如何应对支架内再狭窄－－证据及展望课件.ppt

解放军总医院血管外科 贾鑫、郭伟、刘小平、尹太、熊江、马晓辉等 血管外科医生最头痛的问题 开刀－－移植物闭塞 腔内－－支架内再狭窄（ISR） 支架内再狭窄ISR：In-Stent Restenosis 病理：几乎全部内膜增生 病因：病变部位、病变长度、支架数量、流入流出道 支架断裂可能原因，造成血管壁回缩和刺激内膜增生 抗血小板药物降低ISR？ PTA plus (or) Stent Atherectomy Laser Stentgraft DES or DEB Cryoplasty PTA+STENT 再狭窄率 颈动脉5％ 肾动脉10－20％ 髂动脉5－20％ 腹股沟以下动脉25－50％ Zellar etc, Cath Cardiovasc Interv, 2007, 70 SFA易再狭窄 路径长，侧支少 内收肌管挤压 闭塞多于狭窄 SFA裸支架通畅率(Freedom from TLR) Dorrucci J Vasc Surg, Aug 2004 PTA plus (or) Stent Atherectomy Laser Stentgraft DES or DEB Cryoplasty Atherectomy data SFA病变，22%闭塞， 18％狭窄，平均长度46mm 24月随访，84例 ABI术前0.62，术后0.84，随访0.72 1年通畅率91%, 2年通畅率80％ Zellar etc, J Endo Ther, 2007 Apri LACI（Laser Assisted Angioplasty for Critical Limb Ischemia） 127人，随访6月 SFA病变，平均长度38mm Free from TLR 85% J Laird, etc J Vasc Surg, 2007, Aug Cryoplasty --- Big CHILL trial Prospective multicenter registry 诱导VSMC凋亡, 弹力纤维变性，从而减少弹性回缩 录入102患者，SFA长度48mm, 狭窄病变 9月随访，通畅率72％ Laird J etc, J vasc interv radiol 2005, Feb Covered stent for SFA J Vasc Surg, 2007, May DES for SFA M Dake, Charing cross 2009, May, presentation BTK drug eluting stent trial J Endo Ther, 2005, Dec J Cardio Surg, 2007, Apri Drug coated balloon(Thunder trial) 6 month follow-up Mean 65mm, SFA T Das, 2009 VIVA presentation PTA plus (or) Stent：直径、长度 Atherectomy Laser Stentgraft Cryoplasty DES or DEB 腔内治疗ISR PTA＋STENT Cutting balloon Brachytherapy Laser Stentgraft DES or DEB Cutting balloon 31 patients 36 lesions, CLI Length 32.4mm Primary patency 61% @ 6 month Limb salvage 83% Bosiers M etc, vascular, 2009, Feb Laser/PTA+支架血管 39人，SFA, ISR Rutherford Class 1-6, mean 3 病变平均长度 27cm,(5-44cm) Gary ansel J Vasc Surg, 2009, May 6月随访 Primary patency 73% Primary assisted patency 76% Occluded 24% 18月随访 Primary patency 52% Primary assisted patency 67% Brachytherapy 13例肾动脉支架术后ISR PTA+brachytherapy(12Gy Gamma) 结果:80％通畅率@12月 Stoeteknuel etc J Endo Therapy,2002 Zell