光学相干断层成像评价药物洗脱支架置入术后晚期支架贴壁不良

目的 探讨药物洗脱支架(DES)置入术后晚期支架贴壁不良的特点.方法 分析32例(包括51支血管、共置入71个支架)置入DES 1年后[(14.8±5.2)个月]行光学相干断层成像(OCT)检查的患者资料,对支架节段的OCT图像每间隔0.5 mm取1帧图像进行分析,找出贴壁不良的支架金属结构,测量支架到参照血管内壁的距离及支架表面内膜厚度,分析晚期支架贴壁不良的特点.结果 OCT检查在7例(21.9%)患者中检出支架贴壁不良,其中4例合并支架段血管的正性重构,1例重叠置入支架,2例发现由血栓覆盖支架金属结构,7例患者随访期间无心脏不良事件发生.97.6%的支架金属结构完全贴壁并不同程度的内膜覆盖,2.4%的支架金属结构贴壁不良,包括1.2%的支架金属结构位于血管分支开口.位于血管分支开口的支架金属结构与其他贴壁不良支架表面的内膜覆盖厚度差异无统计学意义[(0.06±0.05)mm比(0.05±0.03)mm,P>0.05].绪论晚期支架贴壁不良见于DES置入最初的贴壁不良、血管壁正性重构、重叠置入支架以及支架金属结构位于分支血管开口;贴壁不良的支架金属结构表面亦有不同程度的内膜覆盖.     

血管内超声评估冠状动脉管腔狭窄伴外弹力膜扩张性血管重构的临床研究

目的:应用血管内超声评估冠状动脉(冠脉)管腔狭窄伴外弹力膜扩张性血管重构的临床研究.方法:103例急性冠状动脉综合症(ACS)患者,男68例,女35例,年龄平均(60±11)岁;常规冠脉造影,血管内超声检测103处靶病变和参考血管处动脉粥样斑块形态学参数.将重构指数＞1为正重构组(n=67),重构指数≤1为负重构组(n=36);计算靶病变处管腔面积与平均参考段的管腔面积的比值(称为管腔狭窄比值).比较分析重构分组之间的斑块形态学特点,比较两组在病变处与参考段之间的差异;并进行管腔狭窄、外弹力膜扩张与斑块负荷的相关性分析.结果:103例患者中有5例ACS患者靶病变的管腔面积与平均参考血管的管腔面积相同,1例患者未见参考血管段的病变.102例存在参考血管段病变患者的资料统计显示,靶病变处与近端和远端参考段比较,斑块负荷的明显增加[依次为(71.76±9.17)%,(39.76±12.54)%,(32.38±13.97)%];管腔面积缩小[依次为(3.81±1.09)mm2,(8.91±2.43)mm2,(9.03±2.16)mm2];靶病变处与远端参考段比较,病变处外弹力膜(EEM)面积缩小[(14.71±2.89)mm2 vs(28.37±4.48)mm2],差异有统计学意义(P均＜0.001).管腔狭窄比值与斑块负荷呈负相关性(r=-0.84,P＜0.001)而与管腔面积呈正相关性(r=0.70,P=0.007);重构指数与其他参数未见相关性.结论:ACS患者冠状动脉存在着管腔狭窄伴外弹力膜扩张的双向重构,管腔狭窄比值可能是评估重构的重要指标.     

急性心肌梗死患者药物支架置入术后支架贴壁不良特征及对预后的影响

目的探讨急性心肌梗死患者置入西罗莫司药物洗脱支架后,支架贴壁不良(ISA)的特征及ISA对临床预后的影响。方法选择197例冠心病(300处病变)患者置入西罗莫司药物洗脱支架。根据临床表现分为急性心肌梗死组(67例,117处病变),不稳定性心绞痛组(73例,99处病变),稳定性心绞痛组(57例,84处病变)。术后1年血管造影时利用血管内超声观察各组患者支架置入处ISA的发生率和特征.根据ISA造声情况又分为贴壁不良患者和非贴壁不良患者.并在复查后1年临床随访主要不良心脏事件(包括靶病变再次血运重建,非致命性心肌梗死,心源性死亡和全因死亡)。结果急性心肌梗死组支架置入后,有17例患者(17处病变.25.4%)在1年随访检查时存在ISA,明显高于不稳定性心绞痛组(7例患者,7处病变,9.6%)和稳定性心绞痛组[(4例患者,4处病变,7.0%),P=0.005]。多因素回归分析显示,病变长度(OR=1.068,P=0.037)、急性心肌梗死(OR=2.399,P=0.031)和非糖尿病(OR=6.472.P=0.013)是晚期ISA的独立危险因素。对ISA患者1年临床随访显示,ISA患者与非ISA患者主要心脏不良事件无统计学差异(7.1% vs 2.4%,P=0.203)。结论急性心肌梗死患者置入西罗莫司药物洗脱支架后ISA的发生率较高。支架置入后晚期ISA与临床事件的关系仍需进一步研究。     

