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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 Hospital, Brescia, 2 Department of Cardiology, Catholic University of the Sacred Heart of Rome, Italy Abstract: Drug-Eluting metal (DMS BES) Stemizements (DMS BES) taneous coronary intervention.Komabe, ngakhale kuti kuyambika kwa DES ya m'badwo wachiwiri kumawoneka kuti kwawongolera chodabwitsa ichi poyerekeza ndi DES ya m'badwo woyamba, nkhawa zazikulu zimakhalabe zokhudzana ndi zovuta zomwe zingatheke mochedwa chifukwa cha kuikidwa kwa stent, monga stent thrombosis (ST) ndi stent resection.Stenosis (isr) .st ndi njira yovuta kwambiri yomwe idachepetsedwa kwambiri chifukwa cha kuchuluka kwa mankhwalawo Kafukufuku wazachipatala komanso mbiri yakale ya Dess adawonetsa umboni wa kukula kopitilira muyeso, zomwe zimadziwika kuti ndi chipatala cha nthawi yayitali.Ndipo mawonekedwe a chotupa cham'mimba;Intracoronary optical coherence tomography pakali pano imatengedwa kuti ndi njira yapamwamba kwambiri yojambula zithunzi. Poyerekeza ndi intravascular ultrasound, imapereka njira yabwinoko (nthawi zosachepera> 10), kulola kufotokozera mwatsatanetsatane mawonekedwe a pamwamba pa khoma la chotengera." -atherosulinosis mkati mwa BMS ndi DES.Choncho, neo-atherosclerosis yakhala yokayikira kwambiri pathogenesis ya kulephera kwa stent mochedwa.Mawu ofunika: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
Kulowererapo kwa chirongo., nkhawa zidakalipo.2-5
Ngati ST ndizochitika zoopsa kwambiri, kuzindikira kuti ISR ​​ndi matenda osadziwika bwino posachedwapa akutsutsidwa ndi umboni wa acute coronary syndrome (ACS) mu odwala ISR.4.
Masiku ano, intracoronary optical coherence tomography (OCT) 6-9 imatengedwa kuti ndi njira yamakono yojambula zithunzi, yomwe imapereka njira yabwinoko kuposa intravascular ultrasound (IVUS)." Maphunziro a kujambula mu vivo, 10-12 yogwirizana ndi zotsatira za histological, amasonyeza "zatsopano" njira ya mitsempha ya MS pambuyo pa kuikidwa kwa stent mkati mwa "Bnevoloscope" ndi DES novos.
Mu 1964, Charles Theodore Dotter ndi Melvin P Judkins anafotokoza angioplasty yoyamba.Icho chinali chithandizo chosinthika koma chinali ndi zovuta za kutsekedwa kwa chotengera choopsa ndi restenosis.13 Izi zinapangitsa kuti pakhale ma stents a coronary: Puel ndi Sigwart adatumiza stent yoyamba ya coronary mu 1986, kupereka stent kuti ateteze kutsekedwa kwa chotengera choopsa komanso mochedwa systolic retraction. , Belgian-Dutch Stent Trial 15 ndi Stent Restenosis Study 16, adalimbikitsa chitetezo cha stenting ndi mankhwala awiri a antiplatelet (DAPT) ndi / kapena njira zoyenera zogwiritsira ntchito.17,18 Pambuyo pa mayeserowa, panali kuwonjezeka kwakukulu kwa ma PCI omwe anachitidwa.
Komabe, vuto la iatrogenic in-stent neointimal hyperplasia lotsatira BMS kuyika linadziwika mwamsanga, zomwe zinachititsa ISR mu 20% -30% ya zotupa zochiritsidwa. 2005, 80% -90% ya ma PCI onse adatsagana ndi DES.
Chilichonse chili ndi zovuta zake, ndipo kuyambira 2005, nkhawa zokhudzana ndi chitetezo cha "m'badwo woyamba" DES zawuka, ndipo ma stents atsopano monga 20,21 apangidwa ndi kuyambitsidwa.22 Kuyambira nthawi imeneyo, zoyesayesa zowonjezera ntchito za stent zakula mofulumira, ndipo matekinoloje atsopano, odabwitsa akupitirizabe kupezeka ndikubweretsedwa ku msika mofulumira.
