,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Titelmasterformat durch Klicken bearbeiten,Textmasterformate durch Klicken bearbeiten,Zweite Ebene,Dritte Ebene,Vierte Ebene,Fnfte Ebene,*,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,金属裸支架在药物洗脱支架时代的作用,1,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！,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,2,注：公布于,2006,年美国,ACC,大会,注：公布于2006年美国ACC大会,3,金属裸支架在药物洗脱支架时代的作用ppt课件,4,金属裸支架在药物洗脱支架时代的作用ppt课件,5,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。,Stone,GW,et al.该文章荟萃分析了个雷帕霉素,6,金属裸支架在药物洗脱支架时代的作用ppt课件,7,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 Plavix,Patients without Plavix,had increased thrombosis in first 6 months,Emphasized Plavix,is needed for 1,st,six months,Days060120180300360420480540Ev,8,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,Cypher,TM,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.,Cypher,TM,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.,不稳定血栓糖尿病无保护分叉病变肾功衰既往血管腔内放射治疗抗小,Daemon J et al.Lancet 2007;369:667-78,Daemon J et al.Lancet 2007;3,10,LAD:,LCX:,OM:,LAD:LCX:OM:,11,金属裸支架在药物洗脱支架时代的作用ppt课件,12,AMI急诊并大量血栓,Vision 3.5*18,AMI急诊并大量血栓Vision 3.5*18,13,金属裸支架在药物洗脱支架时代的作用ppt课件,14,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,BMS Implanted in Big VesselsNo,15,粗大血管,Vision 4.0*,（,28+18+18,）,粗大血管Vision 4.0*（28+18+18）,16,TLR(%Patients,),5/101,0/93,4.0 mm Stent Patients,p=0.0003,89/567,48/56,0,All TAXUS V Patients,p=0.06,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,TLR(%Patients)5/1010/934.0 m,17,Europe,Europe,18,金属裸支架在药物洗脱支架时代的作用ppt课件,19,U.S.,U.S.,20,金属裸支架在药物洗脱支架时代的作用ppt课件,21,金属裸支架在药物洗脱支架时代的作用ppt课件,22,金属裸支架在药物洗脱支架时代的作用ppt课件,23,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。,文章观点汇总Spaulding,C,et al.文章指出：,24,金属裸支架在药物洗脱支架时代的作用ppt课件,25,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适应征不能耐受长期抗血小板治疗,26,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,DES时代BMS适应征特殊病变,27,脑出血,Vision 3.5*23,脑出血Vision 3.5*23,28,B.Braun支架产品,1999:Coroflex,2001:Coroflex Delta,2002:Coroflex Theca,2004:Coroflex Blue(Co-Cr Alloy),2006:Coroflex Please(Drug Eluting Stent),注：以欧洲上市时间为准,B.Braun支架产品1999:Coroflex,29,Coroflex Blue,Rapid Exchange Coronary Stent System,Coroflex Blue,30,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主要产品特点 市场上最薄的支架C,31,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 in Eur,32,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:Basic,33,Coroflex Blue Registry:Basics,Real World Indications,10.5%accumulated 6-month-MACE,5.2%accumulated 6-month-TLR(Re-PTCA&CABG),98.5%success in difficult to treat patients,Coroflex Blue Registry:Basic,34,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！,小 结,35,