药物洗脱支架治疗支架内再狭窄的对照研究

目的 比较3种药物洗脱支架(DES)治疗支架内再狭窄的长期临床效果.方法 回顾性分析阜外医院对支架内再狭窄病例用DES行经皮冠状动脉介入治疗(PCI)的390例患者,其中雷帕霉素药物洗脱支架(Cypher)组187例(C组),紫杉醇药物涂层支架(Taxus)组89例(T组),国产雷帕霉素涂层支架(Firebird)组114例(F组).结果 T组不稳定性心绞痛比率高于另2组,F组左主干病变比率低于另2组,而3支病变比率高于另2组.3组平均临床随访时间为864、848和719 d,主要不良心脏事件发生率差异无统计学意义(P=0.081),3组总的支架内血栓发生率差异无统计学意义(P=0.605).7个月造影随访支架内和血管段再狭窄率T组有增高的趋势(17.9%比29.4%比13.6%.P=0.214和21.8%比35.3%比15.9%,P=0.132).支架内和血管段的晚期丢失T组均明显大于另外2组[(0.31±0.12)mm比(0.75±0.24)mm比(0.31±0.13)mm,P=0.000和(0.33±0.18)mm比(0.61±0.23)mm比(0.31±0.14)mm,P=0.001].结论 3种DES治疗支架内再狭窄病变的长期疗效相似,Cypher和Firebird抑制内膜增生的作用更强.     

生物可降解与非可降解雷帕霉素药物洗脱支架一年临床及七个月造影随访

目的 比较牛物可降解雷帕霉素洗脱支架(Excel,山东古威医疗制品有限公司)和非可降解雷帕霉素洗脱支架(Cypher,美国Cordis公司)的临床效果.方法 回顾性分析从2006年5月至2006年11月在阜外心血管病医院连续置入Excel支架[E组:n:350,(58.1±10.9)岁]和Cypher 支架[C组:n=241,(56.4±10.7)岁]的591例患者.结果 临床基线上E组既往心肌梗死(MI)比率大于C组,左主干病变比率少于C组,而3支病变比率大于C组.基线病变特点上E组参照血管直径、支架卣径、后扩张比率和支架内最小直径均小于C组.两组介入成功率均为100%.主要不良心血管事件发生率E组与C组比较差异无统计学意义(8.3%比7.1%,P=0.641),其巾心原性死亡、非致死性MI和靶血管血运重建率两组差异尤统计学意义(分别为0.9%比0.0%,P=0.274;2.0%比1.2%,P=0.747;5.4%比5.8%,P=0.857).支架内血栓形成发生率E组和C组差异无统计学意义(0.9%比0.4%,P=0.649),早期、晚期支架内血栓形成发牛率两组差异亦无统计学意义(分别为0.6%比0.0%,P=0.516;0.3%比0.4%,P=1.000).7个月造影随访支架内和血管段冉狭窄率E组和C组差异无统计学意义(分别为4.7%比3.2%,P=0.725;5.6%比3.2%,P=0.505),但支架内和血管段的管腔晚期丢失E组均明显小于C组[分别为(0.18 ±0.07)mm比(0.21±0.08)mm,P<0.001;(0.21±0.09)mm比(0.23±0.11)mm,P:0.003].结论 Excel和Cypher支架在真实世界应用具有相似的良好效果.     

