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Marta Francesca Brancati. mgbe itinye aka na akwara akwara.Otú ọ dị, ọ bụ ezie na iwebata DES nke abụọ na-egosi na ọ belatara ihe omume a ma e jiri ya tụnyere ọgbọ mbụ nke DES, nchegbu dị ịrịba ama na-anọgide na-enwe nsogbu ndị nwere ike ime n'oge ikpeazụ nke ntinye stent dị ka stent thrombosis (ST) na stent resection, stenosis (SSI).ST bụ ihe omume nwere ike ịkpata ọdachi nke e belatara nke ukwuu site n'itinye stent kachasị mma, atụmatụ stent ọhụrụ, na ọgwụgwọ antiplatelet abụọ.A na-enyocha usoro nke na-akọwa ihe mere ya, na n'ezie ọtụtụ ihe kpatara ya.A na-ewerebu ISR na BMS dị ka ọnọdụ kwụ ọtọ nke nwere mmalite mmalite hyperplasia (na ọnwa 6) na-esote oge nlọghachi nke ihe karịrị otu afọ.N'ụzọ dị iche, ma nchọpụta ụlọ ọgwụ na akụkọ ihe mere eme nke DES egosipụtawo ihe àmà nke ọganihu neointimal na-adịgide adịgide n'ime ogologo oge nleba anya, ihe a maara dị ka ihe ngosi "mbubreyo".N'oge na-adịbeghị anya agbaghawo echiche na ISR bụ ọnọdụ ụlọ ọgwụ na-adịghị mma site n'ihe àmà na-egosi na ndị ọrịa nwere ISR nwere ike ịmalite nnukwu ọrịa obi.Ihe onyonyo intracoronary bụ usoro mkpasu iwe iji chọpụta plaques atherosclerotic stented na ihe ịrịba ama nke ọgwụgwọ arịa mgbe stenting gasịrị, a na-ejikarị ya emecha diagnostic coronary angiography ma mee usoro ntinye aka.Intracoronary optical coherence tomography ka a na-ewere ugbu a dị ka usoro onyonyo kachasị elu. ọ na-enye, ma e jiri ya tụnyere ultrasound intravascular, mkpebi dị mma (opekata mpe> ugboro 10), na-enye ohere ịkọwapụta nkọwa nke ọdịdị elu nke mgbidi ụgbọ mmiri. ọ na-enye, ma e jiri ya tụnyere ultrasound intravascular, mkpebi dị mma (opekata mpe> ugboro 10), na-enye ohere ịkọwapụta nkọwa nke ọdịdị elu nke mgbidi ụgbọ mmiri. оно. характеризовать поверхностную структуру стенки сосуда. ọ na-enye, ma e jiri ya tụnyere ultrasound intravascular, mkpebi dị mma (opekata mpe> ugboro 10), nke na-enye ohere ịkọwapụta nkọwa nke elu elu mgbidi arịa ahụ.与血管内超声相比，它提供了更好的分辨率（至少> 10 倍）。与血管内超声相比，它提供了更好的分辨率（至少> 10）。E jiri ya tụnyere ultrasound intravascular, ọ na-enye mkpebi dị mma (opekata mpe 10), nke na-enye ohere ịkọwapụta nkọwa nke elu elu mgbidi arịa ahụ.Ọmụmụ ihe onyonyo nke vivo kwekọrọ na nchoputa akụkọ ihe mere eme na-egosi na mbufụt na-adịghị ala ala na/ma ọ bụ arụrụ ọrụ endothelial nwere ike ibute neoatherosclerosis dị elu na HMS na DES.Ya mere, neoatherosclerosis aghọọla ihe a na-enyo enyo na-akpata ọrịa nke ọdịda stent n'oge.Isi okwu: stent akwara, stent thrombosis, restenosis, neoatherosclerosis.
Stented percutaneous coronary intervention (PCI) bụ usoro a na-ejikarị eme ihe maka ọgwụgwọ ọrịa akwara ọbara na-egosi, na usoro a na-aga n'ihu na-etolite.1 Ọ bụ ezie na ọgwụ eluting stent (DES) na-ebelata njedebe nke stent na-enweghị mkpuchi (UES), nsogbu n'oge dị ka stent thrombosis (ST) na stent restenosis (ISR) nwere ike ime site na ntinye stent, na nchegbu siri ike ka dị.2-5
Ọ bụrụ na ST bụ ihe omume nwere ike ịkpata ọdachi, nnabata na ISR bụ ọrịa na-adịghị mma ka agbaala aka n'oge na-adịbeghị anya site na ihe akaebe maka nnukwu ọrịa coronary syndrome (ACS) na ndị ọrịa nwere ISR.anọ
Taa, intracoronary optical coherence tomography (OCT) 6-9 ka a na-ewere dị ka usoro onyonyo ọgbara ọhụrụ na-enye mkpebi dị mma karịa ultrasound intravascular (IVUS).In vivo imaging ọmụmụ10-12 kwekọrọ na nchoputa nke akụkọ ihe mere eme na-egosi usoro nzaghachi vaskụla "ọhụrụ" mgbe etinyere stent na de novo "neoatherosclerosis" n'ime BMS na DES.
