如何应对支架内再狭窄证据及展望

解放军总医院血管外科 贾鑫、郭伟、刘小平、尹太、熊江、马晓辉等 如何应对支架内再狭窄证据及展望 血管外科医生最头痛 的问题 开刀移植物闭塞 腔内支架内再狭窄 （ISR） 支架内再狭窄ISR：In-Stent Restenosis 病理：几乎全部内膜增生 病因：病变部位、病变长度、支架数量、流入流出道 支架断裂可能原因，造成血管壁回缩和刺激内膜增生 抗血小板药物降低ISR？ PTA plus (or) Stent Atherectomy Laser Stentgraft DES or DEB Cryoplasty PTA+STENT 再狭窄率 颈动脉5 肾动脉1020 髂动脉520 腹股沟以下动脉2550 Zellar etc, Cath Cardiovasc Interv, 2007, 70 SFA易再狭窄 路径长，侧支 少 内收肌管挤压 闭塞多于狭窄 SFA裸支架通畅率(Freedom from TLR) Dorrucci J Vasc Surg, Aug 2004 PTA plus (or) Stent Atherectomy Laser Stentgraft DES or DEB Cryoplasty Atherectomy data SFA病变变，22%闭闭塞， 18狭窄，平均长度46mm 24月随访，84例 ABI术前0.62，术后0.84，随访0.72 1年通畅率91%, 2年通畅率80 Zellar etc, J Endo Ther, 2007 Apri LACI（Laser Assisted Angioplasty for Critical Limb Ischemia） 127人，随访6月 SFA病变，平均长度38mm Free from TLR 85% J Laird, etc J Vasc Surg, 2007, Aug Cryoplasty - Big CHILL trial Prospective multicenter registry 诱导VSMC凋亡, 弹力纤维变性，从而减少弹性回缩 录入102患者，SFA长长度48mm, 狭窄病变 9月随访，通畅率72 Laird J etc, J vasc interv radiol 2005, Feb Covered stent for SFA J Vasc Surg, 2007, May DES for SFA M Dake, Charing cross 2009, May, presentation BTK drug eluting stent trial J Endo Ther, 2005, Dec J Cardio Surg, 2007, Apri Drug coated balloon(Thunder trial) 6 month follow-up Mean 65mm, SFA T Das, 2009 VIVA presentation PTA plus (or) Stent：直径、长度 Atherectomy Laser Stentgraft Cryoplasty DES or DEB 腔内治疗ISR PTASTENT Cutting balloon Brachytherapy Laser Stentgraft DES or DEB Cutting balloon 31 patients 36 lesions, CLI Length 32.4mm Primary patency 61% 6 month Limb salvage 83% Bosiers M etc, vascular, 2009, Feb Laser/PTA+支架血管 39人，SFA, ISR Rutherford Class 1-6, mean 3 病变变平均长长度 27cm,(5-44cm) Gary ansel J Vasc Surg, 2009, May 6月随访 Primary patency 73% Primary assisted patency 76% Occluded 24% 18月随访 Primary patency 52% Primary assisted patency 67% Brachytherapy 13例肾动脉支架术后ISR PTA+brachytherapy(12Gy Gamma) 结果:80通畅率12月 Stoeteknuel etc J Endo Therapy,2002 Zellar etc, Cath C