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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Department of Cardiology, Poliambulanza Foundation Tsev Kho Mob, Brescia, 2 Department of Cardiology, Catholic University of the Sacred Heart of Rome, Italy Abstractions (Dr. s (BMS) tom qab percutaneous coronary intervention.Txawm li cas los xij, txawm li cas los xij, txawm li cas los xij, txawm hais tias qhov kev taw qhia ntawm DES tiam thib ob zoo li muaj kev cuam tshuam qhov tshwm sim no piv rau thawj tiam DES, kev txhawj xeeb loj tseem nyob ntawm qhov muaj teeb meem lig ntawm stent implantation, xws li stent thrombosis (ST) thiab stent resection.Stenosis (ISR).ST yog qhov tshwm sim muaj kev puas tsuaj loj uas tau txo qis los ntawm kev ua kom zoo stenting, tshiab stent designs, thiab dual antiplatelet therapy.Qhov tseeb mechanism piav qhia nws qhov tshwm sim yog nyob rau hauv kev tshawb nrhiav, thiab qhov tseeb, ntau yam tseem ceeb yog lub luag haujlwm.ISR hauv BMS yav dhau los suav tias yog lub xeev khov kho nrog lub sijhawm ntxov ntawm contimal replasia (6 xyoo dhau los). Ob qhov kev tshawb fawb soj ntsuam thiab histological ntawm DESs tau pom cov pov thawj ntawm qhov tsis tu ncua neointimal kev loj hlob thaum lub sij hawm mus sij hawm ntev taug qab, ib qho tshwm sim hu ua "late catch-up" phenomenon.Qhov kev xaav tias ISR yog ib qho kev kho mob zoo heev tsis ntev los no tau sib tw los ntawm cov pov thawj tias cov neeg mob ISR tuaj yeem tsim cov kab mob coronary syndromes . plaques thiab cov yam ntxwv ntawm post-stent hlab ntsha kho;Nws feem ntau yog siv los ua kom tiav kev kuaj mob coronary angiography thiab tsav cov txheej txheem cuam tshuam.Intracoronary optical coherence tomography tam sim no suav tias yog cov txheej txheem kuaj pom zoo tshaj plaws.Piv rau intravascular ultrasound, nws muab kev daws teeb meem zoo dua (tsawg kawg> 10 zaug), tso cai rau cov ncauj lus kom ntxaws ntawm cov qauv ntawm phab ntsa ntawm phab ntsa. -stage neo-atherosclerosis nyob rau hauv BMS thiab DES.Yog li ntawd, neo-atherosclerosis tau dhau los ua thawj tus neeg raug tsim txom nyob rau hauv lub pathogenesis ntawm lig stent tsis ua hauj lwm.Keywords: coronary stent, stent thrombosis, restenosis, neoatherosclerosis
Percutaneous coronary intervention (PCI) nrog stent implantation yog cov txheej txheem siv dav tshaj plaws rau kev kho mob ntawm cov kab mob coronary artery, thiab cov txheej txheem txuas ntxiv mus ntxiv.1 Txawm hais tias cov tshuaj eluting stents (DES) txo qis cov kev txwv ntawm bare-metal stents (BMSs), cov teeb meem lig tshwm sim (STenosis) thiab stentosis (IST) so. ua implantation., kev txhawj xeeb tseem ceeb.2-5
Yog tias ST yog qhov tshwm sim muaj kev puas tsuaj loj, kev lees paub tias ISR yog ib tus kab mob benign tsis ntev los no tau raug cuam tshuam los ntawm cov pov thawj ntawm tus mob coronary syndrome (ACS) hauv cov neeg mob ISR.4
Niaj hnub no, intracoronary optical coherence tomography (OCT) 6-9 yog suav tias yog tam sim no lub xeev-of-the-art imaging txheej txheem, muab kev daws teeb meem zoo dua li intravascular ultrasound (IVUS).
Xyoo 1964, Charles Theodore Dotter thiab Melvin P Judkins tau piav txog thawj qhov angioplasty.In 1978, Andreas Gruntzig tau ua thawj lub zais pa angioplasty (plain qub balloon angioplasty);Nws yog ib qho kev kho dua tshiab tab sis muaj qhov tsis zoo ntawm cov hlab ntsha kaw thiab ua rau lub cev tsis muaj zog.13 Qhov no ua rau kev tshawb pom ntawm coronary stents: Puel thiab Sigwart tau siv thawj coronary stent nyob rau hauv 1986, muab ib qho stent los tiv thaiv cov hlab ntsha kaw thiab lig systolic retraction.14 lawv tiv thaiv kev puas tsuaj ntawm cov hlab ntsha loj kawg. Tom qab ntawd, ob qhov kev sim ua pov thawj, Belgian-Dutch Stent Trial 15 thiab Stent Restenosis Study 16, tau tawm tswv yim txog kev nyab xeeb ntawm stenting nrog dual antiplatelet therapy (DAPT) thiab / lossis cov txheej txheem xa tawm tsim nyog.17,18 Tom qab cov kev sim no, muaj qhov nce ntxiv ntawm PCIs ua.