BMS ndi ma mesh woonda waya chubu. Pambuyo pokumana koyamba ndi phiri la "Wall", phiri la Gianturco-Roubin ndi phiri la Palmaz-Schatz, ma BMS ambiri osiyanasiyana tsopano akupezeka.
Mapangidwe atatu osiyanasiyana ndi otheka: koyilo, mauna a tubular ndi chubu chopindika.Mapangidwe a makola amakhala ndi mawaya achitsulo kapena mizere yopangidwa kukhala yozungulira yozungulira;mapangidwe a mauna a tubular amakhala ndi mawaya okulungidwa pamodzi mu mesh kuti apange chubu;machubu otsekedwa amapangidwa ndi machubu achitsulo omwe amadulidwa ndi laser made.Zidazi zimasiyana mosiyanasiyana (zitsulo zosapanga dzimbiri, nichrome, cobalt chrome), mapangidwe apangidwe (mitundu yosiyanasiyana ya strut ndi m'lifupi, ma diameter ndi kutalika, mphamvu ya radial, radiopacity) ndi machitidwe operekera (kudzikulitsa kapena baluni-expandable) .
Nthawi zambiri, BMS yatsopano imakhala ndi aloyi ya cobalt-chromium, yomwe imapangitsa kuti ma struts ang'onoang'ono aziyenda bwino, kukhalabe ndi mphamvu zamakina.
Amakhala ndi nsanja yachitsulo yachitsulo (nthawi zambiri chitsulo chosapanga dzimbiri) komanso yokutidwa ndi polima yomwe imachotsa mankhwala oletsa kufalikira komanso / kapena oletsa kutupa.
Sirolimus (omwe amadziwikanso kuti rapamycin) poyamba adapangidwa ngati antifungal agent. Njira yake yochitira zinthu imachokera ku kutsekereza kufalikira kwa maselo poletsa kusintha kwa gawo la G1 kupita ku gawo la S ndikuletsa mapangidwe a neointima. ndi ISR.makumi awiri ndi zinayi
Paclitaxel idavomerezedwa koyambirira kwa khansa ya ovarian, koma mphamvu zake za cytostatic - mankhwalawa amakhazikika ma microtubules panthawi ya mitosis, amatsogolera kumangidwa kwa cell cycle ndi kulepheretsa mapangidwe a neointimal - kupanga kukhala gulu la Taxus Express PES. nsanja yachitsulo chosapanga dzimbiri kuti iperekedwe mosavuta.
Umboni wotsimikizirika kuchokera ku ndemanga ziwiri zowonongeka ndi kusanthula kwa meta zimasonyeza kuti SES ili ndi mwayi kuposa PES chifukwa cha kuchepa kwa ISR ndi cholinga cha revascularization chombo (TVR), komanso chizolowezi chowonjezeka cha acute myocardial infarction (AMI) mu gulu la PES.27, 28
Zida za m'badwo wachiwiri zachepetsa makulidwe a strut, kusinthasintha / kutulutsidwa, kupititsa patsogolo mbiri ya polymer biocompatibility/mankhwala alution, komanso re-endothelialization kinetics.Muzochita zamakono, ndi mapangidwe apamwamba kwambiri a DES ndi ma stents akuluakulu obzalidwa padziko lonse lapansi.
Taxus Elements ndikupita patsogolo kokhala ndi polima yapadera yopangidwa kuti ipititse patsogolo kumasulidwa koyambirira komanso kachitidwe katsopano ka platinamu-chromium strut system yomwe imapereka ma struts ocheperako komanso ma radiopacity owonjezera.