可降解涂层与不可降解涂层雷帕霉素洗脱支架在急性心肌梗死直接经皮冠状动脉介入治疗中的疗效比较

目的 比较可降解涂层雷帕霉素洗脱支架(Excel)与不可降解涂层雷帕霉素洗脱支架(Cypher Select)在急性ST段抬高型心肌梗死直接经皮冠状动脉介入治疗中的有效性和安全性.方法 连续入选的228例急性ST段抬高型心肌梗死患者随机分至Cypher组(113例)和Excel组(115例).主要终点为术后12个月主要不良心脏事件(包括死亡、心肌梗死和靶血管重建),次要终点为9个月晚期管腔丢失和支架再狭窄.结果 术后9个月Cypher组和Excel组分别有43例(38.1%)和48例(42.1%)患者接受冠状动脉造影随访,两组支架内晚期管腔丢失[(0.17±0.26)mm比(0.18±0.33)mm,P=0.483]、节段内晚期管腔丢失[(0.19±0.36)mm比(0.20±0.42)mm,P=0.419)和支架内再狭窄(2.3%比2.1%,P=0.937)、节段内再狭窄(4.7%比6.3%,P=0.738)的发生率差异无统计学意义.术后12个月Cypher组和Excel组死亡(3.5%比2.6%,P=0.692)、心肌梗死(1.8%比2.6%,P=0.658)、靶血管重建(1.8%比2.6%,P=0.658)、主要不良心脏事件(5.3%比6.1%,P=0.788)及支架内血栓形成(4.4%比3.5%,P=0.724)的发生率差异无统计学意义.结论 可降解涂层与不可降解涂层雷帕霉素洗脱支架在直接经皮冠状动脉介入治疗急性ST段抬高型心肌梗死中的近期疗效和安全性可能是一致的,其远期效果有待进一步研究.     

不同支架植入方式对小血管支架内再狭窄的影响

目的:观察不同支架植入方式对小血管（血管直径≤2.75 mm）支架内再狭窄的影响。方法: 对69（男51,女18）例患者共111处病变进行治疗,实验组（n=38）直接植入支架64枚（雷帕霉素药物洗脱支架53枚,紫杉醇药物洗脱支架11枚）,对照组（n=31）预扩张后植入支架47枚（雷帕霉素药物洗脱支架41枚,紫杉醇药物洗脱支架6枚）,两组患者术后即刻行冠脉血管内超声(IVUS)检测最小支架直径及横截面积。术后有胸闷胸痛症状患者即刻行冠脉造影术及IVUS,无症状患者6个月后复查。通过IVUS检测,对两组管腔丢失及支架内再狭窄率进行比较。结果: 两组支架植入术后即刻最小支架直径实验组为（2.38±0.26）mm,对照组为（2.34±0.24）mm（P＞0.05）;支架横截面积实验组为（4.5±1.0）mm2,对照组为（4.3±0.9）mm2（P＞0.05）;6个月随访后复查两组管腔丢失,实验组为（1.44±0.30）mm,对照组为（0.98±0.24）mm（P=0.01）;支架内再狭窄发生率实验组为15 %;对照组为30%（P＜0.05）。结论: 对冠状动脉小血管病变患者直接药物洗脱支架植入组支架内再狭窄发生率低于预扩张后支架植入组。     

西罗莫司洗脱支架与紫杉醇洗脱支架抑制血管内膜增生的血管内超声比较

目的:利用血管内超声(IVUS)方法比较西罗莫司洗脱支架(CypherTM)与紫杉醇洗脱支架(TaxusTM)对冠心病患者新生内膜增生的抑制作用.方法:自2003-05至2007-04,167例冠心病患者(227处病变)行药物洗脱支架术,并在术后1年行冠状动脉造影和IVUS检查.其中107例患者(138处病变)置入CypherTM支架(Cypher组),60例患者(89处病变)置入TaxusTM支架(Taxus组).结果:两组患者基础临床情况及病变特征相似.造影结果分析显示,Cypher组支架内晚期管腔丢失、节段内晚期管腔丢失明显小于Taxos组[分别为(0.16±0.27)mm比(0.43±0.51)mm,P<0.01;和(0.20±0.32)mm比(0.38±0.33)mm,P=0.01],而两组近端和远端参考血管晚期管腔丢失差异无统计学意义[分别为(0.13±0.29)mm比(0.15±0.32)mm,P=0.689;和(0.08±0.12)mm比(0.09±0.16)mm,P=00500].IVUS分析显示,两组平均支架面积、平均管腔面积、最小支架面积、平均支架体积、平均管腔体积差异均无统计学意义,而Cypher组与Taxus组比平均内膜增生面积[(0.33±0.45)mm2比(1.29±1.26)mm2]、平均内膜增生面积百分数[(5.42±7.33)%比(17.38±13.75)%]、内膜增生最大面积百分数[(10.13±13.85)%比(31.56±20.99)%]、平均内膜增生容积[(2.23±6.50)mm3比(13.43±18.59)mm3]和平均内膜增生容积百分数[(1.59±4.10)%比(8.62±9.90)%],Cypher组均较Taxus组明显减小(P<0.0001),差异均有统计学意义.结论:CypherTM支架治疗冠心病一年再狭窄发生率较低,与TzxusTM支架相比,抑制内膜增生作用更显著.     