Txawm li cas los xij, qhov teeb meem ntawm iatrogenic in-stent neointimal hyperplasia tom qab BMS qhov kev tso kawm tau pom sai sai, ua rau ISR hauv 20% -30% ntawm cov kab mob kho.In 2001, DES tau qhia txog 19 kom txo qis qhov xav tau ntawm restenosis thiab reintervention.DESs tau ua kom muaj kev ntseeg siab ntawm cov kws kho plawv ntawm kev xav tau ntau ntxiv los ntawm kev kho mob ua ntej. ery bypass grafting.In 2005, 80%–90% ntawm tag nrho cov PCIs tau nrog DES.
Txhua yam muaj nws qhov tsis zoo, thiab txij li xyoo 2005, kev txhawj xeeb txog kev nyab xeeb ntawm "thawj tiam" DES tau nce, thiab cov tiam tshiab stents xws li 20,21 tau tsim thiab qhia.22 Txij thaum ntawd los, kev siv zog los txhim kho stent kev ua tau zoo tau loj hlob sai, thiab tshiab, xav tsis thoob technologies tau txuas ntxiv mus nrhiav tau sai thiab coj mus rau kev lag luam.
BMS yog ib lub mesh nyias hlau raj.Tom qab thawj qhov kev paub nrog "Pall" mount, Gianturco-Roubin mount thiab Palmaz-Schatz mount, muaj ntau yam BMSs tam sim no muaj.
Peb qhov sib txawv tsim tau: coil, tubular mesh thiab slotted tube.Coil designs feature hlau xov hlau los yog strips tsim rau hauv ib lub voj voog;tubular mesh tsim muaj cov xov hlau qhwv ua ke hauv ib lub mesh los ua ib lub raj;slotted tube designs muaj cov hlau raj uas yog laser txiav ua.Cov khoom siv no sib txawv hauv cov khoom sib txawv (stainless steel, nichrome, cobalt chrome), cov qauv tsim (cov qauv sib txawv thiab qhov dav, txoj kab uas hla thiab qhov ntev, lub zog radial, radiopacity) thiab cov khoom xa tuaj (tus kheej nthuav dav lossis balloon-expandable).
Feem ntau, BMS tshiab muaj cov cobalt-chromium alloy, uas ua rau cov struts thinner nrog kev txhim kho navigability, tswj lub zog txhua yam.
Lawv muaj cov hlau stent platform (feem ntau stainless hlau) thiab coated nrog ib tug polymer uas elutes anti-proliferative thiab / los yog anti-inflammatory kev kho mob.
Sirolimus (tseem hu ua rapamycin) yog Ameslikas tsim los ua tus neeg sawv cev tiv thaiv kab mob.Nws cov txheej txheem ntawm kev ua haujlwm yog los ntawm kev thaiv lub voj voog ntawm tes los ntawm kev thaiv txoj kev hloov ntawm G1 theem mus rau S theem thiab inhibiting neointima tsim.In 2001, "thawj-hauv-tib neeg" kev paub nrog SES qhia tau hais tias qhov kev loj hlob ntawm kev loj hlob 2. ficacy nyob rau hauv kev tiv thaiv ISR. nees nkaum plaub
Paclitaxel yog thawj zaug pom zoo rau kev mob qog noj ntshav ntawm zes qe menyuam, tab sis nws cov khoom muaj zog cytostatic - cov tshuaj stabilizes microtubules thaum lub sij hawm mitosis, ua rau cell voj voog ntes thiab inhibits neointimal tsim - ua rau nws cov compound rau Taxus Express PES.The TAXUS V thiab VI trials pom tau hais tias lub sij hawm ntev kev ua tau zoo ntawm cov kab mob, PES nyob rau hauv high-term efficacy5. Teb Chaws Asmeskas Liberté featured stainless hlau platform rau kev xa khoom yooj yim dua.
