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ʻO Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Keʻena o Cardiology, Poliambulanza Foundation Hospital, Brescia, 2 Department of Cardiology, Catholic University of the Sacred Heart of Rome, Italia Summants : Drug Stents bareted limitations (DES coronary stents) wawao.Eia nō naʻe, ʻoiai ka hoʻomaka ʻana o ka lua o ka hanauna DES i hōʻemi ʻia i kēia ʻano i hoʻohālikelike ʻia me DES o ka hanauna mua, e mau ana nā hopohopo nui e pili ana i nā hopena hope loa o ka implantation stent e like me ka stent thrombosis (ST) a me ka stent resection, stenosis (SSI).ʻO ST kahi hanana pōʻino i hōʻemi nui ʻia e ka hoʻokomo ʻana i ka stent implantation, nā hoʻolālā stent hou, a me ka lāʻau antiplatelet ʻelua.ʻO ka mīkini pololei e wehewehe ana i kona hanana ʻana ke hoʻokolokolo ʻia nei, a he nui nā kumu ke kuleana.Ua manaʻo mua ʻia ʻo ISR ma BMS he kūlana paʻa me kahi kiʻekiʻe o ka hyperplasia intimal (ma 6 mau mahina) a ukali ʻia e kahi manawa regression ma mua o 1 makahiki.I ka hoʻohālikelike ʻana, ua hōʻike ʻia nā haʻawina lapaʻau a me ka histological o DES i nā hōʻike o ka ulu mau ʻana o ka neointimal i ka wā lōʻihi o ka hahai ʻana, kahi mea i kapa ʻia ʻo ka "hope catch-up" phenomenon.ʻO ka manaʻo o ka ISR he maʻi maʻi maikaʻi loa i hōʻole ʻia e nā hōʻike e hiki i nā maʻi me ISR ke hoʻomohala i nā maʻi maʻi coronary acute.ʻO ke kiʻi kiʻi Intracoronary kahi hana invasive e ʻike ai i nā plaque atherosclerotic stented a me nā hōʻailona o ka ho'ōla ʻana o ka moku ma hope o ka stenting, a hoʻohana pinepine ʻia e hoʻopau i ka angiography coronary diagnostic a hana i nā kaʻina hana.ʻO ka intracoronary optical coherence tomography i kēia manawa i manaʻo ʻia ʻo ke ʻano kiʻi kiʻi ʻoi loa. Hāʻawi ia, ke hoʻohālikelike ʻia me ka ultrasound intravascular, ʻoi aku ka maikaʻi o ka hoʻonā (ma ka liʻiliʻi ma mua o 10 mau manawa), e ʻae ana i ka kikoʻī kikoʻī o ke ʻano papa o ka pā moku. Hāʻawi ia, ke hoʻohālikelike ʻia me ka ultrasound intravascular, ʻoi aku ka maikaʻi o ka hoʻonā (ma ka liʻiliʻi ma mua o 10 mau manawa), e ʻae ana i ka kikoʻī kikoʻī o ke ʻano papa o ka pā moku. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, >10 раз), что полькоть поверхностную структуру стенки сосуда. Hāʻawi ia, ke hoʻohālikelike ʻia me ka ultrasound intravascular, kahi hoʻonā ʻoi aku ka maikaʻi (ma ka liʻiliʻi ma mua o 10 mau manawa), e ʻae i kahi kikoʻī kikoʻī o ke ʻano o ka ʻili o ka pā moku.与血管内超声相比，它提供了更好的分辨率（至少> 11与血管内超声相比，它提供了更好的分辨率（至少> 10），允许详细表征血管管安。Ke hoʻohālikelike ʻia me ka ultrasound intravascular, hāʻawi ia i kahi hoʻonā ʻoi aku ka maikaʻi (ma ka liʻiliʻi he 10 mau manawa), e ʻae ai i kahi kikoʻī kikoʻī o ka ʻili o ka pā o ka moku.ʻO nā haʻawina kiʻi vivo e kūlike me nā ʻike histological e hōʻike ana e hiki ke hoʻoulu i ka neoatherosclerosis holomua ma HMS a me DES.No laila, ua lilo ka neoatherosclerosis i mea hopohopo nui i ka pathogenesis o ka hiki ʻole o ka stent hope.Hua'ōlelo nui: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
ʻO Stented percutaneous coronary intervention (PCI) ke kaʻina hana i hoʻohana nui ʻia no ka mālama ʻana i ka maʻi aʻaʻa coronary symptomatic, a ke hoʻomau nei ka ʻenehana.1 ʻOiai e hōʻemi ana ka lāʻau eluting stents (DES) i nā palena o ka uncoated stents (UES), hiki ke loaʻa nā pilikia lohi e like me ka stent thrombosis (ST) a me ka stent restenosis (ISR) me ka hoʻokomo ʻana i ka stent, a ke mau nei nā hopohopo koʻikoʻi.2-5
Inā he hanana pōʻino ʻo ST, ʻo ka ʻae ʻana he maʻi maikaʻi loa ka ISR i kēia manawa ua hoʻopiʻi ʻia e nā hōʻike no ka maʻi coronary acute (ACS) i nā maʻi me ISR.ʻehā
I kēia lā, manaʻo ʻia ʻo intracoronary optical coherence tomography (OCT) 6-9 he ʻano kiʻi kiʻi kiʻi kiʻi ʻoi aku ka maikaʻi ma mua o ka ultrasound intravascular (IVUS).In vivo imaging studies10-12 like me ka histological loaʻa hōʻike i ka "hou" vascular pane pane ma hope o stent implantation me de novo "neoatherosclerosis" i loko o BMS a me DES.
