药物涂层球囊在下肢动脉硬化闭塞症支架内再狭窄治疗中的应用观察

目的 观察药物涂层球囊(DCB)在下肢动脉硬化闭塞症支架植入术后支架内再狭窄(ISR)治疗中的应用效果.方法 选取ISR患者30例(30条肢体),均接受DCB治疗.观察术后12个月靶血管初级通畅情况,治疗6、12月时Rutherford分级改善情况及治疗12月时临床驱动的靶病变血运重建(CD-TLR)和踝肱指数(ABI...     

准分子激光冠状动脉成形术联合药物涂层球囊在复发性支架内再狭窄病变中的运用探讨

目的 探讨准分子激光冠状动脉成形术联合药物涂层球囊的治疗策略在复发性支架内再狭窄病变中运用的安全性和疗效。方法 回顾性连续纳入2019年10月至2023年4月在中国人民解放军总医院第一医学中心采用准分子激光冠状动脉成形术联合药物涂层球囊进行治疗的27例复发性支架内再狭窄患者（30处病变）的临床资料进行分析。收集患者基线资料、冠状动脉造影及介入数据、住院期间并发症发生数据,并在术后1、3、6个月进行随访,记录重大临床事件发生情况。结果 27例患者,平均年龄（66.4±9.8）岁,共计30处（100%）病变均取得了手术成功和治疗成功,患者住院期间无急性心肌梗死、无冠状动脉穿孔及心脏压塞、无紧急的靶病变再次血运重建、无死亡。6个月的随访,无急性心肌梗死、无死亡发生,共2例患者（共2处病变）接受了靶病变再次血运重建（1例患者进行了重复的药物球囊扩张术,1例接受了冠状动脉旁路移植术）。结论 准分子激光冠状动脉成形术联合药物涂层球囊是治疗复发性支架内再狭窄安全、有效的治疗策略,但尚需更多的研究进一步验证。     

准分子激光消蚀联合药物涂层球囊治疗股腘动脉支架内再狭窄的临床疗效

目的评价准分子激光消蚀联合药物涂层球囊治疗股腘动脉支架内再狭窄的安全性和有效性。方法选择2016年11月～2018年12月在我中心接受准分子激光联合药物涂层球囊治疗股腘动脉支架内再狭窄的患者13例,男11例,女2例,平均年龄(71.46±9.23)岁,平均病程(9.2±4.0)个月。回顾性分析患者病变、围术期及手术前后临床症状改善等临床资料,患者术后1、3、6、12、18和24个月定期随访,采用Kaplan-Meier生存分析计算一期通畅率。结果 13例患者均完成定期随访,平均随访时间(8.62±8.27)个月,手术成功率100%,无穿刺点血肿及围术期死亡患者。13例患者术后临床症状均较术前改善,7例跛行患者跛行距离较术前增长50～500m,3例静息痛患者静息痛消失,术后踝肱指数较术前明显增加(0.81±0.15 vs 0.40±0.30,P0.05)。Kaplan-Meier生存分析计算一期通畅率显示,患者3和6个月的一期通畅率分别为92.3%和83.1%。结论准分子激光消蚀联合药物涂层球囊治疗股腘动脉支架内再狭窄的安全性及近中期疗效尚可,但仍需扩大样本量随访观察远期效果。     

冠脉支架内再狭窄防治研究进展

支架植入术目前已成为最常用的经皮冠状动脉介入治疗手术之一。然而 ,支架内再狭窄亦随之成为介入领域一大难题 ,近年来对其防治进行了大量研究。如药物治疗、药物涂层支架、血管内放疗及基因疗法等 ,本文作者就这些相关进展作一简述     

