Javascript tam sim no raug kaw hauv koj lub browser.Qee qhov nta ntawm lub vev xaib no yuav tsis ua haujlwm yog tias JavaScript raug kaw.
Sau npe nrog koj cov ntsiab lus tshwj xeeb thiab cov tshuaj tshwj xeeb ntawm kev txaus siab, thiab peb yuav phim cov ntaub ntawv koj muab nrog cov ntawv hauv peb cov ntaub ntawv dav dav thiab xa email rau koj daim ntawv PDF tam sim ntawd.
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 cov lus qhia luv luv ntawm kev siv hlau (Dr. (BMS) tom qab percutaneous coronary cuam tshuam.Txawm li cas los xij, thaum qhov kev taw qhia ntawm DES tiam thib ob zoo li tau txo qhov tshwm sim no piv rau thawj tiam DES, kev txhawj xeeb tseem ceeb tseem nyob ntawm qhov ua tau qeeb ntawm stent implantation xws li stent thrombosis (ST) thiab stent resection, stenosis (SSI).ST yog ib qho kev tshwm sim uas muaj kev puas tsuaj loj heev uas tau txo qis los ntawm kev txhim kho stent implantation, tshiab stent designs, thiab kev kho dual antiplatelet.Qhov tseeb mechanism uas piav txog nws qhov tshwm sim yog nyob rau hauv kev tshawb nrhiav, thiab qhov tseeb ntau yam yog lub luag haujlwm.ISR hauv BMS yav dhau los tau suav hais tias yog lub xeev khov kho nrog qhov siab tshaj plaws ntawm qhov tsis txaus ntseeg (ntawm 6 lub hlis) ua raws li lub sijhawm regression ntau dua 1 xyoos.Nyob rau hauv sib piv, ob qho tib si soj ntsuam thiab histological kev tshawb fawb ntawm DES tau ua pov thawj ntawm persistent neointimal loj hlob nyob rau hauv ib tug ntev lub sij hawm soj ntsuam, ib tug tshwm sim hu ua "late catch-up" tshwm sim.Qhov kev xav tias ISR yog ib qho kev kho mob zoo heev tsis ntev los no tau raug lees paub los ntawm cov pov thawj tias cov neeg mob ISR tuaj yeem tsim cov kab mob plawv.Intracoronary imaging yog ib qho txheej txheem invasive los txheeb xyuas cov stented atherosclerotic plaques thiab cov cim qhia ntawm lub nkoj kho tom qab stenting, thiab feem ntau yog siv los ua kom tiav kev kuaj mob coronary angiography thiab ua cov txheej txheem cuam tshuam.Intracoronary optical coherence tomography yog tam sim no suav hais tias yog qhov kev pom zoo tshaj plaws. nws muab, piv rau intravascular ultrasound, 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 cov hlab ntsha. nws muab, piv rau intravascular ultrasound, 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 cov hlab ntsha. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, > 10 чтельта), охарактеризовать поверхностную структуру стенки сосуда. nws muab, piv rau intravascular ultrasound, ib qho kev daws teeb meem zoo dua (tsawg kawg> 10 zaug), uas tso cai rau cov ncauj lus kom ntxaws txog cov qauv ntawm cov phab ntsa ntawm cov hlab ntsha.与血管 的更多内容与血管内超声相比，它提供了更好的分辨率（至少> 10），允许详细表征血管壁的表滓。Piv rau intravascular ultrasound, nws muab kev daws teeb meem zoo dua (tsawg kawg 10 zaug), uas tso cai rau cov ncauj lus kom ntxaws ntawm cov qauv ntawm phab ntsa ntawm cov hlab ntsha.Hauv vivo kev tshawb fawb pom zoo raws li kev tshawb pom histological qhia tias mob o thiab / lossis kev ua haujlwm endothelial tuaj yeem ua rau muaj kev pheej hmoo ntawm neoatherosclerosis hauv HMS thiab DES.Yog li, neoatherosclerosis tau dhau los ua ib tus neeg xav tias tseem ceeb hauv cov kab mob ntawm qhov tsis ua haujlwm stent lig.Cov lus tseem ceeb: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
Stented percutaneous coronary intervention (PCI) yog cov txheej txheem siv dav tshaj plaws rau kev kho mob cov kab mob coronary artery, thiab cov txheej txheem txuas ntxiv mus.1 Txawm hais tias cov tshuaj eluting stents (DES) txo qhov kev txwv ntawm uncoated stents (UES), cov teeb meem lig xws li hauv stent thrombosis (ST) thiab stent restenosis (ISR) tuaj yeem tshwm sim nrog stent implantation, thiab kev txhawj xeeb loj tseem nyob.2-5
Yog tias ST yog qhov tshwm sim muaj kev puas tsuaj loj, qhov kev lees paub tias ISR yog ib tus kab mob benign tsis ntev los no tau raug cuam tshuam los ntawm cov pov thawj rau tus mob coronary syndrome (ACS) hauv cov neeg mob ISR.plaub
Niaj hnub no, intracoronary optical coherence tomography (OCT) 6-9 yog suav tias yog lub xeev-of-the-art imaging modality muab kev daws teeb meem zoo dua li intravascular ultrasound (IVUS).Hauv vivo imaging kev tshawb fawb 10-12 raws li kev tshawb pom histological qhia tau hais tias "tshiab" vascular teb mechanism tom qab stent implantation nrog de novo "neoatherosclerosis" hauv BMS thiab DES.
