支架内血栓发生时间st=stentthrombosis.pptVIP

* * * * * * * * 多聚物高敏 获得性晚期支架贴壁不良 Baseline 8 mo follow-up SIRIUS Trial: 7/80 (8.7%) patients, no 12-month MACE Ako J. et al. JACC 2005;46:1002-5 Cook et al. Circulation 2007 Kotani et al. JACC 2006 Joner et al. JACC 2006 Togni et al. JACC 2005 Abnormal Vasomotion Delayed Healing Delayed Endothelialization Vessel Remodeling DES后病生理机制 Endothelialization 小结 DES支架内血栓发生率： Early: 0.5% - 1.6% Late/Very late: 0.3% - 0.6% 预测因素 Residual dissection, stent underexpansion Diabetes, ACS, bifurcation stenting, stent length, thrombus burden, late aquired stent malapposition, ineffective platelet inhibition 支架内血栓的预防 高危病人的辨认 避免过度支架 长支架, 分叉支架, 支架重叠 支架植入的理想结果 无残留撕裂/夹层 支架膨胀良好 增加抗血小板治疗的有效性 高危病人评估抗血小板药物的反应性 再狭窄低危病人中使用BMS 专家共识 FDA DES Panel Meeting There is an increase in “very late” (1 yr) stent thrombosis associated with current DES ~2-4 per 1000 pts per year (? continous hazard,  ? patient and lesion predictors) Data from multiple sources indicate thatDES are associated with delayed healingresponses and increased inflammation The causes of late DES thrombosis are multi-factorial; device, procedural, and patientfactors (often multiple = perfect storm) 专家共识 FDA DES Panel Meeting There may be a link between post-DES reduced neo-intimal hyperplasia (late loss) and delayed late healing responses which contributes to late stent thrombosis DES stent thrombosis is highly definition dependent; need for revised standardizeddefinitions and adjudication methods (ARC) to facilitate inter-study comparisons 专家共识 “Off-label DES use – increased incidence of late DES thrombosis and death/MI cw “on-label”, butinadequate controls; results inconsistent! Few RCTs (underpowered); FDA sanctioned registries = insufficient sample size and FU, represents major data gap and source of concern Large population studies (SCAAR) fraught with methodologic flaws (e.g. risk adjustment issues) 专家共识 Duration of dual anti-pla