股腘动脉支架内再狭窄的介入处理PPT课件.ppt

股腘动脉支架内再狭窄的介入处理,楼文胜南京医科大学附属南京医院（南京市第一医院）,.,1,股腘动脉ASO腔内治疗现状,普遍存在技术成功率高，再狭窄率不低的情况（随访1年）,.,2,支架内再狭窄(in-stentrestenosis,ISR)就像是支架的孪生兄弟一样，从第一枚支架上市的那天起就一直伴随着我们，是我们前进的动力,.,3,男性，63岁，左下肢间歇性胀痛伴跛行两年余，加重十余天；高血压史8年，吸烟30余年，30支/天,.,4,男性，63岁，左下肢间歇性胀痛伴跛行两年余，加重十余天；高血压史8年，吸烟30余年，30支/天,.,5,7个月后，症状复发,.,6,再次行球囊扩张及溶栓治疗,.,7,5个月后，症状第2次复发,.,8,第3次治疗后,.,9,ISR发生机制,血管损伤内皮细胞缺失（早期反应，数天内），血小板粘附，活化和聚集，血栓形成平滑肌细胞增殖（中期反应，数周内）细胞外基质沉积（延迟反应，数月内）临床和影像学危险因素糖尿病，CLI，病变长度，TASCD，流出道差，严重钙化等其它因素支架断裂，支架设计，支架重叠释放，钙化病变支架未能充分释放，远端血管床流速慢，血管管径小等,.,10,ISR的治疗,传统球囊POBA，CBA药物洗脱球囊Drugelutingballoon切割球囊CuttingBalloon，PCBA冷冻球囊Cryoplasty,球囊扩张Balloon,传统支架Baremetalstent药物洗脱支架Drugelutingstent覆膜支架Endoprostheses,支架成形术Stent,SilverhawkRotarexLaser-Atherectomy,斑块切除术Debulking,旁路手术Bypass,溶栓Thrombolysis,.,11,ISR：球扩+溶栓,.,12,ISR：球囊扩张,.,13,球囊扩张-CBAvs.CuttingBalloon,Dicketal.Radiology248;297-302,2008,.,14,切割球囊,.,15,球囊扩张-CBAvs.Cryoplasty,76reinterventionswereperformedusingCBA(n=39)orcryoplasty(n=37)forin-stentrestenosiswithoutplacementofadditionalstentsThemeantimetorecurrentstenosisorneedforadditionalsecondaryinterventionwassignificantlyshorterforthecyroplastycohortthanfortheCBA,4.09and10.79monthsrespectively(P=.0001)Recurrentstenosis-freesurvivalwassignificantlylowerinthecyroplastycohortat3months(CBA:96.9%,Cyro:88.9%)and6months(CBA:84.0%,Cyro:43.8%;P=.0089),Cyroplastyasamodalityfortreatmentofin-stentstenosisinthefemoropoplitealsegmentoffersNObenefitoverCBA,ShinSH,etal.Vascular.2013,14,.,16,DEB（DCB）,39patientssinglecenterRegistryLesionlength：82.978.9mmCumulativeDEBlength：160mm(120250)Stentlength：150mm(95262.5),StabileE.JAmCollCardiol.2012;60:1739-42,.,17,ISR：传统支架(长期通畅率不高),.,18,ISR：传统支架(长期通畅率不高),.,19,ISR：传统支架(长期通畅率不高),.,20,ISR：传统支架(长期通畅率不高),.,21,ISR：Substenttechnique,A.Diamantopoulos,etal.CardiovascInterventRadiol(2013)36:943949,.,22,ISR：药物洗脱支架（DES）,ZellerTetal.JAmCollCardiolIntv.2013;6:274-281,The1-yearfracturerateofstentsusedinISRlesionswas1.2%,.,23,GOREVIABAHNEndoprosthesis柔顺性好，断裂率02%ePTFE膜完全覆盖原支架，避免金属与内膜接触对长期通畅率的影响肝素生物活性表面进一步增加了血液相容性,SaxonRR,etal.JVascIntervRadiol.2007;18:1341-1349,ISR：覆膜支架,.,24,ISR：RELINE,TheGOREVIABAHNEndoprosthesiswithPROPATENBioactiveSurfaceversusPlainOldBalloonAngioplasty(POBA)fortheTreatmentofSuperficialFemoralArteryIn-StentRestenosis,1yearfollow-up(Prof.BosiersMLINC2013),.,25,ISR：RELINE,1yearfollow-up(Prof.BosiersMLINC2013),79.9%,54.4%,P0.001,74.8%,37.0%,P0.001,.,26,小结,支架内再狭窄、再闭塞是目前的治疗难点DE