New predictors of in-stent restenosis in patients with diabetes mellitus undergoing percutaneous coronary intervention with drug-eluting stent

Background Percutaneous coronary intervention (PCI) had become the major therapeutic procedure for coronary artery disease (CAD), but the high rate of in-stent restenosis (ISR) still remained an unsolved clinical problem in clinical practice. Increasing evidences suggested that diabetes mellitus (DM) was a major risk factor for ISR, but the risk predictors of ISR in CAD patients with DM had not been well characterized. The aim of this study was to investigate the clinical and angiographic characteristic predictors significantly associated with the occurrence of ISR in diabetic patients following coronary stenting with drug-eluting stent (DES). Methods A total of 920 patients with diabetes who diagnosed CAD and underwent coronary DES implantation at Beijing Anzhen Hospital in China were consecutively enrolled from January 2012 to December 2012. Of these, 440 patients underwent the second angiography within ≥ 6 months due to the progression of treated target lesions. Finally, 368 of these patients who met the inclusion and exclusion criteria were followed up by angiography after baseline PCI. According to whether ISR was detected at follow-up angiography, patients were divided into the ISR group (n = 74) and the non-ISR group (n = 294). The independent predictors of ISR in patients with DM were explored by multivariate Cox’s proportional hazards regression models. Results A total of 368 patients (260 women and 108 men) with a mean ages of 58.71 ± 10.25 years were finally enrolled in this study. Of these, ISR occurred in 74/368 diabetic patients (20.11%) by follow-up angiography. Univariate analysis showed that most baseline characteristics of the ISR and non-ISR group were similar. Patients in the ISR group had significantly higher serum very low density lipoprotein cholesterol (VLDL-C), triglyceride (TG) and uric acid (UA) levels, more numbers of target vessel lesions, higher prevalence of multi-vessel disease, higher SYNTAX score, higher rate of previous but lower rate of drinking compared with patients in the non-ISR group. The independent predictors of ISR in patients with DM after DES implantation included VLDL-C (HR = 1.85, 95% CI: 1.24–2.77, P = 0.002), UA (per 50 μmol/L increments, HR = 1.19, 95% CI: 1.05–1.34, P = 0.006), SYNTAX score (per 5 increments, HR = 1.34, 95% CI: 1.03–1.74, P = 0.031) and the history of PCI (HR = 3.43, 95% CI: 1.57–7.80, P = 0.003) by the multivariate Cox’s proportional hazards regression analysis. Conclusions The increased serum VLDL-C and UA level, higher SYNTAX score and the history of previous PCI were independent predictors of ISR in patients with DM after coronary DES implantation. It provided new evidence for physicians to take measures to lower the risk of ISR for the better management of diabetic patients after PCI.     

股浅动脉支架内再狭窄的再干预治疗疗效分析

目的 探讨股浅动脉支架内再狭窄患者再次干预治疗的近期疗效.方法 回顾性分析2011年12月-2013年1月20例股浅动脉支架内再狭窄患者的基本资料、病变特征及再次干预治疗后的症状改善和再狭窄发生情况.结果 20例支架内再狭窄患者就诊时的主要症状为间歇性跛行14例,急性下肢缺血3例,静息痛3例.术前踝肱指数（ankle brachial index,ABI）中位数0.43 （0～0.72）,间歇性跛行距离（238.50±76.80）m.20例患者中65％ （13/20）合并2型糖尿病,45％合并高血压（9/20）,25％合并高脂血症（5/20）.70％ （14/20）为TASCII C／D级病变.再次干预治疗的方法分别为经皮血管腔内成形术（percutaneous transluminal angioplasty,PTA）4例、经皮血管腔内成形术＋支架植入（percutaneous transluminal angioplasty＋stent,PTA＋S）9例、大隐静脉/人工血管旁路术（bypass）3例、斑块旋切治疗（SilverHawk）4例.随访患者14例,平均随访6m （2～18 m）.围手术期未出现死亡、心肌梗死、肾功能不全等并发症,无截肢发生.术后ABI中位数0.69 （0.5～0.85）,与术前ABI相比差异有统计学意义（P＜0.05）.间歇性跛行距离（835.00±217.80）m,（P＜0.01）,术后6m随访时,42.86％患者（6/14）再次出现支架内再狭窄.结论 再次干预治疗可以在近期明显改善支架内再狭窄患者的下肢缺血症状,但仍存在较高的再狭窄率.     

