A halin yanzu an kashe Javascript a cikin burauzar ku.Wasu fasalulluka na wannan gidan yanar gizon ba za su yi aiki ba idan an kashe JavaScript.
Yi rijista tare da takamaiman bayanan ku da takamaiman magungunan sha'awa, kuma za mu dace da bayanin da kuka bayar tare da labarai a cikin babban ma'ajin mu kuma mu aika muku da kwafin PDF nan da nan.
Marta Francesca Brancati. bayan tsaka mai wuya na jijiyoyin jini.Duk da haka, yayin da gabatarwar DES na ƙarni na biyu ya bayyana ya rage wannan al'amari idan aka kwatanta da ƙarni na farko na DES, damuwa mai mahimmanci ya kasance game da yiwuwar rikice-rikice na ƙarshen zamani na stent implantation kamar stent thrombosis (ST) da stent resection, stenosis (SSI).ST wani lamari ne mai yuwuwar bala'i wanda an rage shi sosai ta hanyar ingantattun stent implantation, novel stent designs, da dual antiplatelet far.Ana gudanar da bincike kan ainihin hanyar da ke bayyana abin da ya faru, kuma hakika abubuwa da yawa ne ke da alhakin.ISR a cikin BMS an yi la'akari da shi a matsayin tsayayyen yanayi tare da farkon kololuwar hyperplasia na ciki (a watanni 6) sannan lokacin koma baya na fiye da shekara 1.Sabanin haka, duka binciken asibiti da na tarihi na DES sun nuna shaidar ci gaba da ci gaban neointimal a cikin dogon lokaci mai zuwa, wani sabon abu da aka sani da abin da ya faru na "karshen kamawa".Tunanin cewa ISR wani yanayin rashin lafiya ne kwanan nan an karyata shi ta hanyar shaida cewa marasa lafiya tare da ISR na iya haifar da ciwo mai tsanani.Hoton intracoronary wata dabara ce mai ɓarna don gano stented atherosclerotic plaques da alamun warkaswar jirgin ruwa bayan stenting, kuma ana amfani da su sau da yawa don kammala bincike na angiography na jijiyoyin jini da aiwatar da hanyoyin shiga tsakani.Intracoronary Optical Tomography a halin yanzu ana ɗaukar mafi kyawun tsarin hoto. yana ba da, idan aka kwatanta da duban dan tayi na intravascular, mafi kyawun ƙuduri (aƙalla> sau 10), yana ba da damar cikakken bayanin yanayin yanayin bangon jirgin ruwa. yana ba da, idan aka kwatanta da duban dan tayi na intravascular, mafi kyawun ƙuduri (aƙalla> sau 10), yana ba da damar cikakken bayanin yanayin yanayin bangon jirgin ruwa. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, > 10 разе), характеризовать поверхностную структуру стенки сосуда. yana ba da, idan aka kwatanta da duban dan tayi na intravascular, mafi kyawun ƙuduri (aƙalla> sau 10), wanda ke ba da damar cikakken bayanin fasalin fasalin bangon jirgin ruwa.与血管内超声相比，它提供了更好的分辨率（至少> 10 倍）。与血管内超声相比，它提供了更好的分辨率（至少> 10）。Idan aka kwatanta da duban dan tayi na intravascular, yana samar da mafi kyawun ƙuduri (aƙalla sau 10), wanda ke ba da damar cikakken bayanin fasalin fasalin bangon jirgin ruwa.A cikin nazarin hoto na vivo wanda ya yi daidai da binciken tarihi ya nuna cewa kumburi na yau da kullun da / ko rashin aiki na endothelial na iya haifar da ci gaba neoatherosclerosis a cikin HMS da DES.Don haka, neoatherosclerosis ya zama babban abin tuhuma a cikin pathogenesis na gazawar stent.Mahimman kalmomi: stent na jini, stent thrombosis, restenosis, neoatherosclerosis.
Sentted percutaneous coronary intervention (PCI) ita ce hanya mafi ko'ina da ake amfani da ita don maganin cututtukan cututtukan jijiyoyin jini, kuma fasahar tana ci gaba da haɓakawa.1 Ko da yake miyagun ƙwayoyi eluting stent (DES) yana rage iyakokin da ba a rufe su ba (UES), rikice-rikice na ƙarshe kamar a cikin stent thrombosis (ST) da kuma a cikin stent restenosis (ISR) na iya faruwa tare da stent implantation, kuma damuwa mai tsanani ya kasance.2-5
Idan ST wani lamari ne mai yuwuwar bala'i, yarda da cewa ISR cuta ce mai ƙarancin ƙima ta kwanan nan an ƙalubalanci shaidun cututtukan cututtukan zuciya (ACS) a cikin marasa lafiya tare da ISR.hudu
A yau, intracoronary Optical Coherence tomography (OCT) 6-9 ana ɗaukarsa a matsayin tsarin hoto na zamani wanda ke ba da mafi kyawun ƙuduri fiye da duban dan tayi na intravascular (IVUS).A cikin nazarin hoto na vivo10-12 daidai da binciken tarihi ya nuna "sabon" tsarin amsawa na jijiyoyin jini bayan dasa shuki tare da de novo "neoatherosclerosis" a cikin BMS da DES.
