急性冠状动脉综合征患者雷帕霉素洗脱支架晚期贴壁不良及其对临床预后的影响

Association between late incomplete stent apposition after sirolimus eluting stent implantation and clinical outcomes in patients with acute coronary syndrome

目的观察急性冠状动脉综合征（ACS）患者雷帕霉素洗脱支架晚期贴壁不良发生率及其对临床预后的影响。方法观察2005年2月至2007年3月因ACS（ACS组，54例）和稳定性心绞痛（对照组，83例）行雷帕霉素洗脱支架治疗并于1年后行血管内超声检查患者，检测支架晚期贴壁不良发生率，并观察血管内超声检查后1年内主要不良心血管事件及支架内血栓发生率。结果所有137例患者219处病变中，16例患者25处病变检测到晚期支架贴壁不良。25处晚期支架贴壁不良中ACS组和对照组分别为20处（22．2％）和5处（3．9％）（P〈0．001）。两组患者参照血管外弹力膜面积、参照血管和支架段血管管腔面积和新生内膜面积均相似，但ACS组患者支架段血管外弹力膜面积[（15．34±5．44）mm^2比（13．83±4．51）mm^2，P=0．026]、支架段血管外弹力膜面积与参照血管外弹力膜面积比值（1．13±O．22比1．02±0．18，P〈0．001）、斑块和中膜面积[（8．43±3．93）mm^2比（7．01±2．93）mm^2，P=0．002]较对照组明显增大。Logistic多元回归分析显示，ACS（OR=6．477，P〈0．001）和支架长度≥23mm（OR=3．680，P=0．025）为晚期支架贴壁不良的独立危险因素。血管内超声检查后临床随访1年，两组主要不良心血管事件发生率差异无统计学意义。结论雷帕霉素洗脱支架置入后，ACS患者较稳定性心绞痛患者更多发生晚期支架贴壁不良，然而随访1年的主要不良心血管事件发生率差异无统计学意义。

Objective The impact of late incomplete stent apposition （ISA） post sirolimus eluting stent （SES） implantation in patients with acute coronary syndrome （ACS） on long-term clinical outcomes remains controversial. The aim of the present study was to evaluate the association between late ISA and clinical outcomes in patients with ACS compared with that with stable angina （SA）. Methods From February 2005 to March 2007, 54 ACS patients and 83 SA patients were enrolled in this study, late ISA was determined by means of three-dimensional volumetric intravascular ultrasound （IVUS） analyses one year after SES implantation and clinical outcomes one year post IVUS were obtained in these patients. Results In 219 treated lesions of the 137 patients, late ISA was documented in 25 lesions in 16 patients （20 ISA in 12 ACS patients vs. 5 ISA in 4 SA patients, P 〈 0. 001 ）. Though lumen area in reference and stented segment, neointimal hyperplasia （NIH） area and percentage of NIH in stented segment, and external elastic membrane （EEM） area in reference segment were similar between two groups, EEM area in stented segment [ （ 15. 34 ±5.44） mm^2 vs. （ 13.83 ±4. 51 ）mm^2, P = 0. 026 ], stented/reference segment EEM area ratio （1.13~0.22vs. 1.02＋0.18, P〈 0.001）, plaque and media area [（8.43±3.93） mm^2vs. （7.01 ±2. 93） mm^2, P = 0. 002] was significantly lager in ACS group than that in SA group. Multivariable logistic analysis showed that ACS （ OR 6.477 with 95% CI from 2. 297 to 18. 263, P 〈 0. 001 ） and stent length ≥ 23 mm （OR 3.680 with 95% CI from 1. 181 to 11.469, P =0.025） were main independent factors of occurrence of late ISA. Incidence of main adverse cardiac events （MACE） one year post IVUS was similar between the two groups. Conclusion Compared with patients with SA, ACS patients had larger stented segment EEM area,plaque and media area as well as increased incidence of ISA. However,the incidence of MACE was similar in ACS and SA patients one year after IVUS.