普罗布考对合并糖尿病患者冠状动脉药物洗脱支架置入术后再狭窄及炎症因子的影响

目的评价普罗布考对合并糖尿病的冠心病患者药物洗脱支架置入术后再狭窄发生率及炎症因子的影响,初步探讨普罗布考预防再狭窄的临床价值及可能机制。方法入选72例合并糖尿病并接受药物洗脱支架置入术的冠心病患者,随机分为普罗布考组（36例）和对照组（36例）。普罗布考组在常规药物的基础上加服普罗布考（0.25 g,每日2次）,连续服药至PCI术后6个月,所有患者行冠状动脉造影复查。支架内再狭窄定义为支架内或两端5 mm内出现≥50%狭窄程度的病变。测定术前及术后6个月的血清超敏C反应蛋白、白细胞介素-6、肿瘤坏死因子-α的浓度变化。结果对照组中10例（27.8%）发生再狭窄,普罗布考组仅3例（8.3%）发生再狭窄,两组间比较,差异有统计学意义（P=0.032）;术后6个月时两组患者炎症因子水平较术前均有下降,普罗布考组下降更显著,差异具有统计学意义（P〈0.05）。结论普罗布考能够有效降低合并糖尿病的冠心病患者置入药物洗脱支架置入后再狭窄的发生,其机制可能与抗炎作用有关。     

Coronary in-stent restenosis

Coronary stent implantation was considered as a way of coronary revascularization. It has been widely used in the treatment of coronary heart disease, but restenosis has become the main bottleneck to the development of stent technique. Despite drug-eluting stents used widely, restenosis rate is still about 10%. The incidence of restenosis was associated with intervention injury, patient factors, genetic types, nerve endocrine factors and so on. Overview above aspects is expected to provide some ideas for restenosis prevention and treatment.     

When and How Should We Revascularize Patients With Atherosclerotic Renal Artery Stenosis?

Atherosclerotic renal artery stenosis is the leading cause of secondary hypertension and may lead to resistant (refractory) hypertension, progressive decline in renal function, and cardiac destabilization syndromes (pulmonary edema, recurrent heart failure, or acute coronary syndromes) despite guideline-directed medical therapy. Although randomized controlled trials comparing medical therapy with medical therapy and renal artery stenting have failed to show a benefit for renal artery stenting, according to comparative effectiveness reviews by the Agency for Healthcare Research and Quality, the trials may not have enrolled patients with the most severe atherosclerotic renal artery stenosis, who would be more likely to benefit from renal stenting. Because of limitations of conventional angiography, it is critical that the hemodynamic severity of moderately severe (50% to 70%) atherosclerotic renal artery stenosis lesions be confirmed on hemodynamic measurement. The authors review techniques to optimize patient selection, to minimize procedural complications, and to facilitate durable patency of renal stenting. The authors also review the current American College of Cardiology and American Heart Association guidelines and the Society for Cardiovascular Angiography and Interventions appropriate use criteria as they relate to renal stenting.     

经皮冠状动脉介入治疗术后支架内再狭窄的遗传学与表观遗传学研究进展

冠状动脉粥样硬化性心脏病(简称冠心病)是人类最主要的死亡原因之一,也是消耗巨大医疗资源的疾病.经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)是冠心病治疗的重大进展之一.然而,PCI治疗面临支架内再狭窄(in-stent restenosis,ISR)的重大挑战.尽管药物支架减少了ISR的发生,再狭窄发生率仍达5％～10％.支架后血管内皮细胞过度增生和平滑肌细胞移行是支架术后再狭窄的主要原因.再狭窄个体差异的确切机制还不完全明确,可能存在多种原因.除了高年龄、吸烟、糖尿病等可能增加再狭窄率外,越来越多的研究发现遗传因素和表观遗传学因素对疾病的进展有着重要影响.本文主要对冠心病患者PCI术后发生支架内再狭窄的遗传学和表观遗传学研究进行综述,以期初步确定冠心病患者PCI术后再狭窄发生的遗传危险因素.     

静脉桥再狭窄研究进展

随着社会老龄化的加剧,冠状动脉粥样硬化性心脏病的发病率也逐渐上升。冠状动脉旁路移植术是其重要治疗方法之一。动脉作为移植材料有其自身的优点,但数量限制了它的使用。大隐静脉仍然是冠状动脉旁路移植术的主要移植材料,而静脉桥再狭窄严重影响了冠状动脉旁路移植术的远期疗效,其再狭窄机制一直在研究中,现就目前的一些新进展做一综述。     

Stent implantation and balloon angioplasty for treatment of branch pulmonary artery stenosis in children