Cov pov thawj tseeb los ntawm ob qhov kev tshuaj xyuas thiab kev tshuaj ntsuam xyuas meta qhia tias SES muaj qhov zoo dua PES vim qhov qis dua ntawm ISR thiab lub hom phiaj ntawm lub hlab ntsha revascularization (TVR), nrog rau cov qauv mus rau qhov mob myocardial infarction (AMI) hauv PES cohort.27,28 ib
Cov khoom siv thib ob tau txo cov tuab tuab, txhim kho kev yooj yim / xa tawm, txhim kho polymer biocompatibility / yeeb tshuaj elution profiles, thiab zoo heev re-endothelialization kinetics.Nyob rau hauv kev xyaum, lawv yog cov tshaj plaws DES tsim thiab loj coronary stents implanted thoob ntiaj teb.
Taxus Elements yog ib qho kev nce qib ntxiv nrog ib qho tshwj xeeb polymer tsim los ua kom ntev tshaj plaws kev tso tawm thiab ib qho tshiab platinum-chromium strut system uas muab thinner struts thiab txhim kho radiopacity.The PERSEUS sim 29 tau sau tseg cov txiaj ntsig zoo sib xws ntawm Element thiab Taxus Express txog li 12 lub hlis.Txawm li cas los xij, kev sim sib piv yew cov ntsiab lus tsis muaj lwm yam thib ob.
Lub zotarolimus-eluting stent (ZES) Endeavor yog raws li lub zog cobalt-chromium stent platform nrog kev yooj yim dua thiab me me stent strut loj.Zotarolimus yog ib qho sirolimus analog nrog cov tshuaj tiv thaiv zoo sib xws tab sis txhim kho lipophilicity los txhim kho cov hlab ntsha hauv zos. eluted thaum lub sij hawm pib raug mob, ua raws li arterial kho.Tom qab thawj ENDEAVOR mus sib hais, tom qab ENDEAVOR III mus sib piv ZES nrog SES, uas pom ntau dua lumen poob thiab ISR tab sis tsawg dua qhov teeb meem loj ntawm lub plawv plawv (MACE) dua SES .30 Lub ENDEAVOR III qhov kev sim dua, piv rau IV, tab sis qhov kev sib tw qis dua ntawm ISR. ence ntawm AMI, ostensibly los ntawm heev heev ST nyob rau hauv lub ZES pab pawg neeg.31 Txawm li cas los xij, PROTECT sim ua tsis tau tejyam los qhia qhov txawv ntawm ST tus nqi ntawm Endeavor thiab Cypher stents.32
Endeavor Resolute yog ib qho kev txhim kho ntawm Endeavor stent nrog peb txheej polymer tshiab.Qhov tshiab Resolute Integrity (qee zaum hu ua peb tiam DES) yog raws li lub platform tshiab nrog lub peev xwm xa khoom ntau dua (Kev Ncaj Ncees BMS platform), thiab ib qho tshiab, ntau biocompatible peb txheej polymer, tuaj yeem cuam tshuam cov tshuaj tiv thaiv ntau tshaj 6 hnub tom ntej. lute nrog Xience V (everolimus-eluting stent [EES]) qhia tias tsis muaj kev cuam tshuam ntawm Resolute system hais txog kev tuag thiab lub hom phiaj lesion tsis ua haujlwm.33,34
Everolimus, ib tug derivative ntawm sirolimus, kuj yog ib tug cell voj voog inhibitor siv nyob rau hauv txoj kev loj hlob ntawm Xience (Multi-link Vision BMS platform) / Promus (Platinum Chromium platform) EES.The SPIRIT trial 35-37 qhia tau hais tias kev txhim kho kev ua tau zoo thiab txo MACE nrog Xience V piv rau PES, thaum lub sij hawm SPIRIT trial 35-37 qhia tau hais tias muaj kev txhim kho kev ua tau zoo thiab txo MACE nrog Xience V piv rau PES, thaum lub sij hawm qhov kev txiav txim siab tsis zoo. s ntawm 9 lub hlis thiab cov xwm txheej kho mob ntawm 12 lub hlis.38 Thaum kawg, Xience stent tau pom qhov zoo ntawm BMS hauv kev teeb tsa ntawm ST-segment elevation myocardial infarction (MI).39