Xyoo 1964 Charles Theodore Dotter thiab Melvin P. Judkins tau piav txog thawj qhov angioplasty.Xyoo 1978, Andreas Grunzig tau ua thawj lub zais pa angioplasty (qhov qub pa zais pa angioplasty);Nws yog ib qho kev hloov kho tshiab, tab sis nws kuj muaj qhov tsis zoo ntawm kev mob vascular kaw thiab restenosis.13 Qhov no ua rau kev tshawb pom ntawm coronary stents: Puel thiab Sigwart tau teeb tsa thawj coronary stent hauv xyoo 1986, muab lub stent los tiv thaiv cov hlab ntsha kaw thiab lig systolic retraction.14 Txawm hais tias cov stents thawj zaug no tiv thaiv lub nkoj sai sai, lawv ua rau cov kab mob endothelial puas thiab mob hnyav.Tsis ntev los no, ob qhov kev tshawb fawb txog keeb kwm, Belgian-Dutch Stent Study 15 thiab Stent Restenosis Study 16, tau tawm tswv yim txog kev nyab xeeb ntawm kev kho dual antiplatelet (DAPT) stenting thiab / lossis cov txheej txheem tsim nyog.17,18 Tom qab cov kev sim no, tus naj npawb ntawm PCI tau ua tiav tau nce ntxiv.
Txawm li cas los xij, qhov teeb meem ntawm iatrogenic hauv-stent neointima hyperplasia tom qab BMS kev tso kawm tau raug txheeb xyuas sai, ua rau ISR hauv 20-30% ntawm cov kab mob kho.DES19 tau tshaj tawm hauv xyoo 2001 kom txo qis qhov xav tau rau kev rov ua haujlwm thiab rov ua haujlwm dua.DES tau nce kev ntseeg siab ntawm cov kws kho plawv los ntawm kev tso cai rau kev kho mob ntawm cov kab mob ntau zuj zus uas yav tas los suav hais tias kho tau nrog cov hlab ntsha ntawm cov hlab ntsha bypass grafting.Xyoo 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, tiam tshiab stents xws li 20,21 tau tsim thiab qhia.22 Txij thaum ntawd los, kev siv zog los txhim kho kev ua haujlwm ntawm stents tau loj hlob sai, thiab cov thev naus laus zis tshiab zoo siab tau txuas ntxiv mus nrhiav tau thiab coj mus rau kev lag luam sai.
BMS yog ib tug zoo hlau mesh raj.Tom qab thawj qhov kev paub nrog phab ntsa mount, Gianturco-Rubin mount thiab Palmaz-Schatz mount, muaj ntau yam BMS tam sim no muaj.
Peb qhov sib txawv tsim muaj: serpentine, tubular mesh thiab slotted raj.Coil tsim muaj cov hlau xaim lossis strips ua ib puag ncig coil;nyob rau hauv tubular mesh tsim, hlau dov ua ke rau hauv ib lub mesh ua ib lub raj;slotted designs muaj hlau hlab uas yog laser txiav.Cov khoom siv no sib txawv hauv cov khoom sib txawv (stainless steel, nichrome, cobalt chrome), tsim qauv (ntau yam spacer duab thiab dav, diameters thiab ntev, radial zog, radiopacity), thiab kev xa khoom (tus kheej-expanding lossis balloon-expandable).
Raws li txoj cai, BMS tshiab muaj cov cobalt-chromium alloy, uas ua rau nyias struts, txhim kho kev ua tau zoo ntawm kev tsav tsheb thiab khaws cia txhua yam muaj zog.
Lawv muaj cov hlau stent platform (feem ntau stainless hlau) thiab coated nrog ib tug polymer uas tso tawm anti-proliferative thiab / los yog cov tshuaj tiv thaiv kab mob.
Sirolimus (tseem hu ua rapamycin) yog thawj zaug tsim los ua tus neeg sawv cev tiv thaiv kab mob.Nws cov txheej txheem ntawm kev ua yog cuam tshuam nrog kev thaiv lub voj voog ntawm tes los ntawm kev thaiv kev hloov ntawm G1 theem mus rau theem S thiab inhibiting neointima tsim.Xyoo 2001, "thawj tib neeg" kev paub nrog SES tau pom cov txiaj ntsig tau zoo, ua rau muaj kev txhim kho ntawm Cypher stent.23 Kev sim loj tau pom tias nws muaj txiaj ntsig los tiv thaiv IR.24
Paclitaxel yog thawj zaug pom zoo rau kev kho mob ntawm zes qe menyuam, tab sis nws cov khoom muaj zog cytostatic - cov tshuaj stabilizes microtubules thaum lub sij hawm mitosis, ua rau lub voj voog ntawm tes, thiab inhibits neointimal tsim - ua rau nws ua ib qho chaw rau Taxus Express PES.Qhov kev sim TAXUS V thiab VI tau pom qhov ua tau zoo ntawm PES mus sij hawm ntev hauv kev pheej hmoo siab kab mob plawv.25,26 TAXUS Liberté tom ntej no tau nthuav tawm lub platform stainless hlau rau kev xa khoom yooj yim.
Cov ntaub ntawv pov thawj muaj zog los ntawm ob qhov kev tshuaj xyuas thiab kev tshuaj ntsuam xyuas meta qhia tau hais tias SES muaj qhov zoo dua PES vim qhov qis dua ntawm IVR thiab lub hom phiaj ntawm lub nkoj revascularization (TVA), nrog rau cov qauv ntawm kev nce hauv kev mob myocardial infarction (AMI) hauv PES cohort.27.28 Nws
Cov khoom siv thib ob tau txo cov ncej tuab, txhim kho kev yooj yim / xa tawm, txhim kho polymer biocompatibility / tshuaj tshem tawm cov ntaub ntawv, thiab kev ua kom zoo dua reendothelialization kinetics.Hauv kev xyaum tam sim no, cov no yog cov qauv tsim DES tshaj plaws thiab cov stents loj uas tau cog rau thoob ntiaj teb.
