如何應(yīng)對支架內(nèi)再狹窄－－證據(jù)及展望

解放軍總醫(yī)院血管外科賈鑫、郭偉、劉小平、尹太、熊江、馬曉輝等

如何應(yīng)對支架內(nèi)再狹窄－－證據(jù)及展望血管外科醫(yī)生最頭痛的問題開刀－－移植物閉塞腔內(nèi)－－支架內(nèi)再狹窄（ISR）支架內(nèi)再狹窄ISR：In-StentRestenosis病理：幾乎全部內(nèi)膜增生病因：病變部位、病變長度、支架數(shù)量、流入流出道

支架斷裂可能原因，造成血管壁回縮和刺激內(nèi)膜增生抗血小板藥物降低ISR？PTAplus(or)StentAtherectomyLaserStentgraftDESorDEBCryoplastyPTA+STENT再狹窄率頸動脈5％腎動脈10－20％髂動脈5－20％腹股溝以下動脈25－50％Zellaretc,CathCardiovascInterv,2007,70SFA易再狹窄路徑長，側(cè)支少內(nèi)收肌管擠壓閉塞多于狹窄SFA裸支架通暢率(FreedomfromTLR)DorrucciJVascSurg,Aug2004PTAplus(or)StentAtherectomyLaserStentgraftDESorDEBCryoplastyLACI（LaserAssistedAngioplastyforCriticalLimbIschemia）

127人，隨訪6月SFA病變，平均長度38mmFreefromTLR85%JLaird,etcJVascSurg,2007,AugCryoplasty---BigCHILLtrialProspectivemulticenterregistry誘導(dǎo)VSMC凋亡,彈力纖維變性，從而減少彈性回縮錄入102患者，SFA長度48mm,狹窄病變9月隨訪，通暢率72％LairdJetc,Jvascintervradiol2005,FebCoveredstentforSFAJVascSurg,2007,MayDESforSFAMDake,Charingcross2009,May,presentationBTKdrugelutingstenttrialJEndoTher,2005,DecJCardioSurg,2007,ApriDrugcoatedballoon(Thundertrial)6monthfollow-upMean65mm,SFATDas,2009VIVApresentationPTAplus(or)Stent：直徑、長度AtherectomyLaserStentgraftCryoplastyDESorDEB腔內(nèi)治療ISRPTA＋STENTCuttingballoonBrachytherapyLaserStentgraftDESorDEBCuttingballoon31patients36lesions,CLILength32.4mmPrimarypatency61%@6monthLimbsalvage83%BosiersMetc,vascular,2009,FebLaser/PTA+支架血管39人，SFA,ISRRutherfordClass1-6,mean3病變平均長度27cm,(5-44cm)GaryanselJVascSurg,2009,May6月隨訪Primarypatency73%Primaryassistedpatency76%Occluded24%18月隨訪Primarypatency52%Primaryassistedpatency67%Zellaretc,CathCardiovascInt