冠心病患者冠脉支架术后发生再狭窄的危险因素回归分析

目的:探讨冠心病患者冠脉支架手术后发生再狭窄的危险因素,为提高临床治疗效果和改善预后提供指导。方法:回顾性分析2014年1月至2015年12月我院收治的226例行冠脉支架手术的冠心病患者临床病历资料,采用SPSS21.0分析冠脉再狭窄的发生情况及危险因素。结果:51例冠心病患者冠脉支架术后发生冠脉再狭窄(22.57%)。单因素分析显示,不同吸烟史、糖尿病史、脂蛋白a(Lp(a))水平、空腹血糖、尿素氮(BUN)、总胆红素、术前病变狭窄程度、植入支架支数、长度以及直径组冠心病患者的冠脉再狭窄发生率比较,差异有统计学意义(P0.05)。多因素Logistic回归分析,吸烟史、糖尿病史、Lp(a)水平、术前病变狭窄程度、植入支架支数、长度是冠心病患者冠脉支架术后再狭窄发生的独立危险因素,OR分别为2.261、1.944、3.593、2.798、2.449、3.823,差异有统计学意义(P0.05),植入支架直径是冠脉再狭窄发生的保护因素,OR为0.261,差异有统计学意义(P0.05)。结论:冠脉植入支架的总长度、数量,术前病变的狭窄程度、Lp(a)水平、糖尿病以及吸烟是冠心病患者冠脉支架术后发生再狭窄的独立危险因素,临床应不断优化支架并根据再狭窄的危险因素采取针对性的防治措施。     

介入技术在下肢动脉硬化闭塞症合并血栓形成中的应用

目的:探讨导管接触性溶栓(catheter-directed thrombolysis,CDT)联合球囊及支架成形术治疗下肢动脉硬化闭塞症合并血栓形成的临床疗效及安全性。方法:选择2011年1月~2014年12月收治的36例下肢动脉硬化闭塞症合并血栓形成性病变患者,先行置管溶栓治疗,再联合球囊及支架成形术治疗,观察其溶栓效果及血管再通情况。结果:本组溶栓总有效率为86.1%,尿激酶用量(75.5±34.6)万单位,溶栓后31例下肢缺血症状改善,下肢疼痛症状有不同程度减轻,下肢跛行距离明显延长,无垃圾脚发生。球囊及支架成形术后踝肱指数(ABI)由术前的0.39±0.11升高至术后的0.79±0.19,差异有统计学意义(P0.01)。随访1~48月,无死亡病例,9例出现支架内膜增生血管再狭窄,5例出现糖尿病膝下动脉狭窄闭塞,给予球囊扩张及支架成形术后下肢缺血症状减轻,其中1例患者于术后3年行下肢截肢治疗。结论:CDT联合球囊及支架成形术治疗下肢动脉硬化闭塞症合并血栓形成具有较高的临床价值,可以为PTA血管成形或支架置入赢得时机,改善下肢缺血,该方式创伤小,并发症少。     

11 例锁骨下动脉瘤腔内介入治疗体会

目的：总结锁骨下动脉瘤腔内介入治疗的经验。方法：11 例锁骨下动脉瘤,其中7 例真性动脉瘤4 例假性动脉瘤,均采用覆 膜支架腔内隔绝术进行治疗。结果：本组11 例患者腔内介入治疗成功率100%,共置入覆膜支架12 枚,无严重并发症发生,均痊 愈出院。经平均32.5 个月随访,全部患者无明显内漏发生,无动脉瘤复发,除3 例患者出现覆膜支架内轻度狭窄（<30%）外,余介 入治疗患者的锁骨下动脉血流均通畅。结论：腔内覆膜支架隔绝术治疗锁骨下动脉瘤是一种安全、有效的治疗手段。     