Zotarolimus-eluting stent (ZES) Endeavor imachokera pa nsanja yolimba ya cobalt-chromium stent yokhala ndi kusinthasintha kwakukulu komanso kukula kwa stent stent. Kutupa. Mankhwala ambiri amachotsedwa panthawi yovulazidwa koyambirira, kutsatiridwa ndi kukonzanso kwa mitsempha.Pambuyo pa mayesero oyambirira a ENDEAVOUR, mayesero otsatila a ENDEAVOUR III anayerekezera ZES ndi SES, zomwe zinawonetsa kutayika kwa lumen mochedwa kwambiri ndi ISR ​​koma zochitika zochepa kwambiri za mtima wamtima (MACE) kuposa SES .30 The ENDEAVOUR IV yesero, yomwe inafaniziridwa ndi ZESIcide, yotsika kwambiri, poyerekeza ndi mayesero otsika kwambiri a PESMI, omwe anayerekezera ndi ZES ndi kutsika kwa PESMI, komabe, kuchokera ku ST yapamwamba kwambiri mu gulu la ZES.31 Komabe, kuyesa kwa PROTECT kunalephera kusonyeza kusiyana kwa ST mitengo pakati pa Endeavor ndi Cypher stents.32
Endeavor Resolute ndi mtundu wowongoka wa Endeavor stent wokhala ndi polima watsopano wosanjikiza zitatu. Watsopano Resolute Integrity (omwe nthawi zina amatchedwa DES wa m'badwo wachitatu) amachokera pa nsanja yatsopano yokhala ndi kuthekera kwapamwamba kopereka (platform ya Integrity BMS), ndi buku, biocompatible yochulukirapo yamitundu itatu yotupa komanso yotupa kwambiri yapolymer. kuyesa kuyerekeza Resolute ndi Xience V (everolimus-eluting stent [EES]) kunawonetsa kusakhala pansi kwa dongosolo la Resolute ponena za imfa ndi kulephera kwa zilonda zam'tsogolo.33,34
Everolimus, yochokera ku sirolimus, imakhalanso cell cycle inhibitor yomwe imagwiritsidwa ntchito popanga Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform) EES. The SPIRIT trial 35-37 inawonetsa ntchito yabwino ndikuchepetsa MACE ndi Xience V poyerekeza ndi PES, pamene EXfenining isanayesedwe pa SEXCELLES kusonyeza mochedwa kuti SEXCELLES inali yoyesedwa mochedwa. miyezi ndi zochitika zachipatala pa miyezi ya 12.38 Pomaliza, Xience stent inasonyeza ubwino pa BMS poika ST-segment elevation myocardial infarction (MI) 39
EPCs ndi kagawo kakang'ono ka maselo ozungulira omwe amakhudzidwa ndi vascular homeostasis ndi endothelial repair.Kupititsa patsogolo kwa EPCs pamalo ovulala kwa mitsempha kudzalimbikitsa kukonzanso koyambirira, zomwe zingathe kuchepetsa chiopsezo cha ST.EPC biology kuyesa koyamba pakupanga stent ndi CD34 antibody-yokutidwa ndi anti-yokutidwa ndi Genous stent kupititsa patsogolo mawonekedwe ake a Genous bipontie stent, omwe amatha kupititsa patsogolo mawonekedwe ake. Thelialization.Ngakhale kuti maphunziro oyambirira anali olimbikitsa, umboni waposachedwapa umasonyeza kuti TVR.40 ikukwera kwambiri.
Poganizira zomwe zingawononge machiritso ochedwa polima, zomwe zimagwirizanitsidwa ndi chiopsezo cha ST, ma polima opangidwa ndi bioabsorbable amapereka ubwino wa DES, kupewa nkhawa za nthawi yaitali za kulimbikira kwa polima. 41
Zipangizo za bioabsorbable zili ndi mwayi wofotokozera poyamba kupereka chithandizo chamakina pamene zotanuka zotanuka zimaganiziridwa ndikuchepetsa kuopsa kwa nthawi yaitali kugwirizana ndi zitsulo zomwe zilipo kale.Njira zatsopano zamakono zachititsa kuti pakhale ma polima a lactic acid (poly-l-lactic acid [PLLA]), koma machitidwe ambiri a stent ali pa chitukuko, ngakhale kuti kutsimikizira kulephera kwa mankhwala osokoneza bongo kumapangitsa kuti pakhale zovuta za BBS. ndi mphamvu ya everolimus-eluting PLLA stents.43 M'badwo wachiwiri Absorb stent revision inali kusintha kuposa yapitayi ndi kutsata kwabwino kwa zaka 2.44 Kuyesa kosalekeza kwa ABSORB II, kuyesa koyambirira kosasinthika kuyerekeza Absorb stent ndi Xience Prime stent, kuyenera kupereka deta yowonjezereka, ndi zotsatira zabwino zopezera chitetezo, ndi njira zopezera chitetezo, ndi njira zopezera chitetezo. zotupa za ry ziyenera kufotokozedwa bwino.
