替罗非班对急性心肌梗死经皮冠状动脉介入治疗后支架内血栓形成的影响

目的:探讨替罗非班对经皮冠状动脉介入治疗(PCI)后支架内血栓形成的影响。方法:27例支架内血栓形成患者中,观察组(14例)均首先接受盐酸替罗非班10μg/kg 3 min静脉推注,继以0.15μg.kg-1.min-1持续点滴,之后行急诊PCI或继续静脉点滴72 h。对照组(13例)直接再次行急诊PCI。结果:观察组中死亡2例(14.3%),对照组中死亡3例(23.1%),2组比较,P>0.05;观察组中7例(50%)ST段回落,对照组中无一例ST段回落,2组比较,P<0.05;观察组中胸痛部分或全部缓解者7例(50%),无缓解者7例(50%),对照组中14例患者胸痛均无缓解,2组比较,P<0.05;TIMI血流2~3级者,观察组、对照组分别为5例、0例,2组比较,P<0.05。2组患者均未出现严重出血;观察组轻、中度出血发生率多于对照组(P<0.05)。结论:静脉推注大剂量替罗非班能减少急性或亚急性支架内的血栓量,化解清除部分或全部支架内的血栓,为再次急诊PCI争取时间。     

Iatrogenic left main coronary artery thrombosis during percutaneous coronary intervention

During diagnostic angiographic procedures or percutaneous coronary angioplasty-stenting of the other coronary arteries, the overall risk for a complication related to the left main coronary artery (LMCA) is low; however, if such complications occur, they tend to be life-threatening and contribute to a large part of the total catheter-related mortality. We encountered a case of iatrogenic significant subtotal left main coronary artery thrombotic stenosis in a patient who had undergone prior percutaneous transluminal coronary artery angioplasty-stenting of the left circumflex artery. In light of the literature, an extremely rare clinical presentation of iatrogenic left main coronary artery thrombosis is discussed.     

Entrapment of guidewire in the coronary stent during percutaneous coronary intervention

A 76-year-old man presented with chest discomfort. On coronary angiography, subtotal occlusion in the mid-right coronary artery (RCA) and 60 % tubular stenosis in the distal RCA were revealed. Two intracoronary stents could be placed in the RCA without any difficulty. However, the guidewire could not be removed. The intraoperative finding showed that the guidewire had become entrapped in the coronary stent. The guidewire was successfully removed and emergency coronary bypass grafting was performed.     

Embolised stent into the circumflex coronary artery during percutaneous coronary intervention

Dislodgement and embolisation of the new generation of coronary stents before deployment are rare. If it is impossible to withdraw the embolised stent from the coronary artery, the stent may be crushed into the side wall of the coronary artery with a balloon over a wire passed alongside the embolised stent.     

The outcome of primary percutaneous coronary intervention in patients with stent thrombosis

BackgroundPrimary percutaneous coronary intervention (PCI) is a recommended management strategy for patients with de novo ST-segment elevation myocardial infarction (STEMI). Still, the efficacy of primary PCI in-stent thrombosis (ST) induced STEMI is unclear. The aim was to assess the clinical characteristics and the in-hospital outcomes of patients undergoing primary PCI for STEMI caused by acute, sub-acute, or late ST.MethodsA sample of hundred consecutive patients who presented with STEMI due to ST were included in this study. The angiographic evidence of a flow-limiting thrombus or total vessel occlusion (thrombolysis in myocardial infarction (TIMI) flow grade 0 to II) at the site of the previous stent implant was taken as ST. Primary PCI was performed, and all enrolled patients and in-hospital mortality were observed.ResultsMale patients were 69, and the mean age was 58.9 ± 7.78 years. ST was categorized as acute in 40 patients, sub-acute in 53, and late in the remaining seven patients. Killip class III/IV was observed in 45 patients. Dissection was observed in 25, under deployment in 74, and/or malposition in 24 patients. Thrombus aspiration was performed in 97, plain old balloon angioplasty in 76, and stenting in 22 patients. Final TIMI III flow was achieved in 32 patients. During a mean hospital stay of 4.93 ± 2.46 days, the mortality rate was 27%.ConclusionIn-hospital mortality after primary PCI was observed in more than 1/4th of the patients with STEMI due to ST undergoing primary PCI.     