Ma 1964 Charles Theodore Dotter a me Melvin P. Judkins i wehewehe i ka angioplasty mua.Ma 1978, hana ʻo Andreas Grunzig i ka angioplasty baluna mua (ka angioplasty baluna kahiko kahiko);He lapaʻau hoʻololi ia, akā ua loaʻa nō hoʻi nā hemahema o ka pani ʻana o ka vascular acute a me ka restenosis.13 Ua alakaʻi kēia i ka loaʻa ʻana o nā stents coronary: Ua hoʻokomo ʻo Puel lāua ʻo Sigwart i ka stent coronary mua i ka makahiki 1986, e hāʻawi ana i kahi stent e pale ai i ka pani ʻana o ka moku a me ka hoʻihoʻi hope ʻana o ka systolic.14 ʻOiai ua pale kēia mau stents mua i ka pani koke ʻana o ka moku, ua hōʻeha nui lākou i ka endothelial a me ka mumū.I kēia mau lā, ʻelua mau noiʻi ʻāina, ʻo ka Belgian-Dutch Stent Study 15 a me ka Stent Restenosis Study 16, ua kākoʻo i ka palekana o ka hoʻopaʻa ʻana i nā antiplatelet therapy (DAPT) a me / a i ʻole nā ​​ʻano hana hoʻolālā kūpono.17,18 Ma hope o kēia mau ho'āʻo, ua hoʻonui nui ʻia ka helu o nā PCI.
Eia naʻe, uaʻike kokeʻia ka pilikia o ka iatrogenic in-stent neointima hyperplasia ma hope o ka hoʻokomoʻana o BMS, ka hopena i ka ISR ma 20-30% o nāʻeha i mālamaʻia.Ua hoʻokomo ʻia ʻo DES19 ma 2001 e hōʻemi i ka pono o ka restenosis a me ka hana hou.Ua hoʻonui ʻo DES i ka hilinaʻi o nā cardiologists ma o ka ʻae ʻana i ka mālama ʻana i ka piʻi ʻana o nā maʻi paʻakikī i manaʻo ʻia he hiki ke mālama ʻia me ke kālai ʻia ʻana o ka coronary artery bypass grafting.Ma 2005, 80-90% o nā PCI a pau i hele pū me DES.
Loaʻa i nā mea āpau kona mau drawbacks, a mai ka makahiki 2005 ua hoʻonui ʻia ka hopohopo e pili ana i ka palekana o ka "hanauna mua" DES, ua hoʻomohala a hoʻokomo ʻia nā stents hanauna hou e like me 20,21.22 Mai ia manawa, ua ulu wikiwiki nā hana e hoʻomaikaʻi i ka hana o nā stents, a ua hoʻomau ʻia ka ʻike ʻia ʻana o nā ʻenehana hou a lawe koke ʻia i ka mākeke.
ʻO BMS kahi paipu uea maikaʻi.Ma hope o ka ʻike mua ʻana me Wall mount, Gianturco-Roubin mount a me Palmaz-Schatz mount, nui nā BMS ʻokoʻa i loaʻa i kēia manawa.
ʻEkolu mau hoʻolālā like ʻole: serpentine, tubular mesh a me slotted tube.ʻO nā hoʻolālā wili he mau uwea metala a i ʻole nā ​​ʻāpana e hana ana i ke ʻano pōʻai pōʻai;i loko o nā hoʻolālā mesh tubular, ʻo ka uwea i ʻōwili pū ʻia i loko o ka mesh i hana ʻia he paipu;ʻO nā hoʻolālā slotted he mau paipu metala i ʻoki ʻia i ka laser.ʻOkoʻa kēia mau mea hana i ka haku mele ʻana (stainless steel, nichrome, cobalt chrome), hoʻolālā (nā ʻano spacer like ʻole a me nā laula, nā anawaena a me nā lōʻihi, ka ikaika radial, radiopacity), a me nā ʻōnaehana hoʻopuka (hoʻonui pono a i ʻole balloon-expandable).
Ma ke ʻano maʻamau, ʻo ka BMS hou i loaʻa i ka cobalt-chromium alloy, ka hopena i nā struts thinner, hoʻomaikaʻi i ka hana hoʻokele a hoʻomau i ka ikaika mechanical.
Loaʻa iā lākou kahi paepae stent metala (maʻamau he kila kila) a uhi ʻia me ka polymer e hoʻokuʻu ana i nā mea lapaʻau anti-proliferative a / a i ʻole anti-inflammatory.
Ua hoʻokumu mua ʻia ʻo Sirolimus (ʻike ʻia ʻo rapamycin) ma ke ʻano he antifungal agent.Hoʻopili ʻia kāna hana o ka hana me ka pale ʻana i ka holomua o ka cell cycle ma ke kāohi ʻana i ka hoʻololi ʻana mai ka pae G1 a i ka pae S a me ka pale ʻana i ka hoʻokumu ʻana o neointima.Ma 2001, ua hōʻike ka ʻike "kanaka mua" me SES i nā hopena hoʻohiki, e alakaʻi ana i ka hoʻomohala ʻana o ka Cypher stent.23 Ua hōʻike nā hoʻāʻo nui i kona pono i ka pale ʻana i ka IR.24
Ua ʻae mua ʻia ʻo Paclitaxel no ka mālama ʻana i ka maʻi maʻi ovarian, akā ʻo kona ʻano cytostatic ikaika - hoʻopaʻa ka lāʻau i nā microtubules i ka wā mitosis, hoʻopiʻi i ka pōʻaiapili cell, a pale i ka hoʻokumu ʻana o neointimal-e hoʻohui ia no Taxus Express PES.Ua hōʻike ʻia nā hoʻāʻo ʻo TAXUS V a me VI i ka hopena lōʻihi o ka PES i ka maʻi puʻuwai paʻakikī paʻakikī.25,26 Ua hōʻike ʻia ʻo TAXUS Liberté i kahi paepae kila kila no ka maʻalahi o ka lawe ʻana.
ʻO nā hōʻike ikaika mai ʻelua loiloi ʻōnaehana a me nā meta-analyses e hōʻike ana he ʻoi aku ka maikaʻi o ka SES ma mua o ka PES ma muli o nā haʻahaʻa haʻahaʻa o IVR a me ka revascularization moku pahuhopu (TVA), a me kahi ʻano i ka piʻi ʻana o ka myocardial infarction (AMI) i ka cohort PES.27.28
Ua hōʻemi nā mea hana ʻelua i ka mānoanoa o ka shaft, hoʻomaikaʻi i ka hiki ke maʻalahi/deliverability, hoʻomaikaʻi i ka polymer biocompatibility/nā ʻano hoʻomaʻemaʻe lāʻau, a me nā kinetics reendothelialization kiʻekiʻe.I ka hoʻomaʻamaʻa i kēia manawa, ʻo ia nā hoʻolālā DES kiʻekiʻe loa a me nā stents coronary nui i hoʻokomo ʻia ma ka honua holoʻokoʻa.