采用光学相干断层成像评价无再狭窄药物洗脱支架内膜增生

目的应用冠状动脉血管内光学相干断层成像技术(optical coherence tomography,OCT)评价造影随访无再狭窄的药物洗脱支架(drug eluting stent,DES)内皮增生情况。方法从北京安贞医院2007年9月至2008年9月连续入选DES术后无症状而接受冠状动脉造影复查无明显再狭窄的患者18例,所有患者接受OCT检查,比较不同的DES植入时间、不同DES组之间,每组支架小梁血管内膜增生情况。结果共分析4709个支架小梁,其中被内皮完全覆盖的支架小梁个数4173个(88.6%),被内皮部分覆盖的个数是33个(0.7%),暴露的小梁个数382个(8.1%);贴壁不良的小梁个数121个(2.6%),覆盖支架小梁的内膜的平均厚度是0.099mm,内膜厚度100μm的小梁个数2378个(50.5%);不同药物洗脱支架之间内膜增生厚度、支架小梁内膜覆盖及晚期支架贴壁不良差异有统计学意义;与DES植入时间12个月相比,植入时间12个月血管内膜增生厚度有明显增加趋势(0.1183mm比0.0875mm;P=0.001);支架内膜无覆盖比率分别是:1.7%比6.8%(P0.05);贴壁不良比率是:2.1%比0.5%(P0.001)。结论通过OCT分析16个月左右的药物洗脱支架血管内膜厚度,总的来说90.1%的支架小梁有内膜覆盖,但是仍然有高达9.9%的无内膜覆盖,支架类型、支架置入时间之间内膜覆盖、支架贴壁有一定差异;同时支架植入大于12个月的支架贴壁不良比率高于不足12个月的,提示更晚期的支架贴壁不良情况存在,对于药物洗脱支架的随访时间应该更长,双联抗血小板治疗疗程也许应该更长。     

国产西罗莫司洗脱支架与紫杉醇洗脱支架抑制血管内膜增生的血管内超声比较研究

目的利用血管内超声（IVUS）方法比较国产西罗莫司洗脱支架（Firebird^TM）与紫杉醇洗脱支架（Taxus^TM）对冠心病患者新生内膜增生的抑制作用。方法自2003年5月至2007年6月,203例冠心病患者（283处病变）行药物洗脱支架术并在术后1年行冠状动脉造影和血管内超声（IVUS）检查。其中136例患者（185处病变）置入Firebird^TM支架（Firebird组）,67例患者（98处病变）置入TaxusTM支架（Taxus组）。结果203例患者（283处病变）中168例患者（236处病变）接受了一年随访造影和血管内超声检查,其中Firebird组108例患者（147处病变）,Taxus组60例患者（89处病变）。两组患者基础临床情况及造影特征相似。Firebird组支架内晚期管腔丢失（0.17±0.29mm比0.43±0.51mm,P〈0.0001）和节段内晚期管腔丢失（0.18±0.36mm比0.38±0.33mm,P=0.003）明显小于Taxus组,而两组近端参考血管晚期管腔丢失（0.11±0.27mm比0.15±0.32mm,P=0.321）和远端参考血管晚期管腔丢失（0.08±0.10mm比0.09±0.16mm,P=0.483）差异并无统计学意义。IVUS分析显示,两组间平均支架面积、平均管腔面积、最小支架面积、平均支架体积、平均管腔体积比较,差异均无统计学意义。但Firebird组平均内膜增生面积（0.35±0.58mm^2比1.29±1.26mm^2,P〈0.0001）、平均内膜增生面积百分数（5.45%±9.26%比17.38%±13.75%,P〈0.0001）、内膜增生最大面积百分数（9.41%±14.15%比31.56%±20.99%,P〈0.0001）、平均内膜增生容积（2.09±5.46mm^3比13.43±18.59mm^3,P〈0.0001）和平均内膜增生容积百分数（1.68%±5.84%比8.62%±9.90%,P〈0.0001）较Taxus组均明显减少。结论国产西罗莫司洗脱支架（Firebird^TM）置入术后再狭窄发生率较低,与TaxusTM支架相比,抑制内膜增生作用更显著。     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

