极晚期支架内血栓的临床特征及形成原因

Clinical Features and Causes of Very Late Stent Thrombosis

目的:总结极晚期支架内血栓(VLST)的临床特征,分析其形成原因。方法:分析6 928例行药物洗脱支架(DES)置入术患者中VLST的发生率,记录VLST男女构成比、发病年龄、可能的发病诱因、VLST发生时的药物使用情况、发病时临床表现、置入药物洗脱支架后血栓发生时间、VLST形成的支架类型、第1次PCI术后治疗药物类型和时间、冠脉造影结果、再次急诊置入支架后冠脉血流分级及转归,分析VLST的形成原因。结果:6 928例DES置入术患者中17例发生VLST,发生率为0.24%;男∶女为12∶5,年龄49~78岁,82.35%患者有长期大量主(被)动吸烟;VLST发生时,88.24%患者完全停用氯吡格雷,VLST患者均表现为急性ST段抬高性心肌梗死(STEMI),置入药物洗脱支架后血栓发生时间为403~1 580 d,15例为三支或双支冠状动脉支架置入,88.24%为Simlimus药物洗脱支架,均为单支冠脉支架内血栓形成;第1次PCI术后均接受氯吡格雷+阿司匹林抗血小板治疗1~1.5年,除1例患者后降支(PDA)慢性闭塞,其他冠脉支架通畅;17例患者均再次行急诊支架置入,置入后TIMI血流3级,住院期间死亡率为11%。结论:VLST在临床极为少见,常致STEMI,急诊冠脉介入为首选治疗方法。

Objective： To summarize the clinical features of very late stent thrombosis（ VLST） and analyze the causes of its formation. Methods： The incidence of VLST in 6928 patients undergoing drug-eluting stent implantation was analyzed. The male/female ratio of VLST,the age of onset,the possible inducement,Drug use at the time of VLST,clinical manifestations during onset,time of thrombosis after placement of drug-eluting stent,type of scaffold formed by VLST,type and time of treatment after the first PCI,the results of coronary angiogram,and classification as well as outcome of coronary blood flow after re-placement of stent in emergency department were recorded. The cause of formation of VLST was analyzed. Results： Among the 6928 patients with DES implantation,there were17 cases of VLST,and the rate was 0. 24%. The male/female ratio was 12∶ 5,and the age was from49 to 78. 82. 35% of patients had a long period of active（ passive） smoking. At the time of VLST,88. 24% of the patients stopped clopidogrel completely. All the VLST patients showed acute ST-segment elevation myocardial infarction（ STEMI）. The time of thrombosis after drug-eluting stent placement was 403 ~ 1 580 d in 15 patients with three or two coronary artery stents,and 88. 24% of them were drug-eluting stents of Simlimus,all of which were thrombosis in single coronary stents. All patients received clopidogrel and aspirin antiplatelet therapy for 1 to 1. 5 years after the first PCI. The coronary stents were patency except for one patient with chronic occlusion of posterior descending branch（ PDA）. 17 patients underwent emergency stent implantation and TIMI blood flow was grade 3.The mortality rate during hospitalization was 11%. Conclusion： VLST is very rare in clinical practice and often caused by STEMI,and emergency coronary intervention is the first choice of treatment.