骨髓间充质干细胞捕获支架对犬冠状动脉再狭窄影响的研究

目的:观察骨髓间充质(MSCs)干细胞捕获支架能否预防和减少犬冠状动脉支架植入术后再狭窄.方法:①用乙基纤维素作为包被底物对支架进行包被,然后再包被骨髓间充质干细胞抗体.②以球囊损伤法建立犬冠状动脉狭窄模型,应用标准球囊导管技术,将包被有抗体的支架植入犬(n=20)冠状动脉前将支损伤段远端,再以相同方法在损伤段近端植入裸支架作为对照组(n=20).4w后处死动物,取出支架段血管行血管内超声(IVUS)及血管形态学检测分析血管管腔面积和内膜增生面积.结果:术后4周,骨髓间充质干细胞捕获支架组较裸支架组的最小管腔直径和新生内膜面积较明显减少(P<0.05),而最小管腔面积则明显增加(P<0.05).结论:骨髓间充质干细胞捕获支架能快速修复损伤的血管内膜,降低再狭窄的发生.     

一氧化碳:抑制再狭窄的新武器

介入和冠脉搭桥术是主要的冠心病治疗措施 ,而术后再狭窄的发生一直是困扰临床的一个棘手问题。目前采用涂层支架防治再狭窄的效果较好 ,但是价格昂贵且远期效果尚未确定。最近 ,Otterbein等报道大鼠颈总动脉球囊拉伤前预吸入低浓度的一氧化碳 (CO) (2 5 0ppm ,为毒性剂量的 1/ 2 0 ) 1个小时 ,有效地减轻了 2周后的血管内膜增生 (比对照组降低 74 % ) ,防止了管腔的狭窄。作者还在大鼠降主动脉移植模型上观察到CO吸入抑制了移植后动脉粥样硬化的发展 ,术前分别给予供体和受体大鼠吸入 2 5 0 ppm的CO 2天 ,术后 5 6天吸入CO组移植血管较…     

血管内支架成形术治疗大脑中动脉狭窄

目的:探讨血管内支架成形术治疗大脑中动脉狭窄的疗效及安全性.方法:对22例大脑中动脉狭窄患者行血管内支架成形术,回顾性分析其临床特点、疗效及治疗经验.结果:22例患者共植入22枚支架,均获得成功.术后即刻造影狭窄率为(11.2±4.5)%,较术前(79±15)%明显改善.术后残余狭窄程度均小于20%.临床随访无TIA发作或脑卒中再发,DSA随访除1例外均无再狭窄发生.结论:血管内支架成形术治疗大脑中动脉狭窄安全有效,但远期疗效还需进一步观察.     

加热支架治疗食道癌的研究进展

腔内支架放置是治疗食道癌引起的狭窄与梗阻的有效姑息性治疗手段,但仅仅是机械性的扩张来解除梗阻,肿瘤仍然继续生长,可引起食道的再狭窄.利用各种方法对植入的支架进行加热,对食道癌既进行扩张治疗,又进行积极热疗,是解决这一问题的新方法.     

针刺法作用兔血管再狭窄模型的病理学研究

目的:探讨针刺作用动脉再狭窄的病理学改变,为针刺临床治疗冠状动脉成形术后再狭窄提供理论依据.方法:应用PTCA球囊导管对实验兔行双侧髂动脉内膜剥脱建立动脉粥样硬化模型术后,狭窄者再行PTCA球囊扩张术以建立再狭窄模型,动物组织进行HE染色,观察针刺后髂动脉,冠状动脉及主动脉内膜的形态学变化.结果:针刺组主动脉、髂动脉及冠状动脉脂斑面积与模型组差异不显(P＞0.05);内膜增生程度均较轻,内膜中VSMC、泡沫细胞较少;动脉内膜及中膜面积与模型组差异明显(P＜0.01).结论:针刺法对动脉血管再狭窄具有一定的防治作用.     

