光学相干断层成像评价佐它莫司药物洗脱支架置入后的血管愈合情况

目的:应用光学相干断层成像技术观察佐它莫司药物洗脱支架置入后不同时期的新生内膜覆盖和支架贴壁情况以评估血管愈合.方法:对符合标准的30例置入佐它莫司药物洗脱支架患者进行介入后即刻、介入3个月和介入9个月时的光学相干断层成像检查,每隔1 mm评估横断面影像每个支架柱的新生内膜覆盖和贴壁情况,同时观察每个支架内的血栓发生情...     

Angioscopic Findings after Drug-Eluting Stent Implantation

In-stent restenosis is the Achilles' heel of standard or bare-metal stent (BMS) implantation, occurring in 10-40% of the patients. Drug-eluting stent (DES) are supposed to inhibit inflammation and neointimal growth and, subsequently, in-stent restenosis. The neointimal proliferation inside the stent is recognized as lumen late loss on angiograms or as an obstruction area (or volume) on intravascular ultrasound (IVUS) in chronic phase. Coronary angioscopy provides direct visualization of the lumen and is capable of macroscopic pathologic diagnosis of atherosclerotic plaques and intracoronary thrombi. This modality is also able to supply detailed information on stent coverage with neointimal hyperplasia. The neointimal growth inside the stent is evaluated as white neointimal coverage over the stent struts. Angioscopic view inside the DES is quite different from that inside the BMS. In this article, the difference in angioscopic findings between the DES and the BMS is shown.     

冠状动脉支架术后临床症状影响因素分析

目的 :探讨冠状动脉内支架植入后影响临床症状的因素。方法 :对196例植入冠状动脉支架的病人随访6个月 ,比较出现心前区不适症状病人与未出现症状者间的临床特征及病变血管类型。结果 :196例病人中有42例 ( 2 1.4% )出现心前区不适症状。临床资料中 ,糖尿病、血脂异常、吸烟、高文化程度方面因素有症状组明显高于无症状组 ,两组比较有统计学意义(P <0 .0 5 )。影像学方面 ,多支病变、分叉病变、弥漫性病变、长病变及严重狭窄病变有症状组与无症状组比较有统计学意义 (P <0 .0 5 )。结论 :糖尿病、血脂异常、吸烟、高文化程度以及多支病变、分叉病变、弥漫性病变、病变长度 >15mm、狭窄程度 >99%者 ,可以增加冠心病病人冠状动脉支架术后心前区不适症状的复发。     

心肌桥介入治疗后支架内再狭窄及其再次治疗效果的观察

目的观察心肌桥病变介入治疗的再狭窄率及其治疗效果。方法选择有症状的单纯心肌桥改变且收缩期严重狭窄(≥95%)者17例作治疗组(A组),对照组选择单纯前降支动脉粥样硬化严重狭窄(≥70%)者54例(B组),两组均应用普通冠脉支架介入治疗。结果两组介入手术均成功,两组支架植入后的血管内径及支架长度比较无显著差别(P>0.05)。A组6个月内8例(47%)出现再狭窄,B组8例再狭窄(14.8%),A组和B组的再狭窄率有显著差别(P<0.05);两组中再狭窄病人均再次接受治疗。平均随访20月,A组8例中7例未再发生支架内狭窄及心绞痛事件,1例再次支架内狭窄,B组再次介入治疗的6例中1例再次支架内狭窄。结论心肌桥病变的介入治疗远期疗效尚好,但远期支架内再狭窄率较高,需再次介入治疗。     

Very Late Stent Thrombosis 11 Years after Implantation of a Drug-Eluting Stent

Very late stent thrombosis is an infrequent yet potentially fatal complication associated with drug-eluting stents. We report the case of an 88-year-old man who sustained an ST-segment-elevation myocardial infarction 11 years after initial sirolimus-eluting stent implantation. Optical coherence tomograms of the lesion showed that the focal incomplete endothelialization of the stent struts was the likely cause; neointimal formation, neoatherosclerosis, and late stent malapposition might also have contributed.To our knowledge, this is the longest reported intervening period between stent insertion and the development of an acute coronary event secondary to very late stent thrombosis. The associated prognostic and therapeutic implications are considerable, because they illuminate the uncertainties surrounding the optimal duration of antiplatelet therapy in patients who have drug-eluting stents. Clinicians face challenges in treating these patients, particularly when competing medical demands necessitate the discontinuation of antiplatelet therapy. In addition to the patient''s case, we discuss factors that can contribute to very late stent thrombosis.     

