冠状动脉支架内再狭窄的病理生理及治疗策略
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摘要
冠状动脉支架内再狭窄严重影响冠心病支架置入患者预后,也是当前经皮冠状动脉介入术治疗领域亟待解决的问题。金属裸支架和药物洗脱支架置入术后支架内再狭窄的管理已经成为临床治疗的一种挑战。尸体解剖和血管内成像为支架内再狭窄的病理生理学研究提供了更多的可能。支架内再狭窄基本的治疗策略包括:球囊血管成形术、斑块切除术、血管内放疗、金属裸支架置入、药物涂层球囊、药物洗脱支架置入。最有效的治疗方法取决于患者和病变特点,药物洗脱支架和药物涂层球囊的问世成为冠心病介入治疗(经皮冠状动脉介入术)技术突破的历史性转折点。现主要讨论支架内再狭窄的病理生理、危险因素及治疗策略。
In-stent restenosis( ISR) seriously affects the prognosis of patients and is also an urgent problem urgently that is necessary to be solved in percutaneous coronary intervention therapy.Management of ISR remains a clinical challenge after both bare-metal stent and drug-eluting stent placement.Autopsy studies and intravascular imaging have augmented our understanding of the pathophysiology of ISR.Potential treatment strategies includes plain old balloon angioplasty,rotational atherectomy,vascular brachytherapy,bare-metal stent,drug-coated balloon,and drug-eluting stent placement. The most efficacious therapy depends on patient and lesion characteristics,but drug-eluting stent and drug-coated balloon yield the most successful angiographic and clinical results.Here,we discuss the underlying pathology,risk factors and treatment of ISR.
In-stent restenosis( ISR) seriously affects the prognosis of patients and is also an urgent problem urgently that is necessary to be solved in percutaneous coronary intervention therapy.Management of ISR remains a clinical challenge after both bare-metal stent and drug-eluting stent placement.Autopsy studies and intravascular imaging have augmented our understanding of the pathophysiology of ISR.Potential treatment strategies includes plain old balloon angioplasty,rotational atherectomy,vascular brachytherapy,bare-metal stent,drug-coated balloon,and drug-eluting stent placement. The most efficacious therapy depends on patient and lesion characteristics,but drug-eluting stent and drug-coated balloon yield the most successful angiographic and clinical results.Here,we discuss the underlying pathology,risk factors and treatment of ISR.
引文
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[14]徐博,赵龙,张向阳.切割球囊和普通球囊治疗冠状动脉支架内再狭窄有效性和安全性的Meta分析[J].流行病学研究,2014,22(3):298-303.
[15]张冠龙,王继群.冠状动脉支架内再狭窄的研究新进展[J].中国老年学杂志,2016,36(5):1264-1267.
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[18]Alfonso F,Melgares R,Mainar V,et al.Therapeutic implications of in-stent restenosis located at the stent edge.Insights from the Restenosis Intra-stent Balloon Angioplasty Versus Elective Stenting(RIBS)randomized trial[J].Eur Heart J,2004,25(20):1829-1835.
[19]马丽娟,高明宇.冠状动脉支架材料与炎症反应[J].中国组织工程研究与临床健康,2010,14(21):3887-3890.
[20]Adriaenssens T,Dens J,Ughi G,et al.Optical coherence tomography study of healing characteristics of paclitaxel-eluting balloons vs everolimus-eluting stents for in-stent restenosis:the SEDUCE(safety and efficacy of a drug eluting balloon in coronary artery restenosis)randomised clinical trial[J].Euro Intervention,2014,10(4):439-448.
[21]Pleva L,Kukla P,Kusnierova P,et al.Comparison of the Efficacy of PaclitaxelEluting Balloon Catheters and Everolimus-Eluting Stents in the Treatment of Coronary In-Stent Restenosis:The Treatment of In-Stent Restenosis Study[J].Circ Cardiovasc Interv,2016,9(4):e003316.