Na 1964 Charles Theodore Dotter na Melvin P. Judkins kọwara angioplasty mbụ.N'afọ 1978, Andreas Grunzig rụrụ balloon angioplasty nke mbụ (nke ochie ochie angioplasty balloon);ọ bụ ọgwụgwọ mgbanwe, mana ọ nwekwara ọghọm dị na nnukwu mmechi vaskụla na restenosis.13 Nke a butere nchoputa nke stent nke akwara obi: Puel na Sigwart rụnyere stent mbụ nke akwara obi na 1986, na-enye stent iji gbochie nnukwu mmechi arịa na ndọghachi azụ systolic oge.14 Ọ bụ ezie na stent mbụ ndị a gbochiri imechi ụgbọ ahụ na mberede, ha kpataara nnukwu mmebi na mbufụt nke endothelial.N'oge na-adịbeghị anya, ọmụmụ ihe abụọ dị ịrịba ama, Belgian-Dutch Stent Study 15 na Stent Restenosis Study 16, kwadoro nchekwa nke abụọ antiplatelet therapy (DAPT) stenting na/ma ọ bụ ụzọ ntinye kwesịrị ekwesị.17,18 N'ịgbaso ule ndị a, ọnụọgụ PCI rụrụ mụbara nke ukwuu.
Otú ọ dị, nsogbu nke iatrogenic in-stent neointima hyperplasia mgbe a na-achọpụta BMS ngwa ngwa, na-akpata ISR na 20-30% nke ọnya a na-agwọ.Ewebatara DES19 na 2001 iji belata mkpa restenosis na ịrụ ọrụ ọzọ.DES abawanyela obi ike nke ndị ọkà mmụta obi site n'ikwe ka ọgwụgwọ nke ọnụ ọgụgụ na-arịwanye elu nke ọnya dị mgbagwoju anya nke e weere na mbụ na a ga-agwọ ya site na iji grafting artery bypass.Na 2005, 80–90% nke PCI niile so DES.
Ihe niile nwere ihe ndọghachi azụ ya, ebe ọ bụ na 2005 nchegbu banyere nchekwa nke "ọgbọ mbụ" DES abawanyela, e mepụtara stent ọgbọ ọhụrụ dịka 20,21 ma webata ya.22 Kemgbe ahụ, mbọ iji melite arụmọrụ nke stent etoola ngwa ngwa, na teknụzụ ọhụrụ na-akpali akpali ka na-achọpụtakwa ma weta ngwa ngwa n'ahịa.
BMS bụ eriri waya dị mma.Mgbe ahụmahụ mbụ na mgbidi mgbidi, Gianturco-Roubin mount na Palmaz-Schatz mount, ọtụtụ BMS dị iche iche dị ugbu a.
A na-emepụta atụmatụ atọ dị iche iche: serpentine, tubular mesh and slotted tube.Nhazi eriri igwe nwere waya igwe ma ọ bụ ibe na-akpụ udi eriri igwe okirikiri;na tubular ntupu aghụghọ, waya akpọrepu ọnụ n'ime a ntupu na-etolite a tube;slotted aghụghọ mejupụtara ígwè tubes na laser ịkpụ.Ngwa ndị a dịgasị iche iche na nhazi (igwe anaghị agba nchara, nichrome, cobalt chrome), imewe (ụdị oghere dị iche iche na obosara, dayameta na ogologo, ike radial, radiopacity), na usoro nnyefe (na-agbasa onwe ya ma ọ bụ balloon-expandable).
Dị ka a na-achị, BMS ọhụrụ ahụ nwere alloy cobalt-chromium, na-ebute struts dị gịrịgịrị, ịrụ ọrụ ịnya ụgbọ ala ka mma na ijikwa ike ọrụ.
Ha na-enwe ikpo okwu stent metal (na-abụkarị igwe anaghị agba nchara) ma kpuchie ya na polymer nke na-ewepụta ihe ndị na-agwọ ọrịa na-egbochi mgbasa na / ma ọ bụ mgbochi mkpali.
Sirolimus (nke a makwaara dị ka rapamycin) bụ nke emepụtara na mbụ dị ka onye na-ahụ maka ọgwụ nje.Usoro ọrụ ya na-ejikọta ya na igbochi ọganihu okirikiri cell site na igbochi mgbanwe site na usoro G1 ruo S na igbochi nhazi neointima.Na 2001, ahụmahụ "mmadụ mbụ" na SES gosipụtara nsonaazụ na-ekwe nkwa, na-eduga na mmepe nke Cypher stent.23 Nnukwu ule egosila ịdị irè ya n'igbochi IR.24
A kwadoro Paclitaxel na mbụ maka ọgwụgwọ ọrịa cancer ovarian, ma ihe ndị nwere ike ime cytostatic-ọgwụ ahụ na-eme ka microtubules guzosie ike n'oge mitosis, na-eme ka ejide cell cell, ma na-egbochi nhazi neointimal-eme ka ọ bụrụ onyinye maka Taxus Express PES.Nnwale TAXUS V na VI gosipụtara ịdị ogologo oge nke PES na ọrịa obi siri ike dị mgbagwoju anya.25,26 TAXUS Liberté na-esote gosipụtara igwe anaghị agba nchara maka ịdị mfe nke nnyefe.
Ihe akaebe siri ike sitere na nyocha usoro abụọ na meta-nyocha na-egosi na SES nwere uru karịa PES n'ihi obere ọnụego IVR na revascularization arịa (TVA), yana omume na-abawanye na nnukwu myocardial infarction (AMI) na PES cohort.27.28
Ngwaọrụ ọgbọ nke abụọ ebelatala okpokolo agba, ngbanwe mgbanwe/nfefe dị mma, profaịlụ mkpochapụ polymer biocompatibility/ọgwụ ọgwụ emelitere, yana kinetics reendothelialization dị elu.Na omume ugbu a, ndị a bụ atụmatụ DES kachasị elu yana nnukwu stent coronary etinyere n'ụwa niile.