药物洗脱支架植入后靶血管的病理改变

药物洗脱支架广泛应用于冠心病的治疗,有效地减少了支架再狭窄的发生,但晚期支架内血栓形成、支架动脉瘤形成、靶血管部位超敏反应的发生等一系列的并发症逐渐被人们所重视,现探讨药物洗脱支架植入后靶血管的病理学改变.     

冠状动脉支架术后再狭窄的危险因子

冠心病危险因素、血管造影下冠状动脉病变特征、支架术操作技术参数是影响冠脉病变支架术后再狭窄的主要危险因子。这些危险因子主要有糖尿病、冠脉病变长度、病变狭窄程度、病变类型,以及支架长度、支架类型等,这些危险因子在不同基础疾病和冠脉病变条件下对支架术后再狭窄的影响作用不同。     

药物洗脱支架置入术后冠状动脉瘤及其治疗

药物洗脱支架术后冠状动脉瘤是少见的并发症,但是一旦发生可引起严重的心血管事件,因此引起临床上极大的重视。手术创伤、局部血管的炎症反应,支架贴壁不良及血管本身的结构特点等可能是冠状动脉瘤产生的原因。目前治疗冠状动脉瘤的方法有长期抗血小板治疗、介入治疗和外科手术等。     

Long‐Term Results after Carotid Stent Implantation

Background

Though carotid artery stenting (CS) has gained popularity as an alternative to carotid endarterectomy, studies examining long‐term results are limited.

Methods

All consecutive patients who underwent unilateral CS between 7/1993 and 8/2005 with no or non‐significant contralateral stenosis were included. Follow‐up with duplex sonography and/or angiography and neurological assessment was performed at 6 and/or 12 months. Thereafter, annually, a questionnaire was sent to the patients and their referring physicians.

Results

Two‐hundred and seventy‐nine patients underwent CS. In 99% of procedures stent delivery was successful. The periprocedural major and minor stroke rates were 2.2%, respectively. The periprocedural major stroke or death rate was 2.9%. Median clinical follow‐up was 49 ± 32 months (range: 30 days–12.1 years). Excluding perioperative (<30 days) events, the annual major and minor stroke rate was 1.3% and the annual ipsilateral major and minor stroke rate was 0.6%. In symptomatic and asymptomatic patients, the annual major and minor stroke rates were 2.2% and 0.8%, respectively, and the ipsilateral major and minor stroke rates were 1.1% and 0.3%, respectively. There was no significant difference between ipsilateral and contralateral major or minor strokes at long‐term follow‐up. At last sonographic follow‐up (median 36 ± 32 months), restenosis rates for symptomatic and asymptomatic stenoses were 5% and 3%, respectively.

Conclusion

The results of our study demonstrate very low long‐term cerebral event rates after CS supporting the long‐term safety of CS. Importantly, there was no significant difference in long‐term ipsilateral versus contralateral cerebral events lending support to the hypothesis of plaque stabilization.

     

Outpatient Coronary Stent Implantation

Objectives. This study was performed to explore the feasibility of coronary Palmaz-Schatz stent implantation on an outpatient basis.Background. To optimize the applicability of coronary stenting by limiting bleeding complications and length of hospital stay, the transradial approach has been demonstrated to be an effective technique. Immediate ambulation opens the way to outpatient treatment.Methods. Patients selected for Palmaz-Schatz stent implantation received anticoagulation with Coumadin. At an international normalized ratio >2.5, stenting was performed through the radial approach. Starting in December 1994, patients were treated with Ticlopidin. Heparin was administered during the procedure. Suitability for same-day discharge was assessed on the basis of preprocedural, postprocedural and periprocedural criteria. Patients were mobilized after immediate sheath removal, followed by same-day discharge. Follow-up examinations were performed the next day, at 2 weeks and at 1 month after stenting.Results. Of 188 patients who underwent Palmaz-Schatz coronary stent implantation through the radial artery between May 1994 and July 1995, 88 remained in the hospital for various reasons. In the 100 outpatients (Canadian Cardiovascular Society classes III and IV, n = 90 [90%]), 125 stents had been implanted to cover 110 lesions. No cardiac or bleeding events were encountered within 24 h (95% confidence interval 0 to 3.6) of stenting. At 2-week follow-up, one patient was readmitted (day 4) because of a bleeding abdominal aortic aneurysm requiring operation. Two patients were readmitted 2 weeks after discharge, one with subacute thrombosis and one with angina and anemia that was treated with blood transfusions. At 1-month follow-up, no complications were observed.Conclusions. After an optimal transradial Palmaz-Schatz coronary stent result, patients can safely be discharged on the day of treatment.(J Am Coll Cardiol 1997;29:323–7)     