[22]Scheller B,Fontaine T,Mangner N,et al.A novel drug-coated scoring balloon for the treatment of coronary in-stent restenosis:results from the multi-center randomized controlled PATENT-C first in human trial[J].Catheter Cardiovasc Interv,2016,88(1):51-19.
[23]Miglionico M,Mangiacapra F,Nusca A,et al.Efficacy and safety of paclitaxelcoated balloon restenosis in high-risk patients[J].Am J Cardiol,2015,116(11):1690-1694.
[24]Moses JW,Leon MB,Popma JJ,et al.Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery[J].N Engl J Med,2003,349(14):1315-1323.
[25]Alfonso F,Pérez-Vizcayno MJ,Cárdenas A,et al.A prospective randomized trial of drug-eluting balloons versus everolimus-eluting stents in patients with in-stent restenosis of drug-eluting stents:The RIBSⅣrandomized clinical trial[J].J Am Coll Cardiol,2015,66(1):23-33.
[26]陈佳慧,沈雳,王齐兵.冠状动脉生物可降解支架设计与应用:材料学的进一步革新将带来什么?[J].中国胸心血管外科临床杂志,2007,14(6):4878-4888.
[27]Pereira-da-Silva T,Patrício L,Cruz Ferreira R.Rotational atherectomy combined with bioresorbable vascular scaffold implantation:a feasible approach for recurrent in-stent restenosis when other therapies failed[J].J Invasive Cardiol,2015,27(7):E143-145.
[2]Zhang BC,Karanasos A,Regar E,et al.OCT demonstrating neoatherosclerosis as part of the continuous process of coronary artery disease[J].Herz,2015,40(6):845-854.
[3]Fujii K,Mintz GS,Kobayashi Y,et al.Contribution of stent underexpansion to recurrence after sirolimus-eluting stent implantation for in-stent restenosis[J].Circulation,2004,109(9):1085-1088.
[4]Lee SW,Lee JY,Ahn JM,et al.Comparison of dual versus triple antiplatelet therapy after drug-eluting stent according to stent length(from the pooled analysis of DECLARE trials[J].Am J Cardiol,2013,112(11):1738-1744.
[5]Windecker S,Kolh P,Alfonso F,et al.2014 ESC/EACTS Guidelines on myocardial revascularization:The Task Force on Myocardial Revascularization of the European Society of Cardiology(ESC)and the European Association for CardioThoracic Surgery(EACTS).Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions(EAPCI)[J].Eur Heart J,2014,35(37):2541-619.
[6]Nakazawa G,Otsuka F,Nakano M,et al.The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents[J].J Am Coll Cardiol,2011,57(11):1314-1322.
[7]Tada T,Kadota K,Hosogi S,et al.Association between tissue characteristics assessed with optical coherence tomography and midterm results after percutaneous coronary intervention for in-stent restenosis lesions:a comparison between balloon angioplasty,paclitaxel-coated balloon dilatation,and drug-eluting stent implantation[J].Eur Heart J Cardiovasc Imaging,2015,16(10):1101-1111.
[8]Nijhoff F,Stella PR,Troost MS,et al.Comparative assessment of the antirestenotic efficacy of two paclitaxel drug-eluting balloons with different coatings in the treatment of in-stent renstenosis[J].Clin Res Cardiol,2016,105(5):401-411.
[9]Tocci G,Barbato E,Coluccia R,et al.Blood pressure levels at the time of percutaneous coronary revascularization and risk of coronary in-stent restenosis[J].Am J Hypertens,2016,29(4):509-518.
[10]Brener SJ,Kereiakes DJ,Simonton CA,et al.Everolimus-eluting stents in patients undergoing percutaneous coronary intervention:final 3-year results of the clinical evaluation of the XIENCE V everolimus eluting coronary stent system in the treatment of subjects with de novo native coronary artery lesions trial[J].Am Heart J,2013,166(6):1035-1042.
[11]Zhao LP,Xu WT,Wang L,et al.Influence of insulin resistance on in-stent restenosis in patients undergoing coronary drug-eluting stent implantation after longterm angiographic follow-up[J].Coron Artery Dis,2015,26(1):5-10.