Elements Taxus na-ewe otu nzọụkwụ a n'ihu site na iji polymer pụrụ iche emebere maka ntọhapụ n'oge kachasị na sistemụ platinum-chromium spacer ọhụrụ nke na-enye oghere dị gịrịgịrị na ụbara rediopacity.Nnyocha PERSEUS 29 kwuru nsonaazụ yiri nke ahụ n'etiti Element na Taxus Express ruo ọnwa iri na abụọ.Agbanyeghị, ọnweghị ule zuru oke iji atụnyere ihe yew na ọgbọ nke abụọ ndị ọzọ DES.
Endeavor Zotarolimus Coated Stent (ZES) dabere na ikpo okwu cobalt-chromium stent siri ike nke nwere mgbanwe dị elu yana obere stent strut.Zotarolimus bụ analog sirolimus nwere mmetụta immunosuppressive yiri nke ahụ, mana enwere mmụba nke lipophilicity iji meziwanye ọnọdụ na mgbidi arịa.ZES na-eji mkpuchi phosphorylcholine polima ọhụrụ emebere iji bulie biocompatibility yana belata mbufụt.A na-asachapụ ọtụtụ ọgwụ n'oge mbụ nke mmerụ ahụ, na-esote nrụzi akwara.Mgbe ikpe ENDEAVOR nke mbụ gasịrị, ikpe ENDEAVOR III na-esote tụnyere ZES na SES, nke gosipụtara nkwụsị lumen n'oge na HR ma ọ bụ obere ihe ọjọọ na-adịghị mma nke obi (MACEs) karịa SES.30 Ọmụmụ ENDEAVOR IV tụlere ZES na PES ọzọ chọtara mmụpụta dị elu nke SIS mana ọ dị ala nke MI, ikekwe n'ihi ST na-ahụkarị na otu ZES.31 Otú ọ dị, ọmụmụ PROTECT egosighị ọdịiche dị na ugboro ST n'etiti Endeavor na Cypher stent.32
Endeavor Resolute bụ ụdị emelitere nke Endeavor stent nwere polymer ọhụrụ nwere akwa atọ.Iguzosi ike n'ezi ihe nke ọhụrụ (mgbe ụfọdụ a na-akpọ DES ọgbọ nke atọ) dabere na ikpo okwu ọhụrụ nwere ikike nnyefe dị elu ( ikpo okwu Integrity BMS) yana polymer ọhụrụ nwere oyi akwa atọ nwere ike igbochi nzaghachi mkpali mbụ wee nweta ọtụtụ ọgwụ n'ime ụbọchị 60 na-esote.Nnwale na-atụnyere Resolute na Xience V (everolimus eluting stent [EES]) gosiri na usoro mkpebi siri ike dịkwa irè n'ihe gbasara ịnwụ anwụ na ọdịda ọnya ebumpụta ụwa.33.34
Everolimus, ihe na-emepụta sirolimus, bụkwa onye na-eme ihe nkwụsị nke cell na-eji na mmepe nke EES Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium ikpo okwu).Nnwale SPIRIT 35-37 gosipụtara nsonaazụ ka mma ma belata MACE na Xience V ma e jiri ya tụnyere PES, ebe ikpe mara mma gosipụtara na EES dị mma dị ka SES na-egbochi ọnwụ mbubreyo na ọnwa 9 na ihe omume ụlọ ọgwụ na ọnwa 12.38 N'ikpeazụ, egosiwo na Xience stent dị elu karịa BMS na nhazi nke ST elevation myocardial infarction (MI).39
EPC bụ akụkụ nke mkpụrụ ndụ na-ekesa na-etinye aka na vaskụla homeostasis na nrụzi endothelial.Ịba ụba EPC na saịtị nke mmerụ ahụ vaskụla ga-akwalite n'oge na-emegharịghachi azụ, nwere ike ibelata ihe ize ndụ nke ST.Ihe mbụ EPC Biology mere n'ime imepụta stent bụ Genous stent, nke ejiri ọgwụ mgbochi CD34 kpuchie, nwere ike ijikọ EPC na-ekesa site na akara hematopoietic iji welie endothelialization.Ọ bụ ezie na ọmụmụ ihe mbụ na-agba ume, ihe àmà na-adịbeghị anya na-egosi ọnụ ọgụgụ TVR dị elu.40
Nyere mmetụta nwere ike imebi nke ọgwụgwọ igbu oge na-ebute polymer nke jikọtara ya na ihe ize ndụ ST, polymers bioresorbable na-enye uru nke DES site n'izere nchegbu ogologo oge gbasara nnọgidesi ike polymer.Ruo ugbu a, akwadoro usoro dị iche iche nke bioresorbable (dịka ọmụmaatụ, Nobori na Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), mana akwụkwọ na-akwado nsonaazụ ogologo oge ha nwere oke.41
Ihe ndị a na-ahụ maka ihe ndị na-emepụta ihe nwere uru echiche nke inye nkwado n'ibu na mbụ mgbe a na-eburu nkwụghachi azụ na-ebelata ihe egwu dị ogologo oge jikọtara ya na struts ígwè dị adị.Teknụzụ ọhụrụ emeela ka mmepe nke lactic acid polymers (poly-l-lactic acid [PLLA]), mana ọtụtụ usoro stent na-etolite, ọ bụ ezie na ịchọta nguzozi dị mma n'etiti elution ọgwụ na mmebi kinetics nọgidere bụrụ ihe ịma aka.Ọmụmụ ABSORB gosipụtara nchekwa na ịdị irè nke stent PLLA nwere mkpuchi everolimus.43 Ndozigharị nke ọgbọ nke abụọ Absorb stent dị mma karịa nke gara aga nwere ezigbo nleba anya afọ 2.44 Ọmụmụ ABSORB II dị ugbu a, nnwale nke mbụ na-enweghị usoro na-atụnyere Absorb stent na Xience Prime stent, kwesịrị inyekwu data ọzọ, na nsonaazụ mbụ dịnụ na-ekwe nkwa.45 Otú ọ dị, ọ dị mkpa ka akọwapụta ọnọdụ dị mma, usoro ịkụnye ihe, na profaịlụ nchekwa na ọrịa akwara obi.