涂层支架对冠状动脉支架内再狭窄的防治

随着冠状动脉内支架植入术的广泛应用 ,支架内再狭窄 (in stentrestenosis,ISR)的问题也越来越突出 ,很多冠心病患者在接受支架治疗后的缺血事件复发与ISR有关。目前配合口服抗凝、抗血小板聚集剂及局部放射疗法等对ISR有所改善 ,但不能彻底解决问题。随着ISR病理生理机制的逐渐阐明 ,许多心血管病医生 ,尤其是介入心脏病医生寄希望于———涂层支架。即把能够抑制术后再狭窄的物质 (包括药物、抗凝剂、抗增殖剂、转基因载体、放射物质等 )与支架整合在一起以充分发挥局部作用。这一方法在防治研究中的地位日益受到重视 ,并且某些涂层…     

CYP2C19基因多态性对股腘动脉支架植入术后早期支架内再狭窄的影响

目的 阐明CYP2C19基因多态性与股腘动脉支架植入术后1年内支架内再狭窄的关系。 方法 选择2019年3月至 2021年3月于首都医科大学宣武医院血管外科首次接受股腘动脉支架植入术的118例患者为研究对象,患者术前3d及术后长期服用阿司匹林(100mg/d),并于术前3d至术后1年口服氯吡格雷(75mg/d)。使用聚合酶链反应(PCR)荧光探针法检测氯吡格雷代谢活性基因(CYP2C19*1,*2,*3,*17)的单核苷酸多态性分布及表达。术后使用彩色多普勒超声进行随访观察,以靶血管再狭窄率＞50%判断为再狭窄。采用SPSS 22.0统计软件进行数据分析。根据数据类型,分别采用方差分析或χ²检验进行组间比较。结果 入选的118例患者中,快代谢型(1/17,**17)1例、正常代谢型(1/1)48例、中代谢型(1/2,1/3,2/17,**17)52例和慢代谢型(2/2,***2/3)17例。正常代谢型再狭窄发生率为25.0%(12/48)、中代谢型再狭窄发生率为19.2%(10/52)、慢代谢型再狭窄发生率为53.0%(9/17)。慢代谢型与正常代谢型及中代谢型再狭窄发生率比较,差异均有统计学意义(P＜0.05)。结论 CYP2C19基因多态性可能是股腘动脉支架植入术后早期发生再狭窄的危险因素。慢代谢型再狭窄发生率较快代谢型与中代谢型显著增高。     

药物治疗预防下肢动脉支架成形术后再狭窄的临床观察

目的:观察抗血小板药物在下肢动脉支架成形术后预防再狭窄的效果。方法:收集2008年1月至2010年12月,下肢动脉血管内支架治疗的下肢动脉硬化闭塞症(ASO)患者74例,随机分为治疗组(36例),每日口服盐酸沙格雷脂+拜阿司匹林;对照组(38例)每日皮下注射低分子肝素1 w,并从术后第3天起口服华法令。观察术后6个月、12个月及18个月支架内闭塞、再狭窄以及临床出血。结果:两组患者基本特征比较,差异无统计学意义(P>0.05)。治疗组和对照组:18个月的再闭塞分别是1例和2例,两组比较,差异无统计学意义(P>0.05);支架内再狭窄分别是1例和8例,两组比较,差异有统计学意义(P﹤0.05);出血并发症分别是1例和4例,两组比较差异无统计学意义(P>0.05)。结论:盐酸沙格雷脂联合阿司匹林,可以预防下肢动脉支架成形术后的再狭窄,安全有效。     

复发性支架内再狭窄的研究进展

复发性支架内再狭窄(R-ISR)是指初次支架内再狭窄(ISR)病变经过成功介入治疗后再次发生同一部位的支架内狭窄。目前,ISR是国内外研究的重点,而对于反复ISR的研究较少,但随着越来越多的患者接受经皮冠状动脉介入治疗支架植入术治疗,且ISR发生率无降低趋势,治疗过的ISR患者存在再次发生ISR的风险,所以R-ISR是一个不容忽视的问题。R-ISR的发生发展与ISR的发生发展因素相似,但却不尽相同。最近的研究探索了各种R-ISR的预测因素和治疗策略。现对R-ISR的发生率、发生机制、危险因素、腔内影像学评估、治疗选择和现有知识的空白等方面进行讨论。     

