restenosis,ISR)密切相关。微小RNA(microRNAs)在机体的新陈代谢和疾病发生发展等许多方面有着不可或缺的重要作用,对血管平滑肌细胞起着重要的调控作用,因此可能是防治支架内再狭窄的新热点。本文旨在阐述微小RAN对血管平滑肌细胞的调控作用以及与支架内再狭窄的联系。     

载基因支架治疗血管再狭窄

血管局部定位基因转染是目前血管再狭窄基因治疗研究的热点,它将特异性基因精确定位转染至局部血管壁,实现外源性基因表达,从而最大限度地在血管局部发挥生物学效应。血管内支架作为一种局部定位并长期保留在体内的外源性植入物,是对血管内再狭窄进行基因治疗的比较理想的运载体系。     

冠状动脉内放射治疗对支架内再狭窄的作用

目的　研究应用β射线 (90 Sr/90 y)进行冠状动脉内放射治疗对国人支架内再狭窄的作用。方法　自 1 999年 1 2月至 2 0 0 2年 1月 ,我院对 5 3例患者 [男 4 9例 ,女 4例 ,平均年龄 (5 3 2± 9 8)岁 ]5 5处支架内再狭窄病变 (支架直径≥ 2 5mm ,1 0mm≤病变长度≤ 30mm) ,在球囊 (1 0处病变用普通球囊 ,4 5处病变用切割球囊 )满意扩张后 ,应用Beta Cath系统 (Novoste)进行冠状动脉内放射治疗。放射源长度 4 0mm。术后 8个月随访冠状动脉造影 ,用MEDCONViewer软件包进行定量冠状动脉造影 (QCA)分析。结果　 5 3例患者 5 5处支架内再狭窄病变均被满意扩张 ,冠状动脉内放射治疗全部成功 ,术中并发冠状动脉痉挛 1例 (1 8%) ,无其他并发症。全部患者随访期中无死亡 ,随访≥ 8个月 33例患者中 1例 (3 0 %)发生非Q波心肌梗死 ,6例 (1 8 2 %)进行靶血管重建术。该 33例患者中 2 9例(87 9%) 30处病变进行了随访冠状动脉造影 ,再狭窄率在支架段为 1 0 0 %(3/30 ) ,分析段为 2 3 3 %(7/30 )。最小管径直径术前为 (0 41± 0 2 2 )mm ,术后即刻为 (1 99± 0 42 )mm ,8个月随访时为 (1 73± 0 82 )mm ,平均病变长度为 (2 3 3± 5 4)mm。全部患者无晚期血栓形成、假性动脉瘤及冠状动脉瘤发生。结论　应用90 Sr     

体积法血管内超声波评价坎地沙坦对冠状动脉支架内再狭窄的抑制作用

目的本研究旨在采用体积法血管内超声波(IVUS)来观察常规降压剂量坎地沙坦对冠状动脉支架内再狭窄的作用。方法本试验为前瞻性、安慰剂对照、随机分组研究,47例病人共计52处病变分为对照和坎地沙坦组,坎地沙坦组在介入治疗前至少3天按照血压水平给与4或8mg坎地沙坦,分别分析支架后和6个月随访时支架段的冠状动脉造影和血管内超声。增生内膜面积定义为支架面积减去管腔面积,以Simpson法则计算体积值,并以体积值除以支架长度作为平均体积值。结果两组病人和病变特征均相似,冠状动脉造影定量分析两组在随访时的最小管腔直径(对照组2.17±0.72mm,坎地沙坦组2.25±0.73mm,P=ns)和百分直径狭窄率(对照组25.2±16.5%,坎地沙坦组25.7±16.3%,P=ns)均无差异。IVUS分析,支架后平均管腔体积相等(对照组10.3±2.5,坎地沙坦组10.7±2.3mm3/mm,P=ns),随访时两组的平均内膜体积为3.1±1.3和3.3±1.0mm3/mm,平均管腔体积为7.9±3.0和8.2±2.3mm3/mm,均无显著性差异,6个月的靶病变血管重建率两组也相似,分别为15.6%和10.0%(P=ns)。结论在6个月随访期内,常规剂量的坎地沙坦可能对于预防支架内新生内膜增生无效。     

