药物洗脱支架术后支架内亚急性血栓的发生和原因分析

目的分析冠状动脉药物洗脱支架（drug—eluting stent，DES）置入术后支架内亚急性血栓形成的因素及治疗措施。方法回顾性分析2004年12月至2008年4月我院心内科冠心病患者行药物洗脱支架置入术后11例患者发生支架内亚急性血栓的好发时间、部位及相关危险因素。结果2004年12月至2008年4月，我院共完成PCI术596例，其中DES置入术455例，术后发生支架内亚急性血栓11例，发生率为2．42％，血栓形成时间为3—15d，平均（6．9±4．1）d。其中冠脉3支病变患者5例，2支血管病变4例；左前降支病变6例；置入多支架8例；支架贴壁不良2例。支架置入术后突然出现无其他原因可以解释的明显胸痛者7例；心衰低血压状态2例；以心脏骤停发病者2例，均院外死亡。心电图提示支架段血管支配区域心肌缺血加重或急性心梗2例，造影复查证实原支架内闭塞伴血栓影像7例，术后突然出现无其他原因可以解释死亡2例。4例因停用氯吡格雷而致血栓形成；2例可能支架贴壁不良。经单纯球囊扩张，冠脉内注入血小板GPⅡb／Ⅲa受体拮抗剂等治疗，7例患者存活出院，4例患者死亡（病死率36．4％）。结论亚急性支架内血栓形成与患者临床病变特点、介入操作因素和支架本身、抗凝治疗等有关，多发生在AMI、合并糖尿病或心功能不全、多支血管病变、前降支病变、B／C型复杂病变等患者。急诊再次介入治疗是治疗支架内血栓的首选。

The Factors of Subacute Thrombosis in Coronary Drug-Eluting Stent

Objective To analyze the factors of subacute thrombosis in coronary drug-eluting stent （DES） and to evaluate the efficacy of emergent percutaneous coronary intervention （PCI） for it. Methods Baseline and follow- up data of 596 patients who underwent PCI and 455 patients were implanted DES in our hospital from December 2004 to April 2008. Results 11 subacute coronary in-stent thrombosis was confirmed in 455 patients （2.42%）. The in-stent thrombosis occurred from 3 to 15 days post PCI （median 6.9 ± 4.1 d）. Predictive factors for in-stent thrombosis were muti-vessel diseases, target lesions on left anterior descending artery （LAD） , multi-stent and stent malposition. Among these 11 patients , 7 patients presented recurrent chest pain or ST elevation AMI, 2 patients suffered from cardiac arrests and both of them sudden death out-hospital, 2 patients manifested hypotension and heart failure . 7 patients were confirmed by emergent PCI and 2 diagnosed by electrocardiogram. Four patients occurred after withdraw clopidogrel. 11 patients except 2 death patients were treated with emergent PCI and two were dropped glycoprotein Ⅱ b/Ⅲ a receptor inhibition in coronary artery. Seven patients survived and 4 patients died （ mortality 36.4% ）. Conclusion The risks of developing instent thrombosis were clinical diseases, lesion type , intervention operating fators , stent and anticoagulant therapy, It was higher in patients with AMI, diabetes or heart failure , multi-vessel disease, target lesions on LAD, B/C type lesions,. Emergent PCI are the most effective methods for treating instent thrombosis.