支架内再狭窄分型英文.pdf
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支架内再狭窄分型英文.pdf
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CLINICALRESEARCHSTUDIESFromtheSocietyforVascularSurgeryPatternsofin-stentrestenosisaftercarotidarterystenting:
Classificationandimplicationsforlong-termoutcomeBrajeshK.Lal,MD,a,b,c,dEliasA.Kaperonis,MD,eSalvadorCuadra,MD,a,dIndravadanKapadia,PA,dandRobertW.HobsonII,MD,a,b,dNewark,NJ,andAthens,GreeceObjectives:
Factorspredictingin-stentrestenosis(ISR)andfutureneedfortargetlesionrevascularization(TLR)aftercarotidarterystenting(CAS)remainundetermined.Wehypothesizedthatthepatternsofrestenoticlesionsmayprovideprognosticinformation.Inthisstudy,wedevelopedanultrasoundclassificationschemeforISRbasedonlesionlengthanddistributionandassessedfactorsthatmaypredicttheneedforTLR.Methods:
PatientswerefollowedupafterCASwithB-modeultrasoundimaging,andISRlesions(40%stenosis)wereclassifiedintotypeI(focal10mmend-stentlesions),II(focal10mm,intrastent),IV(diffuse10mmproliferative,extendingoutsidethestent),andV(totalocclusion).Thefrequencyoflesiontypeswasassessed.Accuracyoftheultrasoundclassificationwasconfirmedwithangiography.Werecordedpatient(age,gender,comorbidities),lesion(severity,etiology,symptomaticstatus)andproceduralfeatures(type,number,lengthofstents),andtheneedforTLR.Results:
Eighty-fiveISRlesionsdevelopedafter255CASprocedures.TheirpercentagedistributionwastypeI,40;typeII,25.9;typeIII,12.9;fortypeIV,20;andtypeV,1.2.Accuracyoftheultrasoundclassificationwasconfirmedbyangiography(r2?
0.82).Inter-rateragreementfortheassignmentoflesiontypebasedonultrasoundwas0.88(verygood).TLRwasperformedin13thatwere80%diameterreducing.Onunivariateanalysis,theneedforTLRwashighestintypeIVlesions(0%,0%,27.3%,and58.8%typesItoIV,respectively;P?
.001).HistoryofISR(2.9%,0%,0%,and41.2%typesItoIV;P?
.003)anddiabetesmellitus(20.6%,22.7%,45.5%,and52.9%typesItoIV;P?
.02)occurredmorefrequentlywithtypeIVISRlesions.Onmultivariateanalysisofallpatient,lesion,andproceduralcharacteristics,onlythetypeofISR(oddsratio,5.1)andahistoryofdiabetes(oddsratio,9.7)wereindependentpredictorsofTLR.Conclusions:
TheproposedclassificationaccuratelygradesthemagnitudeofintimalhyperplasiaafterCASandprovidesimportantprognosticinformation.Diffuseproliferative(typeIV)ISRlesionsanddiabetesareimportantdeterminantsoflong-termoutcomeafterCAS.ThisclassificationwillfacilitateastandardizeddescriptionofrecurrenceafterCASandenableearlyidentificationofhigh-riskpatientsforadditionalmonitoring,treatment,andinvestigation.(JVascSurg2007;46:
833-40.)Carotidarterystenting(CAS)hasemergedasalessinvasivealternativetocarotidendarterectomy(CEA)forrevascularizationofextracranialcarotidocclusivedisease.Ourinstitution1-5andothers6-10havereportedthatCAScanbeperformedwithlowperiproceduralmorbidity.Onlong-termfollow-up,wehaveobservedin-stentrestenosis(ISR)of?
40%diameterreductionin42.7%ofourpatients,andof?
60%diameterreductionin16.4%at5yearsoffollow-up.5Similarly,theStentingandAngioplastywithProtectioninPatientsatHighRiskforEndarterectomy(SAPPHIRE)investigatorsreportedISRin19.7%ofpa-tientsat1yearoffollow-up.11Therefore,ISRwillbecomeincreasinglyprevalentduetotheexponentialincreaseintheuseofcarotidstents.Post-CASISRiscurrentlytreatedatathresholdof?
80%diameterreduction(6.4%incidenceat5years5).However,factorsthatpredicttargetvesselfailureremainundetermined.Primarystentingpreventscarotidarteryrecoilandconstrictiveremodeling.12Post-CASISRcanthreforebeprimarilyattributedtoneointimalhyperpla-sia,12,13andstudiesofcoronaryISRindicatethatlongneointimalhyperplasialesionsdiffuselyinvolvingthestentsurfacecorrelatewiththehighestrecurrenceandreinter-ventionrates.14FromtheDivisionofVascularSurgerya,DepartmentofPhysiologyb,andDepartmentofBiomedicalEngineeringc,UniversityofMedicineandDentistry,NewJersey-NewJerseyMedicalSchool;theDivisionofVas-cularSurgery,St.MichaelsMedicalCenterd;andtheDivisionofVascularSurgery,UniversityofAthense.Competitionofinterest:
none.SupportedbygrantsfromtheAmericanHeartAssociation(RA5883,BKL)andtheNationalInstitutesofHealth(NS38384,RWH).PresentedatVASCULAR2007,AnnualMeetingoftheSocietyforVascularSurgery,Baltimore,Md,June7-10,2007.Reprintrequests:
BrajeshKLal,MD,UMDNJ-NewJerseyMedicalSchool,185SOrangeAve,MSB-H570,Newark,NJ07103(e-mail:
lalbkumdnj.edu).0741-5214/$32.00Copyright2007byTheSocietyforVascularSurgery.doi:
10.1016/j.jvs.2007.07.022833ThepatternsofISRdevelopingaftercarotidarterystentinghavenotbeendescribed,andtheirprognosticutilityhasnotbeenstudied.Wethereforedevelopedanultrasoundclassificationschemeforpost-CASISRbasedonthelengthanddistributionofthelesionwithrespecttothestentandverifieditsaccuracywithcarotidangiography.Weth
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