植入药物洗脱支架后出现的晚期支架血栓和自我溶栓病例.ppt

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. Emergency 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 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 TIMI 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 24h-30d Late 30d-1y Very late after 1y Definite/confirmed Probable Possible DES delayed healing: delayed endothelialization DES Polymer Mishaps Polymer in DES: localized hypersensitivity Late malapposition Case due to late malapposition Discussion: others Manufacturing Deliverability High pressure, side branch dilatation Inhomogenous drug delivery Thrombogenicity Restenosis is delayed and 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