Acaseofverylatestentthrombosisandself-thrombolysisafterimplantationofdrugelutingstent阜外心血管病醫(yī)院李崇劍楊躍進(jìn)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):RCADiscussionThrombosisofDESDefinitionThemechanismStrategy？今天討論重點(diǎn)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基線正性管腔重構(gòu)沒有管腔重構(gòu)隨訪在Taxus和Cypher的研究中，發(fā)生晚期貼壁不良的患者停止clopidogrel治療后20%

發(fā)生了支架血栓*！*StudybyDr.Abizaid,presentedatTCT2005.完全閉塞暴露的支架金屬絲M,44y,CypherduetopriorAMI,Clopidegrelwasdiscontinuedafter3m,aspirin150mg/dwascontinued.31mlater,thrombosis.EurHeartJ.21Oct2005.CaseduetolatemalappositionDiscussion:othersManufacturing&DeliverabilityHighpressure,sidebranchdilatationInhomogenousdrugdeliveryThrombogenicityRestenosisisdelayedandbutnoteliminatedAndsoon.Discussion:strategy重要的是對(duì)LaST形成的研究現(xiàn)狀要有清晰的認(rèn)識(shí)，針對(duì)可能的發(fā)生機(jī)制采取綜合措施；該患者年僅49歲，DES術(shù)后堅(jiān)持1年的雙重抗血小板治療，中止氯吡咯雷26個(gè)月后出現(xiàn)LaST，無合并糖尿病、腎功能不全等病史，雖然未評(píng)價(jià)血小板功能，但是推測血栓的形成可能與中止抗血小板治療及LAD支架操作有關(guān)，也很可能是血管對(duì)DES的遲發(fā)反應(yīng)。大多數(shù)專家認(rèn)為雙重抗血小板最少要12個(gè)月，至于是否需要更進(jìn)一步延長還未達(dá)成共識(shí)，需要更多的循證醫(yī)學(xué)證據(jù)來根據(jù)晚期血栓事件的風(fēng)險(xiǎn)對(duì)患者進(jìn)行分層。本患者在DES術(shù)后38個(gè)月發(fā)生靶血管AMI，造影提示支架內(nèi)血栓形成的特點(diǎn)，其臨床過程表現(xiàn)為血栓自溶、血管再通，但是，缺乏血管內(nèi)超聲檢查：再狹窄、內(nèi)皮