目的 以血管内超声评价雷帕霉素洗脱支架置人术后发生支架内再狭窄及血栓形成的机械性危险因素.方法 对雷帕霉素洗脱支架置入术后发生支架内再狭窄或早期(≤30 d)血栓形成的60例患者(事件组)及无支架内再狭窄和早期血栓形成的34例患者(无事件组)的血管内超声资料进行分析比较.结果 事件组发生支架内再狭窄43例,早期血栓形成17例.与无事件组比较,事件组的最小支架面积(MSA)[(4.6±1.6)mm2比(5.8±1.6)mm2,P＜0.01]、最小支架直径[(2.2±0.5)mm比(2.5±0.4)mm,P＜0.01]和支架扩张率[(69.2±20.7)%比(80.6±17.2)%,P＜0.01]较小、纵向支架对称性较差(2.0±0.6比1.7±0.6,P＜0.05).MSA＜4 mm2(43.3%比14.7%,P＜0.01)和支架扩张率＜60%(40.7%比11.8%,P＜0.01)在事件组较常见.与无事件组比较,事件组的近段残余斑块负倚较大[(49.0±15.5)%比(38.4±17.6)%,P＜0.01].Logistic回归分析显示,MSA(OR:0.7,95%CI:0.5～0.8,P＜0.01)和近段残余斑块负荷(OR:280.7,95%CI:17.2～40 583.6,P＜0.01)是药物洗脱支架发生再狭窄或早期血栓形成的独立预测因素.结论 较小的MSA和较重的近段残余病变易导致雷帕霉素洗脱支架发生支架内冉狭窄及早期血栓形成.     

Two-year follow-up intravascular ultrasound analysis after bare metal stent implantation in 120 lesions.

The objective of this study was to examine long-term changes after bare metal stent implantation in a relatively large number of patients. There are few reports of intravascular ultrasound (IVUS) studies performed on stented and nonstented (reference) segments beyond 6 months after bare metal stenting. Using IVUS, we evaluated serial changes in stented and reference segments between 6 and 24 months after stent implantation in 110 patients with 120 lesions. Serial IVUS images were acquired at five equidistant intrastent sites and at two different reference segment sites. Measurements were made of the external elastic membrane (EEM), stent, lumen, and intimal hyperplasia (IH = stent - lumen) area. For the whole patient group, between 6 and 24 months, the mean IH area in stented segments decreased from 2.6 +/- 1.0 to 2.3 36+/- 0.9 mm2 (P < 0.001), and the mean lumen area increased from 6.2 +/- 2.0 to 6.5 +/- 1.9 mm2 (P < 0.001). The mean IH area decreased in 91 lesions (76%) and increased in 29 lesions (24%) between 6 and 24 months. There were no significant changes in EEM or lumen area in the reference segments. Late angiographic restenosis (diameter stenosis > or = 50%) occurred in three lesions between 6 and 24 months. A late target lesion revascularization was performed for one lesion. In the period of time between 6 and 24 months after stenting, IH regression occurred in most (76%) stent lesions, resulting in late lumen increase. However, IH progression was observed in 24% of in-stent lesions. No significant changes of EEM or lumen area occurred in the reference segments.     

Late incomplete stent apposition after sirolimus-eluting stent implantation: a serial intravascular ultrasound analysis.

