支架内血栓In-Stent Thrombosis,北京大学第一医院 李建平,Definite/Confirmed （肯定的）Acute coronary syndrome ANDAngiographic confirmation of thrombus or occlusion ORPathologic confirmation of acute thrombosisProbable （可能的）Unexplained death within 30 daysTarget vessel MI without angiographic confirmation of thrombosis or other identified culprit lesionPossible （不能排除的）Unexplained death after 30 days,ARC 支架内血栓定义,支架内血栓的预后,Similar mortality observed for SES and BMS thrombosis,Pooled Data from RAVEL, SIRIUS, C-SIRIUS, E-SIRIUS,支架内血栓发生时间,ST = stent thrombosis; SAT = subacute stent thrombosis;LST = late stent thrombosis; VLST = very late stent thrombosis.Adapted from Bhatt. J Invasive Cardiol. 2003;15(suppl B):3B.,Stent Thrombosis (%),支架内血栓与抗凝、抗血小板治疗,ASA und Ticlopidine,ASA und Anticoagulation,ASA und Clopidogrel,ASA = Acetylsalicylic acidDES: Drug-eluting stent,Bare Metal Stent,Prasugrel?,DES肯定的ST发生率:Bern - Rotterdam Cohort Study Daemen, Wenaweser et al. Lancet 2007;369:667-78,N=8146,0,1,2,3,4,Time since PCI in years,0,1,2,3,4,5,Cumulative incidence, %,Incidence density1.0 / 100 pt years,3.3%,3.5,0.53% (95% CI=0.44-0.64)/ year,192 definite ST cases,DES肯定的ST发生率:Bern-Rotterdam Cohort Study 4 YearsWenaweser P et al. J Am Coll Cardiol 2008, 52, 1134-,0.52% (95% CI=0.42-0.62)/ year between 30 days and 5 years,DES肯定的支架内血栓发生率:Bern-Cohort Study 5 YearsWenaweser P et al. ESC 2008,DES vs BMSA cohort of 9,175 patients treated with either BMS or DES (SES or PES), all patients with angiographically documented ST were identified as cases,Early Stent Thrombosis,RR=0.7695% CI =0.30-1.80P=0.55,RR=0.8095% CI =0.32-2.03P=0.79,Meta-analysisSES vs BMSBavry A et al. Am J Card 2005,Meta-analysisPES vs BMSStone G et al. NEJM 2007,%,%,Very Late ST 1 Year (Per Protocol),P=0.75,P=0.02,%,P=0.30,P=0.03,%,Stone G et al. NEJM 2007;356:998-1008,Kastrati A et al. NEJM 2007;356:1030-9,Sirolimus-Eluting Stent,Paclitaxel-Eluting Stent,SIRTAX Definite ST 4 YearsWindecker S et al ESC 2008,2.0%,1.8%,2.8%,2.4%,3.7%,3.4%,Cumulative Incidence of Definite STin LEADERS (BES vs. SES)Windecker et al. Lancet, 2008, 372, 1163-,Overall Incidence of ST with DES,ENDEAVOR,XIENCE,BIOMATRIX,High Risk of ST in All-Comer Patient Population and STEMI Patients,%,支架内血栓的病因,STENT THROMBOSIS,PatientGenetic PolymorphismReduced LV-EFAcute Coronary SyndromeHematology Disorder,DrugsResistanceDrug-drug InteractionDuration of AntiplateletTreatement,Vessel ReactionVessel RemodelingHypersensitivity ReactionDelayed Healing,早期支架内血栓的预测因素:残留夹层/撕裂,Bare Metal StentsMACE 30 daysSchhlen H et al. Circulation 1998,N=2,894,Drug-Eluting StentsMACE 30 daysBiondi-Zoccai G et al. EHJ 2006,N=2,418,%,P=0.01,P=0.01,Residual Dissection: Independent Predictor of MACE (OR=2.9),早期支架内血栓IVUS预测因素 With the Use of Sirolimus-Eluting StentsFujii K et al. J Am Coll Cardiol 2005;45:995-8,Minimal Stent CSA,P0.001,mm2,Stent Expansion,Residual Stenosis,%,P0.001,Stent Underexpansion and Residual Reference Segment Stenosis:Independent Predictors of Early Stent Thrombosis!,P0.001,支架内血栓预测因素药物反应异常 Wenaweser P et al. JACC 2005; 45(11):1748-52,服药后血小板活性与DES ST的关系Buonamici P et al JACC 2007,p0.001,p0.001,p0.001,p=ns,Iakovou et alJAMA 2005,Park et alAm J Card 2006,Airoldi et alCirculation 2007,Kuchulakanti et alCirculation 2006,OR=89.8(29.9-270),HR=19.2(5.6-65.5),HR=13.7(4.0-46.7),OR=4.8(2.0-11.1),Odds/Hazard Ratio,过早停用抗血小板药物是支架内血栓的重要预测因素,支架内血栓发生时的抗血小板治疗 Bern-Rotterdam Cohort Study 5 YearsWenaweser P et al. ESC 2008,Triton TIMI 38 Prasugrel vs. Clopidogrel in ACS Patients With StentsWiviott SD et al. Lancet 2008;371:1353-63,Overall Stent Thrombosis,Early Stent Thrombosis,Late Stent Thrombosis,Park et alAm J Card 2006,Airoldi et alCirculation 2007,Iakovou et alJAMA 2005,Machecourt et alJACC 2007,OR=1.03(1.00-1.05),OR=1.01(1.00-1.03),OR=2.75(1.55-4.88),Odds Ratio,支架内血栓的预测因素-支架长度,OR=1.02(1.00-1.04),OR=1.08(1.06-1.1),De la Torre et alJACC 2008,Roy et alJ Interv Card 2007,Kuchulakanti et alCirculation 2006,OR=4.4(2.0-10.0),Odds Ratio,支架内血栓的预测因素-分叉病变,OR=2.4(1.1-5.6),Iakovou et alJAMA 2005,OR=6.4(2.9-14.1),Ong et alJACC 2005*,OR=12.9(4.7-35.8),*in setting of AMI,Joner et al JACC 2006,Park et alAm J Card 2006,Daemen et alLancet 2007,Urban et alCirculation 2006,OR=12.4(1.7-89.7),OR=2.3(1.3-4.0),OR=1.8(1.1-2.7),Odds/Hazard Ratio,支架内血栓的预测因素-ACS,De la Torre et alJACC 2008,HR=2.6(1.3-4.9),Impact of Thrombus Burden on Risk of ST With DES in Patients With STEMISianos G et al. J Am Coll Cardiol 2007;50:573-83,Independent Predictors of ST,Kuchulakanti Circ 2006,Urban Circ 2006,IakovouJAMA 2005,DaemenLancet 2007,Machecourt JACC 2007,OR=2.0(0.8-4.9),OR=2.8(1.7-4.3),HR=3.7(1.7-7.9),HR=2.0(1.1-3.8),OR=2.7(1.4-5.2),Odds/Hazard Ratio,支架内血栓的预测因素-糖尿病,IijimaAm J Card 2007,HR=2.2(1.1-4.3),HR=1.75(1.0-3.0),De la TorreJACC 2008,晚期支架内血栓的可能原因,Chronic inflammatory reaction to the polymer or drugHypersensitivity to the polymer or drugFailure of stents to completely reendothelialize completelyLate incomplete stent appositionDisease progression,