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

A case of very late stent thrombosis and self-thrombolysis after implantation of drug eluting stent 阜外心血管病医院 李崇剑 杨跃进 Case information nMale, 49y. nHT (-), DM (-), Dyslipidemia (-), Smoker (-), FH (-) nAMI (anterior wall) in sep. 2004. nEmergency CAG: ostial LAD 100%, ostial LCX 60%, normal RCA. nEmergency PCI: Cypher in LAD. Detail not acquired. nDrug: (Plavix 75mg/d+ASA 100mg/d)*1y, followed by ASA 75mg/d*qod, other cardio drugs routinely. Case information follow up nAcute chest pain, Re-AMI (anterior) in 6, Nov. 2007. nEmergency CAG: cloud in stent, defect of mid-distal stent, TIMI grade 0. LCX the same as before, normal RCA. nCABG or PCI not performed. nFollowed by drugs: (Plavix 300mg/d+ASA 100mg/d+LWMH 1mg/kg q12h)*12d, other cardio drugs routinely. Angiograhpy (6, Nov. 2007): LAD and LCX Angiograhpy (6, Nov. 2007): RCA Follow up: 2 weeks later nCAG after 2 weeks: no throbosis in stent, LAD TIMI 3. LCX the same as before, normal RCA. Angiography follow up Discussion Thrombosis of DES nDefinition nThe mechanism nStrategy 今 天 讨 论 重 点 DES preventing restenosis after PCI Stent: Vessel Recoil and Remodelling Drug:Intimal Proliferation Dilemma of safety: thrombosis ARC Definition of ST nAcute 0-24h nSubacute 24h-30d nLate 30d-1y nVery late after 1y nDefinite/confirmed nProbable nPossible Time course Angiography and clinical evidence *Antiplatelet Therapy disc Prior Brachy Renal failure Bifurcations ULM Diabetes UA Thrombosis rates according to selected patient characteristics % * Premature discontinuation From A. Colombo, MD Clinical predictors of stent thrombosis 0.01 0.1 1 10 100 0.01 0.1 1 10 100 No thieno* (0-6m) No thieno* (6-18m) LVEF* 30% Prior Brachytherapy RVD* Final atm Stent Length HR=11.7; 95%CI, 3.47-39.24, p0.0001 HR=1.01; 95%CI, 0.30-3.46, p=0.98 HR=4.32; 95%CI, 1.61-11.60, p=0.004 HR=9.89; 95%CI, 3.56-27.46,p0.0001 HR=0.16; 95%CI, 0.03-0.82, p=0.03 HR=0.41; 95%CI, 0.18-0.92, p=0.03 HR=3.41; 95%CI, 1.94-5.97, p0.0001 * * Abbreviations: thieno=thienopyridine; LVEF=left ventricle ejection Abbreviations: thieno=thienopyridine; LVEF=left ventricle ejection fraction; RVD=reference vessel diameterfraction; RVD=reference vessel diameter From A. Colombo, MD DES delayed healing: delayed endothelialization CypherTaxus E F HI 500 m 2 mm 500 m 200 m 500 m 200 m 500 m C 2 mm 200 m J 200 m A BxVelocity 2 mm B D Express L K 2 mm G A. Finn, Renu Virmanin, SOLACI 2006 DES: not only suppress SMC infiltration but also delay endothelialization, leading to stent thrombosis DES Polymer MishapsDES Polymer Mishaps Bonding = polymer sticks to Bonding = polymer sticks to itself forming a bridge when itself forming a bridge when thethe stent stent is expanded is expanded Webbing = polymer pulling away Webbing = polymer pulling away from the expandedfrom the expanded stent stent due to due to stickingsticking Polymer in DES: localized hypersensitivity Virmani, R. et al. Circulation 2004;109:701-705 Late malapposition 基线 正性管腔重构 没有管腔重构 随访 在Taxus和Cypher的研究中，发发生晚 期贴贴壁不良的患者停止clopidogrel治 疗疗后 20% 发生了支架血栓*！ * Study by Dr. Abizaid, presented at TCT 2005. 完全闭塞完全闭塞 暴露的支架金属丝暴露的支架金属丝 M, 44y, Cypher due to prior AMI, Clopidegrel was discontinued after 3m, aspirin 150mg/d was continued. 31m later, thrombosis. Eur Heart J. 21 Oct 2005. Case due to late malapposition Discussion: others nManufacturing & Deliverability nHigh pressure, side branch dilatation nInhomogenous drug delivery nThrombogenicity nRestenosis is delayed and but not eliminated nAnd so on. Discussion: strategy n重要的是对LaST形成的研究现状要有清晰的认识，针对可能的发生机制 采取综合措施； n该患者年仅49岁，DES术后坚持1年的双重抗血小板治疗，中止氯吡咯雷 26个月后出现LaST，无合并糖尿病、肾功能不全等病史，虽然未评价血 小板功能，但是推测血栓的形成可能与中止抗血小板治疗及LAD支架操 作有关，也很可能是血管对DES的迟发反应。大多数专家认为双重抗血 小板最少要12个月，至于是否需要更进一步延长还未达成共识，需要更 多的循证医学证据来根据晚期血栓事件的风险对患者进行分层。 n本患者在DES术后38个月发生靶血管AMI，造影提示支架内血栓形成的特 点，其临床过程