A cikin 1964 Charles Theodore Dotter da Melvin P. Judkins sun bayyana angioplasty na farko.A cikin 1978, Andreas Grunzig ya yi aikin angioplasty na balloon na farko (tsohon angioplasty na balloon na al'ada);magani ne na juyin juya hali, amma kuma yana da rashin lahani na ƙulli mai tsanani na jijiyoyin jini da restenosis.13 Wannan ya haifar da gano stent na jijiyoyin jini: Puel da Sigwart sun shigar da stent na farko a cikin 1986, suna ba da stent don hana rufewar jirgin ruwa da kuma ja da baya a ƙarshen systolic.14 Ko da yake waɗannan stent na farko sun hana rufe jirgin kwatsam, sun haifar da lahani mai tsanani da kumburi.Kwanan nan, binciken ƙasa guda biyu, Nazarin Stent na Belgian-Dutch na 15 da Nazarin Stent Restenosis Study 16, sun ba da shawarar kiyaye lafiyar antiplatelet biyu (DAPT) stenting da/ko hanyoyin turawa da suka dace.17,18 Bayan waɗannan gwaje-gwajen, adadin PCI da aka yi ya ƙaru sosai.
Duk da haka, matsalar iatrogenic in-stent neointima hyperplasia bayan an gano wuri na BMS da sauri, wanda ya haifar da ISR a cikin 20-30% na raunuka da aka yi.An gabatar da DES19 a cikin 2001 don rage buƙatar sake dawowa da sake aiki.DES ta ƙara kwarin gwiwa na likitocin zuciya ta hanyar ba da damar yin maganin ɗimbin ɗimbin rikitattun raunuka waɗanda a baya an yi la’akari da su da za a iya magance su tare da ƙwayar jijiyoyin jini.A cikin 2005, 80-90% na duk PCIs suna tare da DES.
Komai yana da raunin sa, kuma tun lokacin da 2005 damuwa game da amincin "ƙarni na farko" DES ya karu, an ƙaddamar da sababbin tsararraki irin su 20,21 da kuma gabatar da su.22 Tun daga wannan lokacin, ƙoƙarin inganta aikin stent ya karu cikin sauri, kuma an ci gaba da gano sabbin fasahohi masu ban sha'awa da kuma kawo kasuwa cikin sauri.
BMS bututun ragar waya ne mai kyau.Bayan gwaninta na farko tare da Dutsen bango, Gianturco-Roubin Dutsen da Dutsen Palmaz-Schatz, BMS da yawa daban-daban yanzu suna samuwa.
Akwai kayayyaki daban-daban guda uku: serpentine, tubular raga da bututu mai slotted.Zane-zanen coil sun ƙunshi wayoyi na ƙarfe ko ƙwanƙwasa waɗanda ke yin siffar murɗa zagaye;a cikin zane-zanen raga na tubular, waya da aka yi birgima tare a cikin raga ta samar da bututu;slotted kayayyaki kunshi karfe shambura da suke Laser yanke.Waɗannan na'urori sun bambanta a cikin abun da ke ciki (bakin ƙarfe, nichrome, cobalt chrome), ƙira (siffa daban-daban da faɗin sarari, diamita da tsayi, ƙarfin radial, radiopacity), da tsarin bayarwa (faɗaɗa kai ko balloon- faɗaɗawa).
A matsayinka na mai mulki, sabon BMS ya ƙunshi haɗin cobalt-chromium, wanda ya haifar da ƙananan struts, inganta aikin tuki da kuma riƙe ƙarfin injiniya.
Sun ƙunshi dandamali na stent na ƙarfe (yawanci bakin karfe) kuma an lulluɓe su da polymer wanda ke fitar da magungunan ƙwayoyin cuta da / ko ƙwayoyin cuta.
Sirolimus (wanda kuma aka sani da rapamycin) an samo asali ne azaman wakili na antifungal.Tsarin aikin sa yana da alaƙa da toshe ci gaban tsarin tantanin halitta ta hanyar toshe canji daga lokaci na G1 zuwa lokacin S da hana samuwar neointima.A cikin 2001, ƙwarewar "mutum na farko" tare da SES ya nuna sakamako mai ban sha'awa, wanda ke haifar da ci gaba na Cypher stent.23 Manyan gwaje-gwaje sun nuna tasirin sa wajen hana IR.24
An amince da farko Paclitaxel don maganin ciwon daji na ovarian, amma abubuwan da ke da karfi na cytostatic - miyagun ƙwayoyi yana daidaita microtubules a lokacin mitosis, yana haifar da kamawar kwayar halitta, kuma ya hana samuwar neointimal - sanya shi fili don Taxus Express PES.Gwajin TAXUS V da VI sun nuna ingancin dogon lokaci na PES a cikin haɗarin cututtukan zuciya mai haɗari.25,26 TaxUS Liberté na gaba ya fito da dandamalin bakin karfe don sauƙin isarwa.