球囊扩张与支架植入术治疗股浅动脉狭窄闭塞病变的中远期疗效及其影响因素

目的探讨球囊扩张(PTA)与支架植入术治疗股浅动脉狭窄闭塞病变的中远期疗效及其影响因素。方法选取2010年7月至2012年7月该院收治的股浅动脉狭窄闭塞病变患者80例(80支),根据泛大西洋协作组织(TASC)分型将其分为A型12支、B型25支、C型23支、D型20支,其中A型+B型中行PTA者25例,行PTA联合支架植入术者12例;C型和D型者中行PTA者29例,行PTA联合支架植入术者14例,观察术后1~3年一期通畅率及复发情况,并应用Logistic回归分析中远期疗效的危险因素。结果 PTA联合支架植入者术后1~3年的一期通畅率显著高于PTA者(P<0.05),第2、3年C型+D型者PTA+支架植入术显著优于A型+B型,第2年C型+D型者PTA显著高于A型+B型(P<0.05);随访发现,28例患者出现下肢缺血症状复发,其中10例为A型+B型,18例为C型+D型;Logistic多因素分析显示:血糖和TASC是影响中远期疗效的危险因素(P<0.05)。结论球囊扩张联合支架植入术治疗股浅动脉下肢闭塞中远期疗效较好,血糖和TASC分型是影响疗效的危险因素。     

Long-term angiographic follow-up after successful repeat balloon angioplasty for in-stent restenosis

BACKGROUND: Coronary stent implantation is associated with improved angiographic short-term and mid-term clinical outcome. However, restenosis rate still remains between 20 and 30%. HYPOTHESIS: The purpose of the study, performed as a prospective angiographic follow-up to detect restenosis, was to evaluate the immediate and the 6-month angiographic results of repeat balloon angioplasty for in-stent restenosis. METHODS: From April 1996 to September 1997, 335 stenting procedures performed in 327 patients underwent prospectively 6-month control angiography. Of the 96 lesions that showed in-stent restenosis (> 50% diameter stenosis) (29%), 72 underwent balloon angioplasty. RESULTS: The primary success rate was 100%. Follow-up angiogram at a mean of 6.9 +/- 2.4 months was obtained in 54 patients. Recurrent restenosis was observed in 24 of the 55 stents (44%). Repeat intervention for diffuse and body location in-stent restenosis before repeat intervention was associated with significantly higher rates of recurrent restenosis (p < 0.001 and p < 0.05, respectively). Of the 19 patients who underwent further balloon angioplasty (100% success rate), coronary angiography was performed in 18 (95%) at a mean of 8.2 +/- 2.0 months and showed recurrent restenosis in 12 patients (67%). Further repeat intervention for diffuse and severe in-stent restenosis before the second repeat intervention was associated with significantly higher rates of further recurrent restenosis (p < 0.05 and p < 0.005, respectively). CONCLUSIONS: Although balloon angioplasty can be safely, successfully, and repeatedly performed after stent restenosis, it carries a progressively high recurrence of angiographic restenosis rate during repeat 6-month follow-ups. The subgroup of patients with diffuse, severe, and/or body location in-stent restenosis proved to be at higher risk of recurrent restenosis.     