Lawe ʻo Taxus Elements i kēia ʻanuʻu me kahi polymer kūʻokoʻa i hoʻolālā ʻia no ka hoʻokuʻu mua ʻana a me kahi ʻōnaehana platinum-chromium spacer hou e hāʻawi ana i nā spacers thinner a me ka radiopacity hoʻonui.Ua ʻike ka haʻawina PERSEUS 29 i nā hopena like ma waena o Element a me Taxus Express a hiki i 12 mahina.Eia nō naʻe, ʻaʻole lawa nā hoʻāʻo e hoʻohālikelike i nā mea yew me nā DES o nā hanauna ʻelua.
Hoʻokumu ʻia ka Endeavour Zotarolimus Coated Stent (ZES) ma luna o kahi kahua stent cobalt-chromium ikaika me ka ʻoi aku ka maʻalahi a me kahi stent strut liʻiliʻi.ʻO Zotarolimus kahi analogue sirolimus me nā hopena immunosuppressive like, akā me ka lipophilicity hoʻonui e hoʻomaikaʻi i ka localization i ka paia o ka moku.Hoʻohana ʻo ZES i kahi phosphorylcholine polymer coating hou i hoʻolālā ʻia e hoʻonui i ka biocompatibility a hoʻemi i ka mumū.Holoi ʻia ka hapa nui o nā lāʻau lapaʻau i ka wā mua o ka hōʻeha, a ma hope o ka hoʻoponopono ʻana i ke aʻa.Ma hope o ka hoʻāʻo mua ENDEAVOR, ua hoʻohālikelike ka hoʻāʻo ENDEAVOR III ma hope o ZES me SES, kahi i hōʻike ʻia i ka nui o ka nalowale o ka lumen hope a me HR akā ʻoi aku ka liʻiliʻi o nā hanana cardiovascular adverse koʻikoʻi (MACEs) ma mua o SES.30 Ua ʻike hou ʻia ka haʻawina ENDEAVOR IV e hoʻohālikelike ana i ka ZES me ka PES i kahi kiʻekiʻe o ka SIS akā he haʻahaʻa haʻahaʻa o MI, ma muli paha o ka ST maʻamau i ka hui ZES.31 Akā naʻe, ʻaʻole i hōʻike ka noiʻi PROTECT i kahi ʻokoʻa i ka pinepine ST ma waena o nā stents Endeavor a me Cypher.32
ʻO ka Endeavor Resolute kahi mana i hoʻomaikaʻi ʻia o ka Endeavor stent me kahi polymer ʻekolu-layer hou.ʻO ka Resolute Integrity hou (i kekahi manawa i kapa ʻia ʻo ke kolu o ka hanauna DES) i hoʻokumu ʻia ma kahi kahua hou me nā mana hoʻopuka kiʻekiʻe (ka Integrity BMS platform) a me kahi polymer ʻekolu-layer hou, biocompatible hiki ke hoʻopau i ka pane inflammatory mua a elute hou aku o ka lāʻau i nā lā 60 e hiki mai ana.Ua hōʻike ʻia kahi hoʻāʻo e hoʻohālikelike ana i ka Resolute me Xience V (everolimus eluting stent [EES]) i ka maikaʻi o ka ʻōnaehana Resolute ma ke ʻano o ka make a me ka hāʻule ʻana o ka lesion.33.34
ʻO Everolimus, kahi derivative sirolimus, ʻo ia hoʻi kahi mea hoʻokaʻawale cell cycle i hoʻohana ʻia i ka hoʻomohala ʻana o EES Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform).Ua hōʻike ka hoʻāʻo SPIRIT 35-37 i nā hopena i hoʻomaikaʻi ʻia a ua hōʻemi ʻia ka MACE me Xience V i hoʻohālikelike ʻia me PES, aʻo ka hoʻāʻo EXCELLENT i hōʻike i ka maikaʻi o ka EES e like me SES i ke kāohi ʻana i ka nalowale hope ma 9 mahina a me nā hanana lapaʻau ma 12 mahina.38 ʻO ka hope, ua hōʻike ʻia ka Xience stent ma mua o BMS i ka hoʻonohonoho ʻana o ST elevation myocardial infarction (MI).39
ʻO nā EPC kahi ʻāpana o nā cell circulating e pili ana i ka homeostasis vascular a me ka hoʻoponopono endothelial.ʻO ka hoʻonui ʻia ʻana o ka EPC ma ke kahua o ka ʻeha vascular e hoʻoikaika i ka re-endothelialization mua, hiki ke hōʻemi i ka pilikia o ST.ʻO ka hana mua a EPC Biology i loko o ka hoʻolālā stent ʻo ia ka Genous stent, i uhi ʻia me nā antibodies anti-CD34, hiki ke hoʻopaʻa i nā EPC e hoʻopuni ana ma o kāna mau hōʻailona hematopoietic e hoʻomaikaʻi i ka re-endothelialization.ʻOiai ke paipai nei nā haʻawina mua, hōʻike nā hōʻike hou i nā kiʻekiʻe TVR kiʻekiʻe.40
Hāʻawi ʻia i nā hopena maikaʻi ʻole o ka hoʻōla hoʻopaneʻe ʻana o ka polymer e pili ana i ka pilikia ST, hāʻawi nā polymers bioresorbable i nā pono o DES ma ka pale ʻana i nā hopohopo lōʻihi e pili ana i ka hoʻomau polymer.I kēia lā, ua ʻae ʻia nā ʻōnaehana bioresorbable like ʻole (e laʻa, Nobori a me Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), akā ua kaupalena ʻia nā palapala e kākoʻo ana i kā lākou hopena lōʻihi.41
Loaʻa i nā mea bioabsorbable ka pōmaikaʻi o ka hāʻawi ʻana i ke kākoʻo mechanical i ka wā e mālama ʻia ai ka elastic recoil a hōʻemi i nā pilikia lōʻihi e pili ana i nā struts metala.Ua alakaʻi nā ʻenehana hou i ka hoʻomohala ʻana i nā polymers lactic acid (poly-l-lactic acid [PLLA]), akā nui nā ʻōnaehana stent i ka hoʻomohala ʻana, ʻoiai ʻo ka loaʻa ʻana o ke kaulike kūpono ma waena o ka elution lāʻau a me nā kinetics degradation he paʻakikī.Ua hōʻike ka haʻawina ABSORB i ka palekana a me ka pono o nā stents PLLA i uhi ʻia everolimus.43 Ua ʻoi aku ka maikaʻi o ka hoʻoponopono hou ʻana o ka lua o ka hanauna Absorb stent ma mua o ka mea ma mua me ka hahai ʻana i 2 mau makahiki.44 ʻO ka haʻawina ABSORB II o kēia manawa, ʻo ka hoʻāʻo mua i hoʻohālikelike ʻia i ka Absorb stent me ka Xience Prime stent, pono e hāʻawi i nā ʻikepili hou aʻe, a ʻo nā hopena i loaʻa mua he mea hoʻohiki.45 Eia nō naʻe, pono e wehewehe ʻia nā kūlana kūpono, ka ʻenehana implantation maikaʻi loa, a me ka ʻike palekana o ka maʻi ʻaʻaʻa coronary.
