光学相干断层成像在支架植入术后即刻及长期随访中的部分应用

【作者】 刘小宁；

【导师】 杨跃进；

【作者基本信息】 北京协和医学院 ， 心血管内科学， 2014， 博士

【摘要】 光学相干断层成像评价药物洗脱支架术后即刻支架丝贴壁情况及相关因素分析[背景]既往病理研究中发现,药物洗脱支架(DES)术后内膜延迟愈合在致死性晚期和极晚期支架内血栓形成的靶病变中普遍存在。且有研究结果显示DES晚期贴壁不良与延迟内皮化之间有一定联系。目前对DES术后即刻贴壁不良的相关研究尚少。[目的]应用光学相干断层成像(OCT)技术评价冠心病临床诊断类型、支架因素、靶病变局部特征及介入操作因素对DES术后即刻贴壁不良的影响。[方法]回顾性分析2009-06至2010-06介入治疗前、后均行OCT检查的78例患者资料。其中急性ST段抬高型心肌梗死(STEMI)行直接PCI治疗者18例,择期PCI治疗的不稳定型心绞痛(UAP)30例、稳定型心绞痛(SAP)30例,比较术后即刻支架丝贴壁情况,并行临床随访。亚组分析重叠支架组(含同种DES重叠节段靶病变20例)与单支架组术后即刻DES贴壁情况。对58例单支架靶病变行多因素回归分析,探讨靶病变局部特征(包括：血栓负荷、钙化程度、薄纤维帽粥样斑块(TCFA)、病变累及象限、病变长度、狭窄程度)、支架因素及介入操作因素对介入术后即刻DES贴壁不良的影响。[结果]术后即刻支架丝总贴壁不良率为(7.48±4.06)%,三组间差异有统计学意义(STEMI组(9.04±4.67)%vs UAP组(8.10±4.22)%vs SAP组(5.93±2.99)%,P<0.05),STEMI组高于SAP组(P<0.05),UAP组与STEMI组和SAP组间差异均无统计学意义(P均>0.05)。平均临床随访时间为30.73±2.82个月,三组患者严重心脏不良事件(MACE)发生率间差异无统计学意义(P>0.05)。亚组分析结果显示重叠支架组支架丝总贴壁不良率高于单支架组((11.31±5.48)%vs(5.91±4.37)%,P=0.007),主要因为其中重叠节段支架丝贴壁不良率(26.67±9.20)%较单支架组明显增高(P<0.001),而其单层节段(7.54±4.38)%较单支架组有升高趋势但差异无统计学意义(P>O.05)。多元线性回归分析显示,西罗莫司支架(β系数4.3%,P=O.001)、钙化程度(β系数2.0%,P=0.001)、血栓负荷(β系数O.8%,P=0.019)与术后即刻支架丝贴壁不良率呈正相关。而后扩张(β系数-0.2%,P=O.004)与术后即刻支架丝贴壁不良率呈负相关。[结论]本研究初步表明,STEMI直接PCI术后即刻支架丝贴壁不良率高于SAP。重叠DES术后即刻贴壁不良率高于单支架,主要因为其重叠节段贴壁不良率明显增高。SES、钙化程度重、血栓负荷重可增加术后即刻支架丝贴壁不良,而适当的后扩张可减少术后即刻支架丝贴壁不良的发生。光学相干断层成像分析极晚期支架内血栓形成[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,但其具体机制尚不明确。[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组长于DES组((112.00±51.36)月vs(41.39±19.64)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<O.001)。23例VLST靶病变中,OCT明确观察到支架内新生内膜破裂15例(65.22%),DES组与BMS组间差异无统计学意义(55.56%vs100%,P=0.07),破裂位于最小管腔面积处13例(56.52%)。新生内膜含TCFA病变18例(78.26%),支架内再狭窄15例(65.22%)。含未覆盖支架丝17例(73.91%),DES组高于BMS组(88.89%vs20%,P=0.008),与血栓位置相关14例(60.87%)。BMS组未发现贴壁不良支架丝。靶病变血栓处同时有新生内膜破裂和未覆盖支架丝8例(34.78%)。只有2例(8.70%)靶病变血栓处未发现新生内膜破裂或未覆盖支架丝证据。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%vs12.50%,P=0.038)。[结论]本研究结果初步表明,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。光学相干断层成像方法评价远期重叠药物洗脱支架[背景]有动物实验表明药物洗脱支架(DES)重叠节段较非重叠节段内膜愈合延迟。与此相反,有造影研究表明DES重叠节段可能引起内膜增生。目前对重叠DES处内膜愈合情况的相关研究尚少。[目的]应用光学相干断层成像(OCT)方法评价远期重叠DES内膜覆盖情况及支架丝贴壁情况。[方法]入选植入1年以上且含同种DES重叠节段靶病变18例(重叠节段22处),应用OCT评价DES重叠节段内膜覆盖情况及支架丝贴壁情况,并与相临单层节段比较。[结果]支架植入持续时间33.28±22.88月。共分析支架丝17870个。DES重叠节段新生内膜未覆盖支架丝比例及贴壁不良支架丝比例均高于相邻单层节段((2.60±5.05)%vs(1.544±1.94)%,(0.25±0.64)%vs(0.07±0.19)%,P均<0.05)。新生内膜厚度重叠节段小于单层节段((0.22±0.16)mm vs(0.24±0.33)mm,P<0.05)。晚期管腔面积丢失率重叠节段与单层节段相比差异无统计学意义((24.45±14.40)%vs(22.64±16.50)%,P>0.05)。18例靶病变中支架内再狭窄6例(33.33%),均发生于非重叠DES节段(100%),仅有1例同时累及重叠DES节段(16.67%,P<0.05)。[结论]本研究结果初步表明,DES重叠节段与相邻非重叠节段相比内膜愈合延迟,不增加晚期管腔面积丢失率。更多还原

