不同剂量西洛他唑强化抗血小板对冠脉支架术后血小板高反应性的影响

目的：观察临床应用不同方案强化抗血小板治疗改善冠脉支架术后血小板高反应性的可行性、安全性及有效性。方法：选择2009年3月至2011年2月在沈阳军区总医院、中国医科大学第一附属医院、解放军第463医共入选560例冠脉支架术后血小板高反应性（HPR Highon-treatment Platelet Reactivity）患者,在给予阿司匹林300mg／天,氯吡格雷150mg／天,3天后HPR仍未缓解者,随机分为两组,一组在强化抗血小板治疗即阿司匹林300mg,氯吡格雷150mg的基础上加用小剂量西洛他唑（50mg,2／日）,另一组在标准两联方案即阿司匹林300mg,氯吡格雷75mg的基础上加用西洛他唑100mg,2／日,3天后测定HPR的缓解情况。结果：大剂量氯吡格雷治疗3天后HRP的缓解卒为54-3％（304／560）,接受不同西洛他唑剂量治疗3天后又有58．6％的患者HPR缓解,但是西洛他唑50mg组和100mg组HRP缓解率无差别（59．4％VS57．8％,P=0．80）。两组患者30天随访均无死亡及卒中事件,无主要及次要出血事件。结论：强化抗血小板治疗可改善冠脉支架术后的血小板高反应性且未增加出血风险,但其临床获益还需更长时间的随访结果进一步明确,两种强化抗血小板治疗方案对改善冠脉支架术后HPR的作用相似。     

Lin28a up‐regulation is associated with the formation of restenosis via promoting proliferation and migration of vascular smooth muscle cells

To explore the potential role of Lin28a in the development of restenosis after percutaneous transluminal angioplasty, double‐balloon injury surgery and mono‐balloon injury surgery were used to establish restenosis and atherosclerosis models, respectively, so as to better distinguish restenosis from atherosclerotic lesions. Immunohistochemical analysis revealed that significantly higher expression of Lin28a was observed in the iliac arteries of restenosis plaques than that of atherosclerosis plaques. Immunofluorescence studies showed the colocalization of Lin28a with α‐smooth muscle actin in restenosis plaques, rather than in atherosclerosis plaques, which suggested that Lin28a might be related to the unique behaviour of vascular smooth muscle cells (VSMCs) in restenosis. To further confirm above hypothesis, Lin28a expression was up‐regulated by transfection of Lenti‐Lin28a and inhibited by Lenti‐Lin28a‐shRNA transfection in cultured VSMCs, and then the proliferation and migration capability of VSMCs were detected by EdU and Transwell assays, respectively. Results showed that the proliferation and migration of VSMCs were significantly increased in accordance with the up‐regulation of Lin28a expression, while above behaviours of VSMCs were significantly suppressed after inhibiting the expression of Lin28a. In conclusion, the up‐regulation of Lin28a exerts its modulatory effect on VSMCs’ proliferation and migration, which may play a critical role in contributing to pathological formation of restenosis.     

血管内支架介入成形术对老年缺血性脑血管病患者的神经功能、动脉血流速度及预后的影响

摘要 目的：探讨血管内支架介入成形术对老年缺血性脑血管病（ICVD）患者的神经功能、动脉血流速度及预后的影响。方法：选取2018年3月~2019年4月期间我院收治的117例老年ICVD患者作为研究对象,根据随机数字表法分为对照组（n=58）和研究组（n=59）,其中对照组患者予以保守药物治疗,研究组患者予以血管内支架介入成形术治疗,比较两组患者疗效、神经功能、动脉血流速度、预后及并发症情况。结果：研究组治疗6个月后的临床总有效率为91.53%（54/59）,高于对照组的72.41%（42/58）（P<0.05）。两组患者治疗后1个月、治疗后3个月、治疗后6个月美国国立卫生研究院卒中量表（NIHSS）评分均下降（P<0.05）,且研究组低于对照组（P<0.05）。两组患者治疗后6个月大脑中动脉、基底动脉、颈内动脉血流速度均升高（P<0.05）,且研究组高于对照组（P<0.05）。两组患者治疗后1个月、治疗后3个月、治疗后6个月改良Rankin量表（mRS）评分呈下降趋势（P<0.05）,且研究组低于对照组（P<0.05）。两组患者并发症发生率对比未见统计学差异（χ²=2.261,P=0.133）。结论：老年ICVD患者经血管内支架介入成形术治疗后的疗效显著,可有效改善患者神经功能、动脉血流速度及预后,且不增加并发症发生率,具有较高的临床应用价值。     

支架置入术治疗椎动脉起始段狭窄的临床疗效及术后支架内再狭窄的影响因素分析

摘要 目的：研究支架置入术（SI）治疗椎动脉起始段狭窄（VAOS）的临床疗效及术后支架内再狭窄（ISR）的影响因素。方法：选择从2018年1月到2020年2月在我院接受SI治疗的VAOS患者83例纳入本次研究。剔除1例手术失败及1例死亡患者的病例后,对剩余81例患者根据患者是否发生ISR,将其分成ISR组28例和无ISR组53例。随访分析患者的临床疗效,对患者发生ISR进行单因素及多因素Logistic回归分析,同时分析患者美国国立卫生院卒中量表（NIHSS）评分与血管狭窄情况及血流动力学指标的相关性。结果：83例VAOS患者接受SI术式治疗后,手术成功率为98.80%（82/83）。术后有3例患者发生动脉痉挛,另有1例患者在术后7 d由于继发脑出血而死亡,并发症的总发生率为4.82%（4/83）。ISR组的高脂血症、合并颈内动脉的狭窄、椎动脉的狭窄部位为双侧、支架类型为裸支架的比例分别高于无ISR组（均P＜0.05）。根据Pearson法分析相关性显示,患者NIHSS评分与血管狭窄率、狭窄血管长度、收缩期峰值流速（PSV）和舒张期末流速（EDV）均呈正相关（P＜0.05）。根据Logistic回归分析显示,患者发生ISR影响因素包含高脂血症和支架类型为裸支架,以及合并颈内动脉的狭窄和并发双侧椎动脉的狭窄（P＜0.05）。结论：SI术式治疗的VAOS患者的临床疗效较好,且术后ISR的影响因素主要包含高脂血症和支架类型为裸支架,以及合并颈内动脉的狭窄和并发双侧椎动脉的狭窄,临床上应引起相应的重视。     

