光学相干断层成像比较猪冠状动脉西罗莫司洗脱支架与佐他莫司洗脱支架置入后早期新生内膜覆盖情况

目的应用光学相干断层成像(OCT)比较西罗莫司洗脱支架(SES)与佐他莫司洗脱支架(ZES)置入后1月内新生内膜覆盖情况。方法 18只中华小型猪平均分为3组,每只猪分别在前降支和右冠状动脉随机置入SES和ZES支架各一枚,3组实验动物分别在第7天、14天、28天进行OCT检查,测量新生内膜厚度、支架内面积、管腔内面积、新生内膜面积、面积狭窄百分比和新生内膜覆盖率,比较ZES与SES置入后1月内新生内膜覆盖情况。结果 OCT测量结果显示,支架置入7天和14天时,ZES与SES两种支架丝表面新生内膜厚度和新生内膜覆盖率均存在显著统计学差异(P<0.001)。同样支架术后28天时ZES与SES支架丝表面新生内膜厚度存在显著统计学差异(244.3±282.3μmvs136.3±91.1μm,P<0.001),新生内膜覆盖率存在显著差异(94.88%±2.93%vs90.96%±4.35%,P=0.008)。结论在支架置入后1个月内,ZES与SES比较新生内膜增生更显著,支架丝表面新生内膜覆盖率更高。     

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。     

抗CD34抗体抵消雷帕霉素洗脱支架内皮延迟修复研究

目的:雷帕霉素洗脱支架在降低再狭窄风险的同时,通过抑制血管再内皮化,可能增加支架内血栓发生风险,抗CD34抗体通过特异捕获血液中内皮祖细胞,加速支架术后血管再内皮化。本研究目的是将抗CD34抗体涂敷到雷帕霉素洗脱支架上,通过实验小猪支架术后不同时间造影,随访评价抗CD34抗体对雷帕霉素洗脱支架早期再内皮化的影响。方法:将3种不同类型的支架包括金属裸支架(bare-metal stents,BMS)、雷帕霉素洗脱支架(sirolimous-eluting stents,SES)和抗CD34抗体与雷帕霉素洗脱联合支架(anti-CD34 antibody and sirolimous-eluting combined stents,ASES)随机植入到符合条件的10头中华小型猪冠状动脉内(共植入了6个BMS、7个支架和7个ASES),支架植入术后2 w,进行冠状动脉造影及冠状动脉内光学相干断层成像(optical coherence tomography,OCT)检查;动物处死后,对支架段冠状动脉进行病理组织学检查及扫描电镜观察。结果:1.通过对冠状动脉造影、OCT图像及支架段冠状动脉的病理组织学的观察分析,均未发现支架内血栓及小的附壁血栓。2.在2 w OCT检查图像上,ASES新生内膜覆盖率显著高于SES[(55.56±35.27)%vs.(41.82±23.28)%,P=0.047],ASES平均内膜覆盖厚度不但显著高于SES[(89±5.0)μm vs.(32±4.9)μm,P<0.001]、还高于BMS[(89±5.0)μm vs.(44±7.2)μm,P=0.001]。病理组织学观察及扫描电镜观察也显示,ASES和BMS新生内膜覆盖水平及质量均优于SES。结论:将抗CD34抗体联合应用到雷帕霉素洗脱支架上,能够显著抵消后者在支架术后早期对再内皮化的抑制作用。     

光学相干断层显像评价药物洗脱支架置入后内膜增殖和血栓形成

目的 应用光学干涉断层显像(OCT)技术评价雷帕霉素洗脱支架(SES)置入后3个月和2年后内膜增殖和支架内血栓形成情况.方法 对3个月组进行SES置入后3个月的OCT随访观察,对2年组进行SES置入后2年的随访观察.测量每一个支架支撑杆表面的新生内膜厚度,并评估无内膜覆盖支架支撑杆及支架内血栓形成情况.结果 2年组的内膜厚度显著大于3个月组[(71±93)μm比(29±41)μm,P＜0.01],而2年组中的无内膜覆盖支架支撑杆的比例明显低于3个月组(5%比15%,P＜0.01).2年组与3个月组无内膜覆盖支撑杆患者的比例差异无统计学意义(81%比95%,P＞0.05).两组中均有14%的患者出现无临床症状的支架内血栓形成.结论 SES置入后3个月到2年新生内膜的增生在不断进展,无内膜覆盖支撑杆数明显减少.但是直到支架置入后2年,多数患者体内仍然存在部分无内膜覆盖的支架支撑杆.     