华法林预防冠脉支架术后78例血栓形成的疗效

目的: 观察华法林预防冠脉支架术后血栓形成的有效性和安全性。方法: 冠脉支架术后患者78例分为2组,金属裸支架组和药物涂层支架组。在常规治疗的基础上,调整华法林剂量,使INR值保持在2.0左右,观察早期和晚期支架术后患者心绞痛、心肌梗死等临床急性事件的发生及出血并发症。结果: 使用华法林后,两组早期未见临床急性事件出现,也未见出血并发症,晚期出现心绞痛两组分别为3例与1例,未发生心肌梗死事件和出血。对4例心绞痛患者再次行冠脉造影显示,置入支架处未见血栓及再狭窄,而是其他血管和血管段出现了冠脉狭窄。结论: 华法林可防止冠脉支架术后血管形成的急性事件,无论是金属裸支架或药物支架,只要剂量适当,这种作用是安全有效的。     

Acute left main occlusion during percutaneous coronary intervention associated with heparin induced thrombocytopenia with thrombosis syndrome

A 76-year-old male was admitted with Braunwald IIIB unstable angina and treated with intravenous heparin. Coronary angiography 20 days later revealed a severe stenosis in the left circumflex artery. During coronary angioplasty thrombus developed in the circumflex artery, extended in the left main and lead to its occlusion. Normal left coronary artery patency and flow were achieved after intracoronary and intravenous administration of abciximab, and multiple stenting. Platelet-count decrease and an ELISA assay documented the presence of heparin-induced thrombocytopenia with thrombosis syndrome (HITTS). HITTS should be suspected after acute thrombus formation during coronary angioplasty.     

直接冠状动脉介入治疗支架内血栓形成的发生率、危险因素及预后

目的分析过去5年期间常规开展ST段抬高性心肌梗死(STEMI)直接经皮冠状动脉介入治疗(PCI)支架内血栓形成的发生率、危险因素以及对预后的影响.方法 1999年3月至2004年2月5年期间常规对311例STEMI患者经股动脉或桡动脉施行直接PCI.男250例,女61例,平均年龄60.4岁(26～85岁).围手术期采用阿司匹林、氯吡格雷或噻氯匹定、肝素进行标准的三联抗血小板/抗凝治疗.对全部患者随访两个月以上.结果直接PCI手术操作成功率99%(308/311).8例发生9例次支架内急性/亚急性或后期血栓形成,发生率为2.6%(8/308).其中急性血栓形成5例,亚急性或后期血栓形成3例.这8例患者均有血栓形成的多个高危因素.8例中住院死亡3例,其余5例有明显的左心室收缩功能障碍.结论 STEMI直接PCI后的血栓形成发生率较高,小直径的长支架和缺乏有效的抗血小板治疗可能是血栓形成的主要危险因素,血栓形成患者的死亡率高,临床长期预后差.     

Review of subacute stent thrombosis following percutaneous coronary intervention at a low-volume catheterization laboratory

BACKGROUND: The frequency of coronary stent subacute thrombosis (SAT) following percutaneous coronary intervention (PCI) with uncoated stents in recent studies is 0.5%-0.9%. Prior studies have indicated that complication rates are significantly higher when performed in low-volume centers. We sought to determine the incidence and outcomes of SAT following PCI with stent placement at a low-volume catheterization laboratory. METHODS: We reviewed the Brooke Army Medical Center Interventional Database for all consecutive PCIs with stent implantation performed from January 1998 to December 2002. Clinical outcomes were obtained primarily through hospitalization records and clinic follow-up visits. RESULTS: There were 789 interventions with stenting on 750 patients over the specified time period, for an average of 158 procedures on 150 patients per year. There were seven cases of SAT, representing a rate of 0.89%. There was no difference in the clinical characteristics, procedural technique, or postprocedural antithrombotic therapy of the subjects with and without SAT. Of those with SAT, there were no subjects requiring surgical revascularization during index hospitalization, and all survived to index hospital discharge. Six of these seven subjects with SAT (85.7%) were alive at one year, with the single death noncardiovascular related. CONCLUSIONS: The incidence of thrombosis occurring within 30 days of intracoronary stent implantation is similar in low- and high-volume catheterization laboratories. In our low-volume laboratory experience, these events were not associated with significantly increased adverse outcomes.     

Influence of residual stenosis after percutaneous coronary intervention with stent implantation on development of restenosis and stent thrombosis

The aim of this study was to assess the effects of residual stenosis after single-stent implantation on the rate of stent thrombosis, as well as restenosis within a 6-month follow-up period. Coronary angiograms of 2,157 patients with 2,523 lesions treated with a single stent were analyzed by quantitative coronary angiography before, immediately after stent implantation, and at a planned 6-month follow-up. Lesions were classified into 4 subgroups according to the degree of residual stenosis after stent implantation: group 1, gross oversizing <-15%; group 2, slight oversizing -15% to <0%; group 3, mild residual 0% to <15%; group 4, moderate residual 15% to <30%. Stent thrombosis rates were not significantly different among the 4 subgroups (group 1: 0 of 60 [0%]; group 2: 2 of 388 [0.5%]; group 3: 8 of 1,370 [0.6%]; group 4: 8 of 705 [1.1%]; p = NS for all). An adequate dosage of ticlopidine (250 mg twice daily) and aspirin (100 mg/day) led to a lower rate of stent thrombosis (6 of 2,189 cases) than inadequate dosages or missing therapy (12 of 343 cases). In 1,882 stenoses with angiographic follow-up (77.7%), gross oversizing of stents lead to a significantly higher increase of percent stenosis (p <0.001) associated with a higher restenosis rate (group 1: 34.7% vs groups 2, 3, and 4: 32.5%, 28.2%, and 29.6%, respectively). A multiple regression analysis was performed. Optimal results with regard to stent thrombosis and restenosis were achieved with mild residual stenoses between 0% and 15% after stent implantation. Oversizing of stents is no longer necessary with an adequate dosage of ticlopidine and aspirin.     

