Yamanaga Kenshi, Tsujita Kenichi, Shimomura Hideki, Nakamura Yoshinori, Ogura Yuji, Onoue Yoshiro, Chazono Naomi, Nagata Takeshi, Morisaki Shogo, Kudo Takashi, Yamada Yoshihiro, Komura Naohiro, Miyazaki Takashi, Akasaka Tomonori, Horio Eiji, Sato Koji, Arima Yuichiro, Kojima Sunao, Kaikita Koichi, Tayama Shinji, Hokimoto Seiji, Ogawa Hisao
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan; Division of Cardiology, Fukuoka Tokushukai Medical Center, Kasuga, Japan.
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
J Cardiol. 2014 Oct;64(4):279-84. doi: 10.1016/j.jjcc.2014.02.008. Epub 2014 Mar 24.
In-stent restenosis has been decreasing through the introduction of drug-eluting stents (DES). On the other hand, adverse events such as very late stent thrombosis (VLST) and late catch-up phenomenon can occur especially with sirolimus-eluting stents (SES, first-generation DES) in long-term follow-up. However, the precise mechanisms underlying VLST have not been well investigated in vivo.
From 2004 to 2010, 2034 SES were implanted in 1656 patients and caused eight VLST (0.48% per patient) at Fukuoka Tokushukai Medical Center. Of these, serial intravascular ultrasound (IVUS) images (post-stent implantation and at the time of VLST onset) were obtained from three patients with VLST. Comparing them with eight control patients with SES implanted, the vascular reactivity of VLST patients was analyzed. Eight VLST happened 50 ± 15 months after stent implantation and three of the eight patients with VLST had not taken aspirin daily. There were no differences in minimum stent area, maximum external elastic membrane (EEM) area, and stent edge (distal and proximal) EEM area in post-procedural IVUS images. Compared with the control group patients, ΔEEM area (10.6 ± 3.4mm(2) vs. 1.7 ± 1.9 mm(2), p=0.01) and vessel expansion ratio (185.6 ± 40.3% vs. 112.0 ± 12.1%, p=0.01) were significantly greater in the VLST group based on the greater peri-stent plaque expansion (262.1 ± 72.8% vs. 118.7 ± 21.2%, p=0.01).
Our serial IVUS study showed that the vascular positive remodeling after SES implantation is one of the most probable morphological mechanisms for VLST development.
通过引入药物洗脱支架（DES），支架内再狭窄情况一直在减少。另一方面，在长期随访中，尤其是西罗莫司洗脱支架（SES，第一代DES）可能会出现诸如极晚期支架血栓形成（VLST）和晚期追赶现象等不良事件。然而，VLST的确切潜在机制在体内尚未得到充分研究。
2004年至2010年，福冈德洲会医疗中心对1656例患者植入了2034个SES，其中发生了8例VLST（每位患者0.48%）。在这些病例中，获取了3例VLST患者的系列血管内超声（IVUS）图像（支架植入后及VLST发生时）。将其与8例植入SES的对照患者进行比较，分析VLST患者的血管反应性。8例VLST发生在支架植入后50±15个月，8例VLST患者中有3例未每日服用阿司匹林。术后IVUS图像中的最小支架面积、最大血管外弹力膜（EEM）面积以及支架边缘（远端和近端）EEM面积没有差异。与对照组患者相比，基于更大的支架周围斑块扩张（262.1±72.8%对118.7±21.2%，p = 0.01），VLST组的ΔEEM面积（10.6±3.4mm²对1.7±1.9mm²，p = 0.01）和血管扩张率（185.6±40.3%对112.0±12.1%，p = 0.01）显著更大。
我们的系列IVUS研究表明，SES植入后的血管阳性重塑是VLST发生的最可能形态学机制之一。
