52例冠状动脉支架内血栓形成患者的临床特点及介入治疗

目的探讨冠状动脉支架置入术后支架内血栓形成的临床特点及治疗措施。方法回顾性分析近6年我院心内科住院冠心病患者中52例发生冠状动脉支架术后支架内急性和亚急性血栓患者的临床及冠状动脉造影特点,并评价其治疗方法的疗效。结果2000年1月至2006年5月,我院共52例患者于冠心病的介入治疗术后发生支架内急性或亚急性血栓形成(发生率0.75%)。术后发生支架内血栓形成的时间为30min～20d,平均(3.6±4.2)d。多因素回归分析表明急性心肌梗死(AMI)、术前存在心功能不全、病变血管支数、前降支病变及B2/C型病变是支架内血栓发生的独立危险因子。支架内血栓形成后多数患者出现典型的临床表现及心电图改变。行急诊冠状动脉造影复查证实原支架内完全血栓性闭塞48例,原支架内新出现70%～95%狭窄伴血栓影像4例。经急诊经皮冠状动脉介入治疗,47例患者治愈存活出院。5例患者抢救无效死亡(院内病死率9.6%)。结论支架内血栓形成多发生于AMI、术前存在心功能不全、多支血管病变、前降支病变及B2/C型复杂病变的患者。其发病时间主要在支架置入术后1周之内。急诊再次介入治疗是治疗支架内血栓形成的首选治疗方案,尽早实施急诊经皮冠状动脉介入治疗可增加抢救成功率。

Clinical characteristics and management of patients with acute or subacute coronary in-stent thrombosis

OBJECTIVE: To determine risk factors and evaluate the efficacy of emergent PCI for acute or subacute coronary in-stent thrombosis. METHODS: Baseline and follow-up data of 6977 patients who underwent stent implantation in our institution between January 2000 and May 2006 were analyzed. RESULTS: Of 6977 patients, acute or subacute coronary in-stent thrombosis was confirmed in 52 (0.75%) patients by coronary angiogram. The in-stent thrombosis occurred between 30 minutes to 20 days post PCI (mean 3.6 +/- 4.2 days). Predictive factors for in-stent thrombosis showed by multivariate analysis were AMI, B2/C type lesions, multi-vessel diseases, heart failure and target lesions on left anterior descending artery (LAD). Among these 52 patients, 43 presented recurrent chest pain or ST elevation AMI, 6 suffered from cardiac arrests, 1 manifested hypotension and 2 showed no typical clinical symptoms and were diagnosed during scheduled PCI for other diseased vessels. Emergent coronary angiogram evidenced total thrombotic occlusion in 48 patients and 70% - 95% thrombotic stenosis in 4 patients. All 52 patients were treated with emergent PCI. Forty-seven patients survived and 5 patients died (mortality 9.6%). CONCLUSION: The risk of developing in-stent thrombosis was higher in patients with AMI, B2/C type lesions, multi-vessel diseases, heart failure and target lesions on LAD. Emergent PCI is the most effective method for treating in-stent thrombosis and should be carried out as early as possible in order to improve outcomes of this severe complication post stenting.