纤支镜定位法置入支架治疗难治性恶性气管狭窄的护理

目的探讨纤支镜定位法置入支架治疗难治性恶性气管-支气管狭窄的配合与护理。方法对2006~2010年收治的9例难治性恶性气管-支气管狭窄的患者在行气管-支气管支架治疗中,给予精心的护理和密切的病情观察。结果 9例难治性恶性气管-支气管狭窄患者顺利置入支架,术后呼吸困难症状均不同程度改善。结论做好术前充分准备和患者心理护理,准确的护理配合及术后精心护理,对提高支架置入成功率、缩短支架放置时间、减少并发症发生有着重要意义。     

经纤支镜国产气道覆膜支架肺减容术治疗肺气肿模型的应用研究

目的:研究经纤支镜国产气道覆膜支架肺减容术治疗肺气肿动物模型的可行性、治疗效果及并发症发生情况。方法:4只雌性山羊应用局部气管内滴注木瓜蛋白酶方法复制不均一肺气肿模型。经电子支气管镜通过推送装置在肺气肿模型的不同支气管亚段(右肺上叶前段或后段)放入1-2枚气道覆膜支架,术前1天及术后6周测肺功能、查血气分析及胸部CT扫描。观察有无肺部感染等并发症。结果:支架植入后6周发现肺总量(TLC)、功能残气量(FRC)、残气量(RV)均出现下降,与术前比较均有统计学意义(p0.05)。RV/TLC(%)从术前的42.55%降至20.37%。PaO2从(70.50±1.85)mmHg上升至(81.25±1.11)mmHg,有统计学意义(p0.05)。CT检查及肺组织大体标本证实支架远端存在肺不张。仅有一只出现肺部感染早期症状,全部动物未发生气胸、肺脓肿等严重并发症。结论:经纤维支气管镜植入国产气道覆膜支架行肺减容术治疗肺气肿具有治疗效果确切、创伤小、安全性好、操作方便等特点。     

Efficiency of endovascular re-interventions for evolving restenosis of different types of stents

The paper compares the results of different treatment options (balloon angioplasty and restenting) for in-stent restenosis in case of evolving restenosis of drug- and nondrug eluting stents. The investigation enrolled 496 coronary heart disease patients with clinical presentation of angina pectoris and/or signs of myocardial ischemia, as well as hemodynamic restenosis of a previously implanted stent. Of them, 216 and 280 patients had restenosis of previously implanted drug- and nondrug-eluting stents, respectively. In the patients with non-drug-eluting stent restenosis, recurrent angina pectoris and the frequency of repeated restenosis were significantly more frequently observed after balloon dilatation than after drug-eluting stent implantation (28.4 and 10.2%; p < 0.05; 19.9 and 8.7%; p < 0.05). In those with drug-eluting stent restenosis, recurrent angina pectoris and the frequency of repeated restenosis did not differ significantly between balloon dilatation of restenosis and implantation of a second drug-eluting stent.     

Long period of balloon inflation and the implantation of stents potentiate smooth muscle cell death. Possible role of chronic vascular injury in restenosis

BACKGROUND: It has been suggested that the severity of acute vascular injury immediately after percutaneous transluminal coronary angioplasty (PTCA) or stent implantation correlates with the extent of neointimal hyperplasia and restenosis. However, the influence of prolonged or chronic vessel injury on the pathogenesis of restenosis is unclear. METHODS: Rabbit iliac arteries were balloon dilated for a short (1 min) or prolonged (10 min) period of time, or were chronically dilated and received a Palmaz-Schatz stent (balloon inflation for 1 min). All arteries were overexpanded to a balloon:artery ratio of 1.2:1 as determined by angiography. The arteries were removed 30 min and 4 weeks after the angioplasty procedures. The sites of injury were evaluated by gross histology and transmission electron microscopy (TEM). Cell death of medial smooth muscle cells (SMCs) was specified by TEM images 30 min after the procedures. Computer-assisted quantification of the neointimal cross-sectional areas was performed after 4 weeks using a light microscope connected to a digital image analyser. RESULTS: The results show that prolonged balloon dilatation and stent implantation increased necrotic SMC death compared with balloon dilatation for 1 min. After 30 min, increased staining of SMC nuclei, enlarged intercellular spaces and changes in SMC shape in the media indicated cell death induced by prolonged balloon dilatation or chronic stent injury. Stent implantation markedly augmented vessel damage by persistent compression of the media, compared with a balloon dilatation for 1 or 10 min. Both prolonged balloon dilatation and stent implantation increased neointimal hyperplasia at 4 weeks compared with balloon dilatation for 1 min (0.6 3 0.2 and 1.0 3 0.2 mm(2) versus 0.2 3 0.1 mm(2), P < 0.001 versus dilatation for 1 min). CONCLUSION: Prolonged or chronic vascular expansion due to long balloon-inflation periods or the implantation of stents increases medial SMC death, which subsequently stimulates neointimal growth in this restenosis model. Chronic vascular injury may be an important stimulus for restenosis after angioplasty procedures.     