Taxus Elements siv qhov no ib kauj ruam ntxiv nrog ib qho tshwj xeeb polymer tsim rau kev tso tawm ntxov tshaj plaws thiab cov txheej txheem tshiab platinum-chromium spacer uas muab cov spacers thinner thiab nce radiopacity.Txoj kev tshawb fawb PERSEUS 29 tau sau tseg cov txiaj ntsig zoo sib xws ntawm Element thiab Taxus Express mus txog 12 lub hlis.Txawm li cas los xij, tsis muaj kev sim txaus los piv cov ntsiab lus nrog rau lwm tiam DESs thib ob.
Lub Endeavor Zotarolimus Coated Stent (ZES) yog ua raws li lub zog cobalt-chromium stent platform nrog kev ua kom yooj yim dua thiab me me stent strut.Zotarolimus yog ib tug sirolimus analogue nrog zoo xws li cov tshuaj tiv thaiv kab mob, tab sis nrog nce lipophilicity los txhim kho localization nyob rau hauv lub nkoj phab ntsa.ZES siv cov phosphorylcholine polymer txheej tshiab tsim los ua kom biocompatibility thiab txo qhov mob.Feem ntau cov tshuaj raug ntxuav tawm hauv thawj theem ntawm kev raug mob, ua raws li kev kho cov hlab ntsha.Tom qab thawj qhov kev sim ENDEAVOR, qhov kev sim tom ntej ENDEAVOR III piv rau ZES nrog SES, uas pom tau tias qhov lumen poob siab dua thiab HR tab sis tsawg dua cov xwm txheej mob plawv (MACEs) dua li SES.30 ENDEAVOR IV txoj kev tshawb fawb piv ZES nrog PES rov pom qhov tshwm sim ntau dua ntawm SIS tab sis qhov tshwm sim qis dua ntawm MI, suav tias yog vim muaj ntau yam ST hauv pawg ZES.31 Txawm li cas los xij, txoj kev tshawb fawb PROTECT ua tsis tiav los ua kom pom qhov sib txawv ntawm ST zaus ntawm Endeavor thiab Cypher stents.32
Lub 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 kev muaj peev xwm xa khoom ntau dua (Kev Ncaj Ncees BMS platform) thiab ib qho tshiab, ntau dua biocompatible peb-txheej polymer uas tuaj yeem cuam tshuam cov lus teb thawj zaug thiab elute ntau ntawm cov tshuaj nyob rau 60 hnub tom ntej.Ib qho kev sim sib piv Resolute nrog Xience V (everolimus eluting stent [EES]) tau pom tias Resolute system tau txais txiaj ntsig zoo sib xws ntawm kev tuag thiab lub hom phiaj qhov txhab tsis ua haujlwm.33.34 Nws
Everolimus, ib tug sirolimus derivative, kuj yog ib tug cell voj voog inhibitor siv nyob rau hauv txoj kev loj hlob ntawm EES Xience (Multi-link Vision BMS platform) / Promus (Platinum Chromium platform).SPIRIT 35-37 kev sim ua kom pom cov txiaj ntsig tau zoo dua thiab txo MACE nrog Xience V piv rau PES, thaum qhov kev sim EXCELLENT tau pom tias EES zoo li SES hauv kev txo qis qis ntawm 9 lub hlis thiab cov xwm txheej kho mob ntawm 12 lub hlis.38 Thaum kawg, Xience stent tau pom tias zoo dua rau BMS hauv kev teeb tsa ntawm ST elevation myocardial infarction (MI).39
EPCs yog ib feem ntawm cov hlwb uas koom nrog hauv vascular homeostasis thiab kho endothelial.Kev nce EPC ntawm qhov chaw ntawm cov hlab ntsha raug mob yuav txhawb nqa rov qab endothelialization thaum ntxov, uas yuav txo tau qhov kev pheej hmoo ntawm ST.EPC Biology thawj zaug rau hauv stent tsim yog Genous stent, coated nrog anti-CD34 antibodies, muaj peev xwm los khi circulating EPCs los ntawm nws cov cim hematopoietic los txhim kho kev rov ua kom endothelialization.Thaum cov kev tshawb fawb thawj zaug tau txhawb nqa, cov pov thawj tsis ntev los no taw qhia rau TVR tus nqi siab.40
Muab cov txiaj ntsig cuam tshuam ntawm polymer-induced qeeb kho uas cuam tshuam nrog ST kev pheej hmoo, bioresorbable polymers muab cov txiaj ntsig ntawm DES los ntawm kev zam kom tsis txhob muaj kev txhawj xeeb ntev txog polymer persistence.Txog niaj hnub no, ntau lub tshuab bioresorbable tau pom zoo (xws li, Nobori thiab Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), tab sis cov ntaub ntawv txhawb nqa lawv cov txiaj ntsig mus ntev yog txwv.41
Bioabsorbable cov ntaub ntawv muaj qhov zoo tshaj plaws theoretical ntawm kev muab kev txhawb zog thaum pib thaum elastic recoil raug coj mus rau hauv tus account thiab txo cov kev pheej hmoo mus sij hawm ntev cuam tshuam nrog cov hlau struts uas twb muaj lawm.Cov thev naus laus zis tshiab tau ua rau muaj kev txhim kho ntawm lactic acid polymers (poly-l-lactic acid [PLLA]), tab sis ntau lub tshuab stent nyob rau hauv txoj kev loj hlob, txawm hais tias nrhiav qhov zoo tshaj plaws sib npaug ntawm cov tshuaj elution thiab degradation kinetics tseem yog ib qho nyuaj.Txoj kev tshawb fawb ABSORB tau qhia txog kev nyab xeeb thiab kev ua tau zoo ntawm everolimus-coated PLLA stents.43 Kev kho dua tshiab ntawm tiam thib ob Absorb stent tau zoo dua li yav dhau los nrog kev rov qab zoo 2 xyoos.44 Txoj kev tshawb fawb ABSORB II tam sim no, thawj qhov kev sim sib piv piv rau Absorb stent nrog Xience Prime stent, yuav tsum muab cov ntaub ntawv ntxiv, thiab thawj cov txiaj ntsig tau muaj kev cia siab.45 Txawm li cas los xij, cov xwm txheej zoo tshaj plaws, cov txheej txheem kev cog qoob loo zoo tshaj plaws, thiab kev nyab xeeb ntawm cov kab mob plawv yuav tsum tau qhia meej.
