塑料胆道支架引流术治疗复杂性胆总管结石的临床研究

目的:探讨内镜下逆行胰胆管造影术(ERCP)下塑料胆道支架引流术治疗复杂性胆总管结石的临床疗效和安全性。方法:回顾性分析2011年9月至2013年9月在我院经ERCP下胆道支架引流术治疗的32例复杂性胆总管结石患者的临床病例资料。结果:32例患者塑料胆道支架引流术全部成功,平均手术时间15-30分钟。术后,2例发生高淀粉酶血症,经禁食72小时后恢复正常,无穿孔、消化道大出血等ERCP严重并发症发生。术后1周,患者腹痛、发热消失,转氨酶及胆红素水平明显下降,平均住院时间6-15天。3个月复查B超,发现结石缩小19例,结石碎裂1例,支架脱落1例。术后7天、术后3个月的肝功能指标与术前比较均显著改善,差异均有统计学意义(P0.05)。结论:ERCP下塑料胆道支架引流术是一种复杂性胆总管结石安全有效的治疗方法,具有创伤小、风险较低、操作时间短、患者易耐受及手术成功率高等优点。     

Everolimus- and sirolimus-eluting stents in patients with and without ST-segment elevation myocardial infarction

Aims

Everolimus-eluting stents (EES) were superior to sirolimus-eluting stents (SES) in a dedicated myocardial infarction trial, a finding that was not observed in trials with low percentages of ST-elevation myocardial infarction (STEMI). Therefore, this study sought to investigate the influence of clinical presentation on outcome after EES and SES implantation.

Methods

A pooled population of 1602 randomised patients was formed from XAMI (acute MI trial) and APPENDIX-AMI (all-comer trial). Primary outcome was cardiac mortality, MI and target vessel revascularisation at 2 years. Secondary endpoints included definite/probable stent thrombosis (ST). Adjustment was done using Cox regression.

Results

In total, 902 EES and 700 SES patients were included, of which 44 % STEMI patients (EES 455; SES 257) and 56 % without STEMI (EES 447; SES 443). In the pooled population, EES and SES showed similar outcomes during follow-up. Moreover, no differences in the endpoints were observed after stratification according to presentation. Although a trend toward reduced early definite/probable ST was observed in EES compared with SES in STEMI patients, long-term ST rates were low and comparable.

Conclusions

EES and SES showed a similar outcome during 2-year follow-up, regardless of clinical presentation. Long-term safety was excellent for both devices, despite wide inclusion criteria and a large sub-population of STEMI patients.     

The effects of stenting on coronary endothelium from a molecular biological view: Time for improvement?

Coronary artery stenting following balloon angioplasty represents the gold standard in revascularization of coronary artery stenoses. However, stent deployment as well as percutaneous transluminal coronary angioplasty (PTCA) alone causes severe injury of vascular endothelium. The damaged endothelium is intrinsically repaired by locally derived endothelial cells and by circulating endothelial progenitor cells from the blood, leading to re‐population of the denuded regions within several weeks to months. However, the process of re‐endothelialization is often incomplete or dysfunctional, promoting in‐stent thrombosis and restenosis. The molecular and biomechanical mechanisms that influence the process of re‐endothelialization in stented segments are incompletely understood. Once the endothelium is restored, endothelial function might still be impaired. Several strategies have been followed to improve endothelial function after coronary stenting. In this review, the effects of stenting on coronary endothelium are outlined and current and future strategies to improve endothelial function after stent deployment are discussed.     

Bridging therapy for early surgery in patients on dual antiplatelet therapy after drug-eluting stent implantation

Objectives

To evaluate stent-related adverse cardiac events and bleeding complications within 30 days after surgical procedures in patients with recent drug-eluting stent (DES) implantation, in whom a bridging protocol was used.

Methods

In our centre a bridging protocol is used in patients scheduled for cardiac or non-cardiac surgery within 6 months after PCI with DES implantation. Clopidogrel and in some cases also acetylsalicylic acid is discontinued 5 days prior to the planned intervention and patients are admitted 2 to 3 days before the intervention for tirofiban infusion. This is discontinued 4 h before intervention. Close postoperative monitoring is performed and double antiplatelet therapy is restarted as soon as possible. Thirty-six consecutive patients were included in the protocol, 15 receiving coronary artery bypass graft and 21 non-cardiac interventions. Thrombotic and bleeding complications were studied for up to 30 days after the bridged procedure.

