Optical coherence tomography analysis of late and very late stent thrombosis after drug-eluting stent implantation
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摘要: 目的:应用光学相关断层成像(OCT)分析药物洗脱支架置入术后晚期、极晚期支架内血栓形成的可能机制。方法:入选2011-01-2017-12经遵义医学院附属医院行冠状动脉(冠脉)造影明确诊断晚期、极晚期支架内血栓形成患者8例。8例患者在PCI术中均行OCT检查。回顾性分析8例患者的临床资料、PCI过程及OCT图像特征。结果:7例伴有多个心血管危险因素,2例合并轻度左心功能不全。首次支架置入至发生支架血栓的平均时间(818±651) d;双联抗血小板服用平均时间(312.8±76.3) d;低密度脂蛋白胆固醇(LDL-C)平均水平为(3.44±1.35) mmol/L,均未达到目标值;1例在术后停用双联抗血小板3个月、2例在服用双联抗血小板期间、5例在单用阿司匹林期间发生支架内血栓;6例置入依维莫司药物支架,1例行支架内非顺应性高压球囊扩张,1例行紫杉醇药物球囊治疗。OCT图像特征:7例患者支架内异质性新生内膜形成,5例为支架内新生动脉粥样硬化伴斑块破裂,2例为支架内新生动脉粥样硬化伴斑块侵蚀;1例出现严重支架贴壁不良,贴壁不良比例达66.2%;6例患者出现不同程度的支架小梁无内膜覆盖,平均为(10.4±6.2)%;5例支架内见红血栓,3例支架内见白血栓。结论:晚期、极晚期支架内血栓患者首次及再次住院多表现为急性冠脉综合征与高LDL-C水平。支架内新生动脉粥样硬化、支架贴壁不良是导致晚期、极晚期支架内血栓形成的主要原因之一。OCT的应用有助于明确晚期和极晚期支架内血栓形成的机制。Abstract: Objective: To investigate the possible mechanism of late and very late stent thrombosis after implantation of drug-eluting stents (DES) by optical coherence tomography (OCT).Method: Eight patients were selected because of definite diagnosis of late and very late stent thrombosis by coronary angiography from January 2011 to December 2017 in The Affiliated Hospital of Zunyi Medical University.OCT examination was performed in all 8 patients during PCI.Clinical data, PCI process and OCT image features of 8 patients were analyzed retrospectively.Result: There were 7 cases with multiple cardiovascular risk factors and 2 cases with mild left cardiac insufficiency.The mean time from the first stent implantation to the occurrence of stent thrombosis was (818±651)d.The average duration of dual antiplatelet administration was (312.8+76.3) d.The mean LDL-C level of all 8 patients did not reach the target, with an average of (3.44±1.35) mmol/L.Stent thrombosis occurred during the time of stopping dual antiplatelets for 3 months after PCI (n=1), took dual antiplatelets (n=2) and took aspirin alone (n=5).Of the 8 patients, 6 were treated with everolimus drug stents, 1 with non-compliant hyperbaric balloon dilation and 1 with paclitaxel drug balloon therapy.OCT image showed that 7 patients had in-stent heterogeneity neointima formation, including in-stent neoatherosclerosis with plaque rupture in 5 patients and in-stent neoatherosclerosis with plaque erosion in 2 patients.One patient had severe stent malposition, and the stent malposition rate was up to 66.2%.Uncovered struts (10.4±6.2)% was found in 6 patients.Red thrombus was found in 5 cases and white thrombus in 3 cases.Conclusion: Patients with late and very late stent thrombosis who are first hospitalized and rehospitalized present with ACS and high LDL-C levels.In-stent neoatherosclerosis and stent malposition are the main causes of late and very late stent thrombosis.The application of OCT helps to clarify the mechanisms of late and very late stent thrombosis.
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Key words:
- dug-eluting stent /
- optical coherence tomography /
- stent thrombosis
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[1] Mauri L, Hsieh WH, Massaro JM, et al.Stent thrombosis in randomized clinical trials of drug-eluting stents[J].N Engl J Med, 2007, 356(10):1020-1029.
[2] Daemen J, Wenaweser P, Tsuchida K, et al.Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice:data from a large two-institutional cohort study[J].Lancet, 2007, 369(9562):667-678.
[3] Cheneau E, Leborgne L, Mintz GS, et al.Predictors of subacute stent thrombosis:results of a systematic intravascular ultrasound study[J].Circulation, 2003, 108(1):43-47.
[4] Cutlip DE, Windecker S, Mehran R, et al.Clinical end points in coronary stent trials:a case for standardized definitions[J].Circulation, 2007, 115(17):2344-2351.