Shaidu masu ƙarfi daga bita na tsari guda biyu da meta-bincike sun nuna cewa SES yana da fa'ida akan PES saboda ƙananan ƙimar IVR da revascularization na jirgin ruwa (TVA), da kuma haɓakar haɓakar ƙwayar cuta mai ƙwayar cuta (AMI) a cikin ƙungiyar PES.27.28
Na'urori na ƙarni na biyu sun rage kaurin ramin, ingantattun sassauƙawa/bayarwa, ingantattun bayanan bayanan ƙwayoyin cuta na polymer bioocompatibility/magunguna, da ingantaccen haɓakar motsin motsi.A halin yanzu, waɗannan su ne mafi haɓakar ƙira na DES da manyan stent na jijiyoyin jini da aka dasa a duk duniya.
Abubuwan Taxus suna ɗaukar wannan mataki ɗaya gaba tare da na'urar polymer na musamman da aka ƙera don ƙaddamarwa da wuri da sabon tsarin sararin samaniya na platinum-chromium wanda ke ba da mafi ƙarancin sarari da ƙara ƙarfin rediyo.Binciken PERSEUS 29 ya lura da sakamako iri ɗaya tsakanin Element da Taxus Express har zuwa watanni 12.Koyaya, babu isassun gwaje-gwajen da ke kwatanta abubuwan yew da sauran ƙarni na biyu na DES.
Endeavor Zotarolimus Coated Stent (ZES) ya dogara ne akan dandamali mai ƙarfi na cobalt-chromium tare da sassauci mafi girma da ƙarami stent strut.Zotarolimus shine analog na sirolimus tare da irin wannan tasirin immunosuppressive, amma tare da ƙara yawan lipophilicity don inganta wurin zama a bangon jirgin ruwa.ZES yana amfani da sabon rufin phosphorylcholine polymer wanda aka ƙera don haɓaka haɓakar ƙwayoyin cuta da rage kumburi.Yawancin kwayoyi ana wanke su a farkon lokacin rauni, sannan kuma a gyara jijiya.Bayan gwajin ENDEAVOR na farko, gwajin ENDEAVOR III na gaba ya kwatanta ZES tare da SES, wanda ya nuna mafi girman asarar lumen da HR amma ƙarancin abubuwan da ke faruwa na zuciya da jijiyoyin jini (MACEs) fiye da SES.30 Binciken ENDEAVOR IV da ya kwatanta ZES tare da PES ya sake samun mafi girma na SIS amma ƙananan abin da ya faru na MI, mai yiwuwa saboda ST na kowa a cikin rukunin ZES.31 Duk da haka, binciken PROTECT ya kasa nuna bambanci a cikin mitar ST tsakanin Endeavor da Cypher stent.32
Ƙaddamar Ƙaddamarwa shine ingantacciyar sigar Endeavor stent tare da sabon polymer mai Layer uku.Sabuwar Ƙaƙƙarwar Ƙarfafawa (wani lokaci ana kiranta DES ƙarni na uku) ya dogara ne akan sabon dandamali tare da mafi girman damar isarwa (Tsarin Integrity BMS) da kuma sabon, ƙarin nau'in polymer mai Layer uku wanda zai iya kawar da martanin kumburi na farko kuma ya haɓaka ƙarin maganin a cikin kwanaki 60 masu zuwa.Wani gwaji da aka kwatanta Resolute tare da Xience V (everolimus eluting stent [EES]) ya nuna cewa tsarin Ƙaddamarwa yana da tasiri daidai gwargwado dangane da mace-mace da gazawar rauni.33.34
Everolimus, wanda aka samo asali na sirolimus, shine kuma mai hana sake zagayowar tantanin halitta da aka yi amfani da shi a cikin ci gaban EES Xience (Tsarin BMS na Multi-link Vision) / Promus (Platinum Chromium dandamali).Gwajin SPIRIT 35-37 ya nuna ingantaccen sakamako kuma ya rage MACE tare da Xience V idan aka kwatanta da PES, yayin da KYAUTA gwaji ya nuna cewa EES yana da kyau kamar SES a cikin kashe ƙarshen asara a watanni 9 da abubuwan da suka faru na asibiti a cikin watanni 12.38 A ƙarshe, an nuna Xience stent ya fi BMS a cikin saitin ST elevation myocardial infarction (MI).39
EPCs wani yanki ne na sel masu yawo da ke shiga cikin homeostasis na jijiyoyin jini da gyaran endothelial.Ƙara yawan EPC a wurin da ke fama da rauni na jijiyoyin jini zai inganta sake dawowa da wuri, wanda zai iya rage haɗarin ST.Fitowar farko ta EPC Biology cikin ƙira ta stent shine Genous stent, wanda aka lulluɓe da anti-CD34 antibodies, mai iya ɗaure EPCs masu yawo ta alamomin hematopoietic don haɓaka sake dawo da endothelialization.Yayin da binciken farko ya kasance mai ƙarfafawa, shaidun kwanan nan sun nuna babban adadin TVR.40
Ganin yiwuwar lahani na jinkirin warkarwa na polymer wanda ke da alaƙa da haɗarin ST, polymers masu haɓaka suna ba da fa'idodin DES ta hanyar guje wa damuwa mai tsayi game da dagewar polymer.Ya zuwa yau, an yarda da tsarin bioresorbable daban-daban (misali, Nobori da Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), amma wallafe-wallafen da ke goyan bayan sakamakon su na dogon lokaci yana da iyaka.41
Abubuwan da za a iya amfani da su suna da fa'idar fa'ida ta samar da tallafin injina da farko lokacin da aka yi la'akari da juzu'i na roba da kuma rage haɗarin dogon lokaci da ke da alaƙa da haɓakar ƙarfe na yanzu.Sabbin fasahohi sun haifar da haɓakar polymers na lactic acid (poly-l-lactic acid [PLLA]), amma yawancin tsarin stent suna cikin ci gaba, kodayake gano ma'auni mai kyau tsakanin haɓakar miyagun ƙwayoyi da lalata ƙwayoyin cuta ya kasance kalubale.Binciken ABSORB ya nuna aminci da inganci na stent PLLA mai rufi na everolimus.43 Bita na ƙarni na biyu Absorb stent ya fi na baya tare da kyakkyawar bibiyar shekaru 2.44 Nazarin ABSORB II na yanzu, gwaji na farko na bazuwar da aka kwatanta da Absorb stent tare da Xience Prime stent, ya kamata ya ba da ƙarin bayanai, kuma sakamakon farko da aka samu yana da ban sha'awa.45 Koyaya, ingantattun yanayi, ingantacciyar dabarar dasa shuki, da bayanin martaba a cikin cututtukan jijiya na buƙatar fayyace.