Thrombosis na ma BMS na DES nwere nsonaazụ ụlọ ọgwụ ọjọọ.N'ime ndekọ nke ndị ọrịa etinyere na DES, 47 24% nke ikpe ST butere ọnwụ, 60% na MI na-adịghị egbu egbu, yana 7% na angina na-akwụghị ọtọ.PCI maka ST ngwa ngwa na-adịkarị mma, yana nlọghachi na 12% nke ikpe.48
Mgbatị ST nwere nsonaazụ ụlọ ọgwụ na-adịghị mma.N'ime ọmụmụ BASKET-LATE, ọnwa 6-18 mgbe etinyere stent, ọnụ ọgụgụ nke ọnwụ obi na ndị na-adịghị egbu egbu MI dị elu na otu DES karịa na otu SMP (4.9% na 1.3%, n'otu n'otu).20 A meta-analysis of itoolu ọmụmụ nke 5261 ọrịa na-randomed na SES, PES, ma ọ bụ BMS gosiri na mgbe 4 afọ nke nsochi, SES (0.6% vesos 0%, p = 0.025) na PES (0.7%)) mụbara omume nke nnọọ mbubreyo ST = tụnyere BMS site 0.2%, p8).49 N'ụzọ dị iche, na meta-analysis gụnyere ndị ọrịa 5108, 21 na 60% mmụba ikwu na ọnwụ ma ọ bụ MI ka a kọrọ na SES ma e jiri ya tụnyere BMS (p = 0.03), ebe PES jikọtara ya na mmụba na-enweghị isi nke 15% (lee - ruo ọnwa 9 ruo afọ 3).
Ọtụtụ ndebanye aha, nnwale ndị a na-ahaziri ahazi, na meta-analyses enyochala ihe egwu dị na ST mgbe etinyere BMS na DES wee kọpụta nsonaazụ na-emegiderịta onwe ya.Na ndekọ nke ndị ọrịa 6906 na-emeso ya na BMS ma ọ bụ DES, ọ dịghị ihe dị iche iche na nsonaazụ ụlọ ọgwụ ma ọ bụ ọnụego ST na 1 afọ nsochi.48 N'ime ndekọ ọzọ nke ndị ọrịa 8146, ihe ize ndụ nke nkwụsị ST na-adịgide adịgide bụ 0.6% kwa afọ ma e jiri ya tụnyere BMS.49 A meta-analysis nke ọmụmụ tụnyere SES ma ọ bụ PES na SMPs gosiri ihe ize ndụ dị ukwuu nke ọnwụ na MI na mbụ ọgbọ DES tụnyere SMPs, 21 na ọzọ meta-analysis nke 4545 ọrịa randomized na SES ma ọ bụ ST n'etiti PES na BMS na 4 afọ nsochi.50 Ọmụmụ ihe ndị ọzọ dị n'ụwa egosipụtawo ihe ize ndụ dị ukwuu nke ST na MI na-aga n'ihu na ndị ọrịa na-emeso DES ọgbọ mbụ mgbe ịkwụsị DAPT.51
N'inye data na-emegiderịta onwe ya, ọtụtụ nyocha agbakọtara na meta-nyocha gbakọtara ọnụ na DES na ọgbọ mbụ SGM adịghị iche n'ihe ize ndụ nke ọnwụ ma ọ bụ MI, mana SES na PES nwere nnukwu ihe ize ndụ nke ST na-ahụkarị ma e jiri ya tụnyere SGM.Iji nyochaa ihe akaebe dị, US Food and Drug Administration (FDA) họpụtara ọkachamara panel53 nke wepụtara nkwupụta na-aghọta na ọgbọ mbụ DES dị irè dị ka aha ya na ihe ize ndụ nke ọkwa dị elu nke ST dị ntakịrị, ma ọ bụghị nnukwu., Mmụba dị ịrịba ama.N'ihi ya, FDA na mkpakọrịta na-akwado ịgbatị oge DAPT ruo 1 afọ, ọ bụ ezie na e nwere obere ihe akaebe na-akwado nkwupụta a.
Dị ka e kwuru na mbụ, ọgbọ nke abụọ DES ka e jiriwo njiri mara mma mepụta.CoCr-EES emeela nyocha ụlọ ọgwụ kachasị ukwuu.Na meta-analysis site Baber et al.54 nke ndị ọrịa 17,101, CoCr-EES belatara nke ọma / ST na MI ma e jiri ya tụnyere PES, SES, na ZES na ọnwa 21.N'ikpeazụ, Palmerini et al gosipụtara na meta-analysis nke ndị ọrịa 16,775 na CoCr-EES nwere ntakịrị ala n'oge, mbubreyo, 1- na 2 afọ akọwapụtara ST ma e jiri ya tụnyere ndị ọzọ agbakọtara DES.55 Nnyocha ndụ n'ezie egosila mbelata ihe ize ndụ nke ST na CoCr-EES ma e jiri ya tụnyere ọgbọ mbụ DES.56
Atụnyere Re-ZES na CoCr-EES na ọmụmụ RESOLUTE-AC na TWENTE.33,57 Enweghị nnukwu ọdịiche dị na ọnwụ, infarction myocardial, ma ọ bụ akụkụ ST akọwapụtara n'etiti stent abụọ ahụ.
