光学相干断层成像分析极晚期支架内血栓形成
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摘要
背景极晚期支架内血栓形成(VLST)是一种有致死风险的介入术后晚期并发症,但其具体发生机制尚不完全明确。目的应用光学相干断层成像(OCT)评价23例药物洗脱支架(DES)或金属裸支架(BMS)相关的VLST靶病变。方法入选VLST患者23例(18例DES,5例BMS),介入治疗前于靶病变处行OCT检查。结果支架植入至发生VLST的持续时间BMS组明显长于DES组[(112.00±51.36)个月vs(41.39±19.64)个月,P<0.001]。BMS组新生内膜厚度大于DES组[(0.33±0.24)μm vs(0.26±0.22)μm,P<0.001]。23例VLST靶病变中,OCT明确观察到支架内新生内膜含薄纤维帽粥样斑块(TCFA)18例(78.26%),支架内再狭窄15例(65.22%)。新生内膜破裂15例(65.22%),DES组与BMS组间差异无统计学意义(55.56%vs 100%,P=0.07),破裂位于最小管腔面积处13例(56.52%)。存在无内膜覆盖支架丝17例(73.91%),DES组高于BMS组(88.89%vs 20%,P=0.008)。同时存在新生内膜破裂和无内膜覆盖支架丝8例(34.78%)。与无新生内膜破裂相比,有新生内膜破裂病变更易出现TIMI血流<3级(60.00%vs 12.50%,P=0.038)。结论本支架内新生内膜动脉粥样硬化进展至内膜破裂在BMS和DES相关的VLST病变中均普遍存在,且DES早于BMS。新生内膜延迟愈合在DES相关的VLST靶病变中较为多见。
Background Very late stent thrombosis(VLST) is a potentially life-threatening complication,but the underlying mechanisms remain unclear.Objectives We used optical coherence tomography(OCT) to analyse 23 patients who presented with VLST after either drugeluting stent(DES) or bare-metal stent(BMS) implantation.Methods In 23 patients(18 DES-and 5 BMS-treated lesions) with definite VLST,OCT images were acquired before percutaneous coronary intervention(PCI).Results The duration from implantation to VLST in BMS group was longer than in DES group([112.00±51.36] months vs [41.39±19.64] months,P<0.001).The neointimal hyperplasia thickness(NHT) of BMS group was larger than DES group([0.33±0.24]μm vs [0.26±0.22] μm,P<0.001).In the overall cohort,TCFA-containing neointima was observed in 18 patients(78.26%) and late in-stent restenosis in 15 patients(65.22%).VLST was associated with in-stent neointimal rupture in 15 patients(65.22%),and there was no significant difference between DES group and BMS group(55.56% vs 100%,P=0.07).The site of neointimal rupture was near the minimal lumen area in 13 patients(56.52%).Uncovered struts were observed in 17(73.91%) lesions,DES group was higher than BMS group(88.89% vs 20%,P=0.008).There were 8(34.78%) cases together with uncovered struts and neointimal rupture.Compared with lesions without neointimal rupture,lesions with neointimal rupture showed a higher frequency of TIMI<3 grade(60.00% vs 12.50%,P=0.038).Conclusions OCT imaging indicated that in-stent advanced neoatherosclerosis with neointimal rupture was widespread in BMS-VLST and DES-VLST,and that in DES-VLST was earlier than in BMS-VLST.Delayed neointimal healing was observed more in DES-VLST.
Background Very late stent thrombosis(VLST) is a potentially life-threatening complication,but the underlying mechanisms remain unclear.Objectives We used optical coherence tomography(OCT) to analyse 23 patients who presented with VLST after either drugeluting stent(DES) or bare-metal stent(BMS) implantation.Methods In 23 patients(18 DES-and 5 BMS-treated lesions) with definite VLST,OCT images were acquired before percutaneous coronary intervention(PCI).Results The duration from implantation to VLST in BMS group was longer than in DES group([112.00±51.36] months vs [41.39±19.64] months,P<0.001).The neointimal hyperplasia thickness(NHT) of BMS group was larger than DES group([0.33±0.24]μm vs [0.26±0.22] μm,P<0.001).In the overall cohort,TCFA-containing neointima was observed in 18 patients(78.26%) and late in-stent restenosis in 15 patients(65.22%).VLST was associated with in-stent neointimal rupture in 15 patients(65.22%),and there was no significant difference between DES group and BMS group(55.56% vs 100%,P=0.07).The site of neointimal rupture was near the minimal lumen area in 13 patients(56.52%).Uncovered struts were observed in 17(73.91%) lesions,DES group was higher than BMS group(88.89% vs 20%,P=0.008).There were 8(34.78%) cases together with uncovered struts and neointimal rupture.Compared with lesions without neointimal rupture,lesions with neointimal rupture showed a higher frequency of TIMI<3 grade(60.00% vs 12.50%,P=0.038).Conclusions OCT imaging indicated that in-stent advanced neoatherosclerosis with neointimal rupture was widespread in BMS-VLST and DES-VLST,and that in DES-VLST was earlier than in BMS-VLST.Delayed neointimal healing was observed more in DES-VLST.
引文
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[2]Taniwaki M,Radu MD,Zaugg S,et al.Mechanisms of Very Late Drug-Eluting Stent Thrombosis Assessed by Optical Coherence Tomography.Circulation,2016,133(7):650-660.
[3]Gao L,Lee S,Kim CJ,et al.Incidence and morphological predictors of intrastent coronary thrombus after drug-eluting stent implantation.Am J Cardiol,2016,117(3):369-375.
[4]Nakazawa G,Otsuka F,Nakano M,et al.The pathology of eoatherosclerosis in human coronary implants bare-metal anddrug-eluting stents.J Am Coll Cardiol,2011,57:1314-1322.
[5]Hassan AK,Bergheanu SC,Stijnen T,et al.Late stent malapposition risk is higher after drug-eluting stentcompared with bare-metal stent implantation and associates with late stent thrombosis.Eur Heart J,2010,31:1172-1180.
[6]Cutlip DE,Windecker S,Mehran R,et al.for the Academic Research Consortium.Clinical end points in coronary stent trials:a case for standardized definitions.Circulation,2007,115:2344-2351.
[7]Kang SJ,Mintz GS,Akasaka T,et al.Optical coherence tomographic analysis of in-stent neoatherosclerosis after drugeluting stent implantation.Circulation,2011,123:2954-2963.
[8]Finn AV,Otsuka F.Neoatheroselerosis:a culprit in very late stent thrombosis.Circ Cardiovasc Interv,2012,5:6-9.