The potential role of homocysteine in percutaneous coronary interventions (PCI): review of current evidence and plausibility of action.

Several millions of patients with coronary heart disease worldwide are treated by means ofpercutaneous interventions each year. Above all conventional balloon dilation and implantation of uncoated stents are, however, only of limited success as reflected by 6-month restenosis rates of 50% (balloon dilation) and 25-35% (bare-metal stent). It is therefore of utmost importance to identify high-risk groups and explore further secondary-prophylactic measures for the prevention of restenosis. A large body of evidence suggests that elevated homocysteine and/or folate and B-vitamin deficiencies are relevant risk factors for restenoses due to their proatherothrombotic potential. Hyperhomocysteinemia is an ideal target as this parameter can be lowered easily, safely and at a low cost by means of folate and B-vitamin supplementation. The results of published studies exploring a potential correlation between homocysteine levels and the risk of restenosis and those of interventional studies for the reduction of the risk of restenosis have not yet lead to consistent conclusions. However, a critical assessment can by no means exclude the plausibility of postinterventional lowering of homocysteine levels. This review aims at providing insight into the current evidence and biological plausibility of homocysteine-lowering therapy in regard to PCI-related vascular damage. Currently available clinical observational and interventional studies are reviewed in detail.     

Study on the Contact Stress Concentration and the Hyperplasia of the Canine Trachea Granulation Tissue after Stenting

Tracheal stenosis is a common respiratory disease and is usually treated by stent implantation. However, the implanted stent often causes excessive hyperplasia of trachea granulation tissue, leading to the restenosis. Although surgical removal or chemical suppression can be used to alleviate the restenosis, the efficacy is limited. Thus, restenosis remains a thorny complication. We investigated this issue from the perspective of the “tress-growth”relationship. Firstly, the lower airway of 5 experimental dogs were CT-scanned to reconstruct the 3D numerical models; secondly, the implantations of the Nitinol alloy stents were numerically simulated; thirdly, 45 days after the stenting, the dogs were evaluated for the hyperplasia of the trachea granulation tissue by CT imaging, bronchoscopy and histological sectioning; finally, the correlation analysis was performed between the contact stress and the hyperplasic thickness of the granulation tissue. Results show that the hyperplasia of the trachea granulation tissue and the local contact stress are positively correlated (R=0.82) and the high local dilation stress can promote the hyperplasia of the trachea granulation tissue, probably through the recombination of basic fibroblast growth factor or the dysfunction of plasminogen activator inhibitor-1. Therefore, contact stress concentration should be prevented in the future design of the tracheal stent.     

The Cutting Balloon--a new technology?

The Cutting Balloon consists of a standard balloon dilatation catheter with four microtome-sharp blades that incise the plaque and minimize arterial wall trauma. It was used in 31 patients; nine had calcified arteries, ten had non-compliant lesions, three had in-stent restenosis and nine had aorto-ostial lesions. Seventeen lesions were predilated, 28 were post-dilated and 18 required stent implantation. The procedure was very effective in aorto-ostial lesions, non-compliant lesions that were not responsive to high-pressure balloon dilatation, and was partially successful in calcified arteries. It has a very specific niche in selected lesions.     

