正确应用冠状动脉内支架植入术

正确应用冠状动脉内支架植入术高润霖冠状动脉内支架植入术（ｉｎｔｒａｃｏｒｏｎａｒｙｓｔｅｎｔｉｎｇ）于１９８７年由Ｓｉｇｗａｒｔ首先应用于临床，是近年来冠心病介入性治疗最重要的进展之一。现在用于临床的支架已有十数种，植入成功率达９５％以上，重要并发症...     

冠状动脉内支架植入术治疗急性心肌梗死的临床应用

目的：评价冠状动脉内支架治疗急性心肌梗死（ＡＭＩ）的效果。方法：对４８例植入支架的ＡＭＩ连续病例进行回顾性分析。结果：心肌梗死相关血管为：前降支３３例，右冠状动脉８例，回旋支４例，左主干１例以及大隐静脉桥２例。４８例患者共植入５７只支架，其中３４例因球囊扩张后结果不理想，１２例因非闭塞性夹层，２例因闭塞性夹层。支架植入成功率为９３８％，术后残余狭窄降至（２４±７１）％。院内严重并发症３例，其中１例（２１％）死亡，２例（４２％）行急诊冠状动脉旁路移植术。对无院内并发症的４５例患者随访１０．１±７２个月，其中３例失访，出院后２例发生再狭窄和１例有慢性充血性心力衰竭，无其它心脏事件发生。结论：本研究结果表明ＡＭＩ时冠状动脉内植入支架成功率高，并发症少，短期预后良好     

冠状动脉内Palmaz－Schatz支架植入术70例分析

为评价冠状动脉内Ｐａｌｍａｚ－Ｓｃｈａｔｚ支架的临床效果，我们回顾性总结分析了７０例冠心病患者７４支冠状动脉血管８０个Ｐａｌｍａｚ－Ｓｃｈａｔｚ支架植入的临床成功率、并发症及远期疗效。结果：ＤｅＮｏｖｏ支架植入６３个，Ｓｕｂｏｐｔｉｍａｌ支架植入１１个，Ｂａｉｌ－ｏｕｔ支架植入４个，再狭窄病变支架植入２个。左前降支３７处病变植入４１个支架，左回旋支１１处病变植入１１个支架，右冠状动脉２５处病变植入２７个支架，１处病变植入１个支架。支架植入的成功率为９８．７％。术中１例ＳＶＧ支架植入术中近端血管血栓形成。住院期间无亚急性支架血栓形成或严重出血性并发症。术后３～２４个月３０例患者共３３个支架接受冠状动脉造影随访，６例６个支架节段血管有再狭窄，再狭窄率为１８．７％。结果提示：冠脉内Ｐａｌｍａｚ－Ｓｃｈａｔｚ支架是一种安全有效的介入性治疗技术，其成功率高，并发症率低，并可能有降低或延缓血管再狭窄发生的作用     

冠状动脉内支架植入术在冠心病治疗中的应用

报道６８例冠心病患者８０支血管病变植入１１８个支架，植入成功率为９２．１％。其中不稳定心绞痛者占５０％，既往有心肌梗塞史者占４６％，多支病变者占６２．４％，Ｂ２型以上病变占６６．６％，因ＰＴＣＡ术后不良结果而植入支架的病变占２７．５％（２２／８０），因术后急性并发症者１７．５％（１４／８０），Ｄｅｎｏｖｏ病变占５５％（４４／８０）。狭窄程度由术前的８５．５％±１２．９％减至术后的５．８％±１１．４％。术后４周～１年间，６０例患者（８８．２％）症状缓解，６例（８．８％）心绞痛复发，其中４例（５．８％）经冠状动脉造影证实支架部位再狭窄，术后２个月内死亡２例（２．９％），术后１周内发生无Ｑ波心肌梗塞者１例     