EPCs yog ib feem ntawm cov hlwb circulating koom nrog hauv vascular homeostasis thiab endothelial kho.Enhancement ntawm EPCs ntawm qhov chaw ntawm vascular raug mob yuav txhawb nqa rov qab endothelialization thaum ntxov, uas yuav txo tau qhov kev pheej hmoo ntawm ST.EPC biology thawj zaug sim nyob rau hauv lub teb ntawm stent tsim yog CD34 antibody-coated Genous stent, nws muaj peev xwm ntawm rebinding PC endothelialization. .Txawm hais tias qhov kev tshawb fawb thawj zaug tau txhawb nqa, cov pov thawj tsis ntev los no taw qhia rau cov nqi siab ntawm TVR.40
Xav txog qhov muaj feem cuam tshuam ntawm polymer-induced qeeb kho, uas cuam tshuam nrog kev pheej hmoo ntawm ST, bioabsorbable polymers muab cov txiaj ntsig ntawm DES, zam kev txhawj xeeb ntev txog polymer persistence.Tam sim no, cov tshuab bioabsorbable sib txawv tau pom zoo (xws li Nobori thiab Biomatrix, biolimus eluting lawv cov stent, E-term persistence, synthesis, thiab lwm yam. Cov txiaj ntsig tau txwv.41
Bioabsorbable cov ntaub ntawv muaj qhov zoo tshaj plaws ntawm kev pib muab kev txhawb nqa txhua yam thaum elastic recoil raug txiav txim siab thiab txo cov kev pheej hmoo mus ntev uas cuam tshuam nrog cov hlau struts uas twb muaj lawm.Tshiab technologies tau coj mus rau kev txhim kho ntawm lactic acid-raws li polymers (poly-l-lactic acid [PLLA]), tab sis ntau stent systems nyob rau hauv txoj kev loj hlob, txawm hais tias txiav txim siab qhov zoo tshaj plaws kev sib tw ntawm cov tshuaj . Kev soj ntsuam kev nyab xeeb thiab kev ua tau zoo ntawm everolimus-eluting PLLA stents.43 Qhov thib ob-tiam Absorb stent hloov kho yog ib qho kev txhim kho dua yav dhau los nrog kev ua tau zoo 2-xyoo.44 Qhov kev sim tsis tu ncua ABSORB II, thawj qhov kev sim randomized piv rau Absorb stent rau Xience cov ntaub ntawv Prime 5 stent, qhov kev xav tau ntxiv, thiab qhov yuav tsum tau ua kom zoo dua ntxiv. cog cov txheej txheem, thiab kev nyab xeeb profile rau coronary lesions yuav tsum tau kom meej meej zoo dua.
Thrombosis nyob rau hauv ob qho tib si BMS thiab DES muaj cov txiaj ntsig kev kho mob tsis zoo.Hauv kev sau npe ntawm cov neeg mob tau txais DES implantation, 47 24% ntawm cov neeg mob ST ua rau tuag, 60% los ntawm cov neeg tsis tuag MI, thiab 7% los ntawm qhov tsis ruaj tsis khov angina.PCI thaum muaj xwm txheej ceev ST feem ntau yog qhov zoo tshaj plaws, nrog rov tshwm sim ntawm 48%.
Advanced ST muaj peev xwm ua rau muaj qhov tshwm sim tsis zoo.Nyob rau hauv txoj kev tshawb fawb BASKET-LATE, 6 mus rau 18 lub hlis tom qab tso stent, cov neeg mob plawv thiab tsis tuag MI tau siab dua hauv pawg DES dua li hauv BMS pawg (4.9% thiab 1.3%, feem). BMS, tau tshaj tawm tias tom qab 4 xyoos ntawm kev soj ntsuam, SES (0.6% vs 0%, p = 0.025) thiab PES (0.7%)) nce qhov tshwm sim ntawm BMS lig heev piv nrog BMS los ntawm 0.2%, p = 0.028).49 Hauv qhov sib piv, hauv kev ntsuas meta-tshaj nrog rau 5,108 tus neeg mob tuag los yog 21 MI, 21% piv rau MS. .03), whereas PES yog txuam nrog 15% tsis tseem ceeb nce (Tom qab 9 lub hlis mus rau 3 xyoos).
