植入药物洗脱支架后出现的晚期支架血栓和自我溶栓病例

Acaseofverylatestentthrombosisandself-thrombolysisafterimplantationofdrugelutingstent阜外心血管病医院李崇剑杨跃进CaseinformationMale,49y.HT(-),DM(-),Dyslipidemia(-),Smoker(-),FH(-)AMI(anteriorwall)insep.2004.EmergencyCAG:ostialLAD100%,ostialLCX60%,normalRCA.EmergencyPCI:CypherinLAD.Detailnotacquired.Drug:(Plavix75mg/d+ASA100mg/d)*1y,followedbyASA75mg/d*qod,othercardiodrugsroutinely.CaseinformationfollowupAcutechestpain,Re-AMI(anterior)in6,Nov.2007.EmergencyCAG:cloudinstent,defectofmid-distalstent,TIMIgrade0.LCXthesameasbefore,normalRCA.CABGorPCInotperformed.Followedbydrugs:(Plavix300mg/d+ASA100mg/d+LWMH1mg/kgq12h)*12d,othercardiodrugsroutinely.Angiograhpy(6,Nov.2007):LADandLCXAngiograhpy(6,Nov.2007):RCAFollowup:2weekslaterCAGafter2weeks:nothrobosisinstent,LADTIMI3.LCXthesameasbefore,normalRCA.AngiographyfollowupDiscussionThrombosisofDESDefinitionThemechanismStrategy？今天讨论重点DESpreventingrestenosisafterPCIStent:VesselRecoilandRemodellingDrug:IntimalProliferationDilemmaofsafety:

thrombosisARCDefinitionofSTAcute0-24hSubacute24h-30dLate30d-1yVerylateafter1yDefinite/confirmedProbablePossibleTimecourseAngiographyandclinicalevidence*AntiplateletTherapydiscPriorBrachyRenalfailureBifurcationsULMDiabetesUAThrombosisratesaccording

toselectedpatientcharacteristics%*PrematurediscontinuationFromA.Colombo,MDClinicalpredictorsofstentthrombosis0.010.11101000.010.1110100Nothieno*(0-6m)Nothieno*(6-18m)LVEF*≤30%PriorBrachytherapyRVD*FinalatmStentLengthHR=11.7;95%CI,3.47-39.24,p<0.0001HR=1.01;95%CI,0.30-3.46,p=0.98HR=4.32;95%CI,1.61-11.60,p=0.004HR=9.89;95%CI,3.56-27.46,p<0.0001HR=0.16;95%CI,0.03-0.82,p=0.03HR=0.41;95%CI,0.18-0.92,p=0.03HR=3.41;95%CI,1.94-5.97,p<0.0001*Abbreviations:thieno=thienopyridine;LVEF=leftventricleejectionfraction;RVD=referencevesseldiameterFromA.Colombo,MDDESdelayedhealing:delayedendothelializationCypherTaxusEFHI500µm2mm500µm200µm500µm200µm500µmC2mm200µmJ200µmABxVelocity2mmBDExpressLK2mmGA.Finn,RenuVirmanin,SOLACI2006DES:notonlysuppressSMCinfiltrationbutalsodelayendothelialization,leadingtostentthrombosisDESPolymerMishaps

Bonding=polymerstickstoitselfformingabridgewhenthestentisexpanded

Webbing=polymerpullingawayfromtheexpandedstentduetostickingPolymerinDES:localizedhypersensitivityVirmani,R.etal.Circulation2004;109:701-705Latemalapposition基线正性管腔重构没有管腔重构随访在Taxus和Cypher的研究中，发生晚期贴壁不良的患者停止clopidogrel治疗后20%

发生了支架血栓*！*StudybyDr.Abizaid,presentedatTCT2005.完全闭塞暴露的支架金属丝M,44y,CypherduetopriorAMI,Clopidegrelwasdiscontinuedafter3m,aspirin150mg/dwascontinued.31mlater,thrombosis.EurHeartJ.21Oct2005.CaseduetolatemalappositionDiscussion:othersManufacturing&Delive