Na meta-analysis netwọk nke ndị ọrịa 50,844, gụnyere 49 RCTs, 58 CoCr-EES jikọtara ya na ọnọdụ dị ala nke akọwapụtara ST karịa BMS, nchọpụta ahụghị na ndị ọzọ DES;Mbelata ahụ abụghị naanị na "n'oge dị mkpa" na mgbe ụbọchị 30 gasịrị (58).ihe mgbagwoju anya [OR] 0.21, 95% oge ntụkwasị obi [CI] 0.11-0.42) na na 1 afọ (OR 0.27, 95% CI 0.08-0.74) na 2 afọ (OR 0.35, 95% CI 0.17-0.69).Tụnyere PES, SES, na ZES, CoCr-EES jikọtara ya na ọnụego ST dị ala na 1 afọ.
A na-ejikọta ST mbụ na ihe dị iche iche. N'okpuru morphology plaque na thrombus ibu yiri ka ọ na-emetụta ihe ga-esi na ya pụta mgbe PCI; 59 miri emi struts penetration site necrotic core (NC) prolapse, ogologo medial anya mmiri n'ime stent, suboptimal stenting na residual onu dissections ma ọ bụ ịrịba onu stenosis, ezughị ezu apposition, na ezughị ezu mgbasawanye nke nwere ike ime ka usoro ihe ize ndụ nke STplatent 6. t ọgwụ anaghị emetụta n'ụzọ dị ukwuu na mmalite nke ST: na nnwale a na-ahaziri ahazi na-atụnyere BMS na DES, ọnụego nke nnukwu na subacute ST n'oge DAPT yiri (<1%).61 Ya mere, mmalite ST yiri ka ọ bụ isi ihe metụtara ọnya ndị a na-agwọ ọrịa na usoro usoro. N'okpuru morphology plaque na thrombus ibu yiri ka ọ na-emetụta ihe ga-esi na ya pụta mgbe PCI; 59 miri emi struts penetration site necrotic core (NC) prolapse, ogologo medial anya mmiri n'ime stent, suboptimal stenting na residual onu dissections ma ọ bụ ịrịba onu stenosis, ezughị ezu apposition, na ezughị ezu mgbasawanye nke nwere ike ime ka usoro ihe ize ndụ nke STplatent 6. t ọgwụ anaghị emetụta n'ụzọ dị ukwuu na mmalite nke ST: na ule a na-ahaziri ahazi na-atụnyere BMS na DES, ọnụego nke nnukwu na subacute ST n'oge DAPT yiri (<1%) .61 Ya mere, mmalite ST yiri ka ọ bụ isi ihe metụtara ọnya ndị a na-agwọ ọrịa na usoro usoro. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход посрасле ЧКВ;59; порок из-за пролапса некротического ядра (NC), ми. ет увеличить риск ST.60 Терапевтический режим. ST: в рандомизированном исследовании, сравнивающем BMS na DES, частота острого и подострого ST во время ST во время DAPT 6 (1) . м. . . mị. N'okpuru morphology plaque na thrombosis yiri ka ọ na-emetụta nsonaazụ mgbe PCI; 59 miri emi strut penetration n'ihi necrotic nucleus (NC) prolapse, ogologo medial anya mmiri n'ime stent, suboptimal stenting na residual marginal delaminations ma ọ bụ ịrịba akụkụ stenosis, ezughị ezu apposition na ezughị ezu nke usoro ihe ize ndụ na-abawanye ụba nke usoro. ọgwụ antiplatelet adịghị emetụta nke ọma na mmalite nke ST: n'ime ule a na-atụghị anya ya na-atụnyere BMS na DES, ọnọdụ nke nnukwu na subacute ST n'oge DAPT bụ otu (<1%) .61 Ya mere, mmalite ST na-egosi na ọ bụ isi ihe metụtara ọnya na-edozi ahụ na usoro usoro.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)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、不完全完不并不并不并不并不并不并不并不并并不并不并不并不并不并不并不并不并不不不平并不并不不不平平并不内和不不不不并并不，血小板药物的治疗方案不会显着影响早期ST .亚急性ST 的治疗率相似（<1%） .61 因此，早期ST潜在 的 斑块 形态 和 一栓 似乎 影响 影响 pci 后 结果核心 核心 脱垂 导致 的 深 的 支柱 穿透 、 内长次 次 次 不 完全 并置和 并置和小板 的 治疗 方案 不 显着 影响 影响 早期 的急性 发生 发生 发生 发生 发生发生 发生 发生 发生 发生 发生 发生 发生率相似（<1%） .61Ihe dị n'okpuru morphology na thrombosis yiri ka ọ na-emetụta nsonaazụ mgbe PCI gasịrị;59 miri emi strut penetration n'ihi necrotic nucleus (NC) prolapse, medial ruptures n'ogologo stent, nke abụọ dissection na residual akụkụ, ma ọ bụ dị ịrịba n'ókè narrowing kacha mma stenting, ezughị ezu apposition, na ezughị ezu mgbasa60 Antiplatelet regimen enweghị mmetụta dị ịrịba ama na mmalite ST n'oge ikpe nke BPT. MS na DES.bụ isi metụtara ọnya ọgwụgwọ na-akpata na ihe ịwa ahụ.