OBJECTIVES: We sought to identify the frequency of incomplete stent apposition (ISA) in sirolimus-eluting stents (SES) and clarify its findings and clinical sequelae. BACKGROUND: Late-acquired ISA has been reported in bare-metal stents (BMS) and brachytherapy and recently in drug-eluting stents. However, the characteristics of late ISA in SES have not been clarified. METHODS: From the SIRIUS trial, a randomized, multicenter study comparing SES and BMS, serial qualitative intravascular ultrasound (IVUS; at stent implantation and eight-month follow-up) was available in 141 patients (BMS: n = 61; SES: n = 80). The IVUS images were reviewed for the presence of ISA. RESULTS: Incomplete stent apposition at follow-up was observed in 19 patients (BMS: n = 6 [9.8%]; SES: n = 13 [16.3%]; p = NS). Among these, 12 had ISA after intervention and at follow-up (persistent ISA). Late-acquired ISA was seen in the remaining seven cases, all from the SES group (BMS: n = 0; SES: n = 7 [8.7%]; p < 0.05). In late-acquired ISA, there was an increase in external elastic membrane area (after intervention: 16.2 +/- 2.7 m2; follow-up: 18.9 +/- 3.6 mm2; p < 0.05). The location of stent-vessel wall separation was primarily at the stent edges in persistent ISA cases, whereas late-acquired ISA in SES occurred mostly in the mid portion of the stent. There were no negative clinical events reported for any ISA cases at 12-month clinical follow-up. CONCLUSIONS: Late ISA was observed in 8.7% of patients after SES implantation. There were no negative clinical events associated with this IVUS finding at 12-month clinical follow-up; however, careful long-term follow-up will be necessary.     

血管内超声对急性冠状动脉综合征临界病变治疗决策的影响

目的 在血管内超声指导下评价急性冠状动脉综合征(ACS)患者易损斑块介入治疗和单纯药物治疗的疗效和安全性.方法 入选ACS经冠状动脉造影显示狭窄程度在50%-70%的临界狭窄病变患者100例,采用完全随机方法分为介入治疗组和药物治疗组,每组各50例.其中男78例,女22例,年龄在43～74(60.4±14.1)岁.每组再根据血管内超声(IVUS)测定的罪犯病变最小血管腔面积(MLA)分为2个亚组,即MLA≥4 mm2组和MLA＜4 mm2组.对比分析在IVUS指导下临界病变易损斑块介入治疗和单纯药物治疗两组患者住院期间和随访10～12个月的疗效.结果 介入治疗组50例中40例在术后10～12个月进行了冠状动脉造影和IVUS复查,IVUS味发现局部支架内血栓征象,支架内增生内膜负荷量与术后即刻比较差异无统计学意义.随访时最小支架内管腔面积与术后即刻相比差异亦无统计学意义[(8.98±2.12)mm2比(10.12±1.15)mm2,P＞0.05].药物治疗组50例中有9例在随访期间行经皮冠状动脉介入治疗,35例在术后10～12个月进行了冠状动脉造影和IVUS复查,IVUS结果与治疗前比较,狭窄处的MLA较大[(7.32±1. 42)mm2比(4.98±0.89)mm2,P＜0.01],斑块面积较小[(7.70±2.09)mm2比(10.01±2.55)mm2,P＜0.05],斑块负荷较低[(55.94±8.36)%比(67.97±9.36)%,P＜0.01],斑块内低回声区面积较小[(2.27±0.79)mm2比(4.08±0.80)mm2,P＜0.01].介入治疗组MLA≥4 mm2亚组中1例术后第2天前降支支架急性血栓形成.药物治疗组MLA＜4 mm2亚组中9例[37.5%(9/24)]患者在临床随访期间仍反复发作心绞痛,行介入治疗后未再发心绞痛.结论 IVUS测定MLA≥4.0 mm2的ACS 临界病变患者经严格药物治疗可延缓易损斑块进展,使斑块趋于稳定.