Thrombosis a cikin BMS da DES suna da mummunan sakamako na asibiti.A cikin rajista na marasa lafiya da aka dasa tare da DES, 47 24% na lokuta na ST sun haifar da mutuwa, 60% a cikin MI marasa mutuwa, da 7% a cikin angina mara ƙarfi.PCI don gaggawa ST yawanci ba shi da kyau, tare da maimaitawa a cikin 12% na lokuta.48
Extended ST yana da yiwuwar sakamako mara kyau na asibiti.A cikin binciken BASKET-LATE, watanni 6-18 bayan sanyawa stent, adadin yawan mace-mace na zuciya da marasa mutuwa MI sun kasance mafi girma a cikin ƙungiyar DES fiye da ƙungiyar SMP (4.9% da 1.3%, bi da bi).20 Meta-bincike na binciken tara wanda 5261 marasa lafiya sun kasance bazuwar zuwa SES, PES, ko BMS sun nuna cewa bayan shekaru 4 na biyo baya, SES (0.6% da 0%, p = 0.025) da PES (0.7%)) ya karu da yawan marigayi ST = idan aka kwatanta da BMS ta 0.2%, p8).49 Sabanin haka, a cikin wani bincike-bincike ciki har da marasa lafiya 5108, 21 zuwa 60% karuwar dangi a cikin mace-mace ko MI an ruwaito tare da SES idan aka kwatanta da BMS (p = 0.03), yayin da PES ke hade da karuwa maras muhimmanci na 15% (duba - har zuwa watanni 9 zuwa shekaru 3).
Rijista da yawa, gwaje-gwajen da bazuwar, da meta-bincike sun bincika haɗarin ST bayan dasa BMS da DES kuma sun ba da rahoton sakamako masu karo da juna.A cikin rajista na marasa lafiya na 6906 da aka bi da su tare da BMS ko DES, babu bambance-bambance a cikin sakamakon asibiti ko ƙimar ST a 1 shekara ta biyo baya.48 A cikin wani rajista na marasa lafiya 8146, an gano haɗarin ci gaba da wuce gona da iri na ST shine 0.6% a kowace shekara idan aka kwatanta da BMS.49 Meta-bincike na nazarin da aka kwatanta SES ko PES tare da SMPs sun nuna haɗarin mace-mace da MI tare da ƙarni na farko na DES idan aka kwatanta da SMPs, 21 da kuma wani bincike-bincike na 4545 marasa lafiya bazuwar zuwa SES ko ST tsakanin PES da BMS a 4 shekaru masu biyo baya.50 Sauran bincike na ainihi sun nuna haɗarin ci gaba na ST da MI a cikin marasa lafiya da aka bi da su tare da ƙarni na farko na DES bayan dakatar da DAPT.51
Idan aka ba da bayanai masu cin karo da juna, bincike-bincike da yawa da meta-bincike tare sun ƙaddara cewa DES da ƙarni na farko SGM ba su bambanta sosai a cikin haɗarin mutuwa ko MI ba, amma SES da PES suna da haɗarin ST na kowa idan aka kwatanta da SGM.Don nazarin shaidar da ake da su, Hukumar Abinci da Magunguna ta Amurka (FDA) ta nada wani kwararre panel53 wanda ya ba da sanarwa da ke fahimtar cewa ƙarni na farko na DES yana da tasiri kamar yadda aka yi wa lakabi da cewa haɗarin matakan ci gaba ST ƙananan ne, amma ba babba ba., Mahimman haɓaka.A sakamakon haka, FDA da ƙungiyar sun ba da shawarar tsawaita lokacin DAPT zuwa shekara 1, kodayake akwai ƙananan shaida don tallafawa wannan da'awar.