抗CD34抗体优化雷帕霉素洗脱支架疗效的实验研究

目的 评价抗CD34抗体对雷帕霉素洗脱支架早期再内皮化以及远期抗再狭窄的影响.方法 将裸金属支架(BMS)、雷帕霉素洗脱支架(SES)和抗CD34抗体与雷帕霉素洗脱联合支架(ASES)随机置入到22头中华小型猪的冠状动脉内(共置入15枚BMS、17枚SES和16枚ASES).10头中华小型猪在置入支架(共置入6枚BMS、7枚SES和7枚ASES)后2周,另外12头中华小型猪在置入支架(共置入9枚BMS、10枚SES和9枚ASES)后3个月,进行冠状动脉造影及冠状动脉内光学相干断层成像( OCT)检查,并在处死动物后对支架段冠状动脉进行病理组织学检查及扫描电镜观察.结果 (1)支架术后2周,冠状动脉造影、OCT图像及支架段冠状动脉的病理组织学的观察均未发现支架内血栓及小的附壁血栓.对OCT图像的分析显示,ASES新生内膜覆盖率显著高于SES[ (55.56±35.27)％比(41.82±23.28)％,P＜0.05];ASES平均内膜覆盖厚度不但显著高于SES[(89.0±5.0)μm比(32.0±4.9) μm,P＜0.01],而且显著高于BMS[( 89.0±5.0) μ,m比(44.0±7.2)μm,P＜0.01].病理组织学观察及扫描电镜观察显示,ASES和BMS新生内膜覆盖水平及质量均优于SES.(2)支架术后3个月,定量冠状动脉造影显示ASES晚期支架内管腔丢失显著低于BMS [(0.18±0.06)mm比(0.35±0.06)mm,P＜0.05];对OCT图像的分析显示,ASES和SES新生内膜增生百分比均显著低于BMS[ (34.75±2.64)％和(35.63±2.07)％比(48.28±3.25)％,均P＜0.01];组织病理学分析显示,ASES和SES面积再狭窄百分比均显著低于BMS组[(28.65±5.64)％和(29.33±6.07)％比(46.18±8.25)％,均P＜0.05].结论 将抗CD34抗体联合应用到雷帕霉素洗脱支架上能够显著抵消后者在支架术后2周对再内皮化的抑制作用,同时没有削弱雷帕霉素洗脱支架术后3个月的抗再狭窄效能.     

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.     

光学相干断层成像分析极晚期支架内血栓形成

背景极晚期支架内血栓形成(VLST)是一种有致死风险的介入术后晚期并发症,但其具体发生机制尚不完全明确。目的应用光学相干断层成像(OCT)评价23例药物洗脱支架(DES)或金属裸支架(BMS)相关的VLST靶病变。方法入选VLST患者23例(18例DES,5例BMS),介入治疗前于靶病变处行OCT检查。结果支架植入至发生VLST的持续时间BMS组明显长于DES组[(112.00±51.36)个月vs(41.39±19.64)个月,P0.001]。BMS组新生内膜厚度大于DES组[(0.33±0.24)μm vs(0.26±0.22)μm,P0.001]。23例VLST靶病变中,OCT明确观察到支架内新生内膜含薄纤维帽粥样斑块(TCFA)18例(78.26%),支架内再狭窄15例(65.22%)。新生内膜破裂15例(65.22%),DES组与BMS组间差异无统计学意义(55.56%vs 100%,P=0.07),破裂位于最小管腔面积处13例(56.52%)。存在无内膜覆盖支架丝17例(73.91%),DES组高于BMS组(88.89%vs 20%,P=0.008)。同时存在新生内膜破裂和无内膜覆盖支架丝8例(34.78%)。与无新生内膜破裂相比,有新生内膜破裂病变更易出现TIMI血流3级(60.00%vs 12.50%,P=0.038)。结论本支架内新生内膜动脉粥样硬化进展至内膜破裂在BMS和DES相关的VLST病变中均普遍存在,且DES早于BMS。新生内膜延迟愈合在DES相关的VLST靶病变中较为多见。     

