Incidence and predictors of definite stent thrombosis after coronary stent implantation

Background  Coronary stents are widely used in percutaneous coronary intervention (PCI) procedures. We aimed to explore the incidence, predictors and characteristics of stent thrombosis (ST) after coronary stent implantation in routine clinical practice.

Methods  From data of 18 063 consecutive patients who underwent successful stent implantation in Shenyang Northern Hospital from 2004 to 2010, we identified patients with definite ST (n=140) and control patients (n=280) matched on age, diagnosis, sex, current antiplatelet medication and stent type. The incidence, predictors and characteristics of ST after coronary stent implantation were investigated.

Results  The incidence of angiographically confirmed ST was 0.78% (140/18 063). The time distribution of ST was acute in 43 (30.7%), subacute in 50 (35.7%), and late in 47 (33.6%) patients. Binary Logistic regression analysis identified the angiotensin-converting enzyme inhibitor (ACEI) (odds ratio (OR)=0.472, 95% CI: 0.276–0.807, P=0.006) and heparin (OR=0.477, 95% CI: 0.278–0.819, P=0.007) were associated with an reduced risk of cumulative ST. Stent length (OR=1.042, 95% CI: 1.026–1.058, P <0.001), serum creatinine total (OR=1.020, 95% CI: 1.004–1.035, P=0.04), cholesterol (OR=1.267, 95% CI: 1.021–1.573, P=0.032), glucose (OR=1.086, 95% CI: 1.002–1.176, P=0.044), and platelet aggregation (OR=1.113, 95% CI: 1.075–1.154, P <0.001) were associated with an increased risk of cumulative ST.

Conclusion ST is associated with longer stent length and higher level of total cholesterol, glucose and platelet aggregation.

     

Very late stent thrombosis due to multiple stent fracture and stent malapposition

Coronary stent fracture (SF) is a rare but potentially serious complication of coronary artery stenting.Here we report a case of acute myocardial infarction as a consequence of very late in-stent thrombosis due to multiple steut fractures at 8 sites and multiple stent malapposition formation four years after a sirolimus-eluting stent implantation (Firebird,Microport,Shanghai,China). A 43-year-old man with hyperlipidemia and a smoking history was referred for coronary angiography (CAG)following repeated exertion associated chest pain in January 2007.CAG revealed a diffused tortuous stenosis at the proximal segment and a total occlusion at the mid-segment of the left anterior descending (LAD) artery,a 90％ stenosis at the proximal segnent of the left circumflex artery (LCX),and a diffused lesion with a maximal 60％ stenosis of the right coronary artery (RCA).     

Very late coronary aneurysm formation with subsequent stent thrombosis secondary to drug-eluting stent

Drug-eluting stents have changed the practice in interventional cardiology. With the widespread use of these stents important safety concerns regarding stent thrombosis and formation of coronary artery aneurysm have been expressed. While the majority of attention was focused on stent thrombosis, the formation of coronary aneurysm was only described in anecdotal reports. We report on a patient who suffered from very late stent thrombosis in association with coronary artery aneurysm formation secondary to drug-eluting stent but not to bare-metal stent.

     

Coronary aneurysm and very late stent thrombosis formation associated with sirolimus-eluting stent implantation

Since drug-eluting stents （DES） can significantly reduce the risk of instant restenosis compared with bare-metal stents, they have been widely used in interventional therapy for coronary heart disease. With bare-metal stents being rapidly replaced by DES there is a great concern about the safety of DES due to stent thrombosis.Very late stent thrombosis （VLST） has been categorized as occurring beyond 1 year.3 Coronary aneurysm formation induced stent malapposition is a rare but potentially fatal cause of VLST. We report a case of coronary aneurysm with VLST formation 35 months after sirolimus-eluting stent （SES） implantation.     