【Abstract】 The incidence and predictors of malapposition in drug-eluting stent assessed by optical coherence tomography[Background] Pathology studies had described delayed neointimal healing as the common morphologic finding in fatal cases of late and very late stent thrombosis. Several studies revealed that late stent malapposition may delay the neointimal coverage. However, the immediate stent malapposition in drug-eluting stent (DES) was seldom studied.[Objective] To assess the effects of clinical diagnosis, stents, local features of coronary artery lesions and intervention operation factors on immediate stent malapposition of DES by optical coherence tomography (OCT).[Methods] This retrospective study included78patients who accepted OCT both pre-procedure and post-procedure from June2009to June2010. Patients were divided into ST-segment elevation myocardial infarction (STEMI) group(18patients), unstable angina pectoris (UAP) group(30patients) and stable angina pectoris (SAP) group(30patients). Stent malapposition and the clinical outcome of the three groups were analyzed. Subgroup analysis compared the incidence of stent malapposition between the overlapping stent group(n=20) and the single stent group(n=20). Regression analysies assessed the effects of local features of coronary artery lesions (including: thrombus load, the degree of calcification, unstable plaque that is thin-cap fibroatheroma (TCEA), atherosclerosis, lesion length, the degree of stenosis), stents and intervention operation factors on immediate stent malapposition of DES in58cases with single DES.[Result] The percentage of stent malapposition immediately after PCI was (7.48±4.06)%(STEMI group (9.04±4.67)%vs UAP group (8.10±4.22)%vs SAP group (5.93±2.99)%, P<0.05). The percentage of stent malapposition in STEMI group was higher than in SAP group (P<0.05). There was no significant differences of the incidence of MACE among the three groups during30.73±2.82months follow-up (P>0.05). The subgroup analysis revealed that the percentage of stent malapposition was higher in the overlapping stent group than in the single stent group (11.31±5.48%vs5.91±4.37%, P=0.007). Mainly because in the overlapping stent group, the percentage of stent malapposition was much higher in overlapped segments than that in non-overlapped segments. Multivariate analysis revealed that sirolimus-eluting stent (SES)(β=4.3%, P=0.001), calcification(β=2.0%, P=0.001), thrombi(β=0.8%, P=0.019) were positively related to immediate stent malapposition. The post dilatation(β=-0.2%, P=0.004) was negatively correlated to immediate stent malapposition.(Conclusion] This study showed that the percentage of stent malapposition at immediate post-procedure in STEMI was higher than in SAP. Compared with the single stent group, the percentage of stent malapposition in the overlapping stent group was higher, especially in the overlapped segments. SES, calcification, thrombi could increase stent malapposition. Post dilatation might reduce the incidence of stent malapposition. Optical coherence tomography analysis in patients with very late stent thrombosisTBackground] Very late stent thrombosis (VLST) is a potentially life-threatening complication, but the underlying mechanisms remain unclear.[Objective] We used optical coherence tomography (OCT) to analyse23patients who presented with very late stent thrombosis (VLST) after either drug-eluting stent (DES) or bare-metal stent (BMS) implantation.