Thrombosis hauv ob qho tib si BMS thiab DES muaj cov txiaj ntsig tsis zoo.Hauv kev sau npe ntawm cov neeg mob cog nrog DES, 47 24% ntawm cov neeg mob ST ua rau tuag, 60% hauv MI tsis tuag, thiab 7% nyob rau hauv tsis ruaj tsis khov angina.PCI rau kev ceev ST feem ntau yog qhov zoo tshaj plaws, nrog rov tshwm sim hauv 12% ntawm cov neeg mob.48
Extended ST muaj peev xwm ua rau muaj qhov tshwm sim tsis zoo.Hauv BASKET-LATE txoj kev tshawb fawb, 6-18 lub hlis tom qab tso stent, cov neeg mob plawv thiab tsis tuag MI tau siab dua hauv pawg DES dua li hauv pawg SMP (4.9% thiab 1.3%, feem).20 Ib qho kev tshuaj ntsuam meta-tshaj ntawm cuaj txoj kev tshawb fawb uas 5261 cov neeg mob tau randomized rau SES, PES, los yog BMS tau pom tias tom qab 4 xyoo ntawm kev soj ntsuam, SES (0.6% piv rau 0%, p = 0.025) thiab PES (0.7%) ) nce qhov tshwm sim ntawm lig ST.2% piv nrog BMS = 0).49 Nyob rau hauv sib piv, nyob rau hauv ib tug meta-kev soj ntsuam nrog rau 5108 cov neeg mob, 21 ib tug 60% txheeb ze nce nyob rau hauv kev tuag los yog MI tau tshaj tawm nrog SES piv nrog BMS (p = 0.03), thaum PES tau txuam nrog qhov tsis tseem ceeb nce ntawm 15% (saib - mus txog 9 lub hlis mus rau 3 xyoo).
Ntau qhov kev sau npe, kev sim randomized, thiab kev tshuaj ntsuam meta-analyses tau tshuaj 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 6906 cov neeg mob kho nrog BMS lossis DES, tsis muaj qhov sib txawv ntawm cov txiaj ntsig kev kho mob lossis ST tus nqi ntawm 1 xyoo ntawm kev soj ntsuam.48 Hauv lwm qhov kev sau npe ntawm 8146 tus neeg mob, qhov kev pheej hmoo ntawm kev pheej hmoo ST ntau dhau tau pom tias yog 0.6% ib xyoos piv nrog BMS.49 Ib qho kev soj ntsuam meta-kev tshawb fawb sib piv SES lossis PES nrog SMPs pom tias muaj kev pheej hmoo ntawm kev tuag thiab MI nrog thawj tiam DES piv nrog SMPs, 21 thiab lwm qhov kev tshuaj ntsuam meta ntawm 4545 tus neeg mob randomized rau SES lossis ST ntawm PES thiab BMS ntawm 4 xyoo tom qab.50 Lwm yam kev tshawb fawb hauv ntiaj teb no tau pom tias muaj kev pheej hmoo ntau ntxiv ntawm ST thiab MI hauv cov neeg mob tau kho nrog thawj tiam DES tom qab txiav tawm ntawm DAPT.51
Muab cov ntaub ntawv tsis sib haum xeeb, ntau qhov kev txheeb xyuas thiab kev txheeb xyuas meta-kev sib sau ua ke tau txiav txim siab tias DES thiab thawj tiam SGM tsis txawv qhov kev pheej hmoo ntawm kev tuag lossis MI, tab sis SES thiab PES muaj kev pheej hmoo ntau dua ST piv rau SGM.Txhawm rau tshuaj xyuas cov 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 siv tau raws li tau sau tseg thiab tias qhov kev pheej hmoo ntawm qib siab heev ST yog me me, tab sis tsis loj., Qhov tseem ceeb nce.Raws li qhov tshwm sim, FDA thiab lub koom haum pom zoo kom ncua lub sijhawm DAPT mus rau 1 xyoo, txawm tias muaj pov thawj me me los txhawb qhov kev thov no.