Taa, a na-elekwasị anya na mbubreyo/ọgwụgwụ ST.Ọ bụ ezie na usoro usoro na nkà na ụzụ yiri ka ọ na-ekere òkè dị ukwuu na mmepe nke nnukwu na subacute ST, usoro nke ihe omume thrombotic na-egbu oge na-egosi na ọ dị mgbagwoju anya.A na-atụ aro na ụfọdụ njirimara onye ọrịa nwere ike bụrụ ihe ize ndụ maka ST na-aga n'ihu na nke ukwuu: ọrịa shuga mellitus, ACS n'oge ịwa ahụ mbụ, ọdịda akụrụ, afọ ime agadi, mbelata ejection ejection, nnukwu obi obi ọjọọ n'ime ụbọchị 30 nke ịwa ahụ mbụ.Maka BMS na DES, usoro mgbanwe usoro dị ka obere ụgbọ mmiri, bifurcations, ọrịa multivascular, calcification, nkwụsị zuru ezu, ogologo stent na-egosi na ọ na-ejikọta ya na ihe ize ndụ nke ST na-aga n'ihu.62,63 Nzaghachi na-adịghị mma maka ọgwụgwọ antiplatelet bụ isi ihe ize ndụ maka DES thrombosis na-aga n'ihu 51.Nzaghachi a nwere ike ịbụ n'ihi nnabata onye ọrịa na-anabataghị, ime ihe na-adịghị mma, mmekọrịta ọgwụ ọjọọ, nsogbu na-emetụta nzaghachi ọgwụ, mkpụrụ ndụ ihe nketa ọkwa polymorphism (karịsịa nguzogide clopidogrel), na ịgbalite ụzọ ndị ọzọ maka ịgbalite platelet.A na-ewere Stent neoatherosclerosis dị ka usoro dị mkpa maka ọdịda stent n'oge, gụnyere mbubreyo ST64 (ngalaba "Stent Neoatherosclerosis").Endothelium adịghị emebi emebi na-ekewa mgbidi arịa thrombosed na oghere stent site na ọbara ma na-ezobe ihe antithrombotic na vasodilatory.DES na-ekpughe mgbidi arịa ahụ na ọgwụ ndị na-eme ka ọ ghara ịba ụba na ikpo okwu na-ewepụta ọgwụ, na-enwe mmetụta dịgasị iche iche na ọgwụgwọ na ọrụ endothelial, na-enwe ihe ize ndụ nke thrombosis n'oge.65 Ọmụmụ ihe gbasara ọrịa egosila na ndị siri ike nke ọgbọ mbụ DES polymers nwere ike inye aka na mbufụt na-adịghị ala ala, ntinye fibrin na-adịghị ala ala, ọgwụgwọ endothelial na-adịghị mma, na n'ihi ya ka ọ dịkwuo ize ndụ nke thrombosis.3 Ọpụpụ n'oge na-adịghị anya na DES yiri ka ọ bụ usoro ọzọ na-eduga na ST.Virmani et al.[66] kọrọ nchoputa postmortem ka ST na-egosi mgbasawanye aneurysm na akụkụ stent na mmeghachi omume hypersensitivity mpaghara nke gụnyere T-lymphocytes na eosinophils;Nchọpụta ndị a nwere ike igosi mmetụta nke polymers na-adịghị emebi emebi.67 Stent misfit nwere ike ịbụ n'ihi mgbasawanye stent kachasị mma ma ọ bụ mee ọtụtụ ọnwa ka PCI gachara.Ọ bụ ezie na ndakpọ usoro bụ ihe dị ize ndụ maka nnukwu na subacute ST, uru ahụike nke enwetara stent malapposition nwere ike ịdabere na ngbanwe akwara ike ma ọ bụ ọgwụgwọ na-egbu oge nke ọgwụ, mana mkpa ya na ụlọ ọgwụ bụ arụmụka.68
Mmetụta nchebe nke ọgbọ nke abụọ DES nwere ike ịgụnye njedebe ngwa ngwa na nke na-adịghị emebi emebi, yana ọdịiche dị na stent alloy na nhazi, ọkpụrụkpụ strut, polymer Njirimara, na ụdị ọgwụ mgbochi proliferative, dose, na kinetics.
Tụnyere CoCr-EES, mkpa (81 µm) cobalt-chromium stent scaffolds, antithrombotic fluoropolymers, obere polymer ọdịnaya, na ibu ọgwụ nwere ike itinye aka na ala ST ọnụego.Nnyocha nnwale egosila na thrombosis na ntinye platelet dị ntakịrị na stent nwere mkpuchi fluoropolymer karịa na stent enweghị mkpuchi.69 Ma ndị ọgbọ nke abụọ ndị ọzọ nwere ihe onwunwe yiri nke ahụ kwesịrị ọmụmụ ihe ọzọ.