Kamar yadda aka ambata a baya, an haɓaka ƙarni na biyu na DES tare da ingantattun fasalulluka.CoCr-EES ya sami mafi girman bincike na asibiti.A cikin nazarin meta-bincike ta Baber et al.54 na marasa lafiya na 17,101, CoCr-EES ya rage mahimmanci / mai yiwuwa ST da MI idan aka kwatanta da PES, SES, da ZES a watanni 21.A ƙarshe, Palmerini et al ya nuna a cikin meta-bincike na 16,775 marasa lafiya cewa CoCr-EES yana da ƙananan ƙananan farkon farkon, marigayi, 1- da 2-shekara da aka ayyana ST idan aka kwatanta da sauran DES da aka haɗa.55 Nazarin rayuwa na ainihi sun nuna raguwa a cikin hadarin ST tare da CoCr-EES idan aka kwatanta da DES na farko.56
An kwatanta Re-ZES tare da CoCr-EES a cikin nazarin RESOLUTE-AC da TWENTE.33,57 Babu wani gagarumin bambanci a cikin mace-mace, ciwon zuciya na zuciya, ko ƙayyadadden ɓangaren ST tsakanin stent guda biyu.
A cikin meta-bincike na cibiyar sadarwa na marasa lafiya 50,844, ciki har da 49 RCTs, 58 CoCr-EES an haɗa su tare da ƙananan yanayin da aka ayyana ST fiye da BMS, wani binciken da ba a gani tare da sauran DES;raguwa ba kawai a "mahimmanci da wuri" da kuma bayan kwanaki 30 (58).rashin daidaituwa [OR] 0.21, 95% tazarar amincewa [CI] 0.11-0.42) da kuma a shekara ta 1 (OR 0.27, 95% CI 0.08-0.74) da shekaru 2 (OR 0.35, 95% CI 0.17-0.69).Idan aka kwatanta da PES, SES, da ZES, CoCr-EES an haɗa shi da ƙananan ƙimar ST a shekara 1.
Farkon ST yana da alaƙa da abubuwa daban-daban. Ƙarƙashin ƙwayar cuta na plaque da nauyin thrombus yana da alama yana tasiri sakamakon bayan PCI; 59 zurfin struts shigar azzakari cikin farji ta hanyar necrotic core (NC) prolapse, dogon medial hawaye a cikin stent, suboptimal stenting tare da saura gefen dissections ko gagarumin gefen stenosis, rashin cika apposition, da kuma rashin cikar hadarin ST. t kwayoyi ba su da tasiri sosai akan abin da ya faru na farkon ST: a cikin gwajin da bazuwar kwatanta BMSs tare da DESs, ƙimar ST da ƙananan ST a lokacin DAPT sun kasance daidai (<1%).61 Don haka, farkon ST yana da alaƙa da farko da cututtukan da aka bi da su da kuma abubuwan da suka dace. Ƙarƙashin ƙwayar cuta na plaque da nauyin thrombus yana da alama yana tasiri sakamakon bayan PCI; 59 zurfin struts shigar azzakari cikin farji ta hanyar necrotic core (NC) prolapse, dogon medial hawaye a cikin stent, suboptimal stenting tare da saura gefen dissections ko gagarumin gefen stenosis, rashin cika apposition, da kuma rashin cikar hadarin ST. t kwayoyi ba su da tasiri sosai akan abin da ya faru na farkon ST: a cikin gwajin da bazuwar kwatanta BMSs tare da DESs, yawan adadin ST da ƙananan ST a lokacin DAPT sun kasance daidai (<1%) .61 Don haka, farkon ST yana da alaƙa da farko da cututtukan da aka bi da su da kuma abubuwan da suka dace. Морфология лежащей основе бляшки и тромбоз, по-видимому, влияют на исход посрасле ЧКВ;59 порок из-за пролапса некротического ядра (NC), длинного медиального ми краевыми раслоениями или значительным ет увеличить риск ST.60 Терапевтический режим ST. м образом, ранняя ST, по-видимому, в первую очередь связана с лежащими mu. Ƙarƙashin ƙwayar ƙwayar cuta da thrombosis ya bayyana yana tasiri sakamako bayan PCI; 59 zurfin shigar da strut saboda haɓakar necrotic nucleus (NC) prolapse, doguwar tsagewar tsaka-tsaki a cikin stent, stenting suboptimal stenting tare da raƙuman raƙuman raƙuman ruwa ko ƙananan stenosis na gefe, rashin cikawa da rashin cikar haɗari na iya karuwa. magungunan antiplatelet ba su da tasiri sosai game da abin da ya faru na farkon ST: a cikin gwajin gwaji da aka kwatanta da BMS da DES, abubuwan da suka faru na ST da m a lokacin DAPT sun kasance iri ɗaya (<1%) .61 Saboda haka, farkon ST ya bayyana yana da alaka da ƙananan cututtuka da kuma tsarin tsarin.潜在的斑块形态和血栓负荷似乎影响PCI 后的结果；59内长的内侧撕裂、具有残余边缘剥离或显缘剥离或显着边缘狭窄的次优支架、不完全完完不不并不并不并不并不并不并并不不全完不并不并不不不内平并不并不不内和不不不不不内和不不受一小板药物的治疗方案不会显着影响早期ST 的发生率亚急性ST 的发生率相似（<1%） .61 因此，早期ST潜在 的 斑块 形态 和 一栓 似乎 影响 影响 pci 后核心 核心 脱垉次 次 次 不 完全 并置和 并置和小板 的 治疗 方案 不 显着 影响 影响 早期 的 ：急性 发生 发生 发生 发生 发生 发生 发生发生 发生 发生 发生 发生 发生 发生 发生率相似（<1%） .61Ƙwararren ƙwayar ƙwayar cuta da thrombosis ya bayyana yana tasiri sakamakon bayan PCI;59 Deeper strut shigar azzakari cikin farji saboda necrotic tsakiya (NC) prolapse, medial ruptures a cikin stent tsawon, na biyu dissection tare da saura margins, ko gagarumin gefe narrowing Mafi kyau duka stenting, rashin cikakken appposition, da kuma m fadada60 Antiplatelet tsarin mulki ba shi da wani gagarumin tasiri a kan farkon ST in ST in m lokacin gwaji a lokacin gwaji na ST. MS da DES.suna da alaƙa da farko da raunin jiyya na asali da abubuwan tiyata.