Abstract：

Objective To compare the efficacy and safety between the interventional and conservative treatment options for borderline vulnerable plaque lesion in acute coronary syndrome (ACS)patients by intravascular ultrasound(IVUS). Methods A total of 100 ACS patients [78 male, age 43 -74 (60. 4 ± 14. 1 ) years] undergoing coronary angiography (CAG) with borderline lesion ( coronary artery stenosis between 50% - 70% ) were enrolled in May 2007 to February 2009, who were randomly divided into PCI group (50 patients) and conservative therapy group (50 patients). According to minimal lumen area (MLA) detected by IVUS, patients were further divided into MLA ≥4. 0 mm2 sub-group and MLA ＜4.0 mm2 sub-groups. Outcomes during hospitalization and after 10- 12 month follow-up were compared. Results IVUS was performed in 40 patients at 10 - 12 months post PCI, there was no in-stent thrombosis and the extent of stent neointimal hyperplasia was comparable as at the time of immediately post PCI. IVUS was performed in 35 patients at 10 - 12 months post conservative therapy, IVUS results showed that MLA increased signilicantly [(7.32 ± 1.42 ) mm2 vs. (4. 98 ± 0. 89 ) mm2, P ＜ 0. 01], while plaque area [(7.70 ±2.09)mm2 vs. (10.01 ±2.55)mm2,P＜0.05], plaque burden [(55.94 ±8.36)% vs. (67.97 ±9. 36) %] and low echo area [(4. 08 ± 0. 80) mm2 vs. (2. 27 ± 0. 79) mm2] were significantly decreased at follow up compared to those as baseline ( all P ＜0. 01 ). There was one patient in PCI group with MLA ≥4. 0 mm2 developed acute in-stent thrombosis in left anterior descending artery two days after the procedure and 9 patients in conservative therapy and MLA ＜ 4. 0 mm2 group received PCI due to recurrent angina pectoris during follow-up. Conclusions For the borderline lesion with MLA≥4.0 mm2 detected by IVUS, adequate medication could effectively attenuate and or reverse the plaque progression and stabilize plaque.     

国产与进口西罗莫司洗脱支架置入后血管内超声随访的对比

目的 利用血管内超声对比观察国产与进口西罗莫司洗脱支架对冠心病患者支架术后新生内膜增生的抑制作用.方法 2003年5月至2007年3月,对215例冠心病患者(317处病变)置入西罗莫司洗脱支架,并在术后1年行冠状动脉造影和血管内超声(IVUS)检查.其中Firebird组108例患者(147处病变)置入国产西罗莫司洗脱支架(Firebird支架),Cypher组107例患者(138处病变)置入进121西罗莫司洗脱支架(Cypher支架).结果 两组患者一般临床情况差异无统计学意义.两组靶病变部位、病变长度、狭窄程度及病变类型差异均无统计学意义,但Firebird组术后最小管腔直径大于Cypher组[(2.88±0.43)mm比(2.78±0.33)mm,P＜0.05].随访定量冠状动脉造影分析显示,Firebird组与Cypher组支架内晚期管腔丢失[(0.17±0.29)mm比(0.16±0.27)mm,P＞0.05]和节段内晚期管腔丢失[(0.18±0.36)mm比(0.20±0.32)mm,P＞0.05]差异均无统计学意义.IVUS分析显示,与Cypher组比较,尽管Firebird组支架面积[(6.99±2.25)mm~2比(6.46±1.71)mm~2,P＜0.05]、管腔面积[(6.89±2.30)nm~2比(6.36±1.73)mm~2,P＜0.05]、支架体积[(162.5±68.9)mm~3比(140.8±57.9)mm~3,P＜0.01]、管腔体积[(160.4±69.5)mm~3比(138.6±57.6)mm~3,P＜0.01]及最小支架面积[(5.40±1.85)mm~2比(4.92±1.43)mm~2,P＜0.05]均较大,但两组的内膜增生容积[(2.09±5.46)mm~3比(2.23±6.50)mm~3,P＞0.05]和内膜增生容积百分数[(1.68±5.84)%比(1.59±4.10)%,P＞0.05]差异均无统计学意义.结论 Firebird支架置人后再狭窄的发生率较低,抑制内膜增生作用与Cypher支架相似.     