经颈静脉肝内门体支架分流术的并发症及其防治

目的探讨经颈静脉肝内门体支架分流术（ｔｒａｎｓｊｕｇｕｌａｒｉｎｔｒａｈｅｐａｔｉｃｐｏｒｔｏｓｙｓｔｅｍｉｃｓｔｅｎｔ－ｓｈｕｎｔ，ＴＩＰＳＳ）的并发症及其防治。方法分析３１例行ＴＩＰＳＳ术患者的情况。结果手术成功率９６７％，术后近期并发症有转氨酶升高（１００％）、术后炎性反应（３２２％）、胆道出血（６４％）、术后死亡（６４％）、腹膜炎（３２％）。术后远期并发症有胆红素升高（５４８％）、白蛋白下降（２９０％）、支架狭窄或阻塞（１９３％）、低蛋白水肿（１６１％）、肝性脑病（１６１％）、合并肝癌（６４％）。结论ＴＩＰＳＳ术应严格掌握适应证并应严密注意术后并发症的防治。     

冠状动脉支架治疗冠状动脉开口病变的近远期结果分析

目的：评价冠状动脉支架治疗冠状动脉开口病变的近远期临床效果。方法：对２８例冠状动脉开口病变的病人,按常规标准方法进行冠状动脉支架植入术,并在术后６个月接受临床和（或）冠状动脉造影随访。结果：支架植入的技术和临床成功率均为１００％,无死亡、急性心肌梗塞及急诊冠状动脉旁路移植术并发症。支架植入手术前、后血管直径狭窄程度分别为（８７±９）％与（－２±５）％（Ｐ＜０．０１）;管腔最小开放直径分别为０．４７±０．３１ｍｍ与３．１６±０．３７ｍｍ（Ｐ＜０．０１）。临床随访心绞痛复发率为２０％（４／２０）,９例病人接受了冠状动脉造影随访,３例发生了再狭窄。结论：冠状动脉支架植入术治疗冠状动脉开口病变是安全有效的,成功率高且并发症发生率较低。     

雷帕霉素涂层支架治疗老年人冠心病的疗效及再狭窄的随访分析

目的 观察雷帕霉素涂层冠状动脉Cypher支架治疗老年冠心病患者的临床疗效及再狭窄情况。方法 2002年11月至2005年5月在我院心导管室接受Cypher支架治疗的328例60岁以上的老年冠心病患者，观察术后即刻效果，随访6个月记录心脏性死亡、心肌梗死、再次血管重建事件，并进行冠状动脉造影复查。328例中，ST段抬高的急性心肌梗死66例，非ST段抬高的急性心肌梗死21例，不稳定心绞痛149例，稳定型心绞痛92例。结果 支架植入成功率99．1％（325／328），住院期间无死亡。随访6个月出现急性和亚急性血栓各1例，晚期血栓致心肌梗死2例，心力衰竭死亡1例，进行血管重建术7例。住院其间主要心脏不良事件发生率0．6％（2／328），6个月心脏不良事件发生率3．7％（12／328）。术后6个月84例患者冠状动脉造影复查显示，再狭窄率为8．3％（7／84），支架内为2．4％（2／84），靶病变重建率为5．9％（5／84）。结论 应用Cypher支架治疗老年人冠心病是安全和有效的，主要心脏不良事件发生率低，支架内再狭窄率和靶病变重建率明显低于普通金属支架。     

冠状动脉内支架植入术20例初步报告

经皮冠状动脉腔内血管成形术（ＰＴＣＡ）已被公认为治疗冠心病的有效方法之一，但术中和术后易发生难以预测的急性血管闭塞致心肌梗塞或猝死等重大并发症，术后再狭窄率高。冠状动脉内支架植入术（Ｓｔｅｎｔｉｎｇ）可明显减少ＰＴＣＡ的并发症和术后再狭窄。本文报告２...     