冠状动脉支架血流动力学中的几个问题

由于冠状动脉支架介入治疗具有手术创伤小、操作简单、见效快、病人恢复时间短等诸多优点,在治疗心血管动脉粥样硬化或血栓堵塞方面,有逐渐替代外科搭桥手术的趋势。虽然血管支架技术在临床已经有广泛应用,治疗效果也有明显的改善,但是依然存在许多不足需要改进。本文首先回顾了血管支架的发展历程,然后针对血管支架研究中与血流动力学相关的几个待解决的问题进行了论述,以期从血流动力学的角度为血管支架的改进和发展提出建议。     

Revascularization in the acute coronary syndromes

Coronary heart disease is the leading cause of death worldwide, and occurs when the coronary arteries are unable to supply adequate oxygenated blood to the myocardium, which in turn can lead to ischemia and infarction of myocardial tissue. There are three options for revascularization in the setting of acute coronary syndromes. In select patients, coronary artery bypass surgery remains an option. Thrombolytics were initially the mainstay of therapy, which has now shifted to angioplasty, with or without stents, when readily available. Revascularization has been demonstrated to improve patient outcomes, and has evolved rapidly in the recent past.     

药物洗脱支架植入后再狭窄的研究进展

随着药物洗脱支架(Drug Eluting Stent,DES)的出现,再狭窄的问题得到进一步的有效控制.然而,药物洗脱支架也存在较低的再狭窄率,由于应用药物洗脱支架治疗人数非常多,这一比率就不容忽视.本文将阐述DES支架内再狭窄发生的病理生理学机制、临床表现、形态学特征以及处理策略.     

Restenosis begets restenosis: implications for stent selection

Background. Identifying the risk for restenosis is of critical importance in the stent selection process of patients undergoing percutaneous coronary intervention (PCI). Therefore, we sought to determine if a history of clinical recurrence (CR) after PCI increases the risk of CR after treatment of a de novo lesion in another coronary artery. Methods. We retrospectively analysed all 12,763 patients who underwent PCI between 1993 and 2004 and selected patients with two or more interventions in two different native vessels. These patients were divided into two groups: patients without CR, and patients with CR after the first PCI. Clinical recurrence was defined as revascular-isation of the target vessel by either PCI or CABG within one year. Results. A total of 1010 patients with two or more interventions in two different native vessels were identified: 727 patients without and 283 patients with CR after the first PCI. Baseline patient characteristics and conventional risk factors were comparable between the two groups. Patients with a history of CR had a higher risk of CR after a second intervention in a second vessel (OR=3.4, 95% CI=2.3 to 4.9). A total of 112 patients also had a third intervention in a third native vessel: 12 patients with two CR, 30 patients with one CR and 70 patients with no CR after the first two interventions. CR rates in these patients were 50, 17 and 3%, respectively (p<;0.001). Conclusion. Patients with a history of CR have a markedly increased risk of developing CR after a second or third PCI in a different coronary artery. Therefore, in the decision-making process on whether to use a bare metal stent or drug-eluting stent, the history of CR is a simple and powerful aid. (Neth Heart J 2008;16:376-81.)     

药物涂层球囊概述及其在外周动脉疾病治疗中的应用进展

经皮经腔血管成形术(PTA)已广泛用于外周动脉疾病(PAD)的治疗。然而,该技术存在血管壁弹性回缩和内膜增生等不足。PTA术后植入金属裸支架(BMS)虽然可以减少血管壁弹性回缩,但由此引起的支架内再狭窄(ISR)又成为治疗中的一个突出问题。药物洗脱支架(DES)被用来解决狭窄问题,但晚期支架内血栓形成(LST)、内皮化延迟和必须长期抗血小板治疗等问题也随之而来。在这样的背景下,药物涂层球囊(DCB)获得了快速发展。DCB作为非支架方案,可将所携载的活性药物转移至病变段血管壁,对ISR或原发病变均有较好的治疗效果。本文简要介绍了DCB的发展历史,并通过实验室研究、动物实验和临床试验,从机制上阐述涂层技术、涂层药物、赋形剂等对DCB功效和安全性的影响以及DCB在PAD治疗中的应用进展。     

再狭窄与低强度激光治疗

再狭窄是困扰冠心病介入治疗的主要问题,目前尚无完善的解决方法。低强度旬可用于血管内照射的一种照射源,以其不发热,非损害的光生物学过程为持征,应用更为完全,有效和简便易行,而且低温强度激光已在创伤修复等领域应用多年,证明可以促进伤口愈合或调节细胞生理过程。本文概述了再狭窄发生机制,探讨了低温度激光用于预防再狭窄的可能机理,总结了有关动物试验和初期临床应用的结果,认为低强度激光作为一种血管成形术再狭窄的防治手段,无疑具有良好的前景。