A yau, an mayar da hankali kan marigayi/marigayi ST.Duk da yake al'amuran tsari da fasaha suna da alama suna taka muhimmiyar rawa wajen haɓaka ST da m, tsarin jinkirin abubuwan da suka faru na thrombotic ya zama mafi rikitarwa.An ba da shawarar cewa wasu halaye masu haƙuri na iya zama abubuwan haɗari don ci gaba da haɓakar ST: ciwon sukari mellitus, ACS a lokacin aikin tiyata na farko, gazawar koda, tsufa, raguwar raguwar fitarwa, manyan cututtukan zuciya mara kyau a cikin kwanaki 30 na farkon tiyata.Don BMS da DES, sauye-sauyen tsari irin su ƙananan girman jirgin ruwa, bifurcations, cututtuka masu yawa, calcification, cikakkiyar ɓoyewa, dogon stents sun bayyana suna hade da haɗarin ST na ci gaba.62,63 Rashin amsawa mara kyau ga maganin antiplatelet shine babban haɗari ga ci gaba na DES thrombosis 51.Wannan amsa na iya zama saboda rashin yarda da haƙuri, rashin amfani da kwayoyi, hulɗar miyagun ƙwayoyi, cututtukan da ke shafar amsawar miyagun ƙwayoyi, polymorphism na matakin mai karɓa (musamman juriya na clopidogrel), da kunna wasu hanyoyi don kunna platelet.Ana ɗaukar Stent neoatherosclerosis a matsayin muhimmin tsari don gazawar stent, gami da marigayi ST64 (sashe "Stent Neoatherosclerosis").Endothelium maras kyau yana raba bangon jirgin ruwa mai rugujewa da ginshiƙan stent daga magudanar jini kuma yana ɓoye abubuwan antithrombotic da vasodilator.DES yana fallasa bangon jirgin ruwa zuwa magungunan anti-proliferative da dandamali na sakewa da miyagun ƙwayoyi, tare da tasiri daban-daban akan warkaswa da aikin endothelial, tare da haɗarin marigayi thrombosis.65 Nazarin ilimin cututtuka sun nuna cewa masu karfi na farko na DES polymers na iya taimakawa wajen ƙumburi na yau da kullum, ƙaddamar da fibrin na yau da kullum, rashin lafiyar endothelial, kuma sakamakon haka ya karu da haɗarin thrombosis.3 Late hypersensitivity zuwa DES ya bayyana wata hanya ce da ke kaiwa ga ST.Virmani et al.[66] ya ba da rahoton binciken bayan mutuwa bayan ST yana nuna haɓakar anerysm a cikin sashin stent tare da halayen halayen halayen gida wanda ya ƙunshi T-lymphocytes da eosinophils;waɗannan binciken na iya nuna tasirin polymers marasa lalacewa.67 Stent misfit na iya zama saboda ƙaƙƙarfan haɓakar stent ko ya faru watanni da yawa bayan PCI.Ko da yake rashin daidaituwar tsari abu ne mai haɗari ga ST mai tsanani da ƙananan ƙwayar cuta, mahimmancin asibiti na samuwar stent malapposition na iya dogara ne akan gyare-gyaren arterial mai tsanani ko jinkirin jinkirin magani, amma mahimmancinsa na asibiti yana da rikici.68
Tasirin kariyar DES na ƙarni na biyu na iya haɗawa da sauri kuma mafi inganci endothelialization, kazalika da bambance-bambance a cikin gami da tsarin stent, kauri mai ƙarfi, kaddarorin polymer, da nau'in ƙwayar cuta na antiproliferative, kashi, da motsa jiki.
Idan aka kwatanta da CoCr-EES, bakin ciki (81 µm) cobalt-chromium stent scaffolds, antithrombotic fluoropolymers, ƙananan abun ciki na polymer, da lodin ƙwayoyi na iya ba da gudummawa ga ƙananan ƙimar ST.Nazarin gwaji ya nuna cewa thrombosis da ɗigon platelet sun ragu sosai a cikin stent mai rufin fluoropolymer fiye da a cikin stent maras kyau.69 Ko sauran ƙarni na biyu na DES suna da irin wannan kaddarorin ya cancanci ƙarin nazari.