冠状动脉内支架应用的初步体会

自１９９４年４月至１９９６年２月对６３例冠心病患者施行６８次经皮冠状动脉腔内成形术（ＰＴＣＡ）中的６９支冠状动脉植入８３个支架。其中Ｃ型病变占多数。支架全部植入成功。５例ＰＴＣＡ术中急性闭塞者使用支架无死亡、心肌梗塞和紧急冠脉旁路术。随访中１例术后４天发生猝死，１例术后５天心肌梗塞，１２例术后２～６个月胸痛复发（１９．７％）。由于支架的使用，扩大了ＰＴＣＡ的适应证，减少了ＰＴＣＡ的并发症     

冠状动脉内植入金属支架治疗冠心病的体会

１９９４年１０月至１９９６年１２月，在７６例患者的８５支病变冠脉中植入不同种类支架９５枚，ｂａｉｌｏｕｔ植入１８枚，ｓｕｂｏｐｔｉｍａｌ植入４５枚，ｄｅｎｏｖｏ植入３２枚，植入左前降支５９枚，右冠状动脉２３枚，回旋支１２枚，第一钝缘支１枚，植入成功率９７９％，临床成功率９５８％。支架植入后即刻造影示：残余狭窄０～１０％，血流ＴＩＭＩⅢ级。结果表明：冠脉内植入支架是目前处理ＰＴＣＡ术中明显内膜撕裂和急性血管关闭的最有效方法，是对抗ＰＴＣＡ后病变血管弹性回缩和预防术后再狭窄的有效手段。     

老年冠心病患者冠状动脉内支架置入术的疗效评价

目的　评价老年冠心病患者冠状动脉内支架置入术的临床疗效和安全性。方法　对比分析 49例老年 (86支血管 )和 6 1例老年前期 (98支血管 )冠心病患者冠状动脉内支架置入术的结果。结果　老年组冠状动脉病变严重、复杂病变较多 ,在复杂病变内置入支架比率高于老年前期组 ;手术即刻成功率和临床成功率均为 98.0 % ;术前病变平均狭窄率为 (94.5± 5 .6 ) % ,术后残余狭窄率为 (7.4± 8.2 ) % ;因球囊扩张不理想置入支架的为 45 .0 % ,因经皮冠状动脉腔内成形术 (PTCA)并发夹层或濒临闭塞而置入支架的比率高于老年前期组。出现严重并发症 1例(2 .0 % )。结论　老年冠心病患者冠状动脉内支架置入术成功率高 ,并发症发生率低。     

冠状动脉内支架置入术治疗老年患者复杂冠状动脉病变

目的　探讨经皮冠状动脉腔内支架置入术治疗老年患者复杂性冠状动脉病变的疗效及安全性。方法对 4 5例冠心病患者施行冠状动脉内支架置入术 ,病变血管共 5 8支 ,B型病变 4 9处 ,C型病变 1 3处 ,慢性完全闭塞病变 4处 ,共置入支架 64只。置入左前降支 2 7只 ,左回旋支 1 3只 ,右冠状动脉 2 4只。De Novo支架置入 4 4只 ,Suboptimal支架置入 1 5只 ,Bail-out支架置入 3只 ,再狭窄病变支架置入 2只。结果　术后经冠状动脉造影证实疗效满意 ,支架置入成功率为 98.4 %。术前病变平均直径狭窄 (86.5± 7.8) % ,术后残余直径狭窄 (5 .1± 1 0 .3 ) %。住院期间无亚急性支架血栓形成。 1例出现假性动脉瘤 ,1例在术中及术后出现三次心室颤动 ,4例患者术后心绞痛复发 ,复查冠状动脉造影发现了 3个支架节段血管有再狭窄。结论　对于老年冠心病患者复杂冠状动脉病变 ,经皮冠状动脉内支架置入术是一种安全有效的介入性治疗技术 ,其成功率高 ,并发症发生率低     