Myocardial bridging is a potential risk factor of very late stent thrombosis of drug eluting stent

Drug eluting stents have been implanted worldwide and used in nearly 90% of percutaneous coronary interventions in China. Although many randomized trials have confirmed the efficacy and safety profile of drug eluting stents, they were not powered to detect or exclude the effect of drug eluting stents on rare events such as stent thrombosis. Several mechanisms of very late stent thrombosis have been postulated, but are not widely accepted. Virchow's triad describes the 3 main factors of thrombus formation - stasis of blood flow, endothelial injury and hypercoagulability. Myocardial bridging is a common congenital anomaly. Modern anatomy and angiography regard myocardial bridging as widespread, but its pathophysiological response is always ignored. According to Virchow's triad, myocardial bridging negatively affect endothelial function, and the turbulent shear stress and intimal trauma predispose the vessel toward thrombus formation. Therefore, we question whether a relationship between myocardial bridging and very late stent thrombosis of drug eluting stents exists. Also, we propose that myocardial bridging might be a potential risk factor of very late stent thrombosis of drug eluting stents; coronary artery bypass grafting might be a promising and novel choice in the treatment of myocardial bridging with severe stenosis in the coronary artery.
     

Rapid development of late stent malappositon and coronary aneurysm following implantation of a paclitaxel-eluting coronary stent

Late stent malapposition （LSM）, an unusual intravascular ultrasound （IVUS） finding at follow-up,has been reported to be more common alter drug-eluting stem （DES） implantation than after bare metal stent （BMS） implantation. However, there has been no clear elucidation of time course and mechanism. We reported a case who developed LSM and coronary aneurysm very early after paclitaxel-eluting stent （PES） implantation. A review of the literature reveals no previous report describing rapid development of LSM and coronary aneurysm after PES implantation.     

氮氧化钛生物有效性支架与雷帕霉素药物洗脱支架临床应用比较

目的：对比研究氮氧化钛生物有效性支架（Titan2-BAS）与雷帕霉素药物洗脱支架（sirolimus-eluting stent,SES）在冠状动脉血运重建方面的临床疗效.方法：141例冠心病患者,根据植入的支架不同分为A组（Titan2-BAS）87例,B组（SES）54例,均采用经桡动脉或尺动脉途径冠脉血运重建.A组阿司匹林与氯吡格雷治疗1~3 mo,B组至少12 mo.计算A,B两组支架病变的通过率、早期支架内血栓发生率及随访MACE发生率（指死亡、急性心肌梗死、靶血管重建等）.结果：①A组病变内径（3.1±0.4）mm,长度为（24±3）mm,B组病变内径（3.0±0.5）mm,长度为（22±4）mm,两组无显著差异（P〉0.05）.②A组146处〉75%狭窄病变共植入Ti-tan2-BAS 168枚,1枚支架未能通过病变（RCA）,通过率99.3%;B组86处病变共植入SES94枚,通过率100%,两组无显著差异（P〉0.05）.③随访1~17 mo,平均5.8 mo.两组均无死亡病例;A组无急、晚期血栓.B组1例术后2 d出现支架内血栓;A组1例术后3 mo行靶血管重建,B组无靶血管重建;两组MACE发生率无显著差异（P〉0.05）.结论：在本研究样品量情况下,Titan2-BAS与SES在冠脉血运重建方面的近期及远期疗效相近,Titan2不增加MACE发生率.     

Meta-analysis of stent thrombosis after drug-eluting stent implantation: 4-year follow-up

Background Drug-eluting stents （DES） are the most common device used in percutaneous treatment of coronary artery disease. Recently, there has been an increased concern regarding their safety profile, in particular the late and very late stent thrombosis rate compared to bare metal stents （BMS）. The aim of the study was to compare the reported incidence of late and very late stent thrombosis of DES and BMS in patients from published clinical studies with an extended follow-up period to four years.Methods A search strategy was developed to identify publications reporting on late or very late thrombosis of BMS and DES available through MEDLINE and Cochrane Library databases. Two independent reviewers appraised eligible studies and extracted data. Odds ratios （OR） were calculated for each outcome and presented with 95% confidence intervals （CI）.Results Fourteen randomized controlled trials, which were at least single blinded, were identified. There was no difference in the incidence of late and very late stent thrombosis in patients treated with DES compared with patients treated with BMS （late OR 0.55, 95%Cl 0.23-1.31 and late/very late OR=1.08, 95%CI 0.61-1.91）.Conclusions The safety profile of DES was similar to BMS in terms of stent thrombosis. We found no evidence of increased risk of late and very late thrombosis for DES.     