Results

No incidences of stent thrombosis or other adverse cardiac events (mortality, myocardial infarction) were seen in up to 30 days of follow-up. However, 6 bleeding events were reported of which 5 required a blood transfusion.

Conclusion

Our bridging protocol in patients requiring surgery after recent PCI with DES seems adequate to prevent stent thrombosis in this high-risk group. The bleeding risk is not insignificant but in our patient group controllable without major late sequelae. Larger studies should be performed to establish safety and efficacy in order to develop guidelines for these patients.     

Stent‐mediated gene and drug delivery for cardiovascular disease and cancer: A brief insight

This review concisely recapitulates the different existing modes of stent‐mediated gene/drug delivery, their considerable advancement in clinical trials and a rationale for other merging new technologies such as nanotechnology and microRNA‐based therapeutics, in addition to addressing the limitations in each of these perpetual stent platforms. Over the past decade, stent‐mediated gene/drug delivery has materialized as a hopeful alternative for cardiovascular disease and cancer in contrast to routine conventional treatment modalities. Regardless of the phenomenal recent developments achieved by coronary interventions and cancer therapies that employ gene and drug‐eluting stents, practical hurdles still remain a challenge. The present review highlights the limitations that each of the existing stent‐based gene/drug delivery system encompasses and therefore provides a vision for the future with respect to discovering an ideal stent therapeutic platform that would circumvent all the practical hurdles witnessed with the existing technology. Further study of the improvisation of next‐generation drug‐eluting stents has helped to overcome the issue of restenosis to some extent. However, current stent formulations fall short of the anticipated clinically meaningful outcomes and there is an explicit need for more randomized trials aiming to further evaluate stent platforms in favour of enhanced safety and clinical value. Gene‐eluting stents may hold promise in contributing new ideas for stent‐based prevention of in‐stent restenosis through genetic interventions by capitalizing on a wide variety of molecular targets. Therefore, the central consideration directs us toward finding an ideal stent therapeutic platform that would tackle all of the gaps in the existing technology.     

瑞舒伐他汀强化治疗对支架置入术后患者血管再狭窄的影响

目的:探究瑞舒伐他汀强化治疗对行冠状动脉支架置入术后患者再狭窄率、血管内皮功能和血脂水平的影响。方法:选择2013年1月~2015年12月90例于我院行冠状动脉支架置入术后的患者。按照治疗方法的不同将患者随机分为观察组及对照组,每组45例。观察组患者术后给予20 mg/天瑞舒伐他汀强化治疗,对照组患者术后给予常规剂量(5~10 mg/天)瑞舒伐他汀治疗,连续服用6个月。比较两组患者治疗前后的血脂、C反应蛋白(CRP)、白介素8(IL-8)、一氧化氮合酶(e NOS)、内皮素-1(ET-1)水平及术后6个月支架内再狭窄率(ISR)。结果:治疗后,两组患者的胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白(LDL-C)水平均较治疗前显著降低(P0.05),且观察组患者以上指标均显著低于对照组(P0.05);观察组患者高密度脂蛋白(HDL-C)水平较治疗前增加明显(P0.05),而对照组该指标无明显改善(P0.05)。治疗后,两组患者的CRP、IL-8水平均较治疗前显著降低(P0.05),且观察组患者以上指标显著低于对照组(P0.05);观察组患者的一氧化氮合酶(e NOS)水平较治疗前显著提高,血管内皮素-1(ET-1)水平显著降低(P0.05),但对照组以上指标与治疗前相比无明显差异(P0.05)。术后6个月,观察组患者支架内再狭窄率(ISR)显著低于对照组(P0.05)。结论:瑞舒伐他汀强化治疗可通过显著改善患者血脂水平,减轻患者机体炎症状态,积极恢复内皮组织损伤,进而预防ISR的发生。     

