经皮外周血管成形术后再狭窄的分子机制及血管内治疗方法
Molecular mechanisms of restenosis after percutaneous peripheral angioplasty and approach to endovascular therapy.
作者信息
Mongiardo Annalisa, Curcio Antonio, Spaccarotella Carmen, Parise Simona, Indolfi Ciro
机构信息
Cattedra di Cardiologia, Università Magna Graecia, Catanzaro, Italy.
出版信息
Curr Drug Targets Cardiovasc Haematol Disord. 2004 Sep;4(3):275-87. doi: 10.2174/1568006043336258.
Atherosclerosis is the most common cause of peripheral arterial disease (PAD). Interventional procedures are the first treatments proposed for most PAD patients. Balloon angioplasty alone may offer good immediate results; however, has it been proposed that the addition of stents improves the procedural success of angioplasty and extends its application to more types of lesions. Isolated aortic lesions are relatively rare, and the indications for stent placement have not been established. Percutaneous transluminal recanalization of chronic iliac occlusions remains controversial. However, results of recent studies have been encouraging, with initial technical success rates greater than 90%, low complication rates, and good long-term results. About the use of stent in atherosclerotic lesions involving iliac arteries and upper region of femoral arteries, we think that it is feasible. Differently, for the lower region of the femoral artery and for the popliteal artery, the results on the use of stents are controversial. More difficult is the therapy of infrapopliteal arteries disease in which perhaps the best option is medical therapy. The Transatlantic Inter-Society Consensus Group summarized the results of femoropopliteal stenting as follows: in a comparison of 11 trials involving femoropopliteal artery stenting in 585 patients, the primary patency rate was 58% at 36 months. For percutaneous transluminal angioplasty, the patency rates were 51% at 36 months. Although the results are satisfactory in femoral lesions, especially in stenoses shorter than 10 cm, they are less favorable both in longer femoral lesions than in the popliteal artery, where the results were worst. Large clinical series after angioplasty of lower limb arteries have confirmed the clinical and economical impact of restenosis: its rate varies in a range between 30% and 50%. The restenosis after stent deployment is the result of neointima formation; therefore, the interest of investigators turned towards an agent to suppress neointimal growth and restenosis after stent deployment, as Sirolimus and/or Taxolo. The first multicenter, randomized study, evaluating the 6-month outcomes of drug-eluting stent implantation in long-segment obstructions of the superficial femoral artery, was SMART trial, published in 2002. This is the first trial to show that controlled drug release is also feasible using a self-expandable nitinol stent platform. The results at 6 months demonstrate inhibition of in-stent neointimal proliferation, reflecting a trend toward a reduction in late loss.
动脉粥样硬化是外周动脉疾病(PAD)最常见的病因。介入治疗是大多数PAD患者首选的治疗方法。单纯球囊血管成形术可能会取得较好的即时效果;然而,有人提出添加支架可提高血管成形术的手术成功率,并将其应用扩展到更多类型的病变。孤立的主动脉病变相对少见,且支架置入的适应证尚未确定。慢性髂动脉闭塞的经皮腔内再通仍存在争议。然而,近期研究结果令人鼓舞,初始技术成功率超过90%,并发症发生率低,长期效果良好。关于在累及髂动脉和股动脉上段的动脉粥样硬化病变中使用支架,我们认为是可行的。不同的是,对于股动脉下段和腘动脉,使用支架的效果存在争议。腘动脉以下病变的治疗更为困难,其中最佳选择可能是药物治疗。跨大西洋跨学会共识小组总结了股腘动脉支架置入的结果如下:在一项涉及585例患者的11项股腘动脉支架置入试验的比较中,36个月时的主要通畅率为58%。对于经皮腔内血管成形术,36个月时的通畅率为51%。尽管在股动脉病变中结果令人满意,尤其是在长度小于10 cm的狭窄病变中,但在较长的股动脉病变中,结果不如腘动脉病变,腘动脉病变的结果最差。下肢动脉血管成形术后的大型临床系列研究证实了再狭窄的临床和经济影响:其发生率在30%至50%之间。支架置入后的再狭窄是新生内膜形成的结果;因此,研究人员将兴趣转向一种可抑制支架置入后新生内膜生长和再狭窄的药物,如西罗莫司和/或紫杉醇。第一项评估药物洗脱支架植入治疗股浅动脉长段阻塞6个月疗效的多中心随机研究是2002年发表的SMART试验。这是第一项表明使用自膨胀镍钛合金支架平台进行控释药物也是可行的试验。6个月时的结果显示抑制了支架内新生内膜增生,反映出晚期管腔丢失减少的趋势。