Ntau qhov kev sau npe, kev sim randomized, thiab kev tshuaj ntsuam meta-analyses tau tshawb xyuas qhov kev pheej hmoo ntawm ST tom qab BMS thiab DES implantation thiab tau tshaj tawm cov txiaj ntsig tsis sib haum. Hauv kev sau npe ntawm 6,906 tus neeg mob tau txais BMS lossis DES, tsis muaj qhov sib txawv ntawm cov txiaj ntsig kho mob lossis ST tus nqi thaum lub sijhawm 1-xyoo kev soj ntsuam, 48 tus neeg mob ntau dhau ntawm ST. tau pom tias yog 0.6% / xyoo piv nrog BMS.49 Ib qho kev tshuaj ntsuam xyuas meta-kev sim piv rau SES lossis PES nrog BMS tau pom tias muaj kev pheej hmoo ntawm kev tuag thiab MI nrog rau thawj tiam DES piv nrog BMS, 21 thiab lwm qhov kev tshuaj ntsuam meta ntawm 4,545 tus neeg mob randomized rau SES lossis Tsis muaj qhov sib txawv ntawm 5 xyoo ntawm kev ua raws li hauv ntiaj teb MS-0. tau pom tias muaj kev pheej hmoo ntau ntxiv ntawm ST thiab MI hauv cov neeg mob tau txais thawj tiam DES tom qab txiav tawm ntawm DAPT.51
Muab cov pov thawj tsis sib haum xeeb, ntau qhov kev soj ntsuam sib koom ua ke thiab kev tshuaj ntsuam xyuas meta ua ke tau txiav txim siab tias thawj tiam DES thiab BMS tsis txawv ntawm qhov kev pheej hmoo ntawm kev tuag lossis MI, tab sis SES thiab PES muaj kev pheej hmoo siab heev ntawm ST piv nrog BMS.Txhawm rau tshuaj xyuas cov ntaub ntawv pov thawj muaj, US Food and Drug Administration (FDA) tau xaiv ib tus kws tshaj lij panel53 uas tau tshaj tawm tsab ntawv lees paub tias thawj tiam DES tau ua haujlwm zoo rau cov lus qhia ntawm daim ntawv lo thiab tias qhov kev pheej hmoo ntawm ST siab heev yog me me tab sis me me.Ib qho kev nce ntxiv.Yog li ntawd, FDA thiab lub koom haum pom zoo kom ncua lub sijhawm DAPT mus rau 1 xyoo, txawm tias muaj cov ntaub ntawv me me los txhawb qhov kev thov no.
Raws li tau hais ua ntej, tiam thib ob DES nrog cov qauv tsim tau zoo tau tsim kho.CoCr-EESs tau dhau los ua cov kev tshawb fawb soj ntsuam ntau tshaj plaws.In a meta-analysis los ntawm Baber et al,54 suav nrog 17,101 tus neeg mob, CoCr-EES txo qis qhov tseeb / qhov tshwm sim ST thiab MI piv nrog PES, SES, thiab ZES tom qab metalysis ntawm 21 lub hlis. 16,775 tus neeg mob uas CoCr-EES tau txo qis thaum ntxov, lig, 1- thiab 2-xyoo tus kheej ST piv nrog lwm cov kev tshawb fawb DES.55 tiag tiag hauv ntiaj teb tau pom tias txo qis ntawm ST kev pheej hmoo nrog CoCr-EES piv rau thawj tiam DES.56.
Re-ZES tau muab piv nrog CoCr-EES hauv RESOLUTE-AC thiab TWENTE kev sim.
Hauv kev txheeb xyuas network ntawm 50,844 tus neeg mob suav nrog 49 RCTs, 58CoCr-EES tau cuam tshuam nrog qhov tshwm sim qis dua ntawm qhov tseeb ST dua BMS, qhov tshwm sim tsis tau pom hauv lwm DES;Qhov kev txo qis tsis yog tsuas yog nyob rau hauv qhov tseem ceeb thaum ntxov thiab ntawm 30 hnub (qhov sib txawv piv txwv [OR] 0.21, 95% kev ntseeg siab lub sijhawm [CI] 0.11-0.42) thiab tseem nyob rau 1 xyoo (LOSSIS 0.27, 95% CI 0.08-0.74) thiab 2 xyoo (LOSSIS 0.35% S. , thiab ZES, CoCr-EES tau cuam tshuam nrog qis qis ntawm ST ntawm 1 xyoo.
Thaum ntxov ST muaj feem cuam tshuam nrog ntau yam.Cov quav hniav hauv qab ntawm cov quav hniav thiab cov thrombus hnyav tshwm sim los cuam tshuam cov txiaj ntsig tom qab PCI;59 Kev sib sib zog nqus strut vim yog necrotic core (NC) prolapse, cov kua muag nruab nrab ntawm stent ntev, kev txiav tawm thib ob nrog cov npoo seem, lossis cov npoo tseem ceeb nqaim Qhov zoo tshaj plaws stenting, tsis ua tiav, thiab tsis tiav expansion60 Kev kho mob nrog cov tshuaj antiplatelet tsis cuam tshuam rau qhov tshwm sim ntawm STDA thaum ntxov thiab ST. randomized sim muab piv rau BMS nrog DES Tus Nqi Zoo sib xws (<1%).61 Yog li, ST thaum ntxov zoo li feem ntau cuam tshuam nrog cov kab mob hauv qab thiab kev phais.