光学相干断层成像技术评价猪冠状动脉佐他莫司洗脱支架术后早期新生内膜覆盖情况

目的:应用光学相干断层成像(OCT)、病理和扫描电镜评价猪冠状动脉佐他莫司洗脱支架(ZES)术后早期(7天、14天、28天)新生内膜覆盖情况。方法:18只中华小型猪随机分为7天组、14天组和28天组,每组6只,每只猪于右冠状动脉置入一枚佐他莫司洗脱支架,3组实验动物分别于术后7天、14天及28天时进行OCT检查,观察支架表面新生内膜覆盖情况,并取支架段冠状动脉进行病理组织学检查及扫描电镜观察。结果:用OCT观察3个时间段支架表面新生内膜情况,7天组为(61.3±37.7)μm,14天组为(132.6±103.3)μm,28天组为(244.3±282.3)μm,3组间差异有统计学意义(P<0.001),新生内膜覆盖率7天组为(53.62±2.49)%,28天组达到(94.88±2.93)%,病理提示7天时新生内膜以炎性细胞、红细胞、血小板为主,28天时以平滑肌细胞、炎性细胞和血管内皮细胞为主。结论:OCT在支架术后7天即能清晰观察到新生内膜覆盖情况,佐他莫司洗脱支架术后28天大多数支架丝被新生内膜覆盖。     

OCT对于DES术后晚期或晚晚期血栓治疗的指导作用

目的 观察光学相干断层成像（OCT）技术对于药物洗脱支架（DES）术后发生晚期或晚晚期血栓治疗对策的指导作用.方法 选取2010年7月至2013年11月本院收治的行DES支架置入术后发生晚期或晚晚期支架内血栓患者22例,对患者行OCT检查,根据OCT结果采取进一步治疗措施.结果 DES术后晚期或晚晚期血栓的OCT表现为：支架内皮化不全6例、贴壁不良12例、支架内新生动脉粥样硬化斑块形成8例,支架内纤维过度增生较为少见2例,有些患者上述情况同时存在.治疗对策：单纯支架内皮化不全及支架贴壁不良者采取单纯球囊扩张术12例,新生动脉粥样硬化斑块形成或纤维过度增生者采取球囊扩张加支架置入术10例.结论 OCT可以准确了解DES术后晚期或晚晚期血栓的原因,提供更为合适的治疗方案.     

药物洗脱支架置入后血栓形成的原因分析

目的探讨药物洗脱支架置入后血栓形成的发生率以及血栓形成的原因。方法本研究为单中心药物洗脱支架的注册研究,自2001年12月至2005年12月共计3345例冠心病患者接受了药物洗脱支架的治疗,其中使用雷帕霉素洗脱支架（SES）2165例,使用紫杉醇洗脱支架（PES）1180例,完成10个月临床随访为2296例;所有患者均同时口服阿司匹林和氯吡格雷至少9个月。结果3345例患者中9例发生急性血栓形成（O．27％）,其中7例为SES、2例为PES所致（0．32％比0．17％,P=0．637）;7例发生亚急性血栓形成（0．21％）,其中5例为SES、2例为PES所致（0．23％比0．17％,P=0．526）;急性和亚急性血栓发生率为0．48％（16／3345）;13例有晚期血栓形成,5例为SES、8例为PES所致（0．34％比0．95％,P=0．114）;4例晚期血栓形成的主要原因为提前中断抗血小板药物,既往患有心肌梗死病史,心功能差,药物洗脱支架置入后晚期发生血栓致猝死6例。结论支架置入不满意,特别是分叉病变以及支架未能完全覆盖受损伤的病变段是急性和亚急性血栓形成的主要原因;中断抗血小板药物和左心功能不全是晚期血栓形成的主要原因。     

Early Strut Coverage in Patients Receiving Drug-Eluting Stents and its Implications for Dual Antiplatelet Therapy: A Randomized Trial

Objectives

This study sought to measure early strut coverage in patients receiving drug-eluting stents (DESs) and to explore the feasibility of short-term dual antiplatelet therapy (DAPT) based on the degree of early strut coverage.