Raws li tau hais ua ntej, DES tiam thib ob tau tsim nrog kev tsim qauv zoo dua qub.CoCr-EES tau dhau los ntawm kev tshawb fawb soj ntsuam ntau tshaj plaws.Hauv kev txheeb xyuas meta-taw qhia los ntawm Baber et al.54 ntawm 17,101 tus neeg mob, CoCr-EES txo qis qhov tseeb / qhov tshwm sim ST thiab MI piv nrog PES, SES, thiab ZES ntawm 21 lub hlis.Thaum kawg, Palmerini thiab al tau pom nyob rau hauv ib qho kev tshuaj ntsuam meta ntawm 16,775 tus neeg mob uas CoCr-EES muaj qhov qis qis thaum ntxov, lig, 1- thiab 2-xyoo txhais ST piv rau lwm qhov sib xyaw DES.55 Cov kev tshawb fawb ntawm lub neej tiag tiag tau pom tias txo qis ntawm kev pheej hmoo ntawm ST nrog CoCr-EES piv nrog thawj tiam DES.56
Re-ZES tau muab piv nrog CoCr-EES hauv RESOLUTE-AC thiab TWENTE kev tshawb fawb.33,57 Tsis muaj qhov sib txawv tseem ceeb hauv kev tuag, myocardial infarction, lossis txhais ntu ST ntawm ob lub stents.
Hauv kev txheeb xyuas lub network ntawm 50,844 tus neeg mob, suav nrog 49 RCTs, 58 CoCr-EES tau cuam tshuam nrog qhov tshwm sim qis dua ntawm ST dua li BMS, qhov kev tshawb pom tsis pom nrog lwm DES;Kev poob qis tsis yog nyob ntawm "qhov tseem ceeb thaum ntxov" thiab tom qab 30 hnub (58).odds ratio [OR] 0.21, 95% kev ntseeg siab lub sijhawm [CI] 0.11-0.42) thiab ntawm 1 xyoo (OR 0.27, 95% CI 0.08-0.74) thiab 2 xyoos (los yog 0.35, 95% CI 0.17-0.69).Piv rau PES, SES, thiab ZES, CoCr-EES tau cuam tshuam nrog tus nqi qis ST ntawm 1 xyoo.
Thaum ntxov ST yog txuam nrog ntau yam. Hauv qab cov quav hniav morphology thiab thrombus lub nra zoo li cuam tshuam qhov tshwm sim tom qab PCI; 59 qhov sib sib zog nqus struts nkag los ntawm necrotic core (NC) prolapse, ntev nruab nrab tsim kua muag nyob rau hauv stent, suboptimal stenting nrog residual ntug dissections los yog ntug stenosis tseem ceeb, tsis tiav apposition ntawm ST. ntawm cov tshuaj antiplatelet tsis muaj feem cuam tshuam rau qhov tshwm sim ntawm ST thaum ntxov: hauv kev sim randomized piv rau BMSs nrog DESs, tus nqi ntawm cov mob hnyav thiab subacute ST thaum lub sij hawm DAPT zoo sib xws (<1%).61 Yog li, ST thaum ntxov zoo li feem ntau cuam tshuam nrog kev kho mob thiab cov txheej txheem txheej txheem. Hauv qab cov quav hniav morphology thiab thrombus lub nra zoo li cuam tshuam qhov tshwm sim tom qab PCI; 59 qhov sib sib zog nqus struts nkag los ntawm necrotic core (NC) prolapse, ntev nruab nrab tsim kua muag nyob rau hauv stent, suboptimal stenting nrog residual ntug dissections los yog ntug stenosis tseem ceeb, tsis tiav apposition ntawm ST. ntawm cov tshuaj antiplatelet tsis muaj feem cuam tshuam rau qhov tshwm sim ntawm ST thaum ntxov: hauv kev sim randomized piv rau BMSs nrog DESs, cov nqi ntawm cov mob hnyav thiab subacute ST thaum lub sij hawm DAPT zoo sib xws (<1%) .61 Yog li, thaum ntxov ST zoo li feem ntau cuam tshuam nrog kev kho mob thiab cov txheej txheem txheej txheem. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВоболетрапобоз з-за пролапса некротического ядра (NC), длинного медиального разрыва внутри стента, субоптимальноятата субоптимальноятата раевыми расслоениями или значительным краевым стенозом, неполной аппозицией и неполным овненолным расшириенипем жет увеличить риск ST.60 Терапевтический режим антитромбоцитарных препаратов не оказывает сувресния от нерчестве о ST: в рандомизированном исследовании, сравнивающем BMS thiab DES, частота острого и подострого ST во врейлая 1 DAPT ким образом, ранняя ST, по-видимому, в первую очередь связана с лежащими в основе пролеченными пораченными яролеченными xus. Lub hauv paus plaque morphology thiab thrombosis tshwm sim los cuam tshuam cov txiaj ntsig tom qab PCI; 59 qhov tob strut nkag vim necrotic nucleus (NC) prolapse, ntev medial tear nyob rau hauv stent, suboptimal stenting nrog residual marginal delaminations lossis tseem ceeb marginal stenosis, incomplete apposition ntawm ST. tic regimen ntawm cov tshuaj antiplatelet tsis cuam tshuam rau qhov tshwm sim ntawm ST thaum ntxov: nyob rau hauv ib qho kev sim randomized piv rau BMS thiab DES, qhov tshwm sim ntawm tus mob thiab subacute ST thaum lub sij hawm DAPT yog tib yam (<1%) .61 Yog li, thaum ntxov ST zoo nkaus li feem ntau cuam tshuam nrog rau kev kho mob lesions thiab proceducing.潜在的斑块形态和血栓负荷似乎影响PCI 后的结果；59 坏死核心(NC) 脱垂导趴的锩毱、的更多内容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 的随机试验中，DAPT 期间業期率相似(<1%) .61 因此，早期ST 似乎主要与潜在的治疗病变和手术因素有关。潜在的斑块 形态和 血栓 似乎 影响 影响 pci 后 结果 ； ； 栓 ； 坏 帿僿 坏 帿僿核心 脱垂 导致的 淪的 支柱 穿透 、 内长 的 内侧 、 具有 残余 边缘 或 显次着次的优支架、不 完全 并置和 不 扩张 才张扩张物的治疗方案不 显着影响 影响早期的：在项比较比较 bms 与 des 中 影响 项比较 比较 bms 与 des 中 槀朏槀暀生发生 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%) .61Lub hauv paus plaque morphology thiab thrombosis tshwm sim los cuam tshuam cov txiaj ntsig tom qab PCI;59 Kev sib sib zog nqus strut vim yog necrotic nucleus (NC) prolapse, medial ruptures nyob rau hauv stent ntev, ob qho tib si dissection nrog residual margins, los yog tseem ceeb margin nqaim Optimal stenting, tsis tiav apposition, thiab tsis tiav expansion 60 Antiplatelet regimen tsis muaj kev cuam tshuam rau thaum ntxov ST incidence ntawm PTDA thiab ST. sib piv BMS thiab DES.Feem ntau muaj feem xyuam rau cov kab mob hauv qab thiab kev phais mob.