冠脉支架植入术后支架内再狭窄的危险因素研究

目的对冠脉支架植入术后的支架内再狭窄危险因素进行研究。方法在2011年7月-2013年7月期间,我院收治冠脉支架植入术患者120例,对该120例患者术后支架内的再狭窄危险因素进行研究,并采取Logistic多因素分析再狭窄的危险因素。结果通过术后患者危险因素研究可知,与患者的胆固醇、术前狭窄、是否吸烟、有糖尿病及高血压等因素有关,与支架有无药物涂层也有关,表现为负相关,危险度是0.01。结论对糖尿病及高血压患者来说,实施支架植入术之后,出现再狭窄症状的几率增加。同时,冠脉支架患者对危险因素应采取预防措施,如戒烟,避免再狭窄情况出现,提高患者的生存质量。     

尿酸水平对冠状动脉支架内再狭窄的影响

目的探讨尿酸水平对稳定性心绞痛患者支架置入后发生支架内再狭窄的影响。方法 136例稳定性心绞痛成功行支架置入治疗患者,根据术后12~18个月冠状动脉造影结果分为再狭窄组62例及对照组74例;对冠状动脉造影结果用计算机辅助的定量分析法评价。结果对照组尿酸水平明显低于再狭窄组[(364.21±42.47)μmol/L vs(440.66±69.05)μmol/L,P=0.000];对照组术后12~18个月的最小管腔直径明显大于再狭窄组[(2.12±0.38)mmvs(0.76±0.37)mm,P=0.013];狭窄程度术后12~18个月对照组明显低于再狭窄组[(35.84±12.34)%vs(84.53±14.26)%,P=0.000];对照组晚期管腔丢失明显小于再狭窄组[(0.27±0.14)mmvs(1.66±0.57)mm,P=0.000]。尿酸与支架术后再狭窄有关(OR=0.680,95%CI:0.564~0.937,P<0.05)。结论尿酸水平增高可能是稳定性心绞痛患者支架置入后发生支架内再狭窄的原因之一。     

新型血管内支架

冠状动脉内支架能防止急性血管闭塞，降低再狭窄的发生率。但仍有局部血栓形成，新生内膜增殖导致再狭窄及抗凝治疗带来的出血并发症等局限。几种正在研究的新型血管内支架可望减少局部血栓形成和降低再狭窄的发生率。     

药物洗脱支架2年内再狭窄危险因素分析和Nomogram构建

目的探讨冠心病合并2型糖尿病患者药物洗脱支架(DES)植入后2年内再狭窄(ISR)危险因素并构建Nomogram模型。方法回顾性分析2010年1月—2020年2月在中国医学科学院阜外医院深圳医院植入DES的冠心病合并2型糖尿病患者临床资料。PASS估计模型产生队列样本量,根据冠状动脉造影结果分为支架内再狭窄组(DES-ISR)及非狭窄组(non-DES-ISR),对两组之间差异有统计学意义的参数进行单因素和条件性多因素Logistic回归分析构建Nomogram并在验证队列中验证其检验效能。结果模型产生队列共1741例,233例(13.4%)在植入DES后2年内确诊ISR,条件性多因素Logistic回归分析显示,DES-ISR的预测因素为肾小球滤过率(eGFR)<60 mL/(min·1.73 m²)(OR=2.77,95%CI:1.41~5.47,P=0.003)、血脂异常(OR=1.90,95%CI:1.30~2.78,P=0.001)、空腹血糖(FPG)≥6.5 mmol/L(OR=5.50,95%CI:3.05~9.92,P<0.001)、冠状动脉多支病变(OR=7.26,95%CI:3.27~16.11,P<0.001)、冠状动脉弥漫病变(OR=1.80,95%CI:1.13~2.88,P=0.014)、首次PCI操作时间≥60 min(OR=2.62,95%CI:1.13~6.05,P=0.024)和首次PCI为急诊(OR=2.20,95%CI:1.48~3.28,P<0.001)。模型验证队列102例,DES-ISR发生风险随Nomogram评分增高而增加,Nomogram模型受试者工作特征(ROC)曲线下面积为0.791(95%CI:0.753~0.829,P=0.019)。结论冠状动脉病变特征以及PCI操作程序是DES-ISR的重要预测因素,Nomogram能够较好地识别DES-ISR高危人群,能够为高危人群的随访干预提供有效的决策信息。     