Evaluation of coronary plaque and stent deployment by intravascular optical coherence tomography in elderly patients with unstable angina and non-ST-elevation myocardial infarction

Objective To evaluate the feasibility and efficacy of intravascular optical coherence tomography (OCT) in the assessment of plaque characteristics and drug eluting stent deployment quality in the elderly patients with unstable angina (UA) and non-ST segment elevation myocardial infarction (NSTEMI). Methods OCT was used in elderly patients undergoing percutaneous coronary interventions. Fifteen patients, 9 males and 6 females with mean age of 72.6±5.3 years (range 67-92 years) were enrolled in the study. Images were obtained before initial balloon dilatation and following stent deployment. The plaque characteristics before dilation, vessel dissection, tissue prolapse, stent apposition and strut distribution after stent implantation were evaluated. Results Fifteen lesions were selected from 32 angiographic lesions as study lesions for OCT imaging after diagnostic coronary angiography. There were 7 lesions in the left anterior descending artery, 5 lesions in the right coronary artery and 3 lesions in the left circumflex coronary artery. Among them, 12 (80.0%) were lipid-rich plaques, and 10 (66.7%) were vulnerable plaques with fibrous cap thickness 54.2±7.3 μm. Seven ruptured culprit plaques (46.7%) were found; 4 in UA patients and 3 in NSTEMI patients. Tissue prolapse was observed in 11 lesions (73.3%). Irregular stent strut distribution was detected in 8 lesions (53.3%). Vessel dissections were found in 5 lesions (33.3%). Incomplete stent apposition was observed in 3 stents (20%) with mean spacing between the struts and the vessel wall 172±96 mm (range 117-436 mm). Conclusions 1) It is safe and feasible to perform intravascular OCT to differentiate vulnerable coronary plaque and monitor stent deployment in elderly patients with UA and USTEMI. 2) Coronary plaques in elderly patients with UA and USTEMI could be divided into acute ruptured plaque, vulnerable plaque, lipid-rich plaque, and stable plaque. 3) Minor or critical plaque rupture is one of the mechanisms of UA in elderly patients. 4) Present drug eluting stent implantation is complicated with multiple tissue prolapses which are associated with irregular strut distributions. 5) The action and significance of tissue prolapse on acute vessel flow and in-stent thrombus and restenosis need to be further studied.     

The role of optical coherence tomography in coronary intervention

Optical coherence tomography (OCT) is an optical analog of intravascular ultrasound (IVUS) that can be used to examine the coronary arteries and has 10-fold higher resolution than IVUS. Based on polarization properties, OCT can differentiate tissue characteristics (fibrous, calcified, or lipid-rich plaque) and identify thin-cap fibroatheroma. Because of the strong attenuation of light by blood, OCT systems required the removal of blood during OCT examinations. A recently developed frequency-domain OCT system has a faster frame rate and pullback speed, making the OCT procedure more user-friendly and not requiring proximal balloon occlusion. During percutaneous coronary intervention (PCI), OCT can provide detailed information (dissection, tissue prolapse, thrombi, and incomplete stent apposition [ISA]). At follow-up examinations after stent implantation, stent strut coverage and ISA can be assessed. Several OCT studies have demonstrated delayed neointimal coverage following drug-eluting stent (DES) implantation vs. bare metal stent (BMS) placement. While newer DESs promote more favorable vascular healing, the clinical implications remain unknown. Recent OCT studies have provided insights into restenotic tissue characteristics; DES restenotic morphologies differ from those with BMSs. OCT is a novel, promising imaging modality; with more in-depth assessments of its use, it may impact clinical outcomes in patients with symptomatic coronary artery disease.     

采用光学相干断层成像技术评价国产雷帕霉素洗脱支架术内膜覆盖情况

Objective:Confirming complete neointimal coverage after implantation of drug-eluting stent(DES)is clinically important because incomplete stent coverage is maybe responsible for late thrombosis and sudden cardiac death.Optical coherence tomography(OCT)is a high-resolution(≈10 μm)imaging technique capable of detecting a thin layer of neointimal hyperplasia(NIH)inside DES.Helios stent system(KinheIy Bio-tech Co(Shenzhen).Ltd)is a new generation of sirolimus eluting stents.Methods:Motorized optical coherence t...     

Coronary stent strut fracture after drug-eluting stent implantation: a newly recognized complication

Stent strut fracture (SSF) after drug-eluting stent (DES) implantation may be an important complication after DES implantation particularly in patients undergoing sirolimus eluting stent implantation. Since SSF is a highly relevant adverse event which can result in in-stent restenosis and thrombosis, we believe that DES with flexible stent platform or biodegradable DES may be needed to prevent this potential catastrophic complication.     