ʻO ka thrombosis ma BMS a me DES he hopena koʻikoʻi koʻikoʻi.I loko o kahi papa inoa o nā maʻi i hoʻokomo ʻia me DES, 47 24% o nā hihia ST i make, 60% i ka MI non-fatal, a me 7% i ka angina paʻa.ʻO PCI no ka ST koʻikoʻi maʻamau ka suboptimal, me ka hoʻi hou ʻana i 12% o nā hihia.48
Loaʻa i ka ST i hoʻolōʻihi ʻia nā hopena lapaʻau maikaʻi ʻole.Ma ka haʻawina BASKET-LATE, 6-18 mau mahina ma hope o ka hoʻokomo ʻana i ka stent, ʻoi aku ka kiʻekiʻe o ka make ʻana o ka naʻau a me ka MI non-fatal i ka hui DES ma mua o ka hui SMP (4.9% a me 1.3%, kēlā me kēia).20 Ua hōʻike ʻia kahi meta-analysis o ʻeiwa mau haʻawina i hoʻopaʻa ʻia nā maʻi 5261 i SES, PES, a i ʻole BMS ma hope o 4 mau makahiki o ka hahai ʻana, SES (0.6% versus 0%, p = 0.025) a me PES (0.7%)) hoʻonui i ka hanana o ST hope loa i hoʻohālikelike ʻia me BMS e 0.2%, p = 8).49 I ka hoʻohālikelike ʻana, i loko o kahi meta-analysis me nā maʻi 5108, ua hōʻike ʻia ʻo 21 he 60% pili i ka make a i ʻole MI me SES i hoʻohālikelike ʻia me BMS (p = 0.03), ʻoiai ʻo PES i pili me ka piʻi nui ʻole o 15% (e nānā - a hiki i 9 mahina a 3 mau makahiki).
Ua nānā nā helu helu he nui, nā ho'āʻo randomized, a me nā meta-analyses i ka pilikia pili o ST ma hope o ka hoʻokomo ʻana o BMS a me DES a ua hōʻike i nā hopena kū'ē.Ma kahi papa inoa o nā maʻi 6906 i mālama ʻia me BMS a i ʻole DES, ʻaʻohe ʻokoʻa i nā hopena lapaʻau a i ʻole nā ​​helu ST ma 1 makahiki o ka hahai ʻana.48 Ma kahi papa inoa ʻē aʻe o nā maʻi 8146, ʻike ʻia ka pilikia o ka hoʻomau ʻana o ST keu he 0.6% i kēlā me kēia makahiki ke hoʻohālikelike ʻia me BMS.49 ʻO kahi meta-analysis o nā haʻawina e hoʻohālikelike ana i ka SES a i ʻole PES me SMP i hōʻike i ka piʻi nui o ka make a me ka MI me ka DES mua i hoʻohālikelike ʻia me SMPs, 21 a me kahi meta-analysis o nā maʻi 4545 i randomized i SES a i ʻole ST ma waena o PES a me BMS ma 4 mau makahiki o ka hahai ʻana.50 Ua hōʻike ʻia nā haʻawina ʻē aʻe o ka honua i ka piʻi nui ʻana o ka ST a me MI holomua i nā maʻi i mālama ʻia me DES mua ma hope o ka pau ʻana o ka DAPT.51
Hāʻawi ʻia i nā ʻikepili kūʻē, ua hoʻoholo pū kekahi mau ʻano loiloi a me nā meta-analyses ʻaʻole ʻokoʻa loa ka DES a me ka SGM o ka hanauna mua i ka pilikia o ka make a i ʻole MI, akā ʻoi aku ka nui o ka SES a me PES i ka ST maʻamau i hoʻohālikelike ʻia me SGM.No ka nānā ʻana i nā hōʻike i loaʻa, ua koho ka US Food and Drug Administration (FDA) i kahi panela loea53 i hoʻopuka i kahi ʻōlelo e ʻike ana i ka hopena o ka DES o ka hanauna mua e like me ka lepili a he liʻiliʻi ka pilikia o nā pae kiʻekiʻe loa ST, akā ʻaʻole nui., Mahuahua nui.ʻO ka hopena, ʻōlelo ka FDA a me ka hui e hoʻolōʻihi i ka manawa DAPT i 1 makahiki, ʻoiai he liʻiliʻi nā hōʻike e kākoʻo i kēia koi.
