Lee Seung Yul, Mintz Gary S, Kim Jung Sun, Kim Byeong Keuk, Jang Yangsoo, Hong Myeong Ki
Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea.
Cardiovascular Research Foundation, New York, NY, USA.
Korean Circ J. 2020 Oct;50(10):880-889. doi: 10.4070/kcj.2020.0198. Epub 2020 Aug 3.
Previous pathologic, intravascular imaging, and clinical studies have investigated the association between adverse cardiac events and stent malapposition, including acute stent malapposition (ASM, that is detected at index procedure) and late stent malapposition (LSM, that is detected during follow-up) that can be further classified into late-persistent stent malapposition (LPSM, ASM that remains at follow-up) or late-acquired stent malapposition (LASM, newly developed stent malapposition at follow-up that was not present immediately after index stent implantation). ASM has not been associated with adverse cardiac events compared with non-ASM, even in lesions with large-sized malapposition. The clinical outcomes of LSM may depend on its subtype. The recent intravascular ultrasound studies with long-term follow-up have consistently demonstrated that LASM steadily increased the risk of thrombotic events in patients with first-generation drug-eluting stents (DESs). This association has not yet been identified in LPSM. Accordingly, it is reasonable that approaches to stent malapposition should be based on its relationship with clinical outcomes. ASM may be tolerable after successful stent implantation, whereas prolonged anti-thrombotic medications and/or percutaneous interventions to modify LASM may be considered in selected patients with first-generation DESs. However, these treatments are still questionable due to lack of firm evidences.
既往的病理学、血管内影像学及临床研究均对不良心脏事件与支架贴壁不良之间的关联进行了探究，其中包括急性支架贴壁不良（ASM，在首次手术时检测到）和晚期支架贴壁不良（LSM，在随访期间检测到），后者可进一步分为晚期持续性支架贴壁不良（LPSM，随访时仍存在的ASM）或晚期获得性支架贴壁不良（LASM，随访时新出现的支架贴壁不良，在首次支架植入后即刻不存在）。与非ASM相比，ASM与不良心脏事件无关，即使在存在大面积贴壁不良的病变中也是如此。LSM的临床结局可能取决于其亚型。近期进行长期随访的血管内超声研究一致表明，LASM会稳步增加第一代药物洗脱支架（DES）患者发生血栓事件的风险。LPSM尚未发现存在这种关联。因此，合理的做法是，针对支架贴壁不良的处理应基于其与临床结局的关系。成功植入支架后，ASM可能是可耐受的，而对于第一代DES的特定患者，可能需要考虑延长抗血栓药物治疗和/或采用经皮介入治疗来改善LASM。然而，由于缺乏确凿证据，这些治疗方法仍存在疑问。
