植入药物洗脱支架后出现的晚期支架血栓和自我溶栓病例演示文稿.pptVIP

* A case of very late stent thrombosis and self-thrombolysis after implantation of drug eluting stent 阜外心血管病医院 李崇剑 杨跃进 Case information Male, 49y. HT (-), DM (-), Dyslipidemia (-), Smoker (-), FH (-) AMI (anterior wall) in sep. 2004. Emergency CAG: ostial LAD 100%, ostial LCX 60%, normal RCA. Emergency PCI: Cypher in LAD. Detail not acquired. Drug: (Plavix 75mg/d+ASA 100mg/d)*1y, followed by ASA 75mg/d*qod, other cardio drugs routinely. Case information follow up Acute chest pain, Re-AMI (anterior) in 6, Nov. 2007. Emergency CAG: cloud in stent, defect of mid-distal stent, TIMI grade 0. LCX the same as before, normal RCA. CABG or PCI not performed. Followed by drugs: (Plavix 300mg/d+ASA 100mg/d+LWMH 1mg/kg q12h)*12d, other cardio drugs routinely. Angiograhpy (6, Nov. 2007): LAD and LCX Angiograhpy (6, Nov. 2007): RCA Follow up: 2 weeks later CAG after 2 weeks: no throbosis in stent, LAD TIMI 3. LCX the same as before, normal RCA. Angiography follow up Discussion Thrombosis of DES Definition The mechanism Strategy 今天讨论重点 DES preventing restenosis after PCI Stent: Vessel Recoil and Remodelling Drug:Intimal Proliferation Dilemma of safety: thrombosis ARC Definition of ST Acute 0-24h Subacute 24h-30d Late 30d-1y Very late after 1y Definite/confirmed Probable Possible Time course Angiography and clinical evidence DES Polymer Mishaps Bonding = polymer sticks to itself forming a bridge when the stent is expanded Webbing = polymer pulling away from the expanded stent due to sticking Polymer in DES: localized hypersensitivity Virmani, R. et al. Circulation 2004;109:701-705 Late malapposition 基线 正性管腔重构 没有管腔重构 随访 在Taxus和Cypher的研究中，发生晚期贴壁不良的患者停止clopidogrel治疗后 20% 发生了支架血栓*！ * Study by Dr. Abizaid, presented at TCT 2005. 完全闭塞 暴露的支架金属丝 M, 44y, Cypher due to prior AMI, Clopidegrel was discontinued after 3m, aspirin 150mg/d was continued. 31m later, thrombosis. Eur Heart J. 21 Oct 2005. Case due to late malapposition Discussi