[12]Magalhaes MA,Minha S,Chen F,et al.Clinical presentation and outcomes of coronary in-stent restenosis across 3-stent generations[J].Circ Cardiovasc Interv,2014,7(6):768-776.
[13]Nam CW,Rha SW,Koo BK,et al.Usefulness of coronary pressure measurement for functional evaluation of drug-eluting stent restenosis[J].Am J Cardiol,2011,107(12):1783-1786.
[14]徐博,赵龙,张向阳.切割球囊和普通球囊治疗冠状动脉支架内再狭窄有效性和安全性的Meta分析[J].流行病学研究,2014,22(3):298-303.
[15]张冠龙,王继群.冠状动脉支架内再狭窄的研究新进展[J].中国老年学杂志,2016,36(5):1264-1267.
[16]Oliver LN,Buttner PG,Hobson H,et al.A meta-analysis of randomised controlled trials assessing drug-eluting stents and vascular brachytherapy in the treatment of coronary artery in-stent restenosis[J].Int J Cardiol,2008,126(2):216-223.
[17]Benjo A,Cardoso RN,Collins T,et al.Vascular brachytherapy versus drug-eluting stents in the treatment of in-stent restenosis:a meta-analysis of long-term outcomes[J].Catheter Cardiovasc Interv,2016,87(2):200-208.
[18]Alfonso F,Melgares R,Mainar V,et al.Therapeutic implications of in-stent restenosis located at the stent edge.Insights from the Restenosis Intra-stent Balloon Angioplasty Versus Elective Stenting(RIBS)randomized trial[J].Eur Heart J,2004,25(20):1829-1835.
[19]马丽娟,高明宇.冠状动脉支架材料与炎症反应[J].中国组织工程研究与临床健康,2010,14(21):3887-3890.
[20]Adriaenssens T,Dens J,Ughi G,et al.Optical coherence tomography study of healing characteristics of paclitaxel-eluting balloons vs everolimus-eluting stents for in-stent restenosis:the SEDUCE(safety and efficacy of a drug eluting balloon in coronary artery restenosis)randomised clinical trial[J].Euro Intervention,2014,10(4):439-448.
[21]Pleva L,Kukla P,Kusnierova P,et al.Comparison of the Efficacy of PaclitaxelEluting Balloon Catheters and Everolimus-Eluting Stents in the Treatment of Coronary In-Stent Restenosis:The Treatment of In-Stent Restenosis Study[J].Circ Cardiovasc Interv,2016,9(4):e003316.
[22]Scheller B,Fontaine T,Mangner N,et al.A novel drug-coated scoring balloon for the treatment of coronary in-stent restenosis:results from the multi-center randomized controlled PATENT-C first in human trial[J].Catheter Cardiovasc Interv,2016,88(1):51-19.
[23]Miglionico M,Mangiacapra F,Nusca A,et al.Efficacy and safety of paclitaxelcoated balloon restenosis in high-risk patients[J].Am J Cardiol,2015,116(11):1690-1694.
[24]Moses JW,Leon MB,Popma JJ,et al.Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery[J].N Engl J Med,2003,349(14):1315-1323.
[25]Alfonso F,Pérez-Vizcayno MJ,Cárdenas A,et al.A prospective randomized trial of drug-eluting balloons versus everolimus-eluting stents in patients with in-stent restenosis of drug-eluting stents:The RIBSⅣrandomized clinical trial[J].J Am Coll Cardiol,2015,66(1):23-33.
[26]陈佳慧,沈雳,王齐兵.冠状动脉生物可降解支架设计与应用:材料学的进一步革新将带来什么?[J].中国胸心血管外科临床杂志,2007,14(6):4878-4888.
[27]Pereira-da-Silva T,Patrício L,Cruz Ferreira R.Rotational atherectomy combined with bioresorbable vascular scaffold implantation:a feasible approach for recurrent in-stent restenosis when other therapies failed[J].J Invasive Cardiol,2015,27(7):E143-145.