Distribution pattern of neointimal hyperplasia following sirolimus-eluting stent implantation assessed by 3-dimensional intravascular ultrasound

Sirolimus-eluting stents (SES) have been shown to reduce intimal hyperplasia (IH) within the stent. Although angiographic studies have suggested focal distribution of IH, these data are limited by its spatial resolution and the minimal amount of IH. Therefore, the exact distribution pattern of SES IH remains unclear. Ninety-six SIRIUS trial patients who underwent SES (51) or bare metal stent (45) implantation and three-dimensional IVUS at 8 months follow-up were enrolled. Neointimal area (stent-lumen area) was obtained at every 0.5-mm interval throughout the stented segment. The length of each stent with IVUS-detectable neointima was determined and divided by the stented length in each case to normalize the data. Even with IVUS, IH was detectable in very limited SES stented segments (median 8% of total stented length) compared to the diffuse nature of IH within BMS with only 5 stented lesions having segments free from IH. In 25% (13 of 51) of patients, no IH was detectable within whole SES stented segments. In conclusion, SES has reduced not only the total amount of IH, but also limited the distribution. These data suggest that local conditions (heterogeneity of biological responses of particular plaques, pharmacokinetics, or their combination) may play a role in IH following SES implantation.     

Frequency and characteristics of incomplete stent apposition during and after sirolimus-eluting stent implantation

OBJECTIVES: Incomplete stent apposition (ISA) is frequently observed after sirolimus-eluting stent (SES) implantation. This study investigated the incidence, morphological features, and possible mechanisms of this phenomenon. METHODS: Fifty-two lesions in 47 eligible patients were treated with SES and serial intravascular ultrasound (IVUS) assessment at the time of post-intervention and 8-month follow-up. ISA was carefully identified from the IVUS images of these lesions. Specifically, quantitative two dimensional IVUS analysis was performed if the lesions demonstrated ISA, including routine IVUS parameters as well as other measurements related to ISA. RESULTS: Overall, ISA was observed in 13 lesions (25.0%) at follow-up. Persistent ISA (n = 6, 11.5%), defined as ISA consistently observed both at post-intervention and follow-up, and late-acquired ISA (n = 7, 13.5%)were systematically compared. Eighty-three percent of cases of persistent ISA were located around the stent edges, whereas all cases of late-acquired ISA were in the stent body. In the persistent ISA group, no serial changes were observed in the lumen area or external elastic membrane area (EEMA) from post-intervention to follow-up. However, in the late-acquired ISA group, EEMA and lumen area significantly increased from post-intervention to follow-up (EEMA: 13.4 +/- 3.2 vs 17.6 +/- 3.3 mm2, respectively, p < 0.0001 ; lumen area: 6.7 +/- 1.4 vs 9.2 +/- 1.8 mm2, respectively, p = 0.004). No adverse clinical events were observed in either group. CONCLUSIONS: ISA was frequently observed during and after SES implantation in clinical practice. No clinical disadvantages were observed during 16 month clinical follow-up periods. Positive remodeling may potentially cause late-acquired ISA.     

左主干冠状动脉病变的血管内超声研究

目的 血管内超声评价非严蕈钙化性左主干病变的形态特点,探讨开口和非开口部位形成狭窄的不同机制.方法 2004年10月至2007年10月,共入选造影确诊或可疑的狭窄病变并行血管内超声检查的153例(开口47例,非开口106例)非严重钙化性左主干病变,定性和定量分析血管内超声图像;负性重构定义为重构指数＜0.95.结果 左主干参考节段平均管腔直径和血管(外弹力膜)直径为(4.1±0.8)mm和(5.3士0.8)mm.开口病变的纤维性、钙化性和软斑块分别为70.2%、19.2%和8.5%,而非开口病变为35.8%、43.4%和3.8%,两者差异有统计学意义(P=0.01).总体来说,31.1%病例的最小管腔面积＜6 mm2,其中开口组29.5%,非开口组31.9%(P=0.87).最小管腔面积在两组相似,但非开口组的斑块面积[(13.3±5.4)mm2比(10.8±4.5)mm2,P=0.007]和斑块负荷(61.9%±14.5%比54.8%±15.9%,P=0.020)均显著大于开口组,斑块负荷＞50%的比例更高(84.8%比61.3%,P=0.002).开口病变的重构系数显著低于非开口病变(0.9±0.2比1.0.±0.2,P=0.000),而且负性重构更多见(74.5%和34.9%,P=0.000).logistic回归分析发现,病变部位(OR=4.9,P=0.004)、斑块面积(OR=1.2,P=0.01)和斑块负荷(OR=0.003,P=0.000)是左主干发生重构的独立预测因素.结论 负性重构现象在左主干开口病变中更常见,可能是其狭窄形成的机制之一.狭窄程度不确定的冠状动脉左主干病变需要血管内超声精确评价.