植入藥物洗脫支架后出現的晚期支架血栓和自我溶栓病例CaseinformationMale,49y.HT(-),DM(-),Dyslipidemia(-),Smoker(-),FH(-)AMI(anteriorwall)insep.2004.EmergencyCAG:ostialLAD100%,ostialLCX60%,normalRCA.EmergencyPCI:CypherinLAD.Detailnotacquired.Drug:(Plavix75mg/d+ASA100mg/d)*1y,followedbyASA75mg/d*qod,othercardiodrugsroutinely.CaseinformationfollowupAcutechestpain,Re-AMI(anterior)in6,Nov.2007.EmergencyCAG:cloudinstent,defectofmid-distalstent,TIMIgrade0.LCXthesameasbefore,normalRCA.CABGorPCInotperformed.Followedbydrugs:(Plavix300mg/d+ASA100mg/d+LWMH1mg/kgq12h)*12d,othercardiodrugsroutinely.Angiograhpy(6,Nov.2007):LADandLCXAngiograhpy(6,Nov.2007):RCAFollowup:2weekslaterCAGafter2weeks:nothrobosisinstent,LADTIMI3.LCXthesameasbefore,normalRCA.AngiographyfollowupDiscussionThrombosisofDESDefinitionThemechanismStrategy？今天討論重點DESpreventingrestenosisafterPCIStent:VesselRecoilandRemodellingDrug:IntimalProliferationDilemmaofsafety:

thrombosisARCDefinitionofSTAcute0-24hSubacute24h-30dLate30d-1yVerylateafter1yDefinite/confirmedProbablePossibleTimecourseAngiographyandclinicalevidence*AntiplateletTherapydiscPriorBrachyRenalfailureBifurcationsULMDiabetesUAThrombosisratesaccording

toselectedpatientcharacteristics%*PrematurediscontinuationFromA.Colombo,MDClinicalpredictorsofstentthrombosis0.010.11101000.010.1110100Nothieno*(0-6m)Nothieno*(6-18m)LVEF*≤30%PriorBrachytherapyRVD*FinalatmStentLengthHR=11.7;95%CI,3.47-39.24,p<0.0001HR=1.01;95%CI,0.30-3.46,p=0.98HR=4.32;95%CI,1.61-11.60,p=0.004HR=9.89;95%CI,3.56-27.46,p<0.0001HR=0.16;95%CI,0.03-0.82,p=0.03HR=0.41;95%CI,0.18-0.92,p=0.03HR=3.41;95%CI,1.94-5.97,p<0.0001*Abbreviations:thieno=thienopyridine;LVEF=leftventricleejectionfraction;RVD=referencevesseldiameterFromA.Colombo,MDDESdelayedhealing:delayedendothelializationCypherTaxusEFHI500μm2mm500μm200μm500μm200μm500μmC2mm200μmJ200μmABxVelocity2mmBDExpressLK2mmGA.Finn,RenuVirmanin,SOLACI2006DES:notonlysuppressSMCinfiltrationbutalsodelayendothelialization,leadingtostentthrombosisDESPolymerMishaps

Bonding=polymerstickstoitselfformingabridgewhenthestentisexpanded

Webbing=polymerpullingawayfromtheexpandedstentduetostickingPolymerinDES:localizedhypersensitivityVirmani,R.etal.Circulation2004;109:701-705Latemalapposition基線正性管腔重構沒有管腔重構隨訪在Taxus和Cypher的研究中，發生晚期貼壁不良的患者停止clopidogrel治療后20%

發生了支架血栓*！*StudybyDr.Abizaid,presentedatTCT2005.完全閉塞暴露的支架金屬絲M,44y,CypherduetopriorAMI,Clopidegrelwasdiscontinuedafter3m,aspirin150mg/dwascontinued.31mlater,thrombosis.EurHeartJ.21Oct2005.CaseduetolatemalappositionDiscussion:othersManufacturing&DeliverabilityHighpressure,sidebranchdilatationInhomogenousdrugdeliveryThrombogenicityRestenosisisdelayedandbutnoteliminatedAndsoon.Discussion:strategy重要的是對LaST形成的研究現狀要有清晰的認識，針對可能的發生機制采取綜合措施；該患者年僅49歲，DES術后堅持1年的雙重抗血小板治療，中止氯吡咯雷26個月后出現LaST，無合并糖尿病、腎功能不全等病史，雖然未評價血小板功能，但是推測血栓的形成可能與中止抗血小板治療及LAD支架操作有關，也很可能是血管對DES的遲發反應。大多數專家認為雙重抗血小板最少要12個月，至于是否需要更進一步延長還未達成共識，需要更多的循證醫學證據來根據晚期血栓事件的風險對患者進行分層。本患者在DES術后38個月發生靶血管AMI，造影提示支架內血栓形成的特點，其臨床過程表現為血栓自溶、血管再通，但是，缺