E like me ka mea i ʻōlelo ʻia ma mua, ua hoʻomohala ʻia ka lua o ka hanauna DES me nā hiʻohiʻona hoʻolālā maikaʻi.Ua hana ʻo CoCr-EES i ka noiʻi lapaʻau nui loa.Ma ka meta-analysis e Baber et al.54 o 17,101 maʻi, CoCr-EES i hoʻemi nui i ka definite/probable ST a me MI i hoʻohālikelike ʻia me PES, SES, a me ZES ma 21 mahina.ʻO ka mea hope loa, ua hōʻike ʻo Palmerini et al i kahi meta-analysis o nā maʻi 16,775 he haʻahaʻa haʻahaʻa haʻahaʻa loa ʻo CoCr-EES i ka wā mua, hope, 1- a me 2-makahiki i wehewehe ʻia ST i hoʻohālikelike ʻia me nā DES i hoʻohui ʻia.55 Ua hōʻike nā haʻawina ola maoli i ka emi ʻana o ka pilikia o ST me CoCr-EES i hoʻohālikelike ʻia me DES o ka hanauna mua.56
Ua hoʻohālikelike ʻia ʻo Re-ZES me CoCr-EES ma nā haʻawina RESOLUTE-AC a me TWENTE.33,57 ʻAʻohe ʻokoʻa koʻikoʻi i ka make ʻana, ka myocardial infarction, a i ʻole i wehewehe ʻia ka ʻāpana ST ma waena o nā stents ʻelua.
Ma kahi pūnaewele meta-analysis o nā maʻi 50,844, me 49 RCTs, ua pili pū ʻia ʻo 58 CoCr-EES me kahi haʻahaʻa haʻahaʻa o ST i wehewehe ʻia ma mua o BMS, kahi ʻike i ʻike ʻole ʻia me nā DES ʻē aʻe;ʻAʻole wale ka emi ʻana ma "ma mua nui" a ma hope o 30 mau lā (58).ratio odds [OR] 0.21, 95% confidence interval [CI] 0.11-0.42) a ma 1 makahiki (OR 0.27, 95% CI 0.08-0.74) a me 2 makahiki (OR 0.35, 95% CI 0.17-0.69).Hoʻohālikelike ʻia me PES, SES, a me ZES, ua pili ʻo CoCr-EES me kahi haʻahaʻa ST haʻahaʻa ma 1 makahiki.
Hoʻopili ʻia ka ST mua me nā kumu like ʻole. ʻO ka morphology plaque lalo a me ke kaumaha thrombus me he mea lā e hoʻololi i ka hopena ma hope o PCI;59 ke komo ʻana o nā struts hohonu e ka necrotic core (NC) prolapse, long medial waimaka i loko o ka stent, suboptimal stenting me ke koena o ka ʻaoʻao a i ʻole ka stenosis lihi nui, ka hoʻopiʻi ʻole ʻana, a me ka hoʻonui ʻole ʻana o ka lāʻau implanted ʻaʻole hiki ke hoʻonui i ka lāʻau anti-plate. stantially influence incidence of early ST: in a randomized trials comparing BMSs with DESs, the rates of acute and subacute ST during DAPT like (<1%).61 No laila, ʻo ka ST mua me he mea lā e pili ana i nā maʻi i mālama ʻia a me nā kumu hana. ʻO ka morphology plaque lalo a me ke kaumaha thrombus me he mea lā e hoʻololi i ka hopena ma hope o PCI;59 ke komo ʻana o nā struts hohonu e ka necrotic core (NC) prolapse, long medial waimaka i loko o ka stent, suboptimal stenting me ke koena o ka ʻaoʻao a i ʻole ka stenosis lihi nui, ka hoʻopiʻi ʻole ʻana, a me ka hoʻonui ʻole ʻana o ka lāʻau implanted ʻaʻole hiki ke hoʻonui i ka lāʻau anti-plate. stantially influence incidence of early ST: in a randomized trial comparing BMSs with DESs, the rates of acute and subacute ST during DAPT was like (<1%) .61 No laila, ʻo ka ST mua me he mea lā e pili ana i nā maʻi i mālama ʻia a me nā kumu hana. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВ;59 болбока трация пролапса некротического ядра (NC) значительным краевым стенозом, неполной аппозицией и неполным расширением имплантированного стента может увеликичить увеликичить им антитромбоцитарных препаратов не оказывает существенного влияния на частоту раннего ST: в рандомизированном исиранюч, MS исмисл астота острого и подострого ST во время DAPT была одинаковой (<1%) .61 Таким образом, ранняя ST, по-видимому, в п следжуму в основе пролеченными поражениями и процедурными факторами. ʻIke ʻia ka morphology plaque a me ka thrombosis i ka hopena ma hope o ka PCI;59 ke komo hohonu ʻana ma muli o ka necrotic nucleus (NC) prolapse, long medial waimaka i loko o ka stent, suboptimal stenting me ke koena marginal delaminations a i ʻole ka nui o ka stenosis marginal, ka hoʻopiʻi piha ʻole a me ka hoʻonui piha ʻole ʻana o ka lāʻau i hoʻokomo ʻia ʻaʻole hiki ke hoʻonui i ka stent. pili i ka hopena o ka ST mua: ma kahi ho'āʻo randomized e hoʻohālikelike ana i ka BMS a me DES, ua like ka maʻi o ka maʻi a me ka subacute ST i ka wā DAPT (<1%) .61 No laila, ʻike mua ʻia ka ST mua e pili ana i nā mea i mālama ʻia a me nā kumu hana.PCI架内长的内侧撕裂、具有残余边缘剥离或显着边缘狭窄的次优支架、不完守全年血小板药物的治疗方案不会显着影响早期ST 的发生率：在一项比较BMS 与DES 的随间他们月机和亚急性ST 的发生率相似（<1%） .61 因此，早期ST 似乎主要与潜在的治疗病变物和。潜在 的 斑块 形态 和 血栓 似乎 影响 影响 pci 后 结果 ； ； ； ； ； 坏 死 坏 死心 核心 核心 脱垂 导致 的 深 的 支柱 穿透 、 内长 的 内侧 、 具有 残余 边窮次 次 次 次 的 的 的 完 全 并置和 并置和 并置和血 小板 药物 的 治疗 方案 不 显着 影响 影响 早期 的 ： 在 项 比较 比较 des ， pt 中 des ， pt 中亚急性 的 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 发生发生 发生 发生 发生 发生 发生 发生 发生率相似（<1%） .61ʻIke ʻia ka morphology plaque a me ka thrombosis i ka hopena ma hope o PCI;59 ʻO ke komo hohonu ʻana ma muli o ka necrotic nucleus (NC) prolapse, nā ʻāpana medial i ka lōʻihi o ka stent, ka ʻoki lua me nā koena palena, a i ʻole ka hōʻemi ʻana i ka palena ʻoi loa ʻO ka stenting maikaʻi loa, ka hoʻopiʻi ʻole ʻana, a me ka hoʻonui ʻole ʻana60 ʻAʻohe hopena koʻikoʻi o ka regimen Antiplatelet i ka hoʻomaka ʻana o ST a me ka subacute o kahi hoʻokolohua ST a me BTMS ma lalo o ka hoʻāʻo STMS.pili nui i nā maʻi lapaʻau i lalo a me nā kumu hana.
