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-StentRestenosis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？PTAplus(or)StentAtherectomyLaserStentgraftDESorDEBCryoplastyPTA+STENT再狭窄率颈动脉5％肾动脉10－20％髂动脉5－20％腹股沟以下动脉25－50％Zellaretc,CathCardiovascInterv,2007,70SFA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(FreedomfromTLR)DorrucciJVascSurg,Aug2004PTAplus(or)StentAtherectomyLaserStentgraftDESorDEBCryoplastyAtherectomydataSFA病变，22%闭塞，18％狭窄，平均长度46mm24月随访，84例ABI术前0.62，术后0.84，随访0.721年通畅率91%,2年通畅率80％

Zellaretc,JEndoTher,2007ApriLACI〔LaserAssistedAngioplastyforCriticalLimbIschemia〕127人，随访6月SFA病变，平均长度38mmFreefromTLR85%JLaird,etcJVascSurg,2007,AugCryoplasty---BigCHILLtrialProspectivemulticenterregistry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长度48mm,狭窄病变9月随访，通畅率72％LairdJetc,Jvascintervradiol2005,FebCoveredstentforSFAJVascSurg,2007,MayDESforSFAMDake,Charingcross2021,May,presentationBTKdrugelutingstenttrialJEndoTher,2005,DecJCardioSurg,2007,ApriDrugcoatedballoon(Thundertrial)6monthfollow-upMean65mm,SFATDas,2021VIVApresentationPTAplus(or)Stent：直径、长度AtherectomyLaserStentgraftCryoplastyDESorDEB腔内治疗ISRPTA＋STENTCuttingballoonBrachytherapyLaserStentgraftDESorDEBCuttingballoon31patients36lesions,CLILength32.4mmPrimarypatency61%@6monthLimbsalvage83%BosiersMetc,vascular,2021,FebLaser/PTA+支架血管39人，SFA,ISRRutherfordClass1-6,mean3病变平均长度27cm,(5-44cm)GaryanselJVascSurg,2021,May6月随访Primarypatency73%Primaryassistedpatency76%Occluded24%18月随访Primarypatency52%Primaryassistedpatency67%Brachytherapy13例肾动脉支架术后ISRPTA+brachytherapy(12GyGamma)结果:80％通畅率@12月StoeteknueletcJEndoTherapy,2002Zellaretc,Cath