OBJECTIVES:The aim of this study is to investigate the safety and efficacy of excimer laser coronary angioplasty (ELCA) combined with drug-coated balloons (DCBs) in the treatment of in-stent restenosis (ISR), and to explore whether the contrast injection technique would improve the neointimal tissue ablation of ELCA. METHODS:We studied patients diagnosed with ISR between January 2019 and October 2022 at two medical centers. These patients underwent DCB angioplasty guided by optical coherence tomography (OCT). Based on whether ELCA was performed before DCB treatment, patients were categorized into two groups: the ELCA + DCB group and the DCB group. All patients underwent clinical follow-up 1 year after the procedure. The primary endpoint was the 1-year rate of target lesion revascularization (TLR), which was defined as any repeat percutaneous intervention or bypass surgery on the target vessel conducted to address restenosis or other complications related to the target lesion. The secondary endpoints including immediate luminal gain (ΔMLA, defined as the difference in minimum lumen area before and after the intervention). RESULTS:A total of 85 lesions in 75 patients were included. The mean age of the study population was 64.2 ± 12.0 years, with 81.3% male. Baseline clinical characteristics were well-balanced, and procedural success was 100% in both groups. The ELCA + DCB group (n = 24) exhibited a greater ΔMLA compared to the DCB group (n = 61) (3.57 ± 0.79 mm² vs. 2.50 ± 1.06 mm², [95% confidence interval, CI: 0.57-1.69], p < 0.001), The reduction in 1-year TLR was more frequently observed in patients from the ELCA + DCB group compared to the DCB group (hazard ratio 0.33 [95% CI: 0.11-0.99]; log-rank p = 0.048). The exploratory analysis showed that ELCA with contrast infusion is associated with greater acute lumen gain compared to ELCA with saline infusion (p < 0.001). CONCLUSIONS:The combination of ELCA and DCB is a safe and effective treatment strategy for in-stent stenosis. Additionally, compared with saline injection, ELCA with contrast injection is associated with greater acute lumen gain. However, the optimal contrast agent concentration and long-term outcome of the contrast injection technique need confirmation through larger sample sizes and prospective studies.
心血管病死亡是当前我国最主要的死亡原因之一,在临床上多以动脉粥样硬化斑块快速进展相关的急性冠状动脉综合征为主要表现.既往多针对伴发多种危险因素的患者采用指南推荐的冠心病二级预防措施以降低心血管事件发生率.现代医疗背景下,影像学技术的进展使得识别高危斑块特征成为可能,为改善靶向斑块的治疗措施评估提供了依据.近些年研究发现,他汀类药物、前蛋白转化酶枯草杆菌蛋白酶9抑制剂等降脂类药物可通过改善血脂代谢、逆转斑块,为冠心病患者强化降脂治疗提供了有力证据.此外,秋水仙碱、西洛他唑、不饱和脂肪酸等可介导炎症状态、改善内皮功能进而改善斑块性质,成为靶向斑块逆转的潜在治疗药物.冠状动脉CT血管造影(CCTA)检查创伤小、普及性高,相较于冠状动脉造影及其他腔内影像学技术,更适用于斑块性质连续评估.随着CCTA技术革新,其空间分辨率、时间分辨率更加精确,结合心脏体积覆盖与重建算法实现了更高质量的成像与丰富的解剖细节.本文对CCTA评估斑块性质的定性与定量指标进行介绍,并对近些年使用CCTA评估药物治疗改善斑块性质的临床研究进行综述,以期对于临床治疗提供参考与指导.
