【作者】 周圣华；

【导师】 卢才义；

【作者基本信息】 中国人民解放军军医进修学院 ， 老年医学， 2010， 博士

【摘要】 背景药物洗脱支架(DES)明显降低支架内再狭窄和靶病变再次血运重建率,但是支架内血栓仍然是潜在危险。其发生率很低但预后很差。预防支架内血栓仍是目前冠心病介入领域的研究热点和难点。目的通过分析DES早期支架内血栓(EST)发生的危险因素,评价光学相干断层成像(OCT)对改善DES置入质量的指导作用,观察经皮冠状动脉介入治疗(PCI)围术期补液速度与血小板聚集率(RPA)的关系,从而探讨优化介入质量和围术期管理对预防EST的作用。方法1、回顾分析2004年至2008年连续行PCI治疗的冠心病患者的临床及介入资料,建立Excel数据库,查找EST的主要可控危险因素。2、分析2007年至2009年连续行OCT检查及支架置入患者的PCI及OCT资料,分析不同压力下内膜脱垂、夹层及支架贴壁质量。3、设计前瞻性随机对照试验,评价围术期不同补液速度对DES置入后RPA的影响。结果(一)EST的危险因素分析1、570例连续完成PCI治疗的冠心病患者中有4例(0.70%)在DES置入后平均4.25天发生EST。2、发生EST患者的主要危险因素有：高龄、吸烟、多种原因支架贴壁不良及围术期管理不当等；其中主要可控危险因素包括支架贴壁不良和围术期管理不当。3、EST患者的临床表现主要为持续性胸痛和低血压状态,部分合并心源性休克(25%)、上消化道出血(50%)和顽固性心室颤动(25%),虽经急诊介入、药物及其它治疗,但病死率仍高达50%。(二)OCT对DES贴壁质量的观察及后扩张的指导作用1、OCT检查过程中有7例(22.6%)患者发生一过性心绞痛和轻微ST段改变,无恶性心律失常、急性血栓等严重心血管事件发生。2、支架贴壁距离：厚壁支架Cypher和EXCEL之间无统计学差异(140.19±18.08μm比138.98±12.15μm,P>0.05)；薄壁支架Partner和TAXUS之间无统计学差异(124.43±10.50μm比121.08±11.64μm,P>0.05)；厚壁支架Cypher和EXCEL与薄壁支架Partner和TAXUS相比均有统计学差异(P<0.05)3、与命名压扩张相比,4种不同支架在后扩张的支架贴壁距离更近(P<0.05),内膜脱垂和支架边缘微小夹层发生率更低(P<0.05)(三)围术期补液速度对DES置入后RPA的影响1、与常规补液相比,快速补液并不增加出血、心力衰竭等并发症的发生(P>0.05)。2、两组患者的血压、心率、血清渗透压等指标均无统计学差异(P>0.05),但快速补液组术后4小时的RPA较常规补液组明显降低(P<0.05)。3、常规补液组有3例患者在PCI术后发生心绞痛等临床症状,怀疑容量不足致EST,急诊造影检查除外支架内血栓且经快速补液等治疗后临床症状消失。结论1、EST的主要可控危险因素是支架置入质量和围术期管理。2、支架贴壁距离与支架的总厚度有关。3、后扩张明显减少支架贴壁不良,降低内膜脱垂和支架边缘微小夹层的发生率。4、PCI围术期快速补液能够降低RPA,有利于预防EST。5、优化介入质量和围术期管理有可能是降低EST的有效措施。更多还原

【Abstract】 Background Drug-eluting stents (DES) have significantly reduced the restenosis and target lesion revascularization rate, but stent thrombosis (ST) is still a potential danger for patients. Preventing the incidence of ST is still a hot and difficult spot in the coronary intervention.Objective (1) To analyze the main risk factors of early stent thrombosis (EST). (2) To evaluate the guidance of OCT in the optimization of DES implantation. (3) To observe the relationship between fluid infusion speed and RPA during perioperative of PCI. (4) To investigate the effective of optimizing the quality of intervention and perioperative management to prevent EST.Methods (1) A cohort of consecutive patients treated with PCI from 2004 to 2008 were retrospectively analysized. Their clinical and intervention data were recorded and an Excel database was established to analysis the major controllable risk factors of EST. (2) The PCI and OCT data of the patients who have finished OCT examinations and stent implantion from 2007 to 2009 were studied, and the optimization of DES adherence, intimal prolapse degree and dissection were analysized. (3) A prospective and randomized controlled trial was designed to evaluate the effect of different fluid infusion speed on RPA.Results(1) Four patients (0.70%) in 570 patients with coronary heart disease treated with PCI had EST during an average of 4.25 days after DES implantion.(2) Main risk factors of EST include aging, smoking heavy, stent malapposition and perioperative mismanagement.(3) Persistent chest pain and low BP occured in patients with EST. Some had cardiogenic shock (25%) and refractory ventricular fibrillation (25%). Even through treated with emergency treatments,50% mortality were still existed. (4) During OCT examination, only 7 patients had transient angina and mild ST segment changes. There were no serious cardiovascular events.(5) There was no significant difference with stent adherent distance between Cypher and EXCEL stent, as well as Partner and TAXUS stent (P >0.05). There was significant difference between Cyphe/EXCEL group with Partner/TAXUS group (P<0.05).(6) The distance between the vessel wall and stent after post-dilatation was significantly shorter than that of the named stent expansion in kinds of stents (P <0.05). The incidence of intimal prolapse and dissection after post-dilatation were significantly less than that of named stent expansion (P<0.05).(7) Compared with the conventional infusion, rapid infusion did not increase bleeding, heart failure and other complications (P> 0.05).(8) RPA in rapid infusion group was significantly lower than that of conventional infusion group after four hours (P<0.05).(9) There were 3 patients who had angina after PCI in the conventional fluid group. EST was suspected because of insufficient body fluid capacity. Emergency angiography excluded thrombus, but symptoms disappeared after rapid infusion.Conclusions(1) Optimization of DES implantation and perioperative management are major controllable risk factors of EST.(2) The distance of stent adherence depends on the total thickness of stents.(3) Post-dilatation can reduce stent malapposition, depress the incidence of intimal prolapse and dissection.(4) Rapid fluid influsion can reduce perioperativ RPA, and profiting to prevent EST.(5) Optimizing stent implantion and perioperative management could be effective measures to reduce EST.更多还原