Ụkwụ akwara na-eme ka ihe ịga nke ọma nke ịwa ahụ nke mgbatị obi na-eme ka e jiri ya tụnyere omenala percutaneous transluminal coronary angioplasty (PTCA), nke nwere nsogbu usoro (occlusion vascular, dissection, wdg) na ọnụ ọgụgụ dị elu nke restenoses (ruo 40-50% nke ikpe).Ka ọ na-erule ngwụsị nke 1990s, ihe fọrọ nke nta ka ọ bụrụ 70% nke PCI ka ejiri ntinye BGM rụọ ọrụ.70
然而，尽管技术、技术和药物治疗取得了进步，但BMS生率> 40%.然而，尽管技术、技术和药物治疗取得了进步，但BMSOtú ọ dị, n'agbanyeghị ọganihu na nkà na ụzụ, usoro, na ọgwụgwọ, ihe ize ndụ nke restenosis na-esochi ntinye BMS bụ ihe dịka 20%, na ọnụego karịrị 40% na ụfọdụ subgroups.71 N'ozuzu, nchọpụta ụlọ ọgwụ egosiwo na restenosis mgbe etinyere BMS, dị ka nke a na-ahụ na PTCA omenala, ọnụ ọgụgụ kasị elu na ọnwa 3-6 ma kpebie na 1 afọ.72
DES na-ebelata ọnụego ISR,73 n'agbanyeghị na mbelata a dabere na angiographically na ụlọ ọgwụ.Ihe mkpuchi DES polymer na-ewepụta ihe mgbochi mkpali na mgbochi proliferative, na-egbochi nhazi neointima, na-egbu oge nrụzi vaskụla site na ọnwa ma ọ bụ afọ.74 Na nyocha ụlọ ọgwụ na akụkọ ihe mere eme, a hụwo uto neointima na-adịgide adịgide n'ime ogologo oge nleba anya mgbe etinyere DES, ihe a maara dị ka "nkwụsị oge" 75.
mmerụ ahụ akwara n'oge PCI na-ebute usoro mgbagwoju anya nke mbufụt na nrụzi n'ime obere oge (izu ruo ọnwa), na-ebute endothelialization na mkpuchi neointimal.Dika ihe nleba anya nke histopathological si kwuo, neointimal hyperplasia (HMS na DES) mgbe etinyere stent tumadi bu sel akwara na-adighi nma n'ime matriks extracellular proteoglycan bara ụba.70
Ya mere, hyperplasia neointimal bụ usoro nrụzi nke metụtara coagulation na ihe ndị na-egbuke egbuke, yana sel ndị na-eme ka mkpụrụ ndụ na-eme ka ahụ dịkwuo mma na ịmepụta matrix extracellular.Ozugbo PCI gachara, a na-edobe platelet na fibrin n'ahụ mgbidi arịa ahụ ma na-adọta leukocytes site na usoro nke mkpụrụ ndụ adhesion cell.Leukocytes na-atụgharị na-ejikọta na platelet ndị agbakwunyere site na mmekọrịta dị n'etiti leukocyte integrin Mac-1 (CD11b/CD18) na platelet glycoprotein Ibα 53 ma ọ bụ fibrinogen jikọtara ya na platelet glycoprotein IIb/IIIa.76.77
Dị ka data ọhụrụ si kwuo, mkpụrụ ndụ ọkpụkpụ ọkpụkpụ na-etinye aka na mmeghachi omume vaskụla na nhazi nhazi.Ịchịkọta EPC site na ụmị ọkpụkpụ gaa n'ọbara dị n'akụkụ na-akwalite mmeghari endothelial na neovascularization postnatal.Ọ na-egosi na ụmị ọkpụkpụ na-eme ka mkpụrụ ndụ progenitor muscle (SMPCs) na-akwaga na saịtị nke mmerụ ahụ, na-ebute mmụba neointimal.78 Na mbụ, a na-ewere CD34-positive cell dị ka ọnụ ọgụgụ ndị EPC dị iche iche, nchọpụta ndị ọzọ egosiwo na CD34 antigen na-amata n'ezie mkpụrụ ndụ ụmị ọkpụkpụ na-enweghị atụ nke nwere ike ịmata ọdịiche dị n'ime EPCs na PBMC.Mgbanwe nke mkpụrụ ndụ CD34 dị mma n'ime usoro EPC ma ọ bụ SMPC dabere na mpaghara mpaghara;Ọnọdụ ischemic na-eme ka ọdịiche dị na EPC phenotype, nke na-akwalite reendothelialization, ebe ọnọdụ mkpali na-eme ka ọdịiche dị na SMPC phenotype, nke na-akwalite mmụba neointimal.79
Ọrịa shuga na-abawanye ohere nke ISR site na 30-50% mgbe etinyere BMS, ọnụ ọgụgụ dị elu nke restenosis na ndị ọrịa mamịrị ma e jiri ya tụnyere ndị ọrịa na-abụghị ndị ọrịa mamịrị na-adịgidekwa n'oge DES.Usoro ndị dị n'okpuru nleba anya a nwere ike ịbụ multifactorial, gụnyere sistemu (dịka ọmụmaatụ, mgbanwe na nzaghachi mkpali) na anatomical (dịka ọmụmaatụ, obere arịa, ọnya ogologo, ọrịa mgbasa, wdg), nke na-abawanye ohere nke ISR n'onwe ya.70
Dayameta ụgbọ mmiri na ogologo ọnya na-emetụta ọnụ ahịa ISR n'onwe ya, yana obere dayameta / ọnya dị ogologo na-abawanye ọnụ ọgụgụ restenosis nke ukwuu ma e jiri ya tụnyere nnukwu dayameta / ọnya dị mkpụmkpụ.71
Usoro ikpo okwu stent nke ọgbọ mbụ gosipụtara stent stent na ISR dị elu ma e jiri ya tụnyere ọgbọ nke abụọ stent nyiwe nwere struts dị gịrịgịrị.
