股腘动脉支架内再狭窄的腔内治疗研究进展

正股腘动脉(FPA)支架置入血管成形术是针对FPA狭窄或闭塞性病变的腔内治疗方法之一,其目的是改善患者下肢动脉血液供应,缓解患者因下肢缺血引发的间歇性跛行和静息痛等症状。然而在支架置入术后可导致FPA支架内再狭窄(FPA-ISR)。有文献报道,支架后再狭窄或闭塞的发生率高达20%~50%[1-2]。而一旦发生支架内再狭窄(ISR),就会再现下肢缺血,因此对于FPA-ISR的治疗方法相继出现,现将就目前SFA腔内治疗研究进展进行综述。     

支架内再狭窄的治疗

1969年 ,ＣｈａｒｌｅｓＤｏｔｔｅｒ报道了在犬动脉中植入弹簧线圈状支架的实验结果 ,第一次提出了血管内修复的观点 ,今天支架置入技术已经成为冠状动脉血运重建的主要手段。最初 ,支架仅获准用于球囊扩张术后急性血管闭塞的预防与治疗 ,但是完成于 1994年的Ｂｅｎｅｓｔｅｎｔ及ＳＴＲＥＳＳ研究证明支架可以改善手术近期疗效 ,降低再狭窄的发生率[1,2 ] 。同时 ,随着新一代抗血栓药物和无鞘支架的问世 ,以及介入技术的改良 ,使得支架使用量呈指数性增长。但是支架并未“治愈”再狭窄 ,还导致一个新的问题的出现 支架内再狭窄(Ｉｎ …     

老年病人股浅动脉支架植入术后再狭窄的临床干预及效果

目的探讨老年病人股浅动脉支架植入术后再狭窄临床处理方式及优化腔内干预、外科干预选择及操作手段。方法回顾性分析该科自2010年1月至2014年7月112例65岁以上股浅动脉支架植入术后再狭窄患者(共计133条患肢),该组患者年龄中位数为71岁(年龄范围:66~92岁),根据临床处理方式分为外科治疗组和介入治疗组,随访观察两组病例术后近、远期通畅率、再狭窄率、TASC分型、踝肱指数、心脑血管重大事件发生率、严重并发症发生率等,讨论分析腔内干预、外科干预二者的适应证及优化方向。结果 112例患者共计133支病变血管,术后绝大部分患者下肢缺血情况获得明显缓解,其中介入干预64例(77条患肢),无严重并发症;外科干预48例(56条患肢),3例发生术后切口愈合不良,1例发生移植人工血管内血栓形成。术后心脑血管重大事件发生率分别为4.7%和12.1%。结论介入手术治疗与外科开放手术治疗均为处理老年病人股浅动脉支架术后再狭窄的有效手段,但介入治疗组病人的心脑血管重大事件发生率及严重并发症发生率明显降低。     

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     

西罗莫司和紫杉醇洗脱支架治疗支架内再狭窄的临床近期及10个月疗效

目的比较西罗莫司洗脱支架（Cypher或Cypher select）和紫杉醇洗脱支架（TAXUS）治疗支架内再狭窄的临床近期及10个月疗效。方法自2002年12月至2005年3月,对253例支架内再狭窄的患者采用了药物洗脱支架（DES）治疗并完成了10个月的临床随访和冠状动脉造影复查。253例中男性218例,女性35例,年龄30～80岁,平均年龄57．2岁。结果253例（262处病变）中152例使用Cypher支架176个,101例使用TAXUS支架132个。使用的Cypher和TAXUS支架的平均直径分别为（2．96±0．27）mm和（3．05±0,35）mm,P=0．04,平均长度分别为（23.31±6．68）mm和（23．56±6．54）mm,P=0．745。支架内再狭窄表现为100％闭塞29处,≥90％狭窄143处,〈90％狭窄90处。病变类型为A、B1、B2和C型各为9处、45处、73处和135处。PCI的成功率两组均为100％,住院期间无死亡,Cypher组主要心脏不良事件（MACE）发生率为2．63％,TAXUS组为2．97％,P=0．872。10个月临床造影显示在Cypher支架和TAXUS支架组中造影再狭窄率分别为14．0％和29．4％,P=0．075,MACE发生率分别为6．7％和16．0％,P=0．031。结论应用Cypher和TAXUS支架治疗支架内再狭窄有良好的近期临床疗效,10个月疗效Cypher支架优于TAXUS支架。     

Rho激酶与支架内再狭窄

目的 支架内再狭窄与血管平滑肌分化、迁移,细胞外基质的过度增值所致新生内膜增生密切相关.Rho激酶参与支架置入引起的新生内膜增生的调节.长期抑制Rho激酶的表达可阻止新生内膜的增生,可能成为防止支架内再狭窄的一种方法.     