[5] Tearney GJ, Regar E, Akasaka T, et al.Consensus standards for acquisition, measurement, and reporting of intravascular optical coherence tomography studies:a report from the International Working Group for Intravascular Optical Coherence Tomography Standardization and Validation[J].J Am Coll Cardiol, 2012, 59(12):1058-1072.
[6] Claessen BE, Henriques JP, Jaffer FA, et al.Stent thrombosis:a clinical perspective[J].JACC Cardiovasc Interv, 2014, 7(10):1081-1092.
[7] Joner M, Finn AV, Farb A, et al.Pathology of drug-eluting stents in humans:delayed healing and late thrombotic risk[J].J Am Coll Cardiol, 2006, 48(1):193-202.
[8] Guagliumi G, Sirbu V, Musumeci G, et al.Examination of the in vivo mechanisms of late drug-eluting stent thrombosis findings from optical coherence tomography and intravascular ultrasound imaging[J].J Am Coll Cardiol Intv, 2012, 5(1):12-20.
[9] Cook S, Ladich E, Nakazawa G, et al.Correlation of intravascular ultrasound findings with histopathological analysis of thrombus aspirates in patients with very late drug-eluting stent thrombosis[J].Circulation, 2009, 120(5):391-399.
[10] Nakazawa G, Otsuka F, Nakano M, et a1.The pathology of neoatherosclemsis in human coronary implants bare-metal and drug-eluting stents[J].J Am Coil Cardiol, 2011, 57(11):1314-1322.
[11] Souteyrand G, Amabile N, Mangin L, et a1.Mechanisms of stent thrombosis analysed by optical coherence tomography:insights from the national PESTO French registry[J].Eur Heart J, 2016, 37(15):1208-1216.
[12] Kang SJ, Mintz GS, Park DW, et a1.Tissue characterization of in-stent neointima using intravascular ultrasound radiofrequency data analysis[J].Am J Cardiol, 2010, 106(11):1561-1565.
[13] Lee SY, Shin DH, Mintz GS, et a1.Optical coherence tomography-based evaluation of in-stent neoatherosclerosis in lesions with more than 50% neointimal cross-sectional area stenosis[J].EuroIntervention, 2013, 9(8):945-951.
[14] Yonetsu T, Kato K, Kim SJ, et a1.Predictors for neoatherosclerosis:a retrospective observational study from the optical coherence tomography registry[J].Circ Cardiovasc Imaging, 2012, 5(5):660-666.
[15] Kim C, Kim BK, Lee SY, et a1.Incidence, clinical presentation, and predictors of early neoatherosclerosis after drug-eluting stent implantation[J].Am Heart J, 2015, 170(3):591-597.
[16] Kang SJ, Mintz GS, Akasaka T, et a1.Optical coherence tomographic analysis of in-stent neoatherosclerosis after drug-eluting stent implantation[J].Circulation, 2011, 123(25):2954-2963.
[17] Yonetsu T, Kim JS, Kato K, et a1.Comparison of incidence and time course of neoatherosclerosis between bare metal stents and drug-eluting stents using optical coherence tomography[J].Am J Cardiol, 2012, 110(7):933-939.
[18] Wenaweser P, Daemen J, Zwahlen M, et al.Incidence and correlates of drug-eluting stent thrombosis in routine clinical practice.4-yearresults from a large 2-institutional cohort study[J].J Am Coll Cardiol, 2008, 52(14):1134-1140.
[19] Joner M, Koppara T, Byrne RA, et a1.Neoatherosclerosis in patients with coronary stent thrombosis:findings from optical coherence tomography imaging (A Report of the PRESTIGE Consortium)[J].JACC Cardiovasc Interv, 2018, 11(14):1340-1350.
[20] Joner M, Finn AV, Farb A, et al.Pathology of drug-eluting stents in humans:Delayed healing and late thrombotic risk[J].J Am Coll Cardiol, 2006, 48(1):193-202.
[21] Cook S, Wenaweser P, Togni M, et al.Incomplete stent apposition and very late stent thrombosis after drug-eluting stent implantation[J].Circulation, 2007, 115(18):2426-2434.
[22] Im E, Kim BK, Ko YG, et al.Incidences, predictors, and clinical outcomes of acute and late stent malapposition detected by optical coherence tomography after drug-eluting stent implantation[J].Circ Cardiovasc Interv, 2014, 7(1):88-96.
[23] Ozaki Y, Okumura M, Ismail TF, et al.The fate of incomplete stent apposition with drug-eluting stents:an optical coherence tomography-based natural history study[J].Eur Heart J, 2010, 31(12):1470-1476.
[24] Otsuka F, Vorpahl M, Nakano M, et al.Pathology of second-generation everolimus-eluting stents versus first-generation sirolimus-and paclitaxel-eluting stents in humans[J].Circulation, 2014, 129(2):211-23.
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