Noncardiac surgery for patients with coronary artery stents: timing is everything.
Noncardiac surgery for patients with coronary artery stents: timing is everything.
复制标题
冠状动脉支架患者的非心脏手术：时机就是一切。
DOI：
10.1097/aln.0b013e3181870a4b
复制
发表时间：
2008
期刊：
影响因子：
8.8
通讯作者：
HogueJr,CharlesW
中科院分区：
文献类型：
--
作者：
Rade,JeffreyJ;HogueJr,CharlesW
医生们越来越多地面临的问题，关于适当的管理病人最近植入冠状动脉支架谁需要非心脏手术。具体来说，什么是择期手术的最佳时机，以及如何在这些患者中进行抗血小板治疗，特别是那些需要紧急手术的患者？围手术期持续抗血小板治疗可能增加手术出血的风险，而抗血小板治疗中断易发生支架内血栓形成，特别是在某些手术后经常发生的全身性高凝状态下。[1]在本期《麻醉学》中，来自明尼苏达州罗切斯特的马约诊所的两篇论文为这些令人困惑的问题提供了进一步的见解。2，3球囊血管成形术后支架的展开通过封闭冠状动脉夹层降低了血管突然闭合的急性风险，并通过防止弹性回缩和负性血管重塑降低了再狭窄的长期风险。裸金属支架（BMS）不能预防，实际上可能刺激的是新生内膜增生的发展，这是再狭窄的另一个主要决定因素。这为用抑制平滑肌细胞（新生内膜的主要细胞成分）生长和增殖的物质（如西罗莫司和紫杉醇）涂覆支架提供了理论依据。药物洗脱支架（DES）于2003年获得美国食品药品监督管理局（FDA）的批准，与BMS相比，DES对降低靶血管血运重建（再狭窄的最重要临床指标）的发生率具有重大影响，降低幅度高达75%。
Physicians are increasingly being confronted with questions regarding the appropriate management of patients with recently implanted coronary stents who are in need of noncardiac surgery. Specifically, what is the optimal timing of elective procedures and how should antiplatelet therapy be managed in these patients, especially in those in need of emergent procedures? Continued antiplatelet therapy through the perioperative period might increase the risk of surgical bleeding while interruption of antiplatelet therapy predisposes to stent thrombosis, particularly in the setting of systemic hypercoagulation that frequently occurs after some surgeries. 1 In this issue of Anesthesiology, two papers from the Mayo Clinic in Rochester, Minnesota provide further insight into these perplexing issues. 2, 3Deployment of a stent after balloon angioplasty reduces both the acute risk of abrupt vessel closure by sealing coronary artery dissections and the long-term risk of restenosis by preventing elastic recoil and negative vessel remodeling. What bare metal stents (BMS) do not prevent, and may actually stimulate, is the development of neointimal hyperplasia, the other major determinant of restenosis. This provided the rationale for coating stents with substances, such as sirolimus and paclitaxel, which inhibit the growth and proliferation of smooth muscle cells, the major cellular constituent of the neointima. Approved by the Food and Drug Administration in 2003, drug-eluting stents (DES) have had a major impact on reducing the incidence of target vessel revascularization, the most important clinical indicator of restenosis, by as much as 75% compared to BMS.