Coronary artery stenting in active duty soldiers

The treatment of coronary artery disease in young patients must take into account the long-term success of the treatment modality and the possibility of repeat interventions. Elective placement of Palmaz-Schatz coronary stents have been shown to reduce six month restenosis rates in discrete, de novo lesions in native coronary arteries albeit at a significant risk of bleeding and vascular complications. The present study was undertaken to evaluate the role of intracoronary stenting in young active duty soldiers. Between March 1988 and December 1994, fifteen active duty soldiers (age 37 to 53 years) underwent elective placement of one or more Palmaz-Schatz coronary stents at our institution. Angiographic success was 100% with no complications (acute/subacute closure, bleeding requiring transfusion, vascular repair, myocardial infarction, death, or in-hospital coronary artery bypass grafting). Six month angiographic follow-up is available in 13 patients (87%) with angiographic restenosis in one patient (8%) and no target vessel revascularization at six months. Clinical follow-up is available on all patients at a mean of 33 months (range 6-65) after the procedure. There was one death (7%) attributed to progression of coronary disease in another vessel and one patient (7%) who underwent target vessel revascularization for silent ischemia at 24 months after the procedure. These preliminary encouraging results suggest there may be a significant role for intracoronary stenting in active duty soldiers with coronary artery disease.     

Late Clinical Outcome after Intracoronary Palmaz-Schatz Stenting with High Pressure Balloon Dilation without Anticoagulation

In recent studies, the technique of high pressure balloon dilation for stent optimization has been shown to improve procedural success and to reduce subacute closure after stenting. The late clinical outcome, however, is still uncertain after stenting with high pressure balloon dilation. Therefore, we evaluated the effect of high pressure balloon dilation on the subsequent clinical course in patients after intracoronary stenting. One-hundred ninety patients with 197 lesions were treated with Palmaz-Schatz stent implantation. Intracoronary stenting without high pressure balloon dilation and with anticoagulation was performed in 55 patients with 55 lesions (phase 1), whereas intracoronary stenting with high pressure balloon dilation, without anticoagulation was done in 135 patients with 142 lesions (phase 2). We compared the angiographic and clinical results immediately and at follow-up in both phase 1 and phase 2. Coronary angiography was repeated at 6 months in 147 patients (79%) and 150 lesions (77%). The overall incidence of angiographic restenosis was 24% (31% in phase 1 and 21% in phase 2). Angiographic restenosis occurred in 18% of elective stenting on de novo lesions (23% in phase 1 and 15% in phase 2). The target lesion revascularization rate was 19% (26% in phase 1 and 16% in phase 2). The restenosis rate was significantly reduced with high pressure balloon dilation in the infarct-related artery and for a stent size of 3 4.0 mm (p < 0.05). In conclusion, intracoronary stenting using high pressure balloon dilation technique without anticoagulation has good immediate results, negligible stent thrombosis and may have a tendency towards lower rates of restenosis.     

Balloon embedded stenting: A novel technique for percutaneous coronary intervention of bifurcation lesions,experience in Indian population

BackgroundBifurcation lesions account for 15–20% of interventions carried out in a catheterization laboratory. Several techniques have been described for treating bifurcation lesions of which culotte and T-stenting and protrusion(TAP) are commonly used. Both these techniques involve recrossing the struts of primary stent, failing which the flow in second branch which can be impaired and lead to catastrophic events. In this study, we describe a novel balloon embedded stenting technique which can be incorporated with traditional culotte or TAP technique and facilitates conversion to bail out crush in case of such an event.Methods and results28 patients who were treated with balloon embedded stenting for bifurcation lesions were included in the study. Angiographic and procedural success were achieved in all the patients. Primary stent could not be recrossed in 1 patient, who was successfully converted to bail out crush using the technique. There were no complications during the procedure. Mean fluoroscopy time and contrast volume was similar to that of conventional culotte and TAP.ConclusionThe present study suggests that incorporation of balloon embedded stenting into traditional culotte or TAP technique is achievable and can facilitate conversion to bail out crush when required.     