Niaj hnub no, ib qho kev tsom xam yog nyob rau lig / lig heev ST.Yog cov txheej txheem thiab cov txheej txheem kev tshwm sim los ua lub luag haujlwm tseem ceeb hauv kev txhim kho mob thiab subacute ST, cov txheej txheem ntawm kev ncua sij hawm thrombotic tshwm sim ntau dua. Kev phais thawj zaug.Rau BMS thiab DES, cov txheej txheem kev hloov pauv, xws li cov hlab ntsha me me, bifurcations, kab mob polyvascular, calcification, tag nrho occlusion, ntev stents, zoo li cuam tshuam nrog kev pheej hmoo ntawm qib siab ST.62,63 Tsis txaus cov lus teb rau kev kho antiplatelet yog ib qho kev pheej hmoo tseem ceeb rau kev mob siab rau DES thrombosis 51. bidities cuam tshuam rau cov tshuaj teb, genetic polymorphisms nyob rau theem receptor (tshwj xeeb tshaj yog clopidogrel tsis kam), thiab upregulation ntawm lwm yam platelet activation pathways.In-stent neoatherosclerosis yog suav hais tias yog ib qho tseem ceeb mechanism ntawm lig stent tsis ua hauj lwm, suav nrog lig ST64 (section "In-stent neoatherosclerosis ntawm phab ntsa" thiab cov hlab ntsha ntawm cov hlab ntsha sib cais). thiab secretes antithrombotic thiab vasodilatory tshuaj.DES nthuav tawm cov phab ntsa hlab ntsha rau cov tshuaj tiv thaiv kab mob thiab cov tshuaj eluting platform nrog cov teebmeem sib txawv ntawm endothelial kho thiab ua haujlwm, nrog rau kev pheej hmoo ntawm thrombosis lig.65 Pathological cov kev tshawb fawb qhia tias cov polymers ruaj khov ntawm thawj tiam DES tuaj yeem ua rau mob o, ua rau cov kab mob endothelial tsis zoo, thiab kev pheej hmoo ntawm cov kab mob thrombosis. 3 Late hypersensitivity rau DES zoo nkaus li yog lwm txoj hauv kev ua rau ST.Virmani thiab al66 tau tshaj tawm cov kev tshawb pom tom qab ST tom qab kev tshawb pom pom qhov nthuav dav ntawm cov stent ntu nrog cov tshuaj tiv thaiv hauv zos muaj xws li T lymphocytes thiab eosinophils;Cov kev tshawb pom no tuaj yeem cuam tshuam txog kev cuam tshuam ntawm nonnerodible polymers.67 Stent malapposition yuav yog vim qhov kev nthuav dav stent tsis zoo lossis tshwm sim ntau lub hlis tom qab PCI.Txawm hais tias cov txheej txheem malapposition yog qhov muaj feem cuam tshuam rau tus mob hnyav thiab subacute ST, qhov tseem ceeb ntawm kev tshawb nrhiav stent malapposition tuaj yeem yog nyob ntawm cov tshuaj tiv thaiv kab mob hemorrhagic remodeling, tab sis nws tseem ceeb heev. ib. 68
Qhov kev tiv thaiv ntawm DES tiam thib ob yuav suav nrog kev ua kom sai thiab tsis zoo ntawm cov endothelialization, nrog rau qhov sib txawv ntawm cov stent alloy thiab cov qauv, strut thickness, polymer zog, thiab antiproliferative tshuaj hom, koob tshuaj, thiab kinetics.
Kev txheeb ze rau CoCr-EES, nyias (81 µm) cobalt-chromium stent struts, antithrombotic fluoropolymers, tsis tshua muaj polymer, thiab cov tshuaj thauj khoom tuaj yeem ua rau muaj qhov qis dua ntawm ST.Cov kev tshawb fawb tau pom tias cov thrombosis thiab platelet deposition ntawm fluoropolymer-coated stents yog qhov thib ob ntawm cov noob caj noob ces. cov khoom zoo sib xws tsim nyog kawm ntxiv.