准分子激光斑块消蚀术在膝下动脉硬化闭塞症治疗中的效果分析

目的]探讨准分子激光斑块消蚀术(ELA)治疗膝下动脉粥样硬化闭塞症的临床疗效及安全性,以期为膝下动脉硬化闭塞症患者腔内治疗方案提供更多选择。 [方法]回顾性收集2019年12月─2021年12月新疆维吾尔自治区人民医院血管外科收治的50例(计50条肢体)膝下动脉硬化闭塞症患者的临床资料,按照治疗方法的不同分为ELA组(n＝25)和普通球囊扩张术(POBA)组(n＝25),比较两组患者的临床特征、围术期有无严重手术并发症、靶血管术后随访期间一期通畅率、术后踝臂指数(ABI)改善情况、视觉模拟量表(VAS)评分、保肢(趾)率。 [结果]两组手术成功率均为100%,围术期均无严重并发症,两组患者治疗后ABI和VAS较治疗前均显著改善,且术后3天、术后6月ELA组ABI高于POBA组,差异有统计学意义(P＜0.05);术后6月ELA组VAS评分低于POBA组,差异有统计学意义(P＜0.05);随访期内ELA组一期通畅率及保肢(趾)率均高于POBA组(P＜0.05)。 [结论]ELA治疗膝下动脉硬化闭塞症是安全可行的,且初步显示近期疗效优于POBA,为膝下动脉病变腔内治疗提供了更多的选择。     

Malignant restenosis after primary successful excimer laser coronary angioplasty

In a series of 20 coronary excimer laser angioplasties, two patients presented with a peculiar type of malignant restenosis 6 and 8 weeks after a successful laser angioplasty procedure. One patient had a successful recanalization of an occluded left anterior descending (LAD) coronary artery and the second patient had a successful angioplasty of a subtotal proximal stenosis of the left anterior descending coronary artery. After the procedure, no ischemia could be demonstrated by exercise ECG and thallium scintigraphy. Both patients were free of angina until the sudden development of nocturnal angina several hours before reangiography, which showed subtotal restenosis in both cases. One patient had a mammaria graft on the LAD and the second patient underwent a successful balloon angioplasty. This uncommon sudden and malignant development of restenosis seems to be related to the excimer laser angioplasty procedure and warrants some caution with the indiscriminative use of this new angioplasty procedure.     

定向斑块旋切治疗下肢股浅动脉硬化闭塞症

目的探讨定向斑块旋切治疗下肢股浅动脉硬化闭塞症的临床效果。方法选择下肢股浅动脉硬化闭塞症患者42例,随机分为观察组和对照组,各21例。观察组采用TurboHawk定向斑块旋切系统治疗,对照组采用球囊扩张及支架植入术治疗。收集数据,观察比较两组的治疗效果。结果观察组术后临床症状、踝臂指数改善情况与对照组差异无显著性(P>0.05)。观察组术后并发症发生率低于对照组,差异有统计学意义(P<0.05)。术后随访,观察组术后再狭窄率与对照组差异无显著性(P>0.05)。结论定向斑块旋切在治疗下肢股浅动脉硬化闭塞症中可以获得与球囊扩张、支架植入相似的通畅率,是一种安全、实用、有效的方法。     

Intravascular ultrasound imaging after excimer laser angioplasty

To help elucidate the mechanism of excimer laser coronary angioplasty (ELCA), intra-vascular ultrasound (IVUS) imaging was performed in 19 of 29 patients who were treated with ELCA. The results were compared with a non-randomized control group of 18 patients who had IVUS studies both before and after PTCA alone. After ELCA alone, lumen diameter (1.9 × 1.7 mm) and lumen cross-sectional area (CSA) (2.9 mm²) by IVUS were not significantly different from baseline values in the patients before PTCA alone (2.1 × 1.8 mm, 3.2 mm²). After balloon dilatation in the laser treated group, lumen diameter (2.5 × 2.1 mm) and lumen CSA (4.9 mm²) were significantly greater than those post ELCA alone. However, there was no difference in lumen CSA or atheroma CSA in the group treated with excimer laser plus balloon dilatation vs. these measurements in the group treated with PTCA alone. ELCA does not ablate a large amount of atheroma (9% reduction) but creates a pathway to permit easier passage of a PTCA balloon. These quantitative and morphologic results may help explain why the restenosis rate with ELCA is similar to PTCA alone. © 1994 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.     