I kēia lā, ʻo ka manaʻo nui ma ST lohi/lohi loa.ʻOiai he mea nui ka hana o ke kaʻina hana a me ka ʻenehana i ka hoʻomohala ʻana o ST acute a subacute, ʻoi aku ka paʻakikī o ke ʻano o nā hanana thrombotic lohi.Ua manaʻo ʻia ʻo kekahi mau hiʻohiʻona maʻi e lilo i mau kumu pilikia no ka holomua a me ka holomua loa ST: diabetes mellitus, ACS i ka manawa o ka ʻoki mua ʻana, ka hōʻole ʻana o ka renal, ka makahiki kahiko, ka haʻihaʻi ejection i hoʻemi ʻia, nā hanana puʻuwai koʻikoʻi nui i loko o 30 mau lā o ka hana mua.No ka BMS a me DES, ua pili nā ʻano hoʻololi kaʻina hana e like me ka nui o ka moku liʻiliʻi, bifurcations, maʻi multivascular, calcification, hoʻopau piha, ʻike ʻia nā stents lōʻihi me ka pilikia o ka holomua ST.62,63 ʻO ka pane maikaʻi ʻole i ka lāʻau antiplatelet kahi kumu pilikia nui no ka holomua DES thrombosis 51.ʻO kēia pane ma muli paha o ka hoʻokō ʻole ʻana o ka mea maʻi, underdosing, pili i ka lāʻau lapaʻau, comorbidities e pili ana i ka pane ʻana i ka lāʻau, receptor-level genetic polymorphism (ʻoi aku ka pale ʻana o clopidogrel), a me ka hoʻōla ʻana i nā ala ʻē aʻe no ka hoʻōla platelet.Manaʻo ʻia ʻo Stent neoatherosclerosis he hana koʻikoʻi no ka hāʻule ʻana o ka stent hope, me ka ST64 hope loa (ʻāpana "Stent Neoatherosclerosis").Hoʻokaʻawale ka endothelium paʻa i ka paia moku thrombosed a me nā pou stent mai ke kahe koko a hūnā i nā mea antithrombotic a me nā mea vasodilatory.Hōʻike ka DES i ka paia o ka moku i nā lāʻau anti-proliferative a me kahi kahua hoʻokuʻu lāʻau, me nā hopena like ʻole i ka ho'ōla a me ka hana endothelial, me ka hopena o ka thrombosis hope.65 Ua hōʻike ʻia nā noiʻi pathological hiki i nā polymers DES ikaika o ka hanauna mua ke kōkua i ka mumū mau, ka waiho ʻana o ka fibrin mau, ka hoʻōla ʻana i ka endothelial maikaʻi ʻole, a no laila ke piʻi aʻe ka pilikia o ka thrombosis.3 ʻO ka hypersensitivity hope i ka DES ʻike ʻia he ʻano hana ʻē aʻe e alakaʻi ana i ST.ʻO Virmani et al.[66] hōʻike i nā ʻike postmortem ma hope o ST e hōʻike ana i ka hoʻonui ʻana i ka aneurysm i ka māhele stent me nā hopena hypersensitivity kūloko i loaʻa nā T-lymphocytes a me nā eosinophils;Hiki i kēia mau ʻike ke hōʻike i ka mana o nā polymers hiki ʻole ke hoʻopau.67 Ma muli paha o ka hoʻonui ʻia ʻana o ka stent a i ʻole he mau mahina ma hope o PCI.ʻOiai ʻo ka malapposition kaʻina hana he kumu pilikia no ka ST acute a me ka subacute ST, ʻo ke koʻikoʻi o ke koʻikoʻi o ka loaʻa ʻana o ka stent malapposition hiki ke hilinaʻi ʻia i ka hoʻoponopono hou ʻana o ka arterial a i ʻole ka hoʻōla ʻana i ka lāʻau i hoʻopaneʻe ʻia, akā paʻakikī kona pili kino.68
Hiki i nā hopena pale o DES ka lua o ka hanauna ke hoʻokomo i ka endothelialization wikiwiki a paʻa, a me nā ʻokoʻa o ka stent alloy a me ke ʻano, ka mānoanoa strut, nā waiwai polymer, a me ke ʻano lāʻau antiproliferative, dosis, a me nā kinetics.
Ke hoʻohālikelike ʻia me CoCr-EES, hiki i nā scaffolds cobalt-chromium stent scaffolds lahilahi (81 µm), antithrombotic fluoropolymers, haʻahaʻa polymer content, a me ka hoʻouka ʻana i ka lāʻau i ka haʻahaʻa ST.Ua hōʻike ʻia nā haʻawina hoʻokolohua he haʻahaʻa loa ka thrombosis a me ka platelet deposition i loko o nā stents i uhi ʻia i ka fluoropolymer ma mua o nā stents i uhi ʻole ʻia.69 Inā paha he mau waiwai like nā DES o nā hanauna ʻelua e pono ke aʻo hou ʻia.