Coronary stents txhim kho qhov kev ua tiav ntawm kev phais ntawm cov kev cuam tshuam ntawm coronary piv nrog cov tshuaj percutaneous transluminal coronary angioplasty (PTCA), uas muaj cov teeb meem kho tshuab (vascular occlusion, dissection, thiab lwm yam) thiab cov nqi siab (txog 40% -50% ntawm cov neeg mob).Los ntawm lig 1990s, ze li ntawm 70% ntawm PCIs tau ua nrog BMS implantation.70
Txawm li cas los xij, txawm tias muaj kev nce qib hauv cov cuab yeej technology, cov tswv yim, thiab kev kho mob, qhov kev pheej hmoo ntawm restenosis tom qab BMS implantation yog kwv yees li 20%, nrog > 40% nyob rau hauv tej subgroups.71 Zuag qhia tag nrho, cov kev tshawb fawb soj ntsuam tau pom tias restenosis tom qab BMS implantation, zoo ib yam li uas tau soj ntsuam nrog cov pa PTCA, peaks ntawm 3-6 lub hlis.72 tom qab ntawd.
DES ntxiv txo qhov tshwm sim ntawm ISR,73 txawm hais tias qhov kev txo qis no nyob ntawm angiography thiab chaw kho mob.Cov txheej txheem polymer ntawm DES tso tawm cov tshuaj tiv thaiv kab mob thiab tiv thaiv kev loj hlob, inhibits neointima tsim, thiab ncua cov txheej txheem kho vascular rau ntau lub hlis mus rau xyoo.74 Kev loj hlob tsis tu ncua neointimal thaum lub sij hawm ntev kev soj ntsuam-kev soj ntsuam tom qab ES, C. linical thiab histological kev tshawb fawb.75
Vascular raug mob thaum lub sij hawm PCI ua ib tug complex txheej txheem ntawm o thiab kho nyob rau hauv ib tug luv luv lub sij hawm ntawm lub sij hawm (lub lis piam mus rau lub hlis), ua rau endothelialization thiab neointimal kev pab cuam.
Yog li, neointimal hyperplasia sawv cev rau kev kho cov txheej txheem uas cuam tshuam nrog coagulation thiab inflammatory yam tseem ceeb nrog rau cov hlwb uas ua rau cov leeg nqaij leeg loj hlob thiab tsim cov kab mob extracellular matrix.Tam sim tom qab PCI, platelets thiab fibrin tso rau ntawm phab ntsa ntawm cov hlab ntsha thiab nrhiav cov leukocytes los ntawm cov xov tooj ntawm tes adhesion molecules.Rolling adeptocytes ntawm 1-CD platelet sib cuam tshuam los ntawm cov kab mob leukocentin. b/CD18) thiab platelet glycoprotein Ibα 53 los yog fibrinogen khi rau platelet glycoprotein IIb/IIIa.76,77
Raws li cov ntaub ntawv tshwm sim, cov pob txha pob txha-derived progenitor hlwb koom nrog hauv vascular teb thiab kho cov txheej txheem.Mobilization ntawm EPCs los ntawm cov pob txha pob txha mus rau hauv cov ntshav peripheral txhawb endothelial regeneration thiab postnatal neovascularization.Nws zoo nkaus li tias cov pob txha pob txha du leeg nqaij progenitor cells (SMPC) tsiv mus rau qhov chaw ntawm vascular raug mob 8, uas ua rau lub neej yav dhau los. tas cov pejxeem ntawm EPCs;Cov kev tshawb fawb ntxiv tau pom tias CD34 nto antigen tau lees paub qhov tsis sib xws ntawm cov pob txha pob txha qia hlwb nrog lub peev xwm sib txawv rau hauv EPCs thiab SMPCs.Transdifferentiation ntawm CD34-zoo hlwb mus rau EPC lossis SMPC kab mob nyob ntawm thaj chaw ib puag ncig;Cov kab mob ischemic ua rau muaj kev sib txawv ntawm EPC phenotype los txhawb kev rov ua rau endothelialization, thaum cov mob inflammatory ua rau muaj kev sib txawv ntawm SMPC phenotype los txhawb neointimal proliferation.79
Ntshav qab zib mellitus ua rau muaj kev pheej hmoo ntawm ISR los ntawm 30% -50% tom qab BMS implantation, 80 thiab qhov tshwm sim ntau dua ntawm restenosis hauv cov neeg mob ntshav qab zib piv nrog cov neeg mob uas tsis muaj ntshav qab zib kuj tseem muaj nyob rau hauv DES era.Cov txheej txheem hauv qab no kev soj ntsuam yog feem ntau muaj feem cuam tshuam nrog cov kab mob (piv txwv li, kev hloov pauv hauv cov kab mob me me, kab mob tom qab, thiab lwm yam.) ) yam uas nce nws tus kheej Risk ntawm ISR.70
Vessel txoj kab uas hla thiab qhov ntev ntawm qhov chaw ntawm nws tus kheej cuam tshuam qhov tshwm sim ntawm ISR, nrog rau txoj kab uas hla me me / ntev dua cov kab mob ua rau muaj kev cuam tshuam loj dua piv nrog cov kab loj dua / luv dua.71
Thawj-tiam stent platforms pom cov stent tuab thiab siab dua ISR tus nqi piv rau cov thib ob tiam stent platforms nrog thinner struts.