Assessment with optical coherence tomography of a new strategy for bifurcational lesion treatment: The Tryton Side‐Branch Stent

The Tryton‐Side Branch Stent? (Tryton Medical, Inc., Newton, MA, USA) is a dedicated stent designed to provide complete carinal coverage of bifurcational lesions. After implantation of a 18 mm cobalt chromium Tryton stent from the left circumflex into the obtuse marginal branch, recrossing with an everolimus eluting Promus stent and final kissing balloon dilatation, optical coherence tomography (OCT) (LightLab Imaging Inc., Westford, MA, USA) was performed with a non‐occlusive technique with motorized pullback (3 mm/s) during continuous pump injection of iso‐osmolar contrast, in both LCx and OM1. OCT imaging showed good strut apposition at the level of the carina, with full coverage and no stent protrusion at the ostium of the side branch. Few malapposed struts were present in the proximal main vessel in the segment of stent superimposition, with a maximal separation from to the vessel wall of 160 μm. The implantation of the Tryton‐Side Branch Stent? allowed full coverage of the side branch ostium with uniform apposition of the stent struts at the level of the carina assessed by OCT. © 2008 Wiley‐Liss, Inc.     

Neointimal coverage and late apposition of everolimus-eluting bioresorbable scaffolds implanted in the acute phase of myocardial infarction: OCT data from the PRAGUE-19 study

Incomplete stent apposition and uncovered struts are associated with a higher risk of stent thrombosis. No data exist on the process of neointimal coverage and late apposition status of the bioresorbable vascular scaffold (BVS) when implanted in the highly thrombogenic setting of ST-segment elevation acute myocardial infarction (STEMI). The aim of this study was to assess the serial changes in strut apposition and early neointimal coverage of the BVS using optical coherence tomography (OCT) in selected patients enrolled in the PRAGUE-19 study. Intracoronary OCT was performed in 50 patients at the end of primary percutaneous coronary intervention for acute STEMI. Repeated OCT of the implanted BVS was performed in 10 patients. Scaffold area, scaffold mean diameter and incomplete strut apposition (ISA) were compared between baseline and control OCT. Furthermore, strut neointimal coverage was assessed during the control OCT. Mean scaffold area and diameter did not change between the baseline and control OCT (8.59 vs. 9.06 mm²; p = 0.129 and 3.31 vs. 3.37 mm; p = 0.202, respectively). Differences were observed in ISA between the baseline and control OCT (0.63 vs. 1.47 %; p < 0.05). We observed 83.1 % covered struts in eight patients in whom the control OCT was performed 4–6 weeks after BVS implantation, and 100 % covered struts in two patients 6 months after BVS implantation. Persistent strut apposition and early neointimal coverage were observed after biodegradable vascular scaffold implantation in patients with acute ST-segment elevation myocardial infarction.     

Three‐months optical coherence tomography analysis of a biodegradable polymer,sirolimus‐eluting stent

Objective

We aimed to assess early neointimal healing by optical coherence tomography (OCT) 3 months after implantation of the ultrathin Orsiro® sirolimus‐eluting stent with biodegradable polymer.

Background

New generations of drug‐eluting stents with biodegradable polymer have been developed to avoid the continued vascular irritation of durable polymers.

Methods

In this prospective, open‐label study, 34 patients received an Orsiro® sirolimus‐eluting stent with biodegradable polymer. In a subgroup of patients (n = 15), the intervention was performed under OCT guidance. All patients underwent OCT‐examination at three months. The primary endpoint was 3‐month neointimal healing (NIH) score, calculated by weighing the presence of filling defects, malapposed and uncovered struts. Secondary endpoint was maturity of tissue coverage at 3 months.

Results

At 3 months, NIH score was 13.7 (5.4‐22), covered struts per lesion were 90% (84‐97%), malapposed struts were 2.7% (0.8‐5.4%) and rate of mature tissue coverage was 47% (42‐53%). No target lesion failure occurred up to 12 months. Patients with OCT‐guided stent implantation demonstrated a trend toward earlier stent healing as demonstrated by superior NIH scores (angio guided: 17.6% [8.8‐26.4]; OCT‐guided: 9.8% [4.0‐15.5]; mean difference ?8, [95%CI: ?18.7‐2.9], P = 0.123). This group had significantly more covered struts per lesion (angio‐guided: 86% [82‐90]; 95% [92‐99]; mean difference 9% [95%CI: 3‐15], P = 0.001).

Conclusion

The Orsiro® sirolimus‐eluting stent with biodegradable polymer shows early vascular healing with a high rate of strut coverage at 3‐month follow‐up. OCT guided stent implantation had a positive impact on early vascular healing.