药物洗脱支架术后血栓致急性冠状动脉综合征病因分析及处理评价

Analysis and evaluation of stent thrombosis induced acute coronary syndrome after drug eluting stent deployment

目的:分析药物洗脱支架术(DES)后支架内血栓形成导致急性冠状动脉综合征的影响因素。方法:分析38例DES术后形成支架内血栓形成患者的临床特点、冠状动脉病变特点、手术相关资料及患者发生急性冠状动脉综合征后的临床表现,处理措施和预后情况。结果:患者冠状动脉造影显示病变特点比较复杂,其中B2/C型病变占到了71%,分叉病变、慢性完全闭塞(CTO)病变、弥散长病变以及小血管病变也占到了相当大的比例,反映了真实的临床情况;38例患者中52.6%表现为急性ST段抬高心肌梗死,29%的患者表现为急性非ST段抬高心肌梗死;支架内血栓中急性、亚急性血栓形成占63%,晚期及迟发晚期血栓形成占37%;绝大多数患者成功接受了再次血运重建治疗,其中有31.6%的患者死亡;2例患者血小板聚集率≥50%,发生率为8.3%;4例接受冠脉内超声(IVUS)检查的患者结果显示:支架近端贴壁不良1例,支架远端残余夹层1例,支架内膜增生不完全1例,支架两端动脉瘤形成1例。结论:DES术后支架内血栓形成与患者的冠状动脉病变复杂程度、术后抗血小板治疗不充分、支架贴壁不良、夹层形成、内膜增生不完全以及动脉瘤的发生等因素相关,支架内血栓形成(ST)后多数表现为ST段抬高心肌梗死(STEMI),尽管大部分能成功再次血运重建治疗,但死亡率仍然较高(31.6%)。

Objective：To analyze stent thrombosis induced acute coronary syndrome after drug eluting stent deployment. Method： To observe the clinical character of risk factors, platelet aggregation rates, clinical diagnoses, coronary artery lesions, stents implanted, medication of anticoagnlation after operation, reoccurrence of cardiac events, results of coronary angiography in 38 patients after percutaneous coronary intervention with DES. Result： Coronary lesions were complicated by bifurcation, CTO, long lesions and small vessel lesions which reflected the real clinical current status. 52.6% subjects expressed STEMI, and 29% expressed NSTEMI. Among all patients with stent thrombosis, acute and subacute stent thrombosis were 63 %, late and very late stent thrombosis were 37 %. Most of the subjects received repeated revascularization therapies but 31.6% died. The platelet aggregation of two cases were more than 50% ; Four cases received IVUS examination and the results were as follow： one proximal stent malappositlon, one distal stent dissection, one incomplete neointima and one aneurysm formation. Conclusion：Stent thrombosis was related with coronary lesions, aspirin and clopidogrel resistance, malapposition, dissection, incomplete neointima and aneurysm formation. Although successful revascularization could be carried out in these patients, mortality was still high （31.6%）.