Hoʻomaikaʻi nā stents coronary i ka kūleʻa o ke kaʻina hana o ka coronary interventions i hoʻohālikelike ʻia me ka percutaneous transluminal coronary angioplasty (PTCA), nona nā pilikia mechanical (vascular occlusion, dissection, etc.) a me kahi kiʻekiʻe o restenoses (a hiki i 40-50% o nā hihia).Ma ka hopena o nā 1990s, kokoke 70% o nā PCI i hana ʻia me ka implantation BGM.70
然而，尽管技术、技术和药物治疗取得了进步，但BMS 植入后再狭窄的风险物物中中中文安了生率> 40%.然而，尽管技术、技术和药物治疗取得了进步，但BMSEia nō naʻe, ʻoiai ka holomua o ka ʻenehana, nā ʻenehana, a me nā lāʻau lapaʻau, ʻoi aku ka nui o ka restenosis ma hope o ka hoʻokomo ʻana o BMS ma kahi o 20%, me nā uku ma mua o 40% i kekahi mau pūʻulu.71 Ma keʻano laulā, ua hōʻike nā haʻawina hauʻoli i ka restenosis ma hope o ka hoʻokomoʻana o BMS, e like me ka mea iʻikeʻia me ka PTCA maʻamau, piʻi i nā mahina 3-6 a hoʻoholo i ka makahiki 1.72
Hoʻemi hou ʻo DES i nā helu ISR, 73 ʻoiai ʻo kēia hōʻemi ʻana i ka angiographically a me ke kauka.Hoʻokuʻu ka DES polymer coating i nā mea anti-inflammatory a me nā anti-proliferative agents, ke kāohi nei i ka hoʻokumu ʻana o ka neointima, a hoʻopaneʻe i ka hoʻoponopono ʻana i nā vascular e nā mahina a i ʻole mau makahiki.74 I loko o nā haʻawina lāʻau lapaʻau a me ka mōʻaukala, ua ʻike ʻia ka ulu mau ʻana o ka neointima ma kahi lōʻihi o ka hahai ʻana ma hope o ka hoʻokomo ʻia ʻana o DES, kahi ʻano i kapa ʻia ʻo “late catch-up” 75.
ʻO kaʻeha vascular i ka PCI e hoʻoulu i kahi kaʻina hana paʻakikī o ka mumū a me ka hoʻoponopono ʻana i kahi manawa pōkole (he pule a hiki i nā mahina), ka hopena i ka endothelialization a me ka uhi neointimal.Wahi a nā hiʻohiʻona histopathological, neointimal hyperplasia (HMS a me DES) ma hope o ka hoʻokomo ʻana i ka stent i loko o ka nui o nā ʻiʻo ʻiʻo maʻemaʻe proliferative i loko o kahi proteoglycan-rich extracellular matrix.70
No laila, ʻo ka hyperplasia neointimal kahi hana hoʻoponopono e pili ana i ka coagulation a me nā mea ʻona, a me nā cell e hoʻoulu ai i ka hoʻonui ʻana o ka ʻiʻo ʻiʻo a me ka hoʻokumu ʻana o ka matrix extracellular.Ma hope koke o ka PCI, waiho ʻia nā platelets a me ka fibrin ma ka paia o ka moku a huki i nā leukocytes ma o ke ʻano o nā molekole adhesion cell.Hoʻopili ʻia nā leukocytes ʻōwili i nā platelets i hoʻopili ʻia ma o ka pilina ma waena o ka leukocyte integrin Mac-1 (CD11b/CD18) a me platelet glycoprotein Ibα 53 a i ʻole fibrinogen pili me ka platelet glycoprotein IIb/IIIa.76.77
Wahi a nā ʻikepili hou, pili nā pūnaewele progenitor iwi iwi i nā hopena vascular a me nā kaʻina hana hoʻoponopono.ʻO ka hoʻoneʻe ʻana o EPC mai ka iwi iwi a hiki i ke koko peripheral e hoʻoikaika i ka endothelial regeneration a me ka postnatal neovascularization.Me he mea lā e neʻe ana nā pūnaewele progenitor muscle maʻemaʻe o ka iwi iwi (SMPCs) i kahi o ka ʻeha vascular, e hopena i ka hoʻonui ʻana o neointimal.78 Ma mua, ua manaʻo ʻia nā cell CD34-positive ma ke ʻano he heluna kanaka paʻa o nā EPC, ua hōʻike ʻia nā noiʻi hou aʻe i ka CD34 surface antigen e ʻike maoli i nā pūnaewele iwi iwi ʻole me ka hiki ke hoʻokaʻawale i nā EPC a me nā PBMC.ʻO ka hoʻololi ʻana o nā cell CD34-positive i kahi EPC a i ʻole SMPC lineage e hilinaʻi ʻia ma ke kaiapuni kūloko;ʻO nā kūlana ischemic e hoʻohuli i ka hoʻokaʻawale ʻana i ka phenotype EPC, e hoʻolaha ana i ka reendothelialization, aʻo nā kūlana inflammatory e hoʻohuli i ka ʻokoʻa i ka SMPC phenotype, e hoʻolaha ana i ka neointimal proliferation.79
Hoʻonui ka maʻi maʻi i ka pilikia o ka ISR e 30-50% ma hope o ka hoʻokomo ʻana o BMS, a ʻoi aku ka kiʻekiʻe o ka restenosis i ka maʻi diabetes i hoʻohālikelike ʻia me nā maʻi maʻi ʻole i hoʻomau ʻia i ka wā DES.He multifactorial paha nā mīkini i lalo o kēia nānā ʻana, e like me ka systemic (e laʻa, ke ʻano o ka pane ʻana o ka inflammatory) a me nā anatomical (e laʻa, nā moku liʻiliʻi, nā liona lōʻihi, nā maʻi diffuse, a me nā mea ʻē aʻe), e hoʻonui kūʻokoʻa i ka pilikia o ISR.70
ʻO ke anawaena moku a me ka lōʻihi o ka ʻeha i hoʻopili kūʻokoʻa i ka helu ISR, me ka liʻiliʻi liʻiliʻi/ʻoi aku ka lōʻihi o nā ʻeha i hoʻonui nui i ka restenosis i hoʻohālikelike ʻia me nā ʻeha nui/pōkole.71
Ua hōʻike ʻia nā paepae stent hanauna mua i nā stent struts mānoanoa a me nā ISR kiʻekiʻe aʻe i hoʻohālikelike ʻia me nā paepae stent lua o ka hanauna me nā struts thinner.