Tsis tas li ntawd, qhov tshwm sim ntawm restenosis muaj feem xyuam rau qhov ntev stent, nrog stent ntev> 35 hli yuav luag ob zaug ntev npaum li cov <20 mm.Qhov kawg stent yam tsawg kawg nkaus lumen txoj kab uas hla kuj tau ua lub luag haujlwm tseem ceeb: qhov me me kawg qhov kawg lumen txoj kab uas hla tau kwv yees qhov kev pheej hmoo ntawm restenosis.81,82.
Kev lig kev cai, intimal hyperplasia tom qab BMS implantation yog suav tias yog ruaj khov, nrog lub ncov thaum ntxov ntawm 6 lub hlis thiab 1 xyoo, ua raws li lub sij hawm quiescent lig.Thaum ntxov ntawm kev loj hlob intimal tau tshaj tawm, ua raws li intimal regression nrog lumen o ob peb xyoos tom qab stent implantation; 71 smooth nqaij cell maturation thiab alteration ntawm cellular ntxiv rau cov txheej txheem ntawm kev hloov pauv. gression .83 Txawm li cas los xij, cov kev tshawb fawb nrog kev soj ntsuam ntev ntev tau pom cov lus teb triphasic tom qab BMS tso, nrog rau thaum ntxov restenosis, intermediate regression, thiab lig lumen restenosis.84
Nyob rau hauv DES era, lig neointimal kev loj hlob pib tshwm sim tom qab SES los yog PES implantation nyob rau hauv cov qauv tsiaj.85 Ob peb cov kev tshawb fawb IVUS tau pom ib tug thaum ntxov attenuation ntawm intimal loj hlob raws li los ntawm ib tug lig catch-up nyob rau hauv lub sij hawm tom qab SES los yog PES implantation, tejzaum nws yog vim ib tug tsis tu ncua inflammatory txheej txheem.86
Txawm hais tias "kev ruaj ntseg" ib txwm ua rau ISR, kwv yees li ib feem peb ntawm BMS ISR cov neeg mob tsim ACS.4
Muaj ntau cov pov thawj tias mob o thiab/los yog endothelial insufficiency induces advanced neoatherosclerosis nyob rau hauv BMS thiab DES (feem ntau yog thawj tiam DES), uas tej zaum yuav yog ib qho tseem ceeb mechanism rau advanced ISR los yog advanced ST.Inoue li al.87 tau tshaj tawm cov kev tshawb pom histological los ntawm kev kuaj mob autopsy tom qab cog ntawm Palmaz-Schatz coronary stents, qhia tias peri-stent o tuaj yeem ua rau muaj kev hloov pauv atherosclerotic tshiab hauv stent.Lwm cov kev tshawb fawb 10 tau pom tias cov ntaub so ntswg restenotic nyob rau hauv BMS, tshaj 5 xyoo, muaj cov atherosclerosis tshiab los yog tsis muaj periost;Cov qauv los ntawm ACS nkaus xwb qhia cov plaabclerosclerosiology thiab chotlectionscleros tshiab thiab muaj cov roj ntsha ua ke tau yooj yim. BMS qhov mob siab tau tshwm sim 2 xyoo tom qab thiab tseem muaj qhov tsis tshua muaj kev txhim kho kom muaj sijhawm ntau dua li hauv BMS, koj muaj kev sib tw ua ntej nyob rau hauv BMS, muaj peev xwm vim yog ib tug sib txawv pathogenesis.
Qhov cuam tshuam ntawm tiam thib ob DES lossis DES hauv kev txhim kho tseem yuav tau kawm;Txawm hais tias qee qhov kev soj ntsuam tam sim no ntawm DESs88 tiam thib ob qhia tias muaj mob tsawg dua, qhov tshwm sim ntawm neoatherosclerosis zoo ib yam li thawj tiam, tab sis tseem xav tau kev tshawb fawb ntxiv.