新型生物可降解雷帕霉素药物洗脱输尿管支架的构建及性能评估

目的：构建一种新型生物可降解雷帕霉素药物洗脱输尿管支架并评估其机械性能及药物释放特性。方法采用聚乳酸为原料,将其溶于氯仿后加入雷帕霉素粉末,通过溶液挥发法构建螺旋形生物可降解雷帕霉素药物洗脱输尿管支架。通过万能压力机检测新型生物可降解雷帕霉素输尿管支架力学性能,并分别在3周、6周、9周和12周时通过色谱分析仪评估其药物释放特性。结果成功构建的生物可降解雷帕霉素药物洗脱输尿管支架,长度为50 mm,内径为0.8 mm,外径1.4 mm,厚度为200μm,带宽为1 mm。支架不仅具有良好的力学性能,并可有效持续释放药物,支架平均雷帕霉素含量为2755μg,3周后支架平均含药量为2670μg,6周后支架平均含药量为2533μg,9周后支架平均含药量为1541μg,12周后支架平均含药量为744μg。结论构建的生物可降解雷帕霉素药物洗脱输尿管支架具有良好的机械性能,可有效释放药物,有望为输尿管损伤或狭窄的治疗提供一种新的简单有效的材料和方法。     

药物洗脱性支架和裸金属支架植入治疗冠状动脉狭窄的临床随访观察

目的探讨药物洗脱性支架(DES)和裸金属支架(BMS)治疗冠状动脉狭窄的远期疗效。方法对成功进行DES植入术患者2734例和BMS植入患者216例术后6个月、1年进行随访,观察其支架内再狭窄(ISR)发生率、急性心肌梗死发生率、冠状动脉旁路移植(CABG)或再次经皮冠状动脉介入治疗(PCI)治疗率、病死率,分析术后再狭窄的独立危险因素。结果术后6个月、1年时DES组ISR发生率均低于BMS组(9.58%vs 18.98%,18.32%vs 31.94%),差异有统计学意义(P<0.05);随访6个月时,急性心肌梗死发生率、CABG或再次PCI治疗率和病死率方面比较差异无统计学意义(P>0.05),但是随访1年后,其差异有统计学意义(P<0.05);多因素分析发现,支架直径≤3 mm、吸烟和年龄是支架植入术后发生再狭窄的独立危险因素。结论在冠状动脉狭窄的治疗中,DES的远期疗效优于BMS,但临床应用还需要进一步的循证医学研究证据。     

双源CT评价急诊PCI中药物涂层支架及裸支架植入术后再狭窄

目的通过双源CT评价急诊PCI药物涂层支架及金属裸支架植入术后支架内再狭窄。方法 85例急性心梗并行急诊支架植入术后1年的患者行双源CT检查,分析其管腔丢失及支架内再狭窄发生率。结果①双源CT获得80例(94.1%)患者共88枚(93.6%)冠状动脉支架清晰图像。②在管腔丢失方面药物涂层支架与金属裸支架比较有统计学意义;两者在支架内再狭窄方面无统计学意义。结论双源CT可作为支架术后患者的无创随访手段;在急性心梗中使用药物涂层支架可减少管腔丢失。     

Acute coronary syndrome is an independent risk factor for late incomplete stent apposition after sirolimus-eluting stent implantation