Eia kekahi, pili ka loaʻa ʻana o ka restenosis me ka lōʻihi o ka stent, aneane pālua ʻia no ka lōʻihi o ka stent> 35 mm i hoʻohālikelike ʻia me kēlā <20 mm. Eia kekahi, pili ka loaʻa ʻana o ka restenosis me ka lōʻihi o ka stent, aneane pālua ʻia no ka lōʻihi o ka stent> 35 mm i hoʻohālikelike ʻia me kēlā <20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента >35 мм по сравнению <с дмлиной2 стента Eia kekahi, pili ka nui o ka restenosis i ka lōʻihi o ka stent, aneane pālua me ka lōʻihi stent> 35 mm i hoʻohālikelike ʻia me ka lōʻihi 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 的两倍此外，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 больше, чем стента <20 мм. Eia kekahi, ʻo ke alapine o ka restenosis e pili ana i ka lōʻihi o ka stent: ʻo ka lōʻihi o ka stent> 35 mm aneane ʻelua ʻelua o ka stent <20 mm.ʻO ke anawaena liʻiliʻi liʻiliʻi liʻiliʻi loa o ka stent kekahi hana koʻikoʻi: ʻo ka liʻiliʻi liʻiliʻi liʻiliʻi liʻiliʻi lumen anawaena i wānana i ka piʻi nui ʻana o ka restenosis.81.82
ʻO ka mea maʻamau, ʻo ka hyperplasia intimal ma hope o ka hoʻokomo ʻana o BMS i manaʻo ʻia he kūpaʻa, me kahi kiʻekiʻe mua ma waena o 6 mahina a me 1 makahiki a ukali ʻia e kahi manawa dormant hope.ʻO kahi kiʻekiʻe mua o ka ulu ʻana o ka ulu ʻana i ukali ʻia e ka regression intimal me ka hoʻonui ʻana o ka lumen i kekahi mau makahiki ma hope o ka hōʻike ʻana o ka stent implantation;ʻO ka hoʻomaʻamaʻa ʻana o nā ʻiʻo ʻiʻo maʻemaʻe a me nā loli i ka matrix extracellular i manaʻo ʻia e like me nā ʻano hana no ka regression neointima hope.83 Eia naʻe, ua hōʻike nā haʻawina hope lōʻihi i kahi pane triphasic ma hope o ka waiho ʻana o BMS me ka restenosis mua, ka hoʻihoʻi waena, a me ka restenosis luminal hope.84
I ka wā DES, ua hōʻike mua ʻia ka ulu ʻana o ka neointimal ma hope o ka SES a i ʻole PES implantation i nā ʻano holoholona.85 Ua hōʻike ʻia kekahi mau haʻawina IVUS i ka attenuation mua o ka ulu ʻana o ka pilina ma hope o ka hopu ʻana i ka manawa ma hope o ka SES a i ʻole RPE implantation, ma muli paha o kahi kaʻina inflammatory mau.86
ʻOiai ka "paʻa" maʻamau i pili iā ISR, ma kahi o kahi hapakolu o nā maʻi me BMS ISR e hoʻomohala i ka ACS.ʻehā
Ke hoʻonui nei nā hōʻike e hoʻoulu ai ka mumū mau a me / a i ʻole endothelial insufficiency i ka neoatherosclerosis holomua i ka HCM a me DES (ʻoi aku ka nui o ka hanauna mua DES), ʻo ia paha kahi hana koʻikoʻi no ka hoʻomohala ʻana i ka holomua IR a i ʻole ka holomua ST.Ua hōʻike ʻo Inoue et al [87] i nā ʻike autopsy histological ma hope o ka hoʻokomo ʻia ʻana o nā stents coronary Palmaz-Schatz, e hōʻike ana e hiki i ka mumū a puni ka stent ke hoʻololi i nā loli atherosclerotic indolent hou i loko o ka stent.Ua hōʻike ʻia nā haʻawina ʻē aʻe ʻo ka restenotic tissue i loko o 5-makahiki CGM i loaʻa i ka atherosclerosis hoʻomaka hou ʻana me ka ʻaʻa ʻole o ka peritoneal;Hōʻike nā hōʻailona mai nā hihia ACS i nā pā maʻamau maʻamau i loko o nā aʻa coronary maoli.Eia kekahi, i ka hoʻohālikelike ʻana i ka BMS a me DES, ua ʻike ʻia kahi ʻokoʻa koʻikoʻi i ka manawa i ka hoʻomohala ʻana o ka atherosclerosis hou.11,12 Ua hoʻomaka ka hoʻololi atherosclerotic mua loa i ka foamy macrophage infiltration i 4 mau mahina ma hope o ka hoʻokomo ʻana o SES, aʻo nā loli like i nā lesions CGM i loaʻa ma hope o 2 mau makahiki a noho mau ka loaʻa ʻana a hiki i 4 mau makahiki.Eia kekahi, ʻoi aku ka pōkole o ka DES stenting no nā maʻi paʻa ʻole e like me ka thin tegmental fibroatherosclerosis (TCFA) a i ʻole ka rupture intimal he manawa pōkole i ka hoʻomohala ʻana i ka BMS.No laila, ʻike ʻia ka neoatherosclerosis ma mua o ka DES mua ma mua o ka BMS, ma muli paha o kahi pathogenesis ʻē aʻe.
ʻO ka hopena o ka lua o ka hanauna DES a i ʻole DES i ka hoʻomohala ʻana e ʻimi mau ʻia;ʻoiai ke hōʻike nei kekahi mau ʻike o ka lua o ka hanauna DES88 i ka liʻiliʻi o ka mumū, ua like ka maʻi o ka neoatherosclerosis i ka hanauna mua, akā pono nā noiʻi hou aʻe.