Ọzọkwa, a na-ejikọta ihe omume nke restenosis na ogologo stent, ihe fọrọ nke nta ka ọ bụrụ okpukpu abụọ maka ogologo stent> 35 mm ma e jiri ya tụnyere ndị <20 mm. Ọzọkwa, a na-ejikọta ihe omume nke restenosis na ogologo stent, ihe fọrọ nke nta ka ọ bụrụ okpukpu abụọ maka ogologo stent> 35 mm ma e jiri ya tụnyere ndị <20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при > 35 mm. Na mgbakwunye, ọnụ ọgụgụ nke restenosis metụtara ogologo stent, ihe fọrọ nke nta ka ọ bụrụ okpukpu abụọ na ogologo stent> 35 mm ma e jiri ya tụnyere ogologo stent <20 mm.此外，再狭窄的发生率与支架长度有关，支架长度>35 mm 的支架长度几乎是<20 mm 的两关此外，再狭窄的发生率与支架长度有关，支架长度>35 mm Кроме того, частота рестеноза зависела от длины стента: длина стента >35 мм почти в два раза больтим . Tụkwasị na nke ahụ, ugboro ugboro nke restenosis na-adabere n'ogologo stent: ogologo nke stent> 35 mm fọrọ nke nta ka okpukpu abụọ nke stent <20 mm.Dayameta lumen kacha nta nke ikpeazụ nke stent rụkwara ọrụ dị mkpa: obere dayameta lumen ikpeazụ nke ikpeazụ buru amụma na ọ ga-abawanye ohere nke restenosis.81.82
Na omenala, hyperplasia intimal mgbe etinyere BMS ka a na-ewere dị ka ọ kwụsiri ike, yana ọnụ ọgụgụ mbụ dị n'etiti ọnwa 6 na 1 afọ na-esote oge ezumike.Ọnụ ọgụgụ mbụ nke uto na-esote na-esote nchikota nke ntachi obi na mmụba lumen ọtụtụ afọ mgbe etinyere stent n'oge gara aga;maturation nke mkpụrụ ndụ akwara dị nro na mgbanwe na matriks extracellular ka atụpụtara dịka usoro enwere ike maka nlọghachi azụ neointima n'oge.83 Otú ọ dị, ọmụmụ ihe nleba anya ogologo oge egosiwo nzaghachi triphasic mgbe ntinye BMS na mmalite restenosis, nkwụghachi azụ nke etiti, na njedebe luminal restenosis.84
N'oge DES, mbubreyo neointimal ka e gosipụtara na mbụ mgbe etinyere SES ma ọ bụ PES n'ụdị anụmanụ.85 Ọtụtụ nchọpụta IVUS egosila nrịbawanye nke mbụ nke ọganihu na-esote site na njedebe oge na-aga n'ihu mgbe SES ma ọ bụ RPE tinyechara, ikekwe n'ihi usoro mkpali na-aga n'ihu.86
N'agbanyeghị "nkwụsi ike" nke ọdịnala sitere na ISR, ihe dị ka otu ụzọ n'ụzọ atọ nke ndị ọrịa nwere BMS ISR na-etolite ACS.anọ
Enwere ihe akaebe na-abawanye na mbufụt na-adịghị ala ala na / ma ọ bụ endothelial insufficiency na-ebute neoatherosclerosis na-aga n'ihu na HCM na DES (karịsịa ọgbọ mbụ DES), nke nwere ike ịbụ usoro dị mkpa maka mmepe IR na-aga n'ihu ma ọ bụ ST na-aga n'ihu.Inoue et al [87] kọrọ nchoputa nke akụkọ ihe mere eme autopsy mgbe etinyere Palmaz-Schatz coronary stent, na-atụ aro na mbufụt gburugburu stent nwere ike ịkpalite mgbanwe atherosclerotic ọhụrụ n'ime stent.Nnyocha ndị ọzọ10 egosila na anụ ahụ restenotic n'ime afọ 5 CGM nwere mmalite mmalite nke atherosclerosis na ma ọ bụ na-enweghị mbufụt peritoneal;ihe nlere sitere na ikpe ACS na-egosi plaques na-adịghị ike na akwara akwara nke afọ ime ihe omimi ihe omimi nke nwere macrophages foamy na kristal cholesterol.Na mgbakwunye, mgbe a na-atụnyere BMS na DES, a hụrụ nnukwu ọdịiche dị na oge mmepe nke atherosclerosis ọhụrụ.11,12 Mgbanwe mbụ nke atherosclerotic na foamy macrophage infiltration malitere 4 ọnwa mgbe etinyere SES, ebe mgbanwe ndị ahụ na ọnyá CGM mere mgbe afọ 2 gasịrị ma nọgide na-achọta ihe na-adịghị ahụkebe ruo afọ 4.Na mgbakwunye, DES stenting maka ọnya na-akwụghị ọtọ dị ka thin tegmental fibroatherosclerosis (TCFA) ma ọ bụ mgbawa na-akpachi anya nwere obere oge maka mmepe ma e jiri ya tụnyere BMS.Ya mere, neoatherosclerosis yiri ka ọ na-adịkarị ma na-eme na mbụ na ọgbọ mbụ DES karịa na BMS, ikekwe n'ihi ọrịa dị iche iche.
Mmetụta nke ọgbọ nke abụọ DES ma ọ bụ DES na mmepe ka ga-enyocha;ọ bụ ezie na ụfọdụ nchọpụta dị ugbu a nke ọgbọ nke abụọ DES88 na-egosi na ọ bụ obere mbufụt, ọrịa neoatherosclerosis yiri nke ahụ ma e jiri ya tụnyere ọgbọ mbụ, mana ọmụmụ ihe ndị ọzọ ka dị mkpa.