Background Late incomplete stent apposition （ISA） may occur after drug-eluting stent implantation, affecting long-term clinical outcomes. This study aimed to evaluate the impact of clinical presentations of coronary artery disease on late ISA after percutaneous coronary intervention （PCI） with sirolimus-eluting stents （SES） by means of three-dimensional volumetric intravascular ultrasound （IVUS） analyses. Methods One hundred and thirty-seven patients with coronary artery disease received SES implantation during PCI and had repeat angiography with IVUS examination. All patients were followed up one year after the procedure. Results In overall 219 treated lesions （137 patients）, late ISA was identified in 25 lesions （16 patients）. Clinical diagnosis of acute coronary syndrome （ACS） and use of long stents were more common in patients with than in those without late ISA. Patients with late ISA had greater external elastic membrane （EEM） area in stented segment （（15.34±5.44） vs （13.83±4.51） mm^2, P=0.026）, stented-to-reference segment EEM area ratio （1.13±0.22 vs 1.02±0.18, P 〈0.001）, and plaque and media area （（8.43±3.93） vs （7.01±2.93） mm^2, P =0.002） than in those without late ISA. Multivariate Logistic regression analysis showed that clinical diagnosis of ACS and use of long stents were independent risk factors for late ISA （OR 6.477, 95%CI 2.297-18.263, P 〈0.001; OR 3.680, 95%Cl 1.181-11.469, P =0.025; respectively）. During one-year follow-up after IVUS examination, the rate of very late stent thrombosis tended to be higher in patients with than in those without late ISA （18.7% vs 3.3%, P =0.051）. Conclusions The occurrence of late ISA after SES implantation may be related to clinical status, use of long stents, and marked positive vessel remodeling. Late ISA tended to increase the rate of very late stent thrombosis during follow-up, highlighting the importance of long-term dual antiplatelet therapy for these patients.     

紫杉醇药物涂层支架治疗左前降支病变临床研究

目的：探讨紫杉醇药物涂层支架（PES）治疗冠状动脉左前降支（LAD）病变的即刻疗效及预后。方法：2003年2月～2005年3月在本院造影证实连续LAD单支病变患者94例,共107处病变,按常规行经皮冠状动脉成形术加支架置入术,分析患者临床、X线影像学特征及手术成功率,并行随访。结果：94例患者中,29例置入PES,65例置入金属裸支架（BMS）,手术成功率100％。病变弥漫性30例（31．9％）,位于近段52例（55．3％）,中段12例（12．8％）。全部患者均完成术后6个月的随访并行造影复查。PES组术后6个月时造影复查2例（6,9％）发生再狭窄;BMS组1例1个月内因急性前壁心梗死亡,6个月时造影复查21例（32．3％）发生再狭窄。结论：PES置入治疗冠状动脉LAD病变安全有效,术后心源性猝死及非Q波性心肌梗死发生率与置入BMS者相似,支架内再狭窄发生率明显降低,因再狭窄需冠脉搭桥率也显著降低,术后6个月再狭窄率与文献报道冠脉搭桥术相近。     

Recurrent acute myocardial infarction after 32 months: very late stent thrombosis after sirolimus-eluting stent implantation

Recent analyses have suggested that implantation of drug-eluting stents （DES） is associated with a higher rate of very late stent thrombosis when compared with bare metal stents （BMS）. According to Academic Research Consortium （ARC） definition,1 very late stent thrombosis refers to events occurring more than 12 months following stent placement. This complication is evident with sirolimus-eluting stents （SES） as well as polymer-based paclitaxel-eluting stents （PES）,     

双J管在治疗上尿路梗阻中的应用及原理

目的 探讨双J管在尿路梗阻术后的应用效果以及原理。方法 2001年3月至2005年12月，我院治疗84例上尿路梗阻患者（单纯输尿管结石66例，输尿管狭窄合并结石10例，UP10者5例，RBJO者3例），术后留置1-2根双J管。结果 84例患者共留置102根双J管，术后留置时间3周～2．5年，平均5周。37例患者出现不同程度的下腹胀痛、尿痛、血尿等不适，拔管后症状缓解。15例患者双J管上附着结石形成。2例患者双J管上移，输尿管镜下拔除。2例患者双J管下移末端部分顶住膀胱黏膜，血尿较重，提前拔管后好转。结论 治疗上尿路梗阻术后留置双J管具有操作简便、引流效果好、并发症少等优点，可以作为术后常规治疗手段。     