Niaj hnub no, qhov tsom mus rau lig / lig heev ST.Thaum cov txheej txheem thiab cov txheej txheem kev ua haujlwm zoo li ua lub luag haujlwm tseem ceeb hauv kev txhim kho mob thiab subacute ST, cov txheej txheem ntawm cov txheej txheem qeeb thrombotic zoo li nyuaj.Nws tau raug pom zoo tias qee tus neeg mob tus yam ntxwv yuav ua rau muaj kev pheej hmoo rau kev loj hlob thiab siab heev ST: ntshav qab zib mellitus, ACS thaum lub sijhawm pib phais, lub raum tsis ua haujlwm, muaj hnub nyoog siab heev, txo qis ejection feem ntau, cov teeb meem mob plawv loj hauv 30 hnub ntawm kev phais thawj zaug.Rau BMS thiab DES, cov txheej txheem kev hloov pauv xws li cov hlab ntsha me me, bifurcations, kab mob sib kis, calcification, ua tiav occlusion, ntev stents tshwm sim cuam tshuam nrog kev pheej hmoo ntawm ST.62,63 Cov lus teb tsis zoo rau kev kho cov tshuaj antiplatelet yog ib qho kev pheej hmoo loj rau DES thrombosis 51.Cov lus teb no tuaj yeem yog vim tus neeg mob tsis ua raws li kev noj zaub mov tsis zoo, kev siv tshuaj tsis zoo, kev sib txuam tshuaj, cuam tshuam rau cov tshuaj teb, receptor-theem genetic polymorphism (tshwj xeeb yog clopidogrel tsis kam), thiab ua kom muaj lwm txoj hauv kev rau platelet activation.Stent neoatherosclerosis yog suav tias yog ib qho tseem ceeb rau kev ua tsis tiav stent lig, suav nrog lig ST64 (seem "Stent Neoatherosclerosis").Lub endothelium tsis zoo cais cov hlab ntsha thrombosed phab ntsa thiab stent posts los ntawm cov hlab ntsha thiab secretes antithrombotic thiab vasodilatory tshuaj.DES nthuav tawm cov phab ntsa ntawm cov hlab ntsha mus rau cov tshuaj tiv thaiv kab mob thiab cov tshuaj tso tawm platform, nrog rau kev sib txawv ntawm kev kho thiab kev ua haujlwm endothelial, nrog rau kev pheej hmoo ntawm thrombosis lig.65 Cov kev tshawb fawb txog kab mob tau pom tias muaj zog thawj tiam DES polymers tuaj yeem ua rau mob o, mob fibrin deposition, tsis zoo endothelial kho, thiab ua rau muaj kev pheej hmoo ntawm thrombosis.3 Late hypersensitivity rau DES zoo nkaus li yog lwm txoj hauv kev ua rau ST.Virmani et al.[66] qhia postmortem kev tshawb pom tom qab ST qhia aneurysm expansion nyob rau hauv lub stent ntu nrog lub zos hypersensitivity tshua muaj xws li T-lymphocytes thiab eosinophils;Cov kev tshawb pom no tuaj yeem cuam tshuam txog kev cuam tshuam ntawm cov polymers indestructible.67 Stent misfit tej zaum yuav yog vim qhov zoo tshaj plaws stent expansion lossis tshwm sim ob peb lub hlis tom qab PCI.Txawm hais tias cov txheej txheem malapposition yog ib qho kev pheej hmoo rau mob hnyav thiab subacute ST, qhov tseem ceeb ntawm kev kho mob ntawm stent malapposition yuav nyob ntawm qhov kev hloov kho ntawm cov hlab ntsha lossis kev siv tshuaj ua kom qeeb, tab sis nws qhov chaw kho mob muaj teeb meem.68
Kev tiv thaiv los ntawm DES tiam thib ob yuav suav nrog kev ua kom sai thiab ua kom zoo dua qub, nrog rau qhov sib txawv ntawm stent alloy thiab cov qauv, strut thickness, polymer zog, thiab cov tshuaj tiv thaiv kab mob, koob tshuaj, thiab kinetics.
Piv nrog rau CoCr-EES, nyias (81 µm) cobalt-chromium stent scaffolds, antithrombotic fluoropolymers, cov ntsiab lus tsis tshua muaj polymer, thiab cov tshuaj thauj khoom yuav ua rau txo qis ST.Cov kev tshawb fawb soj ntsuam tau pom tias thrombosis thiab platelet deposition yog qhov qis dua hauv cov fluoropolymer-coated stents dua li cov stents tsis muaj coated.69 Txawm tias lwm yam DES tiam thib ob muaj cov khoom zoo sib xws tsim nyog tau txais kev kawm ntxiv.