Differences in restenosis propensity of devices for transluminal coronary intervention: A quantitative angiographic comparison of balloon angioplasty, directional atherectomy, stent implantation and excimer laser angioplasty

With the increasing clinical application of new devices forpercutaneous coronary revascularization, maximization of theacute angiographic result has become widely recognized as akey factor in maintained clinical and angiographic success.What is unclear, however, is whether the specific mode of actionof different devices might exert an additional independent effecton late luminal renarrowing. The purpose of this study was toinvestigate such a difference in the degree of provocation ofluminal renarrowing (or ‘restenosis propensity’)by different devices, among 3660 patients, who had 4342 lesionssuccessfully treated by balloon angioplasty (n=3797), directionalcoronary atherectomy (n= 200), Palmaz-Schatz stent implantation(n= 229) or excimer laser coronary angioplasty (n= 116) andwho also underwent quantitative angiographic analysis pre- andpost-intervention and at 6-month follow-up. To allow valid comparisonsbetween the groups, because of significant differences in coronaryvessel size (balloon angioplasty=2.62±0.55 mm, directionalcoronary atherectomy= 3.28±0.62 mm, excimer laser coronaryangioplasty= 2.51±0.47 mm, Palmaz-Schatz=3.01±0.44mm;P<0.0001), the comparative measurements of interest selectedwere the ‘relative loss’ in luminal diameter (RLoss=losslvessel size) to denote the restenosis process, and the‘relative lumen at follow-up’ (RLfup=minimal luminaldiameter at follow uplvessel size) to represent the angiographicoutcome. For consistency, lesion severity pre-intervention was representedby the ‘relative lumen pre’ (RLpre=minimal luminaldiameter prelvessel size) and the luminal increase at interventionwas measured as ‘relative gain’ (relative gain=gainl vessel size). Differences in restenosis propensity betweendevices was evaluated by univariate and multivariate analysis.Multivariate models were constructed to determine relative lossand relative lumen at follow-up, taking account of relativelumen pre-intervention, lesion location, relative gain, vesselsize and the device used. In addition, model-estimated relativeloss and relative lumen at follow-up at given relative lumenpre-intervention relative gain and vessel size, were comparedamong the four groups. Significant differences were detectedamong the groups both with respect to these estimates, as wellas in the degree of influence of progressively increasing relativegain, on the extent of renarrowing (relative loss) and angiographicoutcome (relative lumen at follow-up), particularly at higherlevels of luminal increase (relative gain). Specifically, lesionstreated by balloon angioplasty or Palmaz-Schatz stent implantation(the predominantly ‘dilating’ interventions) wereassociated with more favourable angiographic profiles than directionalatherectomy or excimer laser (the mainly ‘debulking’interventions). Significant effects of lesion severity and location,as well as the well known influence of luminal increase on bothluminal renarrowing and late angiographic outcome were alsonoted. These findings indicate that propensity to restenosis afterapparently successful intervention is influenced not only bythe degree of luminal enlargement achieved at intervention,but by the device used to achieve it. In view of the clinicalimplications of such findings, further evaluation in largerrandomized patient populations is warranted.     

Mechanism of cutting balloon angioplasty for in-stent restenosis: an intravascular ultrasound study.