Percutaneous lower extremity arterial interventions using primary balloon angioplasty versus cryoplasty: a randomized pilot trial

BackgroundTarget lesion revascularization (TLR) with primary percutaneous transluminal angioplasty (PTA) versus cryoplasty (CRYO) in the treatment of de novo femoropopliteal disease has not been well defined in randomized trials.MethodsIn this prospective, 2-center randomized trial of PTA vs CRYO of femoropopliteal arteries, the primary endpoint of TLR was evaluated at 6 months. Secondary endpoints included the rate of bail out stenting because of suboptimal acute angiographic results (defined as a residual narrowing of ≥30% or type C or higher dissection) and target vessel revascularization (TVR). Major adverse events including death and amputations were recorded. A two sample t test was used to compare the two groups on the continuous variables. For categorical variables, cross tabular analysis was conducted with nonparametric tests (Chi Square and Fisher's Exact) used to test for significant differences.ResultsA total of 40 patients were included in the study. Of these 20 patients (24 vessels) were included in the PTA arm and 20 patients (26 vessels) in the CRYO arm. CRYO was performed at a predefined automated pressure of 8 atm. PTA was performed at a mean pressure of 9.57±1.34 atm (P=.001 compared to CRYO). TLR (10.5% vs. 15%, P=NS) and TVR (10% vs 25%, P=NS) were statistically similar between the PTA arm compared to the CRYO arm respectively. Bail out stenting was performed in 10/24 (41.7%) of vessels in the PTA arm and 10/26 (38.5%) of patients in the CRYO arm (P=NS).ConclusionIn this pilot randomized study of de novo femoropopliteal lesions, CRYO and PTA had the same TLR and TVR at 6 months in treating femoropopliteal de novo lesions. Also, bail out stenting was statistically similar between the 2 groups. Larger studies are needed to confirm these results.     

冠状动脉内支架植入术治疗老年冠心病

目的　 评价冠状动脉内支架植入术治疗冠心病的临床应用价值。　 方法　对 112例 16 8支冠状动脉病变内植入 193只支架。植入左前降支 82只 ,右冠状动脉 6 8只 ,左回旋支 43只。　 结果　支架植入后经冠状动脉造影证实狭窄消失 ,效果良好 ,其中 3 5例急性心肌梗死患者由于急诊植入支架后 ,病情转危为安。 112例患者全部植入成功 ,无 1例发生重要的并发症。　 结论 　冠状动脉内支架植入术治疗冠心病是安全可靠、效果好的介入性治疗技术 ,有良好的应用价值。     

The MUST Trial: Acute Results and Six-Month Clinical Follow-up

Coronary stenting is now an established technique which is associated with improved acute and long-term results and prevents restenosis in comparison to balloon angioplasty in selected patients. However, subacute thrombosis and vascular complications associated with conventional anticoagulant therapy (warfarin for one month, with 4D5 days of IV heparin) remain of concern. By means of a prospective, multi-center registry, we sought to demonstrate that the use of ticlopidine and aspirin as the sole post-stenting treatment was safe by reducing bleeding complications without increasing the risk of major cardiac events. A total of 260 patients with stable and unstable angina and a short, single de novo lesion were enrolled in this registry. Successful stent deployment without ultrasound guidance was achieved in 259 patients. All patients were treated with aspirin 3 100 mg daily for 6 months and ticlopidine 250 to 500 mg daily according to body weight for 1 month. The primary endpoint was safety, defined by the occurrence of death, myocardial infarction (MI), coronary bypass surgery (CABG) or repeat angioplasty (PTCA) within 30 days of the procedure, in addition to subacute stent thrombosis and bleeding and vascular complications within 30 days of the intervention. During hospital stay there were no deaths; 8 patients experienced MI, 1 patient underwent urgent CABG and 4 patients had repeat PTCA. Therefore, the clinical success rate was 96.0%. Bleeding complications requiring blood transfusion or vascular repair occurred in 2 patients. Treatment was discontinued in one patient because of mild reversible leucopenia. At 6 months, event-free survival was 90.3%. Major events involved CABG in 4 patients and a second PTCA at the same site in 14 patients. The target vessel revascularization rate at 6 months was 6.2%. This study demonstrates that Palmaz-Schatz stenting of single de novo lesions with length < 15 mm, without ultrasound guidance but with the routine use of high-pressure balloon dilatation, and with ticlopidine and aspirin as the sole treatment post intervention, is feasible and safe both in terms of clinical outcome and hematologic adverse side-effects. This registry demonstrates that six-month event-free survival exceeding 90% can be achieved.     