目的 探讨 Sentinel脑保护装置(CEPD)在接受经导管主动脉瓣置换术(TAVR)患者中的应用效果和安全性.方法 回顾性分析从2017年3月至2022年10月在澳门镜湖医院进行的TAVR过程中置入CEPD的患者.随访时间截点为7 d和30 d,主要观察终点包括全因死亡、症状性脑卒中、短暂性脑缺血发作(TIA)、CEPD置入成功率、置入CEPD路径的血管并发症、CEPD成功捕获物质事件.绘制CEPD置入的操作时间折线图评价CEPD置入的学习曲线.结果 共29例患者纳入分析,所有患者均成功置入CEPD.女性13例(44.8%),平均年龄为(78.3±7.3)岁.三叶瓣患者16例(55.2%),二叶瓣患者13例(44.8%).所有患者TAVR所使用的的瓣膜均为自膨胀瓣膜,其中55.2%为Evolut R/PRO,44.8%为Venus-A/A Plus.随访7 d和30 d时,29例患者均未出现全因死亡、症状性脑卒中、TIA及桡动脉或肱动脉的血管并发症.根据主动脉瓣的类型将患者分为三叶瓣组和二叶瓣组,两组患者的钙化积分、人工瓣膜类型、置入CEPD操作时间比较,差异均无统计学意义(均P＞0.05).在肉眼观察下,两组均各有7例患者在CEPD中发现捕获血栓、钙化物质或瓣膜组织碎片等,组间比较差异无统计学意义(P＞0.05).随着手术例数的增加,CEPD的操作时间逐渐缩短,从第6例手术开始,操作时间均在11 min以内.结论 在TAVR术中置入CEPD的可操控性强,手术学习周期短且安全性高.Sentinel CEPD能明确捕获术中产生的部分血栓、钙化物质或瓣膜组织碎片,但在国内人群中使用Sentinel CEPD预防脑栓塞事件的有效性尚需要更多大规模随机对照研究的证实.
左心耳封堵术作为心房颤动患者口服抗凝药物的有效且安全替代方式,现已经广泛应用于临床.残余分流,即未完全封堵所致的由左心房进入左心耳的血流,被认为与脑卒中等不良事件相关.心脏CT血管成像可敏感地探查到残余分流,且除了封堵器周围漏外还可以发现封堵器未完全内皮化的现象.本文综述了心脏CT血管成像在评估左心耳封堵术后残余分流方面的优势及其影像上左心耳封堵术后残余分流的分类、发生率与临床预后相关性.
目的 探讨使用血管内超声(IVUS)评估经皮冠状动脉腔内冲击波球囊导管成形术(IVL)应用于钙化小结的有效性及安全性.方法 共纳入2023年1月1日至5月31日郑州大学第一附属医院14例严重钙化患者,按有无钙化小结分为钙化小结组(8例)、无钙化小结组(6例).对15支血管进行了IVL预处理,钙化小结血管组8支,无钙化小结血管组7支.患者均有IVL使用前及支架置入后的IVUS影像.主要有效性终点,在病变水平分析,钙化小结处与钙化角度最大处,支架置入后支架膨胀情况.次要有效性终点,在血管水平分析,比较钙化小结组与无钙化小结组支架置入术后的最小支架内面积.安全性终点,在支架置入术中有无介入并发症,包括严重血管夹层、血管急性闭塞、血管穿孔、慢血流、球囊破裂.结果 在病变水平分析,对15支血管中的钙化病变进一步分组,病变中钙化小结有8处(钙化小结病变组),钙化角度最大处有15处(钙化角度最大病变组).IVL使用前,钙化小结病变组管腔面积高于钙化角度最大病变组[3.68(3.19,5.13)mm2比2.84(2.07,3.15)mm2,P=0.026],钙化小结病变组支架置入后同样部位面积增加低于钙化角度最大病变组[(2.43±1.65)mm2比(4.57±1.75)mm2,P=0.009],但两组支架对称性、支架置入后管腔面积及支架膨胀系数比较,差异均无统计学意义(均P＞0.05).在血管水平分析,钙化小结血管组(7支)与无钙化小结血管组(6支)在支架置入后最小支架内面积比较,差异无统计学意义(P=0.578).两组患者均无介入并发症发生.结论 IVL对于钙化小结病变可以充分预处理,进而保证支架的膨胀及对称性,术中无严重介入并发症出现.IVL治疗钙化小结安全有效.
