9种类型冠状动脉支架的临床应用体会

对 4 0例冠心病患者的 4 1支冠状动脉 4 2处病变植入 51枚冠脉内支架。植入的支架类型包括 :Bestent支架 ,BardXT支架 ,Angio支架 ,AVE支架 ,Devon支架 ,Multi-link支架 ,Wiktor支架 ,CVD支架及Gianturco -RoubinⅡ支架等 9种。支架选择按靶病变长度、近端血管内径大小及病变特点进行。支架释放压力为 6～ 14个atm ,时间为 30～ 6 0秒 ,之后经 2个以上的相互垂直平面造影证实支架充分扩展 ,远端血流达TIMIⅢ级为手术成功 ,手术成功率 96 .1%。其中 5例病人拔除动脉鞘管后压迫股动脉时出现窦缓伴血压下降 ,经静脉推注阿托品后好转 ,2例穿刺部位出现血肿。术后随访 1～ 2 9个月 ,有 4例再发心绞痛 ,其中 3例经造影证实植入支架血管血流正常 ,其它支发生再狭窄导致。我们认为冠状动脉支架术是安全而有效的冠心病介入性治疗方法 ,手术成功率高 ,并发症少。根据靶血管病变特征合理选用不同类型的支架是保证支架植入成功的重要环节。     

Passive and Active Polymer Coatings for Intracoronary Stents: Novel Devices to Promote Arterial Healing

Coronary stent implantation is the second great advance in the treatment of obstructive coronary artery disease since the introduction of balloon catheter angioplasty. However, in-stent restenosis (ISR) caused by neointimal hyperplasia has been a major limitation of stents, occurring in up to 30% of cases. Advances in coronary stent technology both in terms of stent design and function and especially drug-eluting stents (DES) have significantly improved the safety and efficacy of percutaneous coronary intervention (PCI) with stenting, including marked reduction in ISR. This has led to use of DES for increasingly challenging clinical and lesional subsets, with potential for increased risk of stent-associated complications, especially late stent thrombosis (LST). Because restenosis and stent thrombosis are caused by multiple and often interrelated factors, ideal agents for stent coatings should inhibit thrombus formation, inflammatory reaction, and cellular proliferation, while supporting reendothelialization. To avoid undesirable effects of currently applied (durable) polymers, biocompatible, and bioabsorbable polymers as well as DES delivery systems that minimize polymer burden have been produced and tested. Bioabsorbable stents, both polymeric and metallic, have been developed to decrease potential late complications after stent implantation. Novel strategies to address some of these challenges are in various stages of research and development. In this article we outline developments in the field of passive and active stent coatings and evaluate the ongoing role of such coatings in the contemporary era of DES.     

冠状动脉支架V-FlexTM的临床应用及随访结果

为评价V－Flen冠状动脉支架置入后的安全性和再狭窄的发生率,在124例冠心病病人中,138处血管病变植入174个V－Flen冠状动脉支架,成功率为100％。住院期间,1例病人因严重心衰死亡,4例病人出现非Q波心肌梗死,股动脉穿刺血肿5例,其余病人均无支架相关并发症。122例病人6月临床随访中,16例（13％）出现胸痛或运动试验阳性;108例6个月后定量血管造影显示再狭窄率为24．0％。此结果提示,V－Flen冠状动脉支架对治疗冠状动脉狭窄病变具有较高的安全有效性,且再狭窄发生率低。     

Ultrasound Appearances of Coronary Stents as Obtained by Three-Dimensional Intracoronary Ultrasound Imaging In Vitro

Intracoronary ultrasound (ICUS) is an imaging technique which can provide a cross-sectional image of coronary arteries and implanted stents. Different stents may have individual ICUS imaging characteristics. To investigate the imaging characteristics and three-dimensional (3-D) reconstruction of different coronary stent designs, we examined 26 different stents using ICUS in vitro. All stents could be well visualized with planar ICUS. In 18 stents, 3-D imaging succeeded in reconstructing the spatial stent architecture. This was not possible in the other 8 stents, most probably because of predominantly transversally-orientated strut architecture, the small size of the strut wire width, the limited ICUS lateral catheter resolution, and the smoothing and interpolation algorithms applied for 3-D reconstruction. ICUS in vitro provides a means of identifying coronary stent structures which may be applicable in vivo. Three-D reconstruction of the entire stent architecture in vitro can be achieved in stents with mesh or slotted tube design, while stents with coil design and thin strut wires can only be partially reconstructed.     