剪切力与支架内再狭窄

研究表明支架内再狭窄主要由内膜增生、边缘重构和炎症反应等引起。边缘重构对支架内再狭窄与非支架内再狭窄的主要区别在于剪切力的不同。而剪切力能对内皮细胞的形态和功能产生影响。因此,剪切力、内皮细胞和支架内再狭窄三者关系密切。     

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。     

颈动脉支架置入后支架内再狭窄

颈动脉支架置入术已成为颈动脉狭窄的有效治疗方法之一.支架内再狭窄是影响颈动脉支架置入术远期效果的主要原因之一,也是影响患者预后的重要因素.支架内再狭窄的监测、预防和治疗始终是临床上的一大难题.文章就近年来支架内再狭窄的相关研究进展做了综述.     

Late restenosis following placement of a sirolimus eluting stent for in-stent restenosis

Drug eluting stents (DES) are rapidly replacing intravascular brachytherapy for the treatment of bare metal in-stent restenosis (ISR). To date, there are no long-term follow up data supporting this practise. We report symptomatic repeat in-stent restenosis occurring 27 months after sirolimus eluting stent deployment for de novo in-stent restenosis. This case suggests that in a subgroup of patients with ISR, as with brachytherapy, the drug eluting stent may be simply delaying rather than inhibiting the restenotic process.     

Long-term effects of octreotide therapy on in-stent restenosis

The purpose of this study was to assess the long-term effects of octreotide therapy on in-stent restenosis at 6-month follow-up coronary angiography and the clinical events after stenting. A randomized, double-blind, placebo-controlled trial was conducted to assess the effects of octreotide on restenosis after stenting. The patients (n = 148) received either subcutaneous octreotide or placebo 1h before the stenting procedure and then every 8h for 3 weeks. Percent diameter stenosis was interpreted before and after stenting, and on a 6-month follow-up coronary angiogram by quantitative coronary angiography. The mean percent diameter stenosis of the octreotide group was significantly lower than that of the placebo group on the 6-month follow-up coronary angiograms (18.8% ± 14.2% vs 35.0% ± 19.2%, respectively; P = 0.001). The restenosis rate of the octreotide group was statistically lower than that of the placebo group (11.8% vs 26.4%, respectively; P 0.05). With regard to major cardiovascular events, there was no significant difference between the octreotide and placebo groups. The administration of octreotide for treatment of in-stent restenosis results in a relatively low long-term angiographic restenosis rate and no significant acute effects on cardiovascular clinical events.     

What is the best contemporary treatment for in-stent restenosis?

In-stent restenosis (ISR) remains a challenging problem in percutaneous coronary intervention and the optimal treatment strategy remains unclear. The aim of this study was to compare the 18 month clinical outcomes in patients receiving sirolimus-eluting stents (SES) with vascular brachytherapy (VBT) for the treatment of ISR. Twenty-five consecutive patients treated with VBT were compared with 29 patients who had SES deployment for ISR. Major adverse cardiac events (MACE) were defined as a combination of death from cardiac causes, nonfatal myocardial infarction, or repeat TVR. At 18 month follow-up, the MACE rate was significantly lower in the SES compared with the VBT group (14% vs 40%, P=.03). One patient in the VBT group developed late stent thrombosis (at 10 months) and died; there was no stent thrombosis in the SES group. This observational study, taken with other recent reports, offers further credence to the use of SES for ISR. The results of randomized comparisons with VBT are awaited with interest.     

Optimizing dosimetry with high-dose intracoronary gamma radiation (21 Gy) for patients with diffuse in-stent restenosis

BACKGROUND: The efficacy of intracoronary gamma radiation (IRT-gamma) in reducing recurrent in-stent restenosis (ISR) is well established using doses of 14-18 Gy. We sought to examine whether an escalation in dose to 21 Gy is safe and confers additional benefit in reducing repeat revascularization and major adverse cardiac events (MACE) in patients with diffuse ISR. METHODS: Forty-seven patients with diffuse ISR (lesion length 20-80 mm) in native coronary arteries (n=25) and saphenous vein grafts (n=22) underwent percutaneous transluminal coronary angioplasty and/or additional stents followed by IRT-gamma using the Checkmate system (Cordis) with a dose of 21 Gy. All patients were discharged with clopidogrel for 12 months and aspirin indefinitely. Six-month angiographic and 12-month clinical outcomes of these patients were compared to 120 patients treated with 18 Gy using the same system. RESULTS: At baseline, patients in the 21-Gy group had more multivessel, vein graft disease and history of prior myocardial infarctions and coronary artery bypass grafts (P<.001). The use of debulking devices and stents was less in this group (P<.001). Procedural and in-hospital complications were similar. Follow-up at 6 months revealed nonsignificant but lower late loss (in-stent, 0.33+/-0.7 mm; in-lesion, 0.41+/-0.6 mm) in the 21-Gy group compared to the 18-Gy group; follow-up at 12 months revealed a trend toward less overall myocardial infarction, although repeat revascularization and MACE rates were similar. CONCLUSIONS: IRT-gamma therapy for diffuse ISR lesions with a 21-Gy dose is clinically safe and feasible with marked reduction in late loss but does not confer additional benefit with regard to repeat revascularization and MACE when compared to a dose of 18 Gy.     