Ƙwararrun ƙwayoyin cuta suna inganta nasarar aikin tiyata na cututtuka na jijiyoyin jini idan aka kwatanta da na gargajiya na al'ada na al'ada na al'ada (PTCA), wanda ke da rikice-rikice na inji (ƙwaƙwalwar jini, rarrabawa, da dai sauransu) da kuma yawan adadin restenoses (har zuwa 40-50% na lokuta).A ƙarshen 1990s, kusan 70% na PCIs an yi su tare da dasa BGM.70
然而，尽管技术、技术和药物治疗取得了进步，但BMS生率> 40%.然而，尽管技术、技术和药物治疗取得了进步，但BMSDuk da haka, duk da ci gaban fasaha, fasaha, da jiyya, haɗarin restenosis bayan dasawa na BMS shine kusan 20%, tare da ƙimar da ta wuce 40% a wasu ƙananan ƙungiyoyi.71 Gabaɗaya, nazarin asibiti ya nuna cewa restenosis bayan dasa BMS, kama da wanda aka gani tare da PTCA na al'ada, kololuwa a cikin watanni 3-6 kuma ya warware a shekara 1.72
DES ta ƙara rage ƙimar ISR,73 kodayake wannan raguwa ya dogara da angiographically da asibiti.Shafi na DES polymer yana sakin magungunan anti-inflammatory da anti-proliferative, yana hana samuwar neointima, kuma yana jinkirta gyaran jijiyoyi da watanni ko shekaru.74 A cikin bincike na asibiti da na tarihi, an lura da ci gaban neointima na ci gaba a tsawon lokaci mai tsawo bayan dasawa na DES, wani sabon abu da aka sani da "marigayi kama" 75.
Raunin jijiyoyi a lokacin PCI yana haifar da tsari mai rikitarwa na kumburi da gyare-gyare a kan ɗan gajeren lokaci (makonni zuwa watanni), wanda ya haifar da endothelialization da kuma ɗaukar hoto na neointimal.Dangane da abubuwan lura na histopathological, neointimal hyperplasia (HMS da DES) bayan dasa stent galibi sun ƙunshi ƙwayoyin tsoka mai santsi mai yaduwa a cikin matrix extracellular proteoglycan.70
Don haka, hyperplasia neointimal shine tsarin gyarawa wanda ya ƙunshi coagulation da abubuwan kumburi, da kuma sel waɗanda ke haifar da yaduwar ƙwayar tsoka mai santsi da haɓakar matrix na waje.Nan da nan bayan PCI, platelets da fibrin suna ajiyewa akan bangon jirgin ruwa kuma suna jan hankalin leukocytes ta jerin kwayoyin mannewar tantanin halitta.Rubutun leukocytes suna haɗe zuwa platelet ɗin da aka haɗe ta hanyar hulɗa tsakanin leukocyte integrin Mac-1 (CD11b/CD18) da platelet glycoprotein Ibα 53 ko fibrinogen mai alaƙa da platelet glycoprotein IIb/IIIa.76.77
Bisa ga sababbin bayanai, ƙwayoyin ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar ƙwayar cuta ta shiga cikin tsarin jijiyoyin jini da kuma gyaran gyare-gyare.Tattara EPC daga bargon kasusuwa zuwa jini na gefe yana inganta farfadowar endothelial da ciwon jijiyoyin bayan haihuwa.Ya bayyana cewa kasusuwan kasusuwa masu santsi na ƙwayoyin tsoka (SMPCs) sun yi ƙaura zuwa wurin da ke fama da rauni na jijiyoyin jini, wanda ya haifar da yaduwa na neointimal.78, an yi la'akari da sel mai kyau a matsayin tsayayyen yawan adadin EPCs, ƙarin karatuttukan sun nuna cewa sel mai ban sha'awa da kuma ikon rarrabe cikin EPCs da PBMCs.Canja wurin sel CD34-tabbatacce zuwa cikin layin EPC ko SMPC ya dogara da yanayin gida;Yanayin ischemic yana haifar da bambance-bambance zuwa ga EPC phenotype, wanda ke inganta reendothelialization, yayin da yanayin kumburi ya haifar da bambance-bambance zuwa ga SMPC phenotype, wanda ke inganta haɓakar neointimal.79
Ciwon sukari yana ƙara haɗarin ISR da 30-50% bayan dasa BMS, kuma mafi girman adadin restenosis a cikin masu ciwon sukari idan aka kwatanta da marasa lafiya marasa ciwon sukari shima ya ci gaba a zamanin DES.Hanyoyin da ke tattare da wannan lura suna da yuwuwar multifactorial, gami da tsarin tsarin (misali, sauye-sauye a cikin amsawar kumburi) da kuma anatomical (misali, ƙananan tasoshin, raunuka masu tsayi, cututtuka masu yaduwa, da sauransu), waɗanda ke ƙara haɗarin ISR da kansa.70
Diamita na jirgin ruwa da tsayin raunin da kansa ya shafi ƙimar ISR, tare da ƙananan diamita / raunuka masu tsayi suna haɓaka ƙimar restenosis idan aka kwatanta da manyan diamita / gajeriyar raunuka.71
Matakan stent na ƙarni na farko sun nuna kauri mai kauri da ISRs mafi girma idan aka kwatanta da dandamali na stent na ƙarni na biyu tare da siraran struts.