带膜支架对老年冠状动脉介入治疗术中冠状动脉穿孔患者的疗效

目的评价带膜支架治疗经皮冠状动脉介入治疗（PCI）术中发生冠状动脉穿孔老年患者的疗效。方法从2004年6月至2011年6月,本中心共对8例PCI术中发生冠状动脉穿孔后植入带膜支架的老年患者进行了1年随访,观察其主要心脏不良事件（MACE）发生率。结果8例患者中男4例,女4例,年龄65±76岁,平均（70．4±4．1）岁。植入带膜支架直径平均（3．2±O．3）mm,长度平均（21．0±3．4）mm,所有患者破口均被成功封闭,术中无死亡病例。随访1年,1例急性前壁心肌梗死患者术后19天因肺部感染导致多器官功能衰竭而死亡,其余患者均无心绞痛发作。随访期间死亡率为12．5％（1／8）,MACE发生率为12．5％（1／8）。结论带膜支架治疗老年冠状动脉穿孔能达到较好的近期和远期疗效。     

The role of endothelial progenitor cells in restenosis and stent thrombosis after percutaneous coronary intervention

Background After percutaneous coronary intervention (PCI), some patients may suffer from restenosis and stent thrombosis. Many studies suggest that endothelial progenitor cell (EPC) has an important role in preventing restenosis and stent thrombosis. A novel stent which can attract EPC has been designed to provide a better outcome for these problems. Method The data of the present review was obtained by searching PUBMED and other databases (1994-2011) using the key terms of "endothelial progenitor cell", "reendothelialization", "restenosis", "stent thrombosis", and "percutaneous coronary intervention". Result Rapid reendothelialization is essential in preventing restenosis and stent thrombosis. EPC can differentiate into endothelial cell and accelerate the reendothelialization. After numerous preclinical and clinical researches , the correlation between circulating EPCs to restenosis still remains poorly understood. However , many studies have shown the important role of EPC in diminishing the risk of thrombosis following stent implantation. Some pharmacological agents have been reported can increase the number and / or functions of EPC. Recently , CD34+ antibody coated stent has been developed to attract EPC to the healing endothelium , and has showed favorable results. Conclusion EPC has important role in rapid reendothelialization after vascular injury. EPC can prevent stent thrombosis after PCI , however the effects of EPC in preventing restenosis need further investigations. The capturing CD34+ stent is safe and significantly decreases stent thrombosis.     

Acute sialadenitis after percutaneous coronary intervention

A 63 year old woman developed a swelling of the submandibular glands following PTCA. An ENT specialist made the presumptive diagnosis of viral sialadenitis. The submandibular swelling subsided completely within 48 hours.Sialadenitis is a rare side effect of ionic and nonionic radiocontrast agents. The pathogenic mechanism is not known. The swelling is self-limited with an excellent prognosis without specific therapy.     

Acute gastrointestinal bleeding after percutaneous coronary intervention

Bleeding from the GI tract is a commonly encountered clinical problem after percutaneous coronary intervention. The GI tract is likely to become the most commonly encountered site of bleeding as cardiologists adopt smaller access sheath sizes, percutaneous closure devices and a radial artery approach, further reducing access-site bleeding. To appropriately manage gastrointestinal bleeding in this setting, the clinician must strike a balance between arresting hemorrhage and preventing ischemic coronary complications. To do so, an appreciation of both cardiovascular and gastrointestinal issues is required. This review aims to provide the required knowledge, as well as a series of recommendations from our practice, to assist in the management of this potentially fatal complication.     

紫杉醇洗脱支架在冠心病介入治疗中的临床应用

目的观察紫杉醇洗脱支架(商品名TAXUS)治疗冠心病的疗效及安全性。方法选择77例冠心病患者,包括36例稳定型心绞痛、40例急性冠状动脉综合征、1例急性心肌梗死,对其92处病变(1处A型病变.91处B型和C型病变)植入92枚TAXUS。于术后住院期间、术后30日及12个月检查手术部位再狭窄及心脏不良事件。结果全部病例成功植入TAXUS;术前靶病变狭窄程度为(77±10)%,术后残余狭窄程度为(6.2±0.8)%;目标血管的参考直径及长度分别为(3.6±0.4)mm和(15.0±2.0)mm,植入支架的平均直径及长度分别为(3.2±0.4)mm和(24±15)mm。术后30日发生支架内再狭窄1例,术后第4日亚急性血栓形成1例,6个月在观察终点发生支架边缘再狭窄1例。再狭窄发生率2.6%,心脏不良事件发生率3.9%,靶血管血运重建率3.3%。结论TAXUS可有效地预防冠心病介入治疗术后再狭窄,心脏不良事件发生率低。