Coronary stents txhim kho txoj kev phais zoo ntawm cov kev cuam tshuam coronary piv rau cov tshuaj percutaneous transluminal coronary angioplasty (PTCA), uas muaj cov teeb meem kho tshuab (vascular occlusion, dissection, thiab lwm yam) thiab tus nqi siab ntawm restenoses (txog 40-50% ntawm cov neeg mob).Thaum kawg ntawm xyoo 1990, yuav luag 70% ntawm PCIs tau ua nrog BGM implantation.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约为班幇。 40%.然而，尽管技术、技术和药物治疗取得了进步，但BMSTxawm li cas los xij, txawm tias muaj kev nce qib hauv kev siv thev naus laus zis, cov tswv yim, thiab kev kho mob, qhov kev pheej hmoo ntawm restenosis tom qab BMS implantation yog kwv yees li 20%, nrog rau cov nqi siab tshaj 40% hauv qee pawg.71 Feem ntau, cov kev tshawb fawb soj ntsuam tau pom tias restenosis tom qab BMS implantation, zoo ib yam li cov uas pom nrog PTCA cov pa, peaks ntawm 3-6 lub hlis thiab daws ntawm 1 xyoo.72
DES ntxiv txo ISR cov nqi, 73 txawm hais tias qhov kev txo qis no yog angiographically thiab kho mob nyob ntawm seb.Lub DES polymer txheej tso tawm cov tshuaj tiv thaiv kab mob thiab tiv thaiv kev loj hlob, inhibits neointima tsim, thiab qeeb kho vascular los ntawm lub hlis lossis xyoo.74 Hauv kev soj ntsuam thiab kev tshawb fawb histological, tsis tu ncua kev loj hlob neointima tau pom nyob rau lub sijhawm ntev tom qab DES implantation, ib qho tshwm sim hu ua "late catch-up" 75.
Kev raug mob vascular thaum lub sij hawm PCI induces 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 them nqi.Raws li kev soj ntsuam histopathological, neointimal hyperplasia (HMS thiab DES) tom qab stent implantation feem ntau muaj cov qog nqaij hlav qog nqaij hlav hauv cov proteoglycan-nplua nuj extracellular matrix.70
Yog li, neointimal hyperplasia yog kev kho cov txheej txheem uas cuam tshuam nrog coagulation thiab o, nrog rau cov hlwb uas ua rau cov leeg nqaij pob txha loj hlob thiab tsim cov kab mob extracellular.Tam sim ntawd tom qab PCI, platelets thiab fibrin tso rau ntawm phab ntsa ntawm cov hlab ntsha thiab nyiam cov leukocytes los ntawm cov cell adhesion molecules.Rolling leukocytes txuas rau cov platelets txuas los ntawm kev sib cuam tshuam ntawm leukocyte integrin Mac-1 (CD11b / CD18) thiab platelet glycoprotein Ibα 53 lossis fibrinogen cuam tshuam nrog platelet glycoprotein IIb / IIIa.76.77 ib
Raws li cov ntaub ntawv tshiab, cov pob txha pob txha progenitor hlwb tau koom nrog cov tshuaj vascular thiab cov txheej txheem kho.Mobilization ntawm EPC los ntawm cov pob txha pob txha mus rau cov ntshav peripheral txhawb nqa endothelial regeneration thiab postnatal neovascularization.Nws zoo nkaus li tias cov pob txha pob txha pob txha pob txha progenitor hlwb (SMPCs) tsiv mus rau qhov chaw ntawm vascular raug mob, ua rau muaj kev loj hlob ntawm neointimal.78 Yav dhau los, CD34-zoo hlwb raug suav hais tias yog cov pej xeem ruaj khov ntawm EPCs, cov kev tshawb fawb ntxiv tau pom tias CD34 nto antigen tiag tiag paub txog cov pob txha pob txha tsis sib xws nrog lub peev xwm sib txawv rau EPCs thiab PBMCs.Transdifferentiation ntawm CD34-zoo hlwb rau hauv EPC lossis SMPC kab yog nyob ntawm thaj chaw hauv zos;Cov kab mob ischemic ua rau muaj kev sib txawv ntawm EPC phenotype, uas txhawb nqa reendothelialization, thaum cov mob inflammatory ua rau muaj kev sib txawv ntawm SMPC phenotype, uas txhawb nqa neointimal proliferation.79
Mob ntshav qab zib ua rau muaj kev pheej hmoo ntawm ISR los ntawm 30-50% tom qab BMS implantation, thiab qhov siab dua ntawm restenosis hauv cov neeg mob ntshav qab zib piv rau cov neeg mob uas tsis muaj ntshav qab zib kuj tseem nyob hauv DES era.Cov txheej txheem ntawm qhov kev soj ntsuam no yuav muaj ntau yam, suav nrog kev ua haujlwm (xws li kev hloov pauv hauv cov lus teb inflammatory) thiab anatomical (piv txwv li, cov hlab ntsha me, cov kab mob ntev dua, cov kab mob sib kis, thiab lwm yam), uas ua rau muaj kev pheej hmoo ntawm ISR.70
Lub nkoj txoj kab uas hla thiab qhov ntev ntawm qhov txhab ntawm nws tus kheej cuam tshuam rau ISR cov nqi, nrog cov kab me me / ntev dua cov kab mob ua rau cov nqi restenosis piv rau cov kab loj dua / luv dua.71
Thawj tiam stent platforms pom cov stent tuab thiab siab dua ISRs piv rau cov tiam thib ob stent platforms nrog thinner struts.