阿司匹林、氯吡格雷及西洛他唑预防和治疗老年冠脉支架植入术后血小板高反应性的临床效果观察

目的:探讨阿司匹林、氯吡格雷及西洛他唑预防和治疗老年冠脉支架植入术后血小板高反应性的临床效果。方法:选择60例拟行冠脉支架植入术的老年患者,随机地分为加用或未加用200 mg西洛他唑负荷剂量组。术前、术后24小时及术后30天时检测和比较各组患者的血小板聚集功能。结果:三联抗血小板治疗组的PRU、ARU及P2Y12%inhibition值均较两联抗血小板治疗组显著降低,差异具有统计学意义(P0.05)。三联抗血小板治疗和两联负荷剂量的抗血小板治疗的给药时间(第一次投药至冠脉介入治疗的时间间隔)分别为10.2小时(95%可信区间:7.4-13.1小时)和7.8小时(95%可信区间:4.5-11.2小时),三联抗血小板治疗组术前HPPR(83.3%和46.7%,P=0.003)、术后24小时(36.7%和13.3%,P=0.018)及术后30天HPPR(40.0%和16.7%,P=0.045)的发生率均较两联抗血小板治疗组明显降低(P0.05)。在术后30天的随访观察期间,两联抗血小板治疗组2例患者出现支架内血栓,并进行了血运重建术;无1例心源性死亡、缺血性卒中及出血性并发症的发生。两组次要终点的发生率比较无显著性差异(P0.05)。结论:在两联抗血小板聚集治疗的基础上附加200 mg西洛他唑可显著降低冠状动脉支架植入术后血小板的高反应性。     

Ferromagnetic Bare Metal Stent for Endothelial Cell Capture and Retention

Rapid endothelialization of cardiovascular stents is needed to reduce stent thrombosis and to avoid anti-platelet therapy which can reduce bleeding risk. The feasibility of using magnetic forces to capture and retain endothelial outgrowth cells (EOC) labeled with super paramagnetic iron oxide nanoparticles (SPION) has been shown previously. But this technique requires the development of a mechanically functional stent from a magnetic and biocompatible material followed by in-vitro and in-vivo testing to prove rapid endothelialization. We developed a weakly ferromagnetic stent from 2205 duplex stainless steel using computer aided design (CAD) and its design was further refined using finite element analysis (FEA). The final design of the stent exhibited a principal strain below the fracture limit of the material during mechanical crimping and expansion. One hundred stents were manufactured and a subset of them was used for mechanical testing, retained magnetic field measurements, in-vitro cell capture studies, and in-vivo implantation studies. Ten stents were tested for deployment to verify if they sustained crimping and expansion cycle without failure. Another 10 stents were magnetized using a strong neodymium magnet and their retained magnetic field was measured. The stents showed that the retained magnetism was sufficient to capture SPION-labeled EOC in our in-vitro studies. SPION-labeled EOC capture and retention was verified in large animal models by implanting 1 magnetized stent and 1 non-magnetized control stent in each of 4 pigs. The stented arteries were explanted after 7 days and analyzed histologically. The weakly magnetic stents developed in this study were capable of attracting and retaining SPION-labeled endothelial cells which can promote rapid healing.     

国产雷帕霉素药物洗脱支架在冠心病介入治疗中疗效评价

目的:观察国产雷帕霉素药物洗脱支架在冠心病介入治疗中有效性及安全性。方法:2010年1月至2010年12月我院心血管内科收治并行国产雷帕霉素药物洗脱支架(Firebird支架)置入术患者124例,收治并行进口雷帕霉素药物洗脱支架(Cypher^TM支架)置入术患者167例,于不同支架置入患者中各随机选68例,命名为国产组与进口组。术后1年、5年分别随访两组,观察两组患者支架置入后在不同时间段不良心血管事件发生情况及冠脉造影复查结果。结果:两组患者不良事件比较,国产组术后1年随访结果与术后5年随访结果比较,差异无统计学意义(P0.05);进口组术后1年随访结果与术后5年随访结果比较,差异无统计学意义(P0.05);国产组术后5年随访结果与进口组术后5年随访结果比较,差异无统计学意义(P0.05)。两组患者冠脉造影复查结果比较,差异无统计学意义(P0.05)。结论:国产雷帕霉素药物洗脱支架在冠脉介入治疗中具有安全性和有效性,与进口雷帕霉素药物洗脱支架比较无明显差异,值得临床推广应用。     

An initial case of suppressed restenosis with nuclear factor‐kappa B decoy transfection after percutaneous coronary intervention

Background

Nuclear factor‐kappa B (NF‐κB) is well known for playing a pivotal role in restenosis after percutaneous coronary intervention (PCI).

Methods and Results

This is the first report to demonstrate an effect of NF‐κB decoy oligodeoxynucleotides (ODN) to prevent restenosis after PCI after a 4‐year observation using a coronary computed tomography (CT) scan. We showed that the decoy treatment suppressed neointimal formation after stent implantation compared to that in the same artery.

Conclusion

Thus, for the first time, we demonstrate the clinical usefulness of the CT scan to reveal the effects of NF‐κB decoy ODN transfer after PCI. Copyright © 2008 John Wiley & Sons, Ltd.