双J管在治疗上尿路梗阻中的应用及原理

目的探讨双J管在尿路梗阻术后的应用效果以及原理。方法2001年3月至2005年12月,我院治疗84例上尿路梗阻患者(单纯输尿管结石66例,输尿管狭窄合并结石10例,UPJO者5例,UBJO者3例),术后留置1～2根双J管。结果84例患者共留置102根双J管,术后留置时间3周～2.5年,平均5周。37例患者出现不同程度的下腹胀痛、尿痛、血尿等不适,拔管后症状缓解。15例患者双J管上附着结石形成。2例患者双J管上移,输尿管镜下拔除。2例患者双J管下移末端部分顶住膀胱黏膜,血尿较重,提前拔管后好转。结论治疗上尿路梗阻术后留置双J管具有操作简便、引流效果好、并发症少等优点,可以作为术后常规治疗手段。     

药物洗脱支架和金属裸支架对冠心病患者近远期疗效比较

目的对比观察药物洗脱支架(DES)和金属裸支架(BMS)治疗冠心病(CHD)患者近远期临床疗效的影响。方法收集我院2005年1月至2007年1月CHD患者305例,随机分为治疗组和对照组,其中治疗组接受DES治疗,对照组接受BMS治疗,于术后1、3、6、9和12个月进行电话或门诊随访,并于12个月做冠状动脉造影,观察不良心脏事件、支架内血栓及再狭窄的发生率,并评价两组不同因素对再狭窄的影响。结果治疗组置入支架成功率为98.7%,而对照组置入支架成功率为100%。在主要临床事件方面,治疗组主要心脏不良事件、支架内狭窄发生率明显低于对照组,二者相比有显著性差异(P<0.01);而近期血栓事件发生率为2.58%,与对照组相比无显著性差异(P>0.05)。亚组分析,治疗组中在弥漫病变、重叠支架、长支架时的再狭窄率小,与对照组相比,具有显著性差异(P<0.01)。结论在经皮冠状动脉介入治疗术支架置入中,DES具有较低的不良心脏事件、近期血栓及再狭窄的发生率,同BMS相比有显著的优势,近远期疗效是安全、可靠的。     

比较125I粒子支架与普通胆管支架在不可切除胆管癌患者姑息治疗中疗效的Meta分析

目的 比较125I粒子支架与普通胆管支架在不能切除的胆管癌患者姑息治疗中的作用。方法 在PubMed,MEDLINE,EMBASE、Cochrane Library、中国知网数据库系统检索2000年1月～2019年12月所有关于对125I粒子支架和普通胆管支架在不能手术切除的胆管癌治疗进行疗效比较的随机对照试验。观察分析两组的总胆红素水平、支架通畅持续时间、生存时间和并发症的发生率。结果 与普通支架组相比,125I组术后的总胆红素水平显著降低(P0.05)、生存时间(P0.00001)及支架通畅时间(P0.00001)均明显延长,而并发症发生率(P0.05)无统计学意义。结论 与普通支架相比,125I粒子支架可以降低不可切除胆管癌患者的总胆红素水平,延长支架通畅时间和患者生存时间,且不增加并发症发生率,效果更佳。     

Percutaneous drug-eluting stent implantation in dextrocardia: case report

Although situs inversus with dextrocardia is a rare clinical phenomenon, the association with coronary artery disease（CAD） is at the same frequency as in the general popuLation. Few cases of dextrocardia complicated with CAD was reported before. The feasibility and prognosis of percutaneous coronary intervention （PCI） in such case still remains unclear because of the uncommon anatomical abnormality, especially in the drug-eluting stent （DES） era. Here we report a female case with dextrocardia and CAD was successfully treated by DES implantation.     

Clinical and angiographic follow-up study of sirolimus-eluting stent for treatment of in-stent restenosis

ithwidespreadperformanceofcoronaryartery stenting,thenumberofin stentrestenosis (ISR)hasincreasedinrecentyears.Howtotreat ISReffectivelyhasbeenagreatchallengeinthefield ofcardiology.Recently,somenotableclinicaltrials haveconfirmedthatsirolimus elutingstents(SESs) (CYPHERTM,Cordis,J&JInc,USA)reduceISR ratedramatically.Sofar,therehavebeenfew reportsontheefficacyofusingSESstotreatISR.1,2 So,weusedSESstotreat27patientswithISR andfollowedupforatleastsixmonths. METHODS Patients Tw…