In-stent restenosis in the drug-eluting stent era

The introduction of the drug-eluting stent (DES) proved to be an important step forward in reducing rates of restenosis and target lesion revascularization after percutaneous coronary intervention. However, the rapid implementation of DES in standard practice and expansion of the indications for percutaneous coronary intervention to high-risk patients and complex lesions also introduced a new problem: DES in-stent restenosis (ISR), which occurs in 3% to 20% of patients, depending on patient and lesion characteristics and DES type. The clinical presentation of DES ISR is usually recurrent angina, but some patients present with acute coronary syndrome. Mechanisms of DES ISR can be biological, mechanical, and technical, and its pattern is predominantly focal. Intravascular imaging can assist in defining the mechanism and selecting treatment modalities. Based upon the current available evidence, an algorithm for the treatment approaches to DES restenosis is proposed.     

Ten-year outcomes after percutaneous coronary intervention of in-stent restenosis in saphenous vein grafts

Background

Only few data is available for long-term outcomes of patients being treated for in-stent restenosis (ISR) in saphenous vein grafts (SVG).

Aims

Thus, the aim of this observational, retrospective study was to close this lack of evidence.

Methods

Between January 2007 and February 2021 a total of 163 patients with 186 ISR lesions located in SVG were treated at two large-volume centers in Munich, Germany. Endpoints of interest were all-cause mortality, target lesion revascularization (TLR) and target vessel myocardial infarction (TVMI). Furthermore, recurrent ISR were assessed. Outcomes are presented as Kaplan–Meier event rates.

Results

Mean age was 72.6 ± 8.6 years, 90.8% were male, 36.8% were diabetics and 42.3% presented an acute coronary syndrome. ISR were treated with DES in 64.0% and with balloon angioplasty (BA) in 36.0%. After 10 years, the rates for all-cause mortality, TVMI and TLR were 58.2%, 15.4%, and 22.6%, respectively. No statistically relevant differences were found between the types of treatment (DES or BA) regarding all-cause mortality (55.7% vs. 63.2%, p = 0.181), TVMI (13.8% vs. 18.6%, p = 0.215) and TLR (21.8% vs. 25.0%, p = 0.764). Median time between first and recurrent ISR was 270.8 days. Recurrent ISR were treated with DES in a comparable proportion as during first ISR (p = 0.075). Independent predictor of TLR is patient age (p = 0.034). The median follow-up duration was 5.1 years (75% CI 2.8; 8.5).

Conclusions

Clinical event rates after intervention of ISR located in SVG are high without statistically relevant differences regarding the type of treatment. However, further studies are needed.     