We investigated by intravascular ultrasound (IVUS) the mechanism of action of cutting balloon (CB) angioplasty in patients with in-stent restenosis. Seventy-one consecutive restenotic lesions of 66 patients were studied by quantitative coronary angiography (QCA) and IVUS before, immediately after, and, in 20 cases, at 24-hr time interval after CB. CB was selected according to 1:1 CB-to-stent ratio and inflated at 8 atm for 60-90 sec. Both IVUS planar and volumetric (Simpson's rule, 25 patients) analysis were carried out. IVUS measurements included external elastic membrane area (EEMA), stent area (SA), minimal lumen area (MLA), and restenosis area (RA). Following CB, QCA analysis showed increase of minimal lumen diameter (1.17 +/- 0.46 vs. 2.45 +/- 0.51 mm; P < 0.0001) and decrease of diameter stenosis (64% +/- 13% vs. 21% +/- 9%; P < 0.0001). IVUS measurements showed a significant increase of MLA (2.18 +/- 0.80 vs. 7.31 +/- 1.8 mm(2); P < 0.0001), SA (9.62 +/- 2.6 vs. 10.7 +/- 2.75 mm(2); P < 0.0001), and EEMA (17.27 +/- 5 vs. 18.1 +/- 5 mm(2); P < 0.0001) and a decrease of RA (7.43 +/- 2.63 vs. 3.45 +/- 1.39 mm(2); P < 0.0001). No significant change was observed in the original plaque + media area (7.65 +/- 3 vs. 7.38 +/- 2.9 mm(2); P = NS). Thus, of the total lumen enlargement (5.13 +/- 1.85 mm(2)), 23% was the result of increase in mean SA, whereas 77% was the result of a decrease in mean RA. These changes were associated with a 5% increase in EEMA. IVUS volumetric changes paralleled planar variations. Angiographic and IVUS changes were well maintained at 24 hr. CB enlarges coronary lumen mainly by in-stent tissue reduction associated with a moderate degree of additional stent expansion. Favorable QCA and IVUS acute results are maintained at 24 hr.     

Treatment of coronary in-stent restenosis: a systematic review

Coronary stent implantation has significantly improved percutaneous coronary intervention and enabled the management of early complications of plain balloon angioplasty. However, a new complication has accompanied these improvements: in-stent restenosis (ISR) arising from neointimal hyperplasia. ISR after coronary angioplasty is currently one of the main limitations of this method, leading to the recurrence of exertional angina pectoris or acute coronary syndromes. The clinical incidence of ISR after bare-metal stent (BMS) implantation is approximately 20%–35%. The use of drug-eluting stents (DES) has led to a further decrease in the occurrence of ISR to 5%–10%. Evidence resulting from controlled clinical studies suggests that DES and drug-eluting balloon catheters (DEB) provide the best clinical and angiographic results in the treatment of ISR. We undertook a systematic review of the pathophysiology, diagnostics and treatment options for BMS- and DES-ISR. We discuss recent randomised studies, comparing different DES or DEB used for BMS or DES-ISR treatment, as well as the use of new biovascular scafolds and the topic of scafold restenosis.     

Directional coronary atherectomy vs. rotational atherectomy for the treatment of in-stent restenosis of native coronary arteries.

Management of in-stent restenosis has become a significant challenge in interventional cardiology. Since the mechanism of in-stent restenosis is predominantly intimal hyperplasia, debulking techniques have been used to treat this condition. This study is a nonrandomized comparison of the immediate and long-term results of directional coronary atherectomy (DCA; n = 58) vs. high-speed rotational atherectomy (ROTA; n = 61) for the treatment of in-stent restenosis of native coronary arteries. There were no in-hospital deaths, Q-wave myocardial infarctions, or emergency coronary artery bypass surgery in either group. DCA resulted in a larger postprocedural minimal luminal diameter of (2.57 +/- 0.51 vs. 2.14 +/- 0.37 mm; P < 0.0001) and a larger acute gain (1.83 +/- 0.52 vs. 1.42 +/- 0.48 mm; P < 0.0001). Furthermore, 12-month clinically indicated target lesion revascularization (39% vs. 21%; P = 0.02) and long-term follow-up MACE (44% vs. 28%; P = 0.03) was greater in the ROTA group. The present study suggests that DCA appears to be superior to ROTA for the treatment of in-stent restenosis of native coronary arteries. Compared to ROTA, the debulking effect of DCA leads to a larger postprocedure minimal luminal diameter, and a lower incidence of subsequent target lesion revascularization and MACE.