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.     

普通球囊与切割球囊成形术对冠状动脉支架内再狭窄的近远期疗效

目的　对切割球囊成形术 (CBA)与普通球囊成形术 (POBA)支架内再狭窄病变的近远期血管造影结果比较 ,评价 CBA对支架内再狭窄病变的有效性。方法　 37例 ,共 39处病变 ,2 3处进入 CBA组 ,16处进入 POBA组。分别比较术后即刻及远期定量冠状动脉造影最小血管径 (ML D)、狭窄度 (DS)、再狭窄率、即刻管腔获得 (AL G)、即刻血管弹性回缩 (AR)及弹性回缩率 (ARR)。结果　术后即刻 ML D、DS、AL G两组差异无显著性。 CBA组最大扩张压、AR及 ARR均较 POBA组低 (P<0 .0 5或 P<0 .0 0 1)。随访造影结果 ,CBA组 ML D明显大于 POBA组 (P<0 .0 5 ) ;DS及再狭窄率均小于 POBA组 (P<0 .0 1)。结论　 CBA组的低压扩张治疗支架内再狭窄病变是有效的 ,对血管损伤小于 POBA,且获得较 POBA低的再狭窄率 ,值得进一步探讨     

Registry data evaluating the effectiveness of drug-eluting stents for the treatment of symptomatic in-stent restenosis

BACKGROUND: In this new-era of drug-eluting stents (DES) the impact of symptomatic in-stent restenosis (ISR) is diminishing. However, world wide bare-metal stents remain widely used and therefore, it is imperative to establish a simple and effective form of treatment. The objective of this registry database was to evaluate the 'real-world' effectiveness of DES for the treatment of symptomatic bare-metal stent ISR. METHODS: All patients presenting with symptomatic ISR were evaluated between February 2003 and February 2005. Patients had 9-month angiographic follow-up with primary endpoint evaluation of binary restenosis (>50%). Secondary endpoints included in-segment late loss, target lesion revascularization (TLR) and the difference in late loss between sirolimus (n=23) and paciltaxel (n=36) eluting stents. RESULTS: Fifty eight patients with fifty nine ISR lesions were evaluated, 36% of patients had diabetes mellitus. All procedures were performed safely with no adverse peri-procedural events documented. At 9-month follow-up the median in-segment late loss was 0.24 mm (IQR 0.1, 0.53), with a binary restenosis rate of 17%. At long-term follow-up greater than 1 year, the incidence of TLR was 10%. No difference in the angiographic parameter of in-segment late loss was seen between the sirolimus and paclitaxel-eluting stents. CONCLUSIONS: In this cohort of patients with long-term angiographic and clinical follow-up, DES is an effective and safe treatment for symptomatic bare-metal stent ISR.     

血清高迁移率族蛋白2与冠状动脉支架内再狭窄的关系研究

目的:探讨血清高迁移率族蛋白2(HMGB2)与冠状动脉支架内再狭窄(ISR)的关系。方法:在行经皮冠状动脉介入术并于约1年后行冠脉动脉造影复查的2 513例患者中,262例为ISR患者(ISR组),于剩余患者中随机入选298例无ISR的冠心病患者作为对照(无ISR组)。检测患者血清HMGB2水平及生化指标,并收集患者的临床资料。多变量logistic回归分析发生ISR的独立危险因素。结果:ISR组血清HMGB2水平显著高于无ISR组(P0.001)。与无ISR组相比,ISR组患者的吸烟率及糖尿病、高脂血症和心肌梗死的发生率更高,血清肌酐、总胆固醇、高敏C反应蛋白、低密度脂蛋白胆固醇水平更高,使用胰岛素治疗更多,冠状动脉病变更严重,累及的血管更多,肾小球滤过率、血清高密度脂蛋白胆固醇、左室射血分数更低,使用双重抗血小板治疗及他汀类药物治疗更少,支架直径更小(P均0.05)。HMGB2水平按三分位数分组,多变量logistic回归分析在校正了可能的混杂因素后,血清HMGB2高水平组发生ISR的风险是低水平组的6.532倍(OR=6.532,95%CI:3.605~11.834,P0.001),中水平组发生ISR的风险是低水平组的2.175倍(OR=2.175,95%CI:1.207~3.919,P=0.010)。结论:血清HMGB2水平与ISR的发生相关,是ISR的独立危险因素。