徐立,王乐丰,杨新春,李奎宝,张大鹏,王红石,刘宇,李惟铭,孙昊,倪祝华,夏昆,何冀芳,迟永辉

• 1:首都医科大学附属北京朝阳医院心脏中心

摘要(Abstract)：

目的分析药物洗脱支架(drug eluting stent,DES)置入术后极晚期血栓(very late stent thrombosis,VLST)患者再次发生支架内血栓的临床情况,探讨反复发生支架内血栓可能的相关因素。方法 2006年1月到2014年2月,共完成4463例急诊冠状动脉造影,入选经造影证实为DES置入术后VLST的患者66例。根据随访期间是否再次出现支架内血栓,将患者分为再发血栓组和对照组。比较两组患者的基线资料、造影和介入治疗资料以及抗血小板药物治疗情况。分析VLST患者再次发生支架内血栓的临床特点,探讨反复发生支架内血栓可能的相关因素。结果随访0.5~90个月,共有8例(12.1%)患者再发支架内血栓,为再发血栓组;其余58例未再发支架内血栓的患者为对照组。对两组患者的性别、年龄、VLST距第一次PCI时间、VLST时AMI部位(前壁ST段抬高)、Killip心功能Ⅰ~Ⅱ级、高血压等进行单因素分析,差异均无统计学意义(均P>0.05)。Cox单因素分析发现持续双重抗血小板治疗(dual anti-platelets therapy,DAPT)(HR 0.09,P=0.022)和再次置入第1代DES(HR 3.27,P=0.096)两项因素的P<0.1,纳入Cox多因素分析,结果提示,坚持持续的DAPT是随访中无再发支架内血栓的唯一预测因素(HR 0.10,95%CI 0.01~0.90,P=0.04)。结论DES置入术后VLST患者可再次发生支架内血栓,值得临床重视。避免再次置入第一代DES和坚持DAPT可能有助于减少支架内血栓事件的再次发生率。

关键词(KeyWords)： 药物洗脱支架;支架内血栓;经皮冠状动脉介入治疗;随访

Abstract:

Keywords:

基金项目(Foundation):

作者(Author): 徐立,王乐丰,杨新春,李奎宝,张大鹏,王红石,刘宇,李惟铭,孙昊,倪祝华,夏昆,何冀芳,迟永辉

参考文献(References)：

• [1]Stone GW,Moses JW,Ellis SG,et al.Safety and efficacy of sirolimus-and paclitaxel-eluting coronary stents.N Engl J Med,2007,356:998-1008.
• [2]Iakovou I,Schmidt T,Bonizzoni E,et al.Incidence,predictors,and outcome of thrombosis after successful implantation of drugeluting stents.JAMA,2005,293:2126-2130.
• [3]Natsuaki M,Morimoto T,Furukawa Y,et al.On behalf of the CREDO-Kyoto PCI/CABG registry cohort-2 investigators.Late adverse avents after implantation of Sirolimus-Eluting Stent and Bare-Metal Stent:Long-Term(5-7 Years)follow-up of the coronary revascularization demonstrating outcome study-kyoto registry cohort-2.Circ Cardiovasc Interv,2014,7:168-179.
• [4]Cutlip DE,Windecker S,Mehran R,et al.Clinical end points incoronary stent trials:a case for standardized definitions.Circulation,2007,115:2344-2351.
• [5]Thygesen K,Alpert JS,Jaffe AS,et al.The writing group on behalf of the joint ESC/ACCF/AHA/WHF task force for the universal definition of myocardial infarction.third universal definition of myocardial infarction.Eur Heart J,2012,33:2551-2567.
• [6]Sammel AM,Chen D,Jepson N.New generation coronary stent technology—is the future biodegradable?Heart Lung Circ,2013,22:495-506.
• [7]Stefanini GG,Byrne RA,Serruys PW,et al.Biodegradable polymer drug-eluting stents reduce the risk of stent thrombosis at4 years in patients undergoing percutaneous coronary intervention:a pooled analysis of individual patient data from the ISAR-TEST 3,ISAR-TEST 4,and LEADERS randomized trials.Eur Heart J,2012,33:1214-1222.
• [8]Palmerini T,Biondi-Zoccai G,Della Riva D,et al.Stent thrombosis with drug-eluting stents is the paradigm shifting?J Am Coll Cardiol,2013,62:1915-1921.
• [9]王佳鑫,刘越,尹新华,等.新一代冠状动脉支架与支架内血栓的临床研究进展.中国介入心脏病学杂志,2013,21:51-52.
• [10]Nakazawa G.Stent thrombosis of drug eluting stent:pathological perspective.J Cardiol,2011,58:84-91.
• [11]Viamani R,Guagliumi G,Farb A,et al.Local hypersensituty and late coronary thrombosis secondary to a sirolimus-eluting stent:should we be cautious?Circulation,2004,109:701-705.
• [12]Kang SJ,Lee CW,Song H,et al.OCT analysis in patients with very late stent thrombosis.JACC Cardiovasc Imaging,2013,6:695-703.
• [13]Kubo S,Kadota K,Ichinohe T,et al.Comparison of long-term outcome after percutaneous coronary intervention for stent thrombosis between early,late,and very late stent thrombosis.Circ J,2014,78:101-109.
• [14]Kimura T,Morimoto T,Kozuma K,et al.Comparisons of baseline demographics,clinical presentation,and long-term outcome among patients with early,late,and very late stent thrombosis of sirolimus-eluting stents:Observations from the Registry of Stent Thrombosis for Review and Reevaluation(RESTART).Circulation,2010,122:52-61.
• [15]Kim U,Kim DK,Kim YB,et al.Long-term clinical outcomes after angiographic ally defined very late stent thrombosis of drugeluting stent.Clin Cardiol,2009,32:526-529.
• [16]van Werkum JW,Heestermans AA,de Korte FI,et al.Longterm clinical outcome after a first angiographically confirmed coronary stent thrombosis an analysis of 431 cases.Circulation,2009,119:828-834.
• [17]Park SJ,Park DW,Kim YH,et al.Duration of dual antiplatelet therapy after implantation of drug-eluting stents.N Engl J Med,2010,362:1374-1382.
• [18]Valgimigli M,Campo G,Monti M,et al.Short-versus long-term duration of dual-antiplatelet therapy after coronary stenting:a randomized multicenter trial.Circulation,2012,125:2015-2026.
• [19]Levine GN,Bates ER,Blankenship JC,et al.2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention:a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the society for cardiovascular angiography and interventions.J Am Coll Cardiol,2011,58:e44-e122.
• [20]Geisler T,Zürn C,Simonenko R,et al.Early but not late stent thrombosis is influenced by residual platelet aggregation in patients undergoing coronary interventions.Eur Heart J,2010,31:59-66.