[Methods] In23patients (18DES-and5BMS-treated lesions) with definite VLST, OCT images were acquired before percutaneous coronary intervention (PCI).[Result] The duration from implantation to VLST in DES group was longer than in BMS group((112.00±51.36) months vs (41.39±19.64) months, P<0.001). The neointimal hyperplasia thickness(NHT) of DES group was larger than of BMS group((0.33±0.24)μm vs (0.26±0.22) μm, P<0.001). In the overall cohort, VLST was associated with in-stent neointimal rupture in15patients (65.22%), and there was no significant difference between DES group and BMS group (55.56%vs100%, P=0.07). The site of neointimal rupture was near the minimal lumen area in13patients (56.52%). TCFA-containing neointima was observed in18patients (78.26%) and late in-stent restenosis in15patients (65.22%). Uncovered struts were observed in17(73.91%) lesions, and14of them at the site of thrombi. All BMS with VLST showed no malapposition. The proportion of uncovered struts in DES group were more than in BMS group(2.04%vs0.68%, P=0.028).8(34.78%) stented segments with uncovered struts also had neointimal rupture. Only2(8.70%) lesions had no evidence of neointimal rupture or uncovered struts. Compared with lesions without neointimal rupture, lesions with neointimal rupture showed a higher frequency of TIMI<3grade (60.00%vs.12.50%, P=0.038).[Conclusion] 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. Long-term follow-up of the neointimal coverage and stent malapposition of the overlapping drug-eluting stents by optical coherence tomography[Background] Histologic experimental studies reported that in drug-eluting stents (DES) overlapped segments impaired neointima healing in animals. On the contrary, angiographic studies suggested that overlapping DES maybe elicited neointimal hyperplasia. By far, the neointima healing in overlapping DES was seldom studied.[Objective] Using optical coherence tomography (OCT) to assess coverage and apposition of overlapping DES on long-term follow-up.[Methods] This retrospective analysis included18patients with22overlapped segments of homogeneous DES over1year after implantation. Neointimal coverage and stent apposition of overlapped segments and the corresponding nonoverlapped segments were detected by OCT.[Result] The mean follow-up duration was33.28±22.88months. A total of17,870struts were analyzed. The rate of uncovered struts and malapposed struts in overlapped segments were higher than in nonoverlapped segments((2.60±5.05)%vs(1.54±1.94)%,(0.25±0.64)%vs (0.07±0.19)%, respectively, both P<0.05).The neointimal hyperplasia thickness(NHT) in overlapped segments was less than that in nonoverlapped segments ((0.22±0.16) mm vs (0.24±0.33) mm, P<0.05). There were no differences in the proportion of late lumen area loss between overlap and nonoverlap segments ((24.45±14.40)%vs (22.64±16.50)%,(0.21±0.15) mm vs (0.23±0.32) mm, respectively, both P>0.05). In-stent restenosis was observed in6/18(33.33%) lesions and all of them were at the site of nonoverlapped segments, only one case both involved overlapped segment.[Conclusion] Compared with nonoverlap segments, the vascular healing was delayed at the site of overlapping DES segments. There were no differences in the proportion of late lumen area loss.更多还原