Is Palmaz-Schatz stenting effective for second restenosis?

The long-term outcome after coronary stent placement in restenotic lesions after balloon angioplasty (percutaneous transluminal coronary angioplasty: PTCA)may be less favorable compared to stent treatment of de novo lesions, but the role of stents in restenotic lesions after 2 prior PTCA procedures is unknown. Elective Palmaz-Schatz stent placement was performed in 124 consecutive patients. Stents were placed in 70 patients(56%) in the native coronary arteries for de novo lesions(de novo group), in 33 patients (27%)for restenotic lesions after one prior PTCA(restenosis group), and 21 patients(17%)for restenotic lesions after 2 prior PTCA(second restenosis group). The 3 groups were well matched with respect to lesion type, lesion length, and reference diameter. Stent size was similar in the 3 groups. Follow-up angiograms taken about 6 months after stenting were available for all patients. The restenosis rate after stenting was similar for the de novo group and restenosis group(19% vs 27%, NS). The second restenosis group tended to have a higher restenosis rate after stenting than the de novo group(38% vs 19%, p = 0.06). The frequency of diffuse type in-stent restenosis of the second restenosis group tended to be higher than that of the de novo group(63% vs 13%, p = 0.08). Our results suggest that the restenosis rate after stenting was higher in patients with repeated restenosis. Therefore, other therapeutic methods should be considered.     

Direct stenting with the Bx VELOCITY™ balloon-expandable stent mounted on the Raptor ® rapid exchange delivery system versus predilatation in a European randomized Trial: the VELVET trial

AIMS: This study examined the six-month angiographic results of direct coronary stenting, and compared the nine-month safety, efficacy and cost of this strategy versus stenting after balloon predilatation. METHODS: In phase I of VELVET, 122 patients (mean age = 62.3 &#45 10.1 years, 77% male, 11% with diabetes) with angina pectoris or myocardial ischemia resulting from a single de novo 51% to 95% coronary stenosis underwent direct stenting. The endpoints of phase I included angiographic findings and rates of major adverse cardiac events up to six months of follow-up. In phase II, 401 patients (mean age = 61.3 &#45 10.8 years, 79% male, 16% with diabetes) with angina pectoris or documented myocardial ischemia resulting from single or multiple, de novo or restenotic, coronary lesions were randomized between direct stenting and stenting after predilatation. The immediate angiographic results, and clinical outcomes and costs associated with the two treatment strategies up to nine months of follow-up were compared. RESULTS: In phase I the mean diameter stenosis immediately before and after the procedure, and at six months was 61.7 &#45 9.4%, 13.5 &#45 6.3%, and 33.6 &#45 16.2%, respectively. The six-month binary restenosis rate was 11%. The overall rate of major adverse cardiac events, including two non-cardiac deaths, was 9.8%. In phase II, the success rates of the intended delivery strategies were 87.9% and 97.9% for direct stenting and predilatation, respectively (p < 0.001), while the procedural success rates were similar (93.9% vs 96.5%). Over a follow-up period of nine months, major adverse cardiac events rates were 12.0% and 10.9% in patients randomized to direct stenting and predilatation, respectively (non-significant). Analyses of the costs incurred up to nine months in each treatment group revealed a mean saving of e362 per patient in favor of the direct stenting strategy (non-significant). CONCLUSIONS: Compared with a strategy of stenting preceded by balloon dilatation, direct stenting was associated with an equivalent procedural success rate, equivalent clinical results up to nine months of follow-up, and a reduction in procedural and in-hospital costs (p < 0.0001 and p < 0.001, respectively), that was no longer significant after nine months.