Antiplatelet Versus Warfarin Therapy: Platelet, Neutrophil, and Thrombus Deposition for Intracoronary Stents in a Porcine Model

Antiplatelet therapy may offer an advantage over warfarin in reducing adverse clinical events after intracoronary stem implantation. The mechanism of this effect has not been elucidated but platelet adhesion may play a predominant role in the process of subacute stent thrombosis. This study compared the effect on platelet, neutrophil, and thrombus deposition of three different anticoagulation regimens (aspirin/warfarin vs aspirin/ticlopidine vs aspirin alone) after intracoronary stenting in juvenile swine. Thirty stents were deployed in 15 juvenile farm swine randomized to one of 3 anticoagulation protocols: aspirin 325 mg/day; aspirin 325 mg/day and ticlopidine 500 mg/day; aspirin 325 mg/day and warfarin 0.1 mg/kg/day. Autologous platelets were labeled using ¹¹¹Indium-oxime and a slotted tube metal stent was deployed using a high pressure balloon. Platelet deposition in the stented segment was determined at 24 hours. Each segment was analyzed by light microscopy to document an injury score; mean and maximum thrombus deposition per strut were measured; and neutrophils were counted on each metal strut and in the vessel wall. Platelet deposition at 24 hours was significantly higher in the aspirin/warfarin group (3.69 ± 1.16 ± 10⁸ plts/cm²) than in the aspirin/ticlopidine (1.74 ± 0.45 ± 10⁸ plts/cm², P = 0.0009) or aspirin (2.42 ± 2.13 ± 10⁸ plts/cm², P = 0.03) groups. There was no significant difference between the aspirin and aspirin/ticlopidine groups (P = 0.9). Mean thrombus area per strut was significantly greater in the aspirin/warfarin group (0.027 ± 0.006 mm²) compared to the aspirin/ticlopidine group (0.017 ± 0.002 mm², P = 0.002). The majority of the thrombus (79%) but minority of neutrophils (24%) were found on the stent struts. In this coronary stent model, warfarin given with aspirin was associated with greater thrombogenicity and more platelet deposition than either aspirin/ticlopidine or aspirin alone.     

Placement of Intracoronary Stents Mounted on Over the Wire Balloon Catheters Without Using Long Guidewires

The aim of this study is to investigate the feasibility, effectiveness, and safety of placement of intracoronary stents mounted on over the wire balloon catheters without using long guidewires. Fifteen consecutive patients underwent GR II stent placement. Over the wire balloon catheters and short guidewires were used. The new method was successful in 14 of 15 cases. No complications were observed. This novel technique using a short (instead of long) guidewire to place intracoronary stents mounted on over the wire balloon catheters was successful, and more convenient. (J Interven Cardiol 2000; 13:27–30)     

冠心病患者行经皮冠状动脉内支架植入术前后C-反应蛋白的变化

为观察炎症因子C 反应蛋白在经皮冠状动脉内支架植入术前后的变化 ,探讨C 反应蛋白在急性冠状动脉综合征的意义 ,我们回顾性分析了 10 5例行冠状动脉内支架植入术患者及同期 2 4 2例行冠状动脉造影患者的资料 ;利用散射比浊法测量其术前术后C 反应蛋白。结果发现 ,行经皮冠状动脉内支架植入术的患者术后C 反应蛋白明显高于术前 (6 .7± 0 .5比 17.6± 1.0 ,P <0 .0 1) ,而冠状动脉造影组术前术后C 反应蛋白则无明显变化 (3.5±0 .7比 3.6± 0 .8,P >0 .0 5 )。因此 ,C 反应蛋白作为炎症的反应蛋白 ,在经皮冠状动脉内支架植入术后明显升高 ,可能与冠状动脉内支架术治疗后斑块撕裂、内皮损伤以及局部血管炎症有关 ,推测C 反应蛋白升高是急性冠状动脉综合征的一个表现。     

Stents for esophageal disease

Opinion statement  

Polymer-Free Biolimus-Eluting Stents or Polymer-Based Zotarolimus-Eluting Stents for Coronary Bifurcation Lesions

BackgroundA polymer-free biolimus-eluting stent (PF-BES) and a zotarolimus-eluting stent (ZES) recently showed similar clinical profiles and appear to be competing options in specific clinical settings of patients undergoing percutaneous coronary intervention (PCI). Whether they perform similarly also in complex procedural settings as coronary bifurcation lesions remains unaddressed.MethodsAll consecutive patients undergoing coronary bifurcation PCI with PF-BES or the new iteration of the ZES from three large multicenter real-world registries were included. The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI), target lesion revascularization (TLR) and stent thrombosis (ST). Multiple analyses to adjust for baseline differences were carried out including propensity-score matching, propensity-score stratification and inverse-probability-weighting. Outcomes are reported according to Cox proportional hazard models censored at 400-day follow-up.Results1169 patients treated with PF-BES (n = 440) or ZES (n = 729) on the main branch of a coronary bifurcation lesion were included (mean age 69 ± 11 years, 75.4% male, 53.8% acute coronary syndrome at presentation, 26.6% left main bifurcation, median dual antiplatelet therapy duration 12 [range 12–12] months). MACE, all-cause death, TLR and ST tended towards non-statistically higher rates with the PF-BES as compared to the ZES. Higher MI and target vessel revascularization occurrence was observed with PF-BES.ConclusionsIn this large contemporary cohort of patients undergoing coronary bifurcation PCI, the occurrence of MACE was non-statistically different with the use of PF-BES and ZES devices. However, differences favoring the ZES device that may entail clinical relevance were observed. Further studies are needed to confirm these findings and explore whether they remain valid when a short dual antiplatelet therapy is adopted.     