药物洗脱球囊的临床应用进展与展望

支架内再狭窄的最佳治疗手段目前尚不明确。我们围绕药物洗脱球囊的发展历史、有效性与安全性进行综述。文献主要来自2001年一2013年11月发表的随机对照试验及相关资料。结果显示,药物洗脱球囊有望成为支架内再狭窄、分又病变和小血管病变等多种情况的新的治疗手段。但其有效性和安全性仍需更多大样本、随机、对照临床试验的验证。     

药物洗脱支架与单纯球囊扩张术在急性心肌梗死小血管罪犯病变中应用的对照研究

目的探讨药物洗脱支架在急性心肌梗死小血管罪犯病变介入治疗中的安全性与有效性。方法共入选1 364例罪犯血管为小血管病变（靶血管直径≤2.5 mm）的急性心肌梗死并接受成功PCI治疗患者,根据治疗方案分为药物洗脱支架组（支架组,n=683）,单纯球囊扩张组（球囊扩张组,n=681）,对比两组患者随访8个月时的主要不良心脏事件的发生情况。结果支架组与球囊扩张组相比,总病死率显著减低（P=0.049）,其他不良心脏事件发生率两组间比较无统计学差异。结论急性心肌梗死小血管病变患者即使闭塞血管已再通,置入药物洗脱支架也是必要的。     

Alterations in reference vessel diameter following intracoronary stent implantation: Important consequences for restenosis based on percent diameter stenosis

The scaffolding effect of stent implantation has the potential to alter vascular geometry and dimensions. The objective of this study was to determine the impact of intracoronary stent implantation on the reference vessel diameter and the consequences of this on the frequency of restenosis applying the binary definitions of restenosis based on percent diameter stenosis. Routine angiographic follow-up was performed in 79/80 consecutive patients who had a single elective Palmaz-Schatz stent implanted in denovo lesions in native coronary arteries 6.5±3.4 mo after the index procedure. Complete quantitative angiographic follow-up was available in 78 (98%). The mean reference vessel diameter was 2.9±0.6 mm preprocedure, increased to 3.1±0.5 mm immediately poststent implantation and was 2.6±0.6 mm at follow-up (F = 6.45, P = 0.0001, ANOVA for repeated measures). In view of the varying reference vessel diameter, percent diameter stenosis postangioplasty and at follow-up was determined by two methods: (1) automatically by the quantitative coronary angiographic analysis system and (2) by expressing the minimal luminal diameter postangioplasty and at follow-up as a function of the original preprocedural reference vessel diameter. The restenosis rate was significantly greater for all definitions of restenosis when the minimal luminal diameter was determined as a function of the original preprocedure reference vessel diameter (e.g., 34% vs. 18% for the ?50% criterion, P = 0.018). Stent implantation results in alterations in reference vessel diameter, which have important consequences for the frequency of restenosis presented as a binary variable based on percent diameter stenosis. © 1995 Wiley-Liss, Inc.     

Coronary in-stent restenosis

Coronary stent implantation was considered as a way of coronary revascularization. It has been widely used in the treatment of coronary heart disease, but restenosis has become the main bottleneck to the development of stent technique. Despite drug-eluting stents used widely, restenosis rate is still about 10%. The incidence of restenosis was associated with intervention injury, patient factors, genetic types, nerve endocrine factors and so on. Overview above aspects is expected to provide some ideas for restenosis prevention and treatment.     

The evolving role of inflammatory biomarkers in risk assessment after stent implantation

The main adverse reactions to coronary stents are in-stent restenosis (ISR) and stent thrombosis. Along with procedural factors, individual susceptibility to these events plays an important role. In particular, inflammatory status, as assessed by C-reactive protein levels, predicts the risk of ISR after bare-metal stent implantation, although it does not predict the risk of stent thrombosis. Conversely, C-reactive protein levels fail to predict the risk of ISR after drug-eluting stent (DES) implantation, although they appear to predict the risk of stent thrombosis. Of note, DES have abated ISR rates occurring in the classical 1-year window, but new concern is emerging regarding late restenosis and thrombosis. The pathogenesis of these late events seems to be related to delayed healing and allergic reactions to polymers, a process in which eosinophils seem to play an important role by enhancing restenosis and thrombosis. The identification of high-risk individuals based on biomarker assessment may be important for the management of patients receiving stent implantation. In this report, we review the evolving role of inflammatory biomarkers in predicting the risk of ISR and stent thrombosis.