OBJECTIVES: Comparison of the results of branch pulmonary artery stenosis treated with balloon angioplasty (BA) or stent implantation (SI) in children. BACKGROUND: Branch pulmonary artery stenosis may be treated with BA or SI. METHODS: We compared the results of 147 interventions of branch pulmonary artery stenosis in 87 children (median age 3.6 years). Patients were treated during 1989-2000 with BA and during 2001-2004 with SI. Primary endpoints were acute complications and reintervention during follow up. Secondary variables were age, vessel diameter increase, acute success rate, balloon/vessel diameter ratio, pulmonary artery hypoplasia indices, and procedure related factors. RESULTS: The acute vessel diameter increase with BA (4.31 +/- 1.98 vs. 7.15 +/- 2.31 mm) and SI (3.71 +/- 1.58 vs. 6.97 +/- 2.68 mm) was significant within both groups (P < 0.001), but not between both groups. The reintervention rate was comparable between both groups, but median time to reintervention was shorter after SI in infants compared to BA. The balloon/vessel diameter ratio was on average higher in BA than the stent/vessel diameter ratio in SI (3.49 +/- 2.16 vs. 2.42 +/- 0.56; P < 0.05) and was a significant risk factor (P < 0.01) for the higher complication rate after BA (BA: 14.1% vs. SI: 4.8%). No mortality occurred in both groups. CONCLUSION: BA and SI are safe interventional catheter therapies of branch pulmonary artery stenosis. The immediate results of BA and SI are comparable. The higher complication rate after BA, especially in infants, was associated with a higher balloon/vessel diameter ratio. SI seems to be a safe permanent alternative with foreign material, but requires more reinterventions in infants due to its therapeutic strategy.     

药物洗脱支架内再狭窄的危险因素分析

目的 探讨冠状动脉药物洗脱支架内再狭窄的危险因素.方法 对157例行冠状动脉药物洗脱支架植入术患者的临床资料进行回顾性分析,按照冠状动脉造影结果分为再狭窄组33例和无再狭窄组124例,采用单因素及Logistic多因素回归分析其临床及冠状动脉造影特征与药物洗脱支架内再狭窄的相关性.结果 再狭窄组33例,糖尿病18例(54.5%),术后反复心绞痛26例(78.8%);无再狭窄组124例,糖尿病31例(25.0%),术后反复心绞痛72例(58.1%),组间差异有统计学意义(χ2=10.60,P＜0.01;χ2=4.77,P=0.03).2组慢性完全闭塞分别为11例(19.3%)、12例(7.6%),分叉病变12例(21.1%)、16例(10.2%),弥漫病变15例(26.3%)、19例(12.1%),组间差异有统计学意义(χ2值分别为5.92、4.34、6.32,P均＜0.05).再狭窄组植入支架57枚,无再狭窄组植入157枚.Logistic多因素分析显示糖尿病、术后反复心绞痛、慢性完全闭塞、分叉病变、弥漫病变和支架长度与支架内再狭窄相关(OR分别为3.52、2.59、3.05、3.14、3.08、0.93,95%CI分别为1.56～7.90,1.02～6.59,1.11～8.36,1.30～7.59,1.34～7.05,0.88～0.98,P均＜0.05).结论 冠状动脉药物洗脱支架植入术后,糖尿病史、术后反复发生心绞痛、慢性完全闭塞、分叉病变、弥漫病变及支架长度为支架内再狭窄的危险因素.

Abstract：

Objective To investigate the risk factors of in-stent restenosis (ISR) after coronary implantation of drug-eluting stent Methods One hundred and fifty-seven patients including 118 males and 39 females,who underwent successful implantation of drug-eluting stent, were recruited in the study. The patients were divided into the restenosis group (33 patients) and non-restenosis group ( 124 patients) according to the angiographic results. The associations of ISR with clinical and coronary angiographic characteristics were analyzed using univiriate analysis and logistic regression. Results In the restenosis group,there were 18 cases of diabetes mellitus ( 54. 5% ), 26 cases of frequency angina ( 78. 8% ), which were significantly higher than those of 31 cases of diabetes (25.0%) and 72 case of frequent angina (58. 1% ) in the non-restenosis group (χ2 = 10. 60, P ＜ 0. 01, χ2 = 4. 77, P = 0. 03 for diabetes mellitus and frequent angina, respectively). Compared to non-restenosis group, the occurrence rates of chronic total occasion, bifurcatus lesions, diffuse lesions were significandy higher in the restenosis group ( 19. 3% vs 7. 6% χ2 =5.92,21.1% vs 10. 2% χ2 =4. 34,26. 3%vs 12. 1% χ2 =6. 32,Ps ＜0. 05). Fifty-seven stents were implanted into the restenosis group,and one hundred and fifty-seven into the non-restenosis group. Logistic regression analysis showed that diabetes, frequent angina,chronic total occlusion lesions, bifurcatus lesions, diffuse lesions, stent length and diameter were significantly associated with restenosis ( OR value were 3.52,2. 59,3.05,3. 14,3.08,0. 93,95% CI were 1.56 - 7.90,1.02 - 6. 59,1.11 - 8. 36,1.30 - 7.59,1.34 - 7.05,0. 88 - 0. 98 respectively, Ps ＜ 0. 05 ). Conclusion After implantation of drug-eluting stent, diabetes mellitus, chronic total occasion lesions, frequent angina, diffuse lesions, bifurcatus lesions and stent length and diameter are associated with follow-up restenosis.