Bare-Metal Stents Versus Drug-Eluting Stents for Primary Angioplasty: Long-Term Outcome

Percutaneous transluminal coronary intervention (PCI) is the most used myocardial revascularization technique for patients with coronary artery disease. Primary PCI with stent implantation is widely considered the gold standard for the treatment of ST-elevation myocardial infarction patients. Coronary stents, compared with balloon angioplasty, have reduced focal lesion restenosis. To reduce in-stent restenosis, drug-eluting stents (DES) were designed to locally release drugs inhibiting neointimal growth. Recent concerns have emerged on the potential higher risk of stent thrombosis with DES that might be even more pronounced among myocardial infarction patients. For these reasons, DES for primary PCI remains an “off-label” use. In the last several years, a number of randomized trials and registries have tested the safety and efficacy of DES in primary PCI. Data from these studies were analyzed in several meta-analyses, reasonably consistently demonstrating that the use of DES significantly decreased the need for revascularization without an increase in the incidence of death, recurrent infarction, or stent thrombosis at long-term follow-up.     

分叉专用支架的进展

分叉病变的介入治疗具有很大的挑战性,分叉专用支架是为克服常规的分叉病变介入治疗的局限性而设计。大多数分叉专用支架的目的就是易于在必要时置入边支支架。这是一种令人激动的全新技术,可能使复杂的分叉病变治疗简单化。目前有11种分叉专用支架完成或正在进行人体试验。随着更多的药物释放支架平台和更大规模的对照试验出现,在不久的将来成为正式的治疗方法前其真正的临床价值、有效性和安全性会得到充分证明。     

药物洗脱支架联用普通金属支架治疗多支冠状动脉病变的疗效评价

目的探讨多支冠状动脉病变患者药物洗脱支架与普通金属支架(普通支架)联用预防再狭窄的疗效及安全性。方法801例行多支冠状动脉内支架置入术达到完全血运重建的冠心病患者分3组。药物洗脱支架组206例、药物洗脱支架与普通支架联用组(联用组)158例及普通支架组437例。比较3组支架术后近期及远期结果。结果3组患者冠心病危险因素、心功能、冠状动脉病变程度、支架术成功率及并发症发生率均无显著差异。术后平均随访(17.3±10.9)个月,总随访率和造影随访率无显著差异。联用组普通支架置入于31.3%的前降支病变(均为A、B1型病变)及81.6%的回旋支病变和69.9%的右冠状动脉病变。与普通支架组相比,药物洗脱支架组和联用组造影再狭窄率明显降低,分别为20.3%vs7.3%和8.8%(P均<0.05),且主要不良心脏事件发生率均较低,分别为18.4%vs6.5%和9.9%(P均<0.05)。但药物洗脱支架组与联用组相比上述各指标无显著差异。结论多支冠状动脉病变患者单用药物洗脱支架或合理联用普通支架后再狭窄率降低,安全性近似,均优于单用普通支架。     

Intracoronary brachytherapy for treatment of in-stent restenosis

Randomized, double-blind, placebo-controlled trials have demonstrated that intracoronary brachytherapy is more efficacious than placebo in reducing death, myocardial infarction, and target vessel revascularization at long-term follow up of patients with in-stent restenosis. Intracoronary brachytherapy is efficacious in treating totally occluded in-stent restenotic lesions, in treating de novo and in-stent restenotic lesions in saphenous vein grafts, in treating diffuse in-stent restenosis, in treating native coronary ostial in-stent restenotic lesions, in treating patients with diabetes with in-stent restenosis, in treating patients at high-risk for recurrence of restenosis, in treating elderly patients, and in treating patients who failed intracoronary radiation. Beta and gamma intracoronary brachytherapy are equally effective in treating in-stent restenosis. Long-term aspirin and clopidogrel should be administered for at least 1 year to reduce late vessel thrombosis. Inadequate radiation may cause edge stenosis.