金属裸支架在药物洗脱支架时代的作用乔树宾.ppt
金属裸支架在药物洗脱支架时代的作用,阜外心血管病医院 乔树宾2009-5-16,毫无疑问，药物支架在降低再狭窄率方面是被广泛临床实践所验证的。但也存在值得关注的问题！,注：公布于2006年美国ACC大会,Stone,GW,et al.该文章荟萃分析了个雷帕霉素的随机对比研究和个紫杉醇的对比研究，随访四年表明：与裸支架相比，药物涂层支架总的血栓发生率并没有明显增加，但是植入药物涂层支架一年后血栓发生率增加。,Days,0,60,120,180,300,360,420,480,540,Events Rate,0.00,0.02,0.04,0.06,0.08,0.10,0.12,0.14,0.16,Patients without Plavix,Patients on Plavix,Cumulative incidence of ST=58/3021 pts(1.9%),ST within 6 mo 1.4%,ST after 6 mo 0.5%,240,Source:Chieffo,TCT 06.,Milan Study Shows Patients on Plavix having LST,Chieffo&Colombo:Showed 9 of the 16 LST patients were on PlavixPatients without Plavix had increased thrombosis in first 6 monthsEmphasized Plavix is needed for 1st six months,不稳定心绞痛,血栓,糖尿病,无保护左主干,分叉病变,肾功衰,既往血管腔内放射治疗,抗小板治疗过早终止,支架血栓发生率(%),“过早中断持久的抗血小板治疗的患者有29%发生支架血栓,坚持药物的抗血小板治疗极为重要.”Iakovou et al,Overall stent thrombosis=1.3%(P=0.09,N=2229),累计支架血栓单变量预测因素(9个月)对 TAXUS 支架和 CypherTM 支架的分析,成功植入药物释放支架后支架血栓的发生率,预测因素,和结果 Iakovou et al.,JAMA.2005;293:2126-2130,Iakovou et al.JAMA.2005;293:2126.,CypherTM is a registered trademark of Cordis Corporation,TAXUS Stents are contraindicated in patients with lesions involving a bifurcation,unprotected left main and presence of definite or propable intraluminal thrombus.,Daemon J et al.Lancet 2007;369:667-78,LAD:,LCX:,OM:,AMI急诊并大量血栓,Vision 3.5*18,BMS Implanted in Big Vessels,No.1 2005,Vessel=2.8 mm,No.4,Mar 2007,Vessel=3.5 mm,No.5,Aug 2007,Vessel=3.5 mm,No.6,Jun 2007,Vessel=4 mm,No.7,Aug 2008 Vessel=3.0,No.3,2006,Vessel=3 mm,No.2 2006,Vessel=3 mm,No.8,2009,Vessel=3.2 mm,粗大血管,Vision 4.0*（28+18+18）,TLR(%Patients),5/101,0/93,4.0 mm Stent Patients,89/567,48/560,All TAXUS V Patients,Control,TAXUS,TLR for 4.0 Stents,TAXUS 4.0 mm,CYPHER 4.0 mm,15.7,5.0,8.6,0.0,P=NS,P=NS,Europe,U.S.,文章观点汇总,Spaulding,C,et al.文章指出：总体上雷帕霉素和裸支架没有区别，但糖尿病患者的生存率雷帕霉素支架组略低于裸支架组。Kastrati,A,et al文章指出：雷帕霉素与裸支架没有明显区别，但一年后血栓发生率略有增加。Lagerqvist,B,et al.文章指出：6个月之后，药物洗脱支架组的病人出现明显增高的事件率；到3年时，药物支架组病人死亡率明显增高。Stone,GW,et al.该文章荟萃分析了个雷帕霉素的随机对比研究和个紫杉醇的对比研究，随访四年表明：与裸支架相比，药物涂层支架总的血栓发生率并没有明显增加，但是植入药物涂层支架一年后血栓发生率增加。,DES时代BMS适应征,不能耐受长期抗血小板治疗出血高危（出血体质）或肝肾功能受损（肾透析病人）高龄患者抗血小板药物过敏或严重不良反应近期拟行手术（心脏/非心脏外科手术、起搏器植入、组织活检等）再狭窄低危的病人或病变非糖尿病病人参考血管直径3.0毫米，病变长度20毫米非前降支或左主干病变,DES时代BMS适应征,特殊病变血栓性病变瘤样扩张病变CTO病变多支病变杂交支架/DES型号不全对涂层药物或涂层过敏者,过敏体质经济困难，不能承受DES及长期抗血小板治疗费用第一代药物洗脱支架不能通过的病变,脑出血,Vision 3.5*23,B.Braun支架产品,1999:Coroflex 2001:Coroflex Delta2002:Coroflex Theca2004:Coroflex Blue(Co-Cr Alloy)2006:Coroflex Please(Drug Eluting Stent)注：以欧洲上市时间为准,Coroflex BlueRapid Exchange Coronary Stent System,Coroflex Blue主要产品特点,市场上最薄的支架 65 m 管壁厚度循证观点：低管壁厚度低再狭窄率 市场上通过性最佳的支架 最小的预装外径（小于1毫米）最小的通过外径（头端外径：0.017英寸）最小的推送系统,Coroflex Blue Worldwide Registry,Coroflex Blue Registry in Europe&Asia,Germany,Sweden,Poland,UK,France,Spain,Portugal,Czech Rep.,Norway,Slovak Rep.,Cyprus,Thailand,Malaysia,as of April 18,2006,Coroflex Blue Registry:Basics,documented stents within the registry as of April 18,2006:2,427 stents documented patients within the registry:2,333 patients 13 countries in Asia and Europe 57 centers(mostly local competence centers),Coroflex Blue Registry:Basics,Real World Indications10.5%accumulated 6-month-MACE 5.2%accumulated 6-month-TLR(Re-PTCA&CABG)98.5%success in difficult to treat patients,小 结,DES在降低再狭窄方面的作用勿庸置疑；在DES时代，金属裸支架有其特定的适用范围；Coroflex Blue支架，有最薄的管壁和最佳的通过性，是临床最佳的金属裸支架选择！,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,
