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1、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,Male, 49y. HT (-), DM (-), Dyslipidemia (-), Smoker (-), FH (-) AMI (anterior wall) in sep. 2004. Emergency CAG: ostial LAD 100%, ostial LCX 60%, normal RCA. Emergenc
2、y PCI: Cypher in LAD. Detail not acquired. Drug: (Plavix 75mg/d+ASA 100mg/d)*1y, followed by ASA 75mg/d*qod, other cardio drugs routinely.,Case information follow up,Acute chest pain, Re-AMI (anterior) in 6, Nov. 2007. Emergency CAG: cloud in stent, defect of mid-distal stent, TIMI grade 0. LCX the
3、same as before, normal RCA. CABG or PCI not performed. Followed 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,CAG after 2 weeks: no throbosis in stent, LAD TI
4、MI 3. LCX the same as before, normal RCA.,Angiography follow up,Discussion,Thrombosis of DES Definition The mechanism Strategy,DES preventing restenosis after PCI,Stent: Vessel Recoil and Remodelling Drug:Intimal Proliferation Dilemma of safety: thrombosis,ARC Definition of ST,Acute 0-24h Subacute 2
5、4h-30d Late 30d-1y Very late after 1y,Definite/confirmed Probable Possible,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,Fro
6、m 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=9.8
7、9; 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 fraction; RVD=reference vessel diameter,From A. Colombo, MD,DES delayed healing: delayed endothelia
8、lization,A. Finn, Renu Virmanin, SOLACI 2006,DES: not only suppress SMC infiltration but also delay endothelialization, leading to stent thrombosis,DES Polymer Mishaps,Bonding = polymer sticks to itself forming a bridge when the stent is expanded,Webbing = polymer pulling away from the expanded sten
9、t due to sticking,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，发生晚期贴壁不良的患者停止clopidogrel治疗后,20% 发生了支架血栓*！,* Study by Dr. Abizaid, presented at TCT 2005.,完全闭塞,M, 44y, Cypher due to prior AMI, Clopide
10、grel 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,Manufacturing & Deliverability High pressure, side branch dilatation Inhomogenous drug delivery Thrombogenicity Restenosis is delayed and
11、but not eliminated And so on.,Discussion: strategy,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； 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。 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，其临床过程表现为血栓自溶、血管再通，但是，缺乏血管内超声检查：再狭窄、内皮、血栓、重构。 该患者幸免于第二次植入支架，是否意味着DES心肌梗死患者如果错过了急诊介入时机，造影显示血栓负荷较重者可以先强化抗栓治疗一段时间后再决定是否介入治疗，这种情况下的抗血小板、抗凝治疗方案、治疗时间长短均有待进一步研究。 最强有力的GPb/a受体拮抗剂在DES晚期血栓形成治疗中的效果以及对心功能的改善作用？,谢谢,