Ntxiv mus, qhov tshwm sim ntawm restenosis yog txuam nrog ntev stent, ze li ob npaug rau stent ntev> 35 mm piv rau cov <20 mm. Ntxiv mus, qhov tshwm sim ntawm restenosis yog txuam nrog stent ntev, ze li ob npaug rau stent ntev> 35 mm piv rau cov <20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента > 35 мрейта по <20 hli. Tsis tas li ntawd, tus nqi ntawm restenosis yog cuam tshuam nrog stent ntev, yuav luag ob npaug nrog stent ntev> 35 hli piv rau stent ntev <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 的两個。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 <2тчета , Tsis tas li ntawd, qhov zaus ntawm restenosis nyob ntawm qhov ntev ntawm stent: qhov ntev ntawm stent> 35 mm yog yuav luag ob npaug ntawm stent <20 mm.Qhov kawg yam tsawg kawg nkaus lumen txoj kab uas hla ntawm stent kuj tau ua lub luag haujlwm tseem ceeb: qhov kawg me me qhov kawg lumen txoj kab uas hla tau kwv yees qhov kev pheej hmoo ntawm restenosis.81.82 ib
Raws li kev lig kev cai, intimal hyperplasia tom qab BMS implantation yog suav tias yog ruaj khov, nrog rau thaum ntxov ncov ntawm 6 lub hlis thiab 1 xyoo tom qab lub sij hawm dormant lig.Lub ncov thaum ntxov ntawm kev loj hlob intimal ua raws li intimal regression nrog lumen o ob peb xyoos tom qab stent implantation tau tshaj tawm yav dhau los;kev loj hlob ntawm cov leeg nqaij du thiab kev hloov pauv hauv cov kab mob extracellular matrix tau raug npaj ua cov txheej txheem ua tau rau lig neointima regression.83 Txawm li cas los xij, cov kev tshawb fawb txuas ntxiv mus ntev tau pom cov lus teb triphasic tom qab tso BMS nrog rau thaum ntxov restenosis, intermediate regression, thiab lig luminal restenosis.84
Nyob rau hauv DES era, lig neointimal kev loj hlob tau pib tshwm sim tom qab SES los yog PES implantation nyob rau hauv cov qauv tsiaj.85 Ntau qhov kev tshawb fawb IVUS tau pom tias muaj kev txo qis ntawm kev loj hlob sai sai tom qab tau lig dhau lub sijhawm tom qab SES lossis RPE implantation, tej zaum yog vim muaj cov txheej txheem tsis tu ncua.86
Txawm hais tias "kev ruaj ntseg" ib txwm ua rau ISR, kwv yees li ib feem peb ntawm cov neeg mob nrog BMS ISR tsim ACS.plaub
Muaj ntau cov pov thawj tias mob o thiab/lossis endothelial insufficiency ua rau muaj kev loj hlob ntawm neoatherosclerosis hauv HCM thiab DES (feem ntau yog thawj tiam DES), uas tej zaum yuav yog ib qho tseem ceeb rau txoj kev loj hlob ntawm IR los yog ST.Inoue et al [87] tau tshaj tawm histological autopsy kev tshawb pom tom qab cog ntawm Palmaz-Schatz coronary stents, qhia tias qhov mob nyob ib ncig ntawm lub stent yuav ua rau muaj kev hloov pauv atherosclerotic tshiab hauv stent.Lwm cov kev tshawb fawb10 tau pom tias cov ntaub so ntswg so hauv 5-xyoo CGM muaj qhov pib tsis ntev los no atherosclerosis nrog lossis tsis muaj qhov mob peritoneal;Cov qauv ntawm ACS cov ntaub ntawv qhia pom cov kab mob tsis zoo hauv cov hlab ntsha hauv cov hlab ntsha hauv cov hlab ntsha Histological block morphology nrog foamy macrophages thiab cov roj cholesterol.Tsis tas li ntawd, thaum sib piv BMS thiab DES, qhov sib txawv tseem ceeb hauv lub sijhawm rau kev txhim kho atherosclerosis tshiab tau raug sau tseg.11,12 Qhov ntxov tshaj plaws atherosclerotic hloov pauv hauv foamy macrophage infiltration pib 4 lub hlis tom qab SES implantation, thaum tib qhov kev hloov pauv hauv CGM qhov txhab tshwm sim tom qab 2 xyoos thiab tseem tsis tshua pom txog 4 xyoo.Tsis tas li ntawd, DES stenting rau cov kab mob tsis ruaj khov xws li nyias nyias tegmental fibroatherosclerosis (TCFA) lossis intimal rupture muaj lub sij hawm luv dua rau kev loj hlob piv rau BMS.Yog li, neoatherosclerosis zoo nkaus li muaj ntau dua thiab tshwm sim ua ntej hauv thawj tiam DES dua li hauv BMS, tej zaum vim muaj qhov sib txawv ntawm cov kab mob.
Qhov cuam tshuam ntawm tiam thib ob DES lossis DES ntawm kev txhim kho tseem yuav raug tshawb nrhiav;Txawm hais tias qee qhov kev soj ntsuam tam sim no ntawm DES88 tiam thib ob qhia tias muaj mob tsawg dua, qhov tshwm sim ntawm neoatherosclerosis zoo ib yam piv rau thawj tiam, tab sis tseem xav tau kev tshawb fawb ntxiv.