冠状动脉内支架术后即刻明胶酶变化的研究

目的：探讨在急性心肌梗塞患者冠状动脉支架术（PTCA）明胶酶的变化；方法：15例确诊为单支血管病变的急性心肌梗塞患者，在PTCA术前及术后5分钟内冠状动脉窦内取抗凝血2ml，利用Gelatin—PAGE法测冠状动脉内明胶酶的活性表达；结果：在术后明胶酶A比术前高（P〈0．05），明胶酶B与术前无明显变化（P〉0．05）。结论：明胶酶可能参与支架术后再狭窄过程。     

Comparison between Plain Old Balloon Angioplasty and Drug‐Eluting Stent Implantation for the Treatment of Stent Fracture

Objectives

The aim of this study was to evaluate clinical outcomes after percutaneous coronary intervention (PCI) for stent fracture (SF).

Background

SF has been reported as a predictor of in‐stent restenosis (ISR) and stent thrombosis (ST).

Methods

Between January 2009 and December 2012, consecutive SF cases treated with either drug‐eluting stent (DES) or plain old balloon angioplasty (POBA) were retrospectively enrolled in this study. The study endpoints were all‐cause death, cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), ST, re‐stent fracture (re‐SF), and major adverse cardiac events (MACE) defined as the composite of cardiac death, MI, and TLR.

Results

Of 135 SF cases, 67 (49.6%) cases were treated with DES, whereas 68 (50.4%) cases with POBA. Median follow‐up period was 1,401 (IQR: 967–1,771) days. The estimated MACE rate at 3 years was significantly lower in the DES group as compared with the POBA group largely driven by less TLR (25.7 vs. 55.8%, P < 0.001). Moreover, 1‐year landmark analysis after PCI for SF revealed that MACE continued to occur even after 1 year irrespective of the treatment option (P = 0.47). On multivariable Cox regression analysis, POBA and large post‐procedure angle (Δ) defined as the degree difference between the end systolic and diastolic angle were identified as independent predictors for TLR.

Conclusions

DES implantation for SF is associated with better clinical outcomes as compared to POBA alone, due to a lower need for TLR. Large post‐procedural angle (Δ) appears to be an independent predictor of TLR.

     

雷帕霉素涂层支架术后抗血小板治疗与支架内血栓形成

<正> 抗血小板治疗的中断对于支架内血栓形成的影响及对DES术后患者远期预后的影响尚未被充分的阐述。Takeshi Kimura等在日本的一项观察研究中(J-Cypher registry),纳入了10 778例置入雷帕霉素涂层支架的患者,分析其2年的结果。对这些患者2年随访期间的抗血小板治疗资料进行收集分     

抗血小板与抗凝药物在冠状动脉内支架植入术后的应用

由冠状动脉阻塞所致的缺血性心脏病在临床上较为常见,经皮冠状动脉腔内成形术（ＰＴＣＡ）是冠心病的主要治疗手段之一。冠状动脉内支架植入术是在ＰＴＣＡ基础上发展起来的介入技术,其应用在很大程度上提高了介入技术对于血管病变的临床价值。但坎是ＰＴＣＡ还是冠脉内支架植入术均面临着急性血管闭塞和再狭窄的难题,特别是冠状动脉内支架植入术显著激活血小板而增加了亚急性支架血栓形成的风险。目前,主要预防措施是应用抗血小