Release of TNF-alpha during stent implantation into saphenous vein aortocoronary bypass grafts and its relation to plaque extrusion and restenosis

The reduction in plaque volume during stent implantation is associated with the release of particulate debris and plaque-derived soluble substances. We studied the potential release of the proinflammatory cytokine TNF-alpha into the coronary circulation and whether such release is related to the reduction in plaque volume and, possibly, a predictor for restenosis. In 18 male patients (n = 24 stents) with severe stenosis in a saphenous vein aortocoronary bypass graft (SVG), we used a distal balloon occlusion-aspiration device during stent implantation. The aspirate TNF-alpha levels were determined before and after stent implantation and related to the angiographic and intravascular ultrasound-assessed severity of stenosis and restenosis. We found that TNF-alpha is, indeed, released into the aspirate of stented SVG (9 +/- 1 and 28 +/- 3 pg/ml before and after stent implantation, respectively, P < 0.0001) and that such release is related to the reduction in plaque volume (r = 0.88, P < 0.0001) and associated with restenosis after 5 mo (r = 0.71, P = 0.001). The periprocedural release of plaque-derived TNF-alpha possibly represents the amount and activity of the atherosclerotic process and might be a predictor for restenosis.     

阿托伐他汀对颈动脉狭窄并支架置入术后患者临床预后及炎症因子的影响

目的：研究阿托伐他汀对颈动脉狭窄并支架置入术后患者临床预后及炎症因子的影响。方法：选取2013 年1 月到2014 年1 月我院收治的接受支架置入术的颈动脉狭窄患者90例,按照随机数字表法将患者分为研究组和对照组,每组45 例,对照组给予 常规治疗,研究组在对照组的基础上给予阿托伐他汀治疗,连续治疗1 年,比较两组支架内再狭窄率及不良反应发生率,分析治 疗前和治疗后两组超敏C反应蛋白（hs-CRP）、白细胞介素-6（IL-6）水平。结果：研究组1 年内支架再狭窄率显著低于对照组,两 组比较差异具有统计学意义（P＜0.05）;治疗后两组hs-CRP 和IL-6 水平均显著低于治疗前,且研究组显著低于对照组,比较差异 具有统计学意义（P＜0.05）;两组不良反应比较无统计学意义（P＞0.05）。结论：阿托伐他汀治疗颈动脉狭窄并支架置入术患者,能 显著降低支架内再狭窄率及炎症因子水平。     

Immediate and long-term results of coronary stent implantation without predilatation (direct stenting) in patients with coronary heart disease

The paper assesses the immediate and long-term results of direct stenting (without the stage of predilation) and compares with the outcomes of conventional stent implantation. A prospective study included 183 patients. All the patients were divided into two groups according to the procedure of stent implantation. In 85 (46.7%) patients, the stent was implanted without preliminary predilation of stenosis (direct stenting). These patients formed Group 1. Group 2 comprised 97 (53.3%) patients in whom the stent was placed by using the routine procedure. All the patients enrolled into the study had types A, B1, and B2 stenoses according to the ACC/AHA classification and received the conventional antiaggregatory and anticoagulant therapy. The technical success of direct stenting was 97.7%. There were no cases of stent dislocation and loss during direct stenting or expansion of a balloon and stent. Analyzing the immediate results in all the patients of the both groups showed a positive angiographic success. Thus, a primary angiographic and clinical success of direct stenting was achieved in all (100%) patients. Recurrent angina pectoris with restenosis was observed in 8 (9.4%) patients in Group 1 and in 21 (21.6%) in Group 2 (p < 0.05). Direct stenting significantly differs from the routine stent implantation in all procedure parameters. Thus, direct stenting in patients with uncomplicated stenoses is a safe and feasible procedure.