Thrombosis mu BMS ndi DES ili ndi zotsatira zoipa zachipatala.Mu kaundula wa odwala omwe amalandira DES implantation, 47 24% ya STS inachititsa imfa, 60% kuchokera ku MI yosapha, ndi 7% kuchokera ku angina yosakhazikika.PCI muzochitika zadzidzidzi ST nthawi zambiri zimakhala zochepa, ndikuyambiranso mu 12% ya milandu.48
Mu phunziro la BASKET-LATE, miyezi 6 mpaka 18 pambuyo pa kuikidwa kwa stent, chiwerengero cha imfa ya mtima ndi MI yosapha inali yapamwamba mu gulu la DES kusiyana ndi gulu la BMS (4.9% ndi 1.3%, motero) 20 Meta-analysis ya 5, SES6, yomwe inafotokozedwa mwachisawawa, 5, kapena mayesero asanu ndi anayi a SES2, omwe amayesedwa mwachisawawa, a PES2, kapena mayesero asanu ndi anayi (20). pazaka 4 zotsatiridwa, SES (0.6% vs 0%, p = 0.025) ndi PES (0.7%) ) inachulukitsa chiwerengero cha ST mochedwa kwambiri poyerekeza ndi BMS ndi 0.2%, p = 0.028) .49 Mosiyana, mu meta-analysis kuphatikizapo odwala 5,108, 21 a 60 a PMS ndi 60% poyerekeza ndi imfa ya ES = 0 ES poyerekeza ndi imfa ya 60% poyerekeza ndi BMS. idalumikizidwa ndi 15% yosakhala yofunikira (Kutsatira miyezi 9 mpaka zaka 3).
Ma registries ambiri, mayesero osasinthika, ndi kusanthula kwa meta afufuza za chiopsezo chochepa cha ST pambuyo pa BMS ndi DES implantation ndipo afotokoza zotsatira zotsutsana.Mu registry ya odwala 6,906 omwe amalandira BMS kapena DES, panalibe kusiyana kwa zotsatira zachipatala kapena ST rates pa 1 chaka chotsatira. poyerekeza ndi BMS.49 Meta-analysis of trials poyerekeza SES kapena PES ndi BMS inasonyeza chiopsezo chowonjezeka cha imfa ndi MI ndi DES ya m'badwo woyamba poyerekeza ndi BMS, 21 ndi meta-analysis ina ya odwala 4,545 osinthidwa ku SES kapena Panalibe kusiyana pakati pa zochitika za ST pakati pa PES ndi BMS pa zaka 4 za maphunziro a STMI omwe akuwonjezeka kwambiri pazaka 4 za maphunziro apamwamba a STMI ndi owonetsa omwe ali ndi chiopsezo chowonjezereka. m'badwo wa DES pambuyo pa kutha kwa DAPT.51
Chifukwa cha umboni wotsutsana, kusanthula kambiri kophatikizidwa ndi kusanthula kwa meta pamodzi kunatsimikizira kuti DES ndi BMS ya m'badwo woyamba sizinasiyane kwambiri pa chiopsezo cha imfa kapena MI, koma SES ndi PES zinali ndi chiopsezo chowonjezereka cha ST yapamwamba kwambiri poyerekeza ndi BMS.Kuti tiwunikenso Umboni womwe ulipo, bungwe la US Food and Drug Administration (FDA) linasankha gulu la akatswiri53 lomwe linapereka mawu ovomereza kuti DES ya m'badwo woyamba inali yothandiza pa zizindikiro zolembera komanso kuti chiopsezo cha ST yapamwamba kwambiri chinali chaching'ono koma chaching'ono.Kuwonjezeka kwakukulu.Chotsatira chake, a FDA ndi bungwe amalimbikitsa kuwonjezera nthawi ya DAPT kwa chaka cha 1, ngakhale kuti pali deta yochepa yochirikiza izi.
Monga tanenera kale, DES yachiwiri yokhala ndi mapangidwe apamwamba apangidwa.CoCr-EESs adachita maphunziro ochuluka kwambiri a zachipatala.Mu meta-analysis ndi Baber et al, 54 kuphatikizapo odwala 17,101, CoCr-EES yachepetsedwa kwambiri yotsimikizika / mwinamwake ST ndi MI poyerekeza ndi PES, SES, ndi ZES pambuyo pa 21 metanat-anali-7 miyezi ya Palmerini-7 ya Palmerini-7 ya miyezi ya 21 ya Palmerini-7 ya Palmerini-EES adawonetsa. Odwala a 5 omwe CoCr-EES anali ndi otsika kwambiri oyambirira, mochedwa, 1- ndi 2-year yotsimikizika ST poyerekeza ndi maphunziro ena a DES.55 Real-world awonetsa kuchepetsa chiopsezo cha ST ndi CoCr-EES poyerekeza ndi DES.56 ya m'badwo woyamba.
Re-ZES inayerekezedwa ndi CoCr-EES mu mayesero a RESOLUTE-AC ndi TWENTE.33,57 Panalibe kusiyana kwakukulu pazochitika za imfa, myocardial infarction, kapena ST yotsimikizika pakati pa ma stents awiri.
Mu meta-analysis ya intaneti ya odwala 50,844 kuphatikizapo 49 RCTs, 58CoCr-EES inagwirizanitsidwa ndi zochitika zotsika kwambiri za ST kuposa BMS, zotsatira zomwe sizinawonedwe mu DES zina;kuchepetsa sikunali kokha Kufunika koyambirira komanso pamasiku a 30 (zosamveka chiŵerengero [OR] 0.21, 95% nthawi yodalirika [CI] 0.11-0.42) komanso pa 1 chaka (OR 0.27, 95% CI 0.08-0.74) ndi zaka 2 (OR 0.35% ESCI 0.7-0.6 SPA), ndi 0.35 ESCI 7, SCI 6. , ndi ZES, CoCr-EES inagwirizanitsidwa ndi chiwerengero chochepa cha ST pa chaka cha 1.
Early ST ikugwirizana ndi zinthu zosiyanasiyana.Pansi pa plaque morphology ndi katundu wa thrombus amawoneka kuti amakhudza zotsatira pambuyo pa PCI;59 Kulowera kozama kwambiri chifukwa cha necrotic core (NC) prolapse, misozi yapakati pamtunda wautali, kugawanika kwachiwiri ndi mitsinje yotsalira, kapena kuchepetsedwa kwakukulu kwa malire Oyenerera, osakwanira apposition, ndi kufalikira kosakwanira60 Chithandizo cha mankhwala ndi antiplatelet sichimakhudza kwambiri STPT mu nthawi yachisawawa: kuyesa kuyerekeza BMS ndi DES Mitengo inali yofanana (<1%) .61 Choncho, ST yoyambirira ikuwoneka kuti ikugwirizana kwambiri ndi zilonda zam'mimba zochiritsira komanso zinthu zopangira opaleshoni.
Masiku ano, cholinga chapadera ndi pa ST.Ngati zinthu za ndondomeko ndi zamakono zimawoneka kuti zikuthandizira kwambiri pa chitukuko cha matenda opatsirana kwambiri ndi subacute ST, njira ya kuchedwa kwa zochitika za thrombotic ikuwoneka kuti ndi yovuta kwambiri.Zanenedwa kuti zizindikiro zina za odwala zingakhale zoopsa za ST: matenda a shuga, ACS panthawi ya opaleshoni yoyamba, kulephera kwaimpso, kukalamba, zaka zoyamba za D30, kuchepetsedwa kwa zochitika zapakatikati za D30 ndi kuchepetsedwa kwa Djercardi . ES, zosinthika zamachitidwe, monga kukula kwa chotengera chaching'ono, bifurcations, polyvascular disease, calcification, occlusion kwathunthu, stents yaitali, zikuwoneka kuti zikugwirizana ndi chiopsezo cha ST.62,63 Kuyankha kosakwanira kwa antiplatelet therapy ndi chiopsezo chachikulu cha DES thrombosis 51 .Yankho ili likhoza kukhala chifukwa cha kusagwirizana kwa mankhwala, kusagwirizana kwa mankhwala, kusagwirizana kwa mankhwala, kusagwirizana kwa mankhwala, kusagwirizana kwa mankhwala, kusagwirizana kwa mankhwala a polymorphic, kusagwirizana kwa mankhwala, kusagwirizana kwa mankhwala. (makamaka clopidogrel resistance), ndi kuwongolera njira zina zoyambitsa mapulateleti. In-stent neoatherosclerosis imaonedwa kuti ndi njira yofunika kwambiri ya kulephera kwa stent mochedwa, kuphatikizapo mochedwa ST64 (gawo la "In-stent neoatherosclerosis"). mankhwala osokoneza bongo ndi malo opangira mankhwala osokoneza bongo omwe ali ndi zotsatira zosiyana pa machiritso a endothelial ndi ntchito, ndi chiopsezo cha thrombosis mochedwa.65 Kafukufuku wa pathological amasonyeza kuti ma polima olimba a DES a m'badwo woyamba angapangitse kutupa kosatha, kutayika kwa fibrin kosatha, machiritso osauka a endothelial, ndipo zotsatira zake zowonjezera chiopsezo cha thrombosis.3 Kuchedwa kwa hypersensitivity kwa post-6ST kumapangitsa kuti apeze chidziwitso cha post-6ST chodziwika bwino cha ST. kusonyeza kuwonjezeka kwa aneurysm pa gawo la stent ndi zochitika zam'deralo za hypersensitivity zomwe zimapangidwa ndi T lymphocytes ndi eosinophils;Zotsatirazi zikhoza kusonyeza mphamvu ya ma polima osasinthika.67 Stent malapposition ikhoza kukhala chifukwa cha kuwonjezereka kwa stent kapena kumachitika miyezi ingapo pambuyo pa PCI.
Zotsatira zoteteza za m'badwo wachiwiri wa DES zingaphatikizepo endothelialization yofulumira komanso yosasunthika, komanso kusiyana kwa stent alloy ndi mapangidwe, makulidwe a strut, katundu wa polima, ndi mtundu wa mankhwala osokoneza bongo, mlingo, ndi kinetics.
Mogwirizana ndi CoCr-EES, zowonda (81 µm) za cobalt-chromium stent stent, antithrombotic fluoropolymers, polima yochepa, ndi kulongedza kwa mankhwala kungathandize kuchepetsa chiwerengero cha ST. Kafukufuku wa Experimental asonyeza kuti thrombosis ndi kuikidwa kwa mapulateleti kwa fluoropolymer-coated-coated stents ndi ma stents otsika kwambiri a D99 otsika kwambiri. ali ndi katundu wofanana akuyenera kuphunziranso.
Ma coronary stents amathandizira kuti maopaleshoni apambane akuyenda bwino poyerekeza ndi chikhalidwe cha percutaneous transluminal coronary angioplasty (PTCA), chomwe chimakhala ndi zovuta zamakina (vascular occlusion, dissection, etc.) komanso kuchuluka kwa restenosis (mpaka 40% -50% ya milandu).Pofika kumapeto kwa zaka za m'ma 1990, pafupifupi 70% ya ma PCI anachitidwa ndi BMS implantation.70
Komabe, ngakhale kupita patsogolo kwa teknoloji, njira, ndi chithandizo chamankhwala, chiopsezo cha restenosis pambuyo pa kuikidwa kwa BMS ndi pafupifupi 20%, ndi> 40% m'magulu enaake.71 Ponseponse, maphunziro a zachipatala asonyeza kuti restenosis pambuyo pa kuikidwa kwa BMS, zofanana ndi zomwe zimawonedwa ndi PTCA wamba, zimafika pa 3-6 miyezi ndipo zimathetsa pambuyo pa 1 chaka.72.
Panafupinso zimachepetsa kuchuluka kwa istr, 73 ngakhale kuti Kuchepetsa uku kumadalira kukonzekera kwa anti-kutupa kwa nthawi yayitali ", Adawonedwa m'maphunziro azachipatala komanso mbiri yakale.75
Kuvulala kwa mitsempha pa PCI kumapanga njira yovuta yotupa ndi kukonzanso mu nthawi yochepa (masabata mpaka miyezi), zomwe zimatsogolera ku endothelialization ndi neointimal coverage. Malingana ndi kuwonetsetsa kwa histopathological, neointimal hyