1、支架内血栓支架内血栓In-Stent Thrombosis北京大学第一医院北京大学第一医院 李建平李建平 Definite/Confirmed（肯定的）（肯定的）Acute coronary syndrome AND Angiographic confirmation of thrombus or occlusion OR Pathologic confirmation of acute thrombosis Probable（可能的）（可能的）Unexplained death within 30 days Target vessel MI without angiographic conf
2、irmation of thrombosis or other identified culprit lesion Possible（不能排除的）（不能排除的）Unexplained death after 30 daysARC 支架内血栓定义支架内血栓定义支架内血栓的预后支架内血栓的预后DeathMyocardial InfarctionFatal MIQ Wave MINon-Q Wave MI SES(N=13)413485BMS(N=15)513458支架内血栓发生时间支架内血栓发生时间ST=stent thrombosis;SAT=subacute stent thrombosis;
3、LST=late stent thrombosis;VLST=very late stent thrombosis.Adapted from Bhatt.J Invasive Cardiol.2003;15(suppl B):3B.Stent Thrombosis(%)支架内血栓与抗凝、抗血小板治疗支架内血栓与抗凝、抗血小板治疗ASA und TiclopidineASA und AnticoagulationASA und ClopidogrelDESASA=Acetylsalicylic acidDES:Drug-eluting stent Bare Metal StentPrasugre
4、l?BMS支架内血栓发生率支架内血栓发生率Days108642003060120 600NEarly1.2%(N=71)Late0.4%(N=24)Study population 1995-2002-6,058 patients undergoing PCI with BMSWenaweser P et al.EHJ 2005N=1,191N=1,855N=361N=6,058Stent Thrombosis(%)DES肯定的肯定的ST发生率发生率:Bern-Rotterdam Cohort Study Daemen,Wenaweser et al.Lancet 2007;369:667-7
5、80.6%/yearEarly ST 91 pts(60%)Late ST 61 pts(40%)Incidence density:1.3/100 patient yearsN=814601234Time since PCI in years012345Cumulative incidence,%MonthsCumulative incidence,%Patients at risk11.27538121.67210242.15164362.72790483.31051Incidence density1.0/100 pt years3.3%3.50.53%(95%CI=0.44-0.64)
6、/year192 definite ST casesDES肯定的肯定的ST发生率发生率:Bern-Rotterdam Cohort Study 4 YearsWenaweser P et al.J Am Coll Cardiol 2008,52,1134-0.52%(95%CI=0.42-0.62)/year between 30 days and 5 yearsDES肯定的支架内血栓发生率肯定的支架内血栓发生率:Bern-Cohort Study 5 YearsWenaweser P et al.ESC 2008Favours DESFavours BMS180 days31-180 day
7、s 0-30 daysTime after PCI.1.2.512510 2050 100Odds RatioFavors DESFavors BMS.1.2.5125102050 100Odds RatioAdjusted Resultswith interaction terms for time since PCIEarly period:0-30 daysOR 0.59,95%CI.35-1.01Late period:31-180 daysOR 0.52,95%CI.16 1.75Very late period:180 daysOR 9.4,95%CI 2.56 34.70Wena
8、weser et al.ACC 2007DES vs BMSA cohort of 9,175 patients treated with either BMS or DES(SES or PES),all patients with angiographically documented ST were identified as casesEarly Stent ThrombosisRR=0.7695%CI=0.30-1.80P=0.55RR=0.8095%CI=0.32-2.03P=0.79Meta-analysisSES vs BMSBavry A et al.Am J Card 20
9、05Meta-analysisPES vs BMSStone G et al.NEJM 2007%Very Late ST 1 Year(Per Protocol)P=0.75P=0.02%P=0.30P=0.03%Stone G et al.NEJM 2007;356:998-1008Kastrati A et al.NEJM 2007;356:1030-9Sirolimus-Eluting StentPaclitaxel-Eluting StentSIRTAX Definite ST 4 YearsWindecker S et al ESC 20082.0%1.8%2.8%2.4%3.7%
10、3.4%0.000.050.100.150.20Cumulative Incidence of ST(%)0.25.5.7511.25 1.5 1.7522.25 2.5 2.7533.25 3.5 3.754Follow-up(years)Sirolimus StentPaclitaxel Stent1-year HR1.12 0.46,2.76P=0.012-year HR0.86 0.40,1.87P=0.713-year HR0.90 0.47,1.73P=0.754-year HR1.06 0.57,1.95P=0.86SES 4.2%PES 3.9%Cumulative Incid
11、ence of Definite STin LEADERS(BES vs.SES)Windecker et al.Lancet,2008,372,1163-Early:1.6%2.0%SES1.9%BESOverall Incidence of ST with DESCYPHERTAXUSENDEAVOR XIENCE BIOMATRIX0.40.30.70.51.61.40.8TAXUS IITAXUS IVTAXUS VTAXUS VIREALITYSIRTAXISAR-DM10.50.81.9Endeavor IEndeavor IISpirit IIILeaders0.21.120.6
12、1.80.800123SIRIUSE-SIRIUSC-SIRIUSREALITYSIRTAXARTS IIISAR-DM%High Risk of ST in All-Comer Patient Population and STEMI Patients%支架内血栓的病因支架内血栓的病因STENT THROMBOSISStentDesign/LengthPolymerSurfaceDrugsLesionVessel SizeThrombusInterventionResidual DissectionIncomplete Stent AppositionAntithromobotic Medi
13、cationPatientGenetic PolymorphismReduced LV-EFAcute Coronary SyndromeHematology DisorderDrugsResistanceDrug-drug InteractionDuration of AntiplateletTreatementVessel ReactionVessel RemodelingHypersensitivity ReactionDelayed Healing早期支架内血栓的预测因素早期支架内血栓的预测因素:残留夹层残留夹层/撕裂撕裂Bare Metal StentsMACE 30 daysSch
14、hlen H et al.Circulation 1998N=2,894Drug-Eluting StentsMACE 30 daysBiondi-Zoccai G et al.EHJ 2006N=2,418%P=0.01P=0.01Residual Dissection:Independent Predictor of MACE(OR=2.9)早期支架内血栓早期支架内血栓IVUS预测因素预测因素 With the Use of Sirolimus-Eluting StentsFujii K et al.J Am Coll Cardiol 2005;45:995-8Minimal Stent
15、CSAP0.001mm2Stent ExpansionResidual Stenosis%P0.001Stent Underexpansion and Residual Reference Segment Stenosis:Independent Predictors of Early Stent Thrombosis!P0.001支架内血栓预测因素支架内血栓预测因素药物反应异常药物反应异常 Wenaweser P et al.JACC 2005;45(11):1748-52 服药后血小板活性与服药后血小板活性与DES ST的关系的关系Buonamici P et al JACC 2007p0.001p0.001p风险风险