Bugu da ƙari, abin da ya faru na restenosis yana hade da tsayin stent, kusan ninki biyu don tsayin stent> 35 mm idan aka kwatanta da waɗanda <20 mm. Bugu da ƙari, abin da ya faru na restenosis yana haɗuwa da tsayin stent, kusan ninki biyu don tsayin stent> 35 mm idan aka kwatanta da waɗanda <20 mm. Кроме того, частота рестеноза связана с длиной стента. mun. Bugu da ƙari, ƙimar restenosis yana da alaƙa da tsayin stent, kusan sau biyu tare da tsayin stent> 35 mm idan aka kwatanta da tsayin stent <20 mm.此外，再狭窄的发生率与支架长度有关，支架长度>35 mm 的支架长度几乎是<20 mm 的两关此外，再狭窄的发生率与支架长度有关，支架长度>35 mm Кроме того, частота рестеноза зависела от длины стента: длина стента >35 мм почти в два раза больтам в два раза больтме , . Bugu da ƙari, mita na restenosis ya dogara da tsawon tsayin daka: tsayin stent> 35 mm kusan kusan sau biyu na stent <20 mm.Matsakaicin mafi ƙarancin lumen diamita na stent shima ya taka muhimmiyar rawa: ƙarami mafi ƙarancin lumen diamita na ƙarshe ya annabta ƙarin haɗarin sake dawowa.81.82
A al'adance, hyperplasia na ciki bayan dasawa na BMS ana ɗaukarsa tsayayye, tare da farkon kololuwa tsakanin watanni 6 da shekara 1 tare da ƙarshen lokacin barci.An farkon kololuwar haɓakar haɓakar haɓakar haɓakar haɓakar haɓakar haɓakawa tare da haɓakar lumen shekaru da yawa bayan dasa shuki a baya an ba da rahoto a baya;maturation na santsin ƙwayoyin tsoka da canje-canje a cikin matrix extracellular an gabatar da su azaman hanyoyin da za a yi don ƙarshen koma bayan neointima.83 Duk da haka, binciken da aka biyo baya na tsawon lokaci ya nuna amsawar triphasic bayan sanyawa BMS tare da farfadowa na farko, tsaka-tsakin tsaka-tsakin, da kuma ƙarshen luminal restenosis.84
A cikin zamanin DES, an fara nuna haɓakar ƙarshen neointimal bayan dasa SES ko PES a cikin ƙirar dabba.85 Yawancin bincike na IVUS sun nuna farkon haɓakar haɓakar haɓakar haɓakar haɓakar haɓakar haɓakar haɓakar haɓakar haɓakar haɓakar haɓakawa ta ƙarshe ta hanyar kamawa a cikin lokaci bayan ƙaddamarwar SES ko RPE, mai yiwuwa saboda ci gaba mai kumburi tsari.86
Duk da "kwantar da hankali" a al'adance ga ISR, kusan kashi uku na marasa lafiya tare da BMS ISR suna haɓaka ACS.hudu
Akwai ƙarin shaida cewa kumburi na yau da kullun da / ko ƙarancin endothelial yana haifar da neoatherosclerosis na ci gaba a cikin HCM da DES (yawancin ƙarni na farko na DES), wanda zai iya zama muhimmiyar hanya don haɓaka IR mai ci gaba ko ST.Inoue et al [87] sun ba da rahoton binciken binciken autopsy na tarihi bayan dasa shuki na Palmaz-Schatz coronary stent, yana ba da shawarar cewa kumburi a kusa da stent na iya haifar da sabbin canje-canje na atherosclerotic a cikin stent.Sauran nazarin10 sun nuna cewa nama na restenotic a cikin 5-shekara CGM ya ƙunshi kwanan nan farkon atherosclerosis tare da ko ba tare da kumburi na peritoneal ba;samfurori daga shari'o'in ACS suna nuna alamun rauni na yau da kullun a cikin jijiyoyin jijiyoyin jini na asali na tarihin toshe ilimin halittar jiki tare da macrophages kumfa da lu'ulu'u na cholesterol.Bugu da ƙari, lokacin da aka kwatanta BMS da DES, an lura da babban bambanci a lokaci zuwa ci gaban sabon atherosclerosis.11,12 Canje-canje na farko na atherosclerotic a cikin kumfa macrophage infiltration ya fara watanni 4 bayan dasawa na SES, yayin da irin wannan canje-canje a cikin raunuka na CGM ya faru bayan shekaru 2 kuma ya kasance wani abu mai ban mamaki har zuwa shekaru 4.Bugu da ƙari, DES stenting don raunuka marasa ƙarfi kamar na bakin ciki fibroatherosclerosis (TCFA) ko rupture na ciki yana da ɗan gajeren lokaci don ci gaba idan aka kwatanta da BMS.Don haka, neoatherosclerosis ya bayyana ya zama ruwan dare kuma yana faruwa a baya a cikin ƙarni na farko na DES fiye da na BMS, watakila saboda wani nau'i na pathogenesis.
Tasirin ƙarni na biyu na DES ko DES akan ci gaba ya rage don bincika;ko da yake wasu abubuwan lura na ƙarni na biyu na DES88 sun ba da shawarar ƙarancin kumburi, abin da ya faru na neoatherosclerosis yana kama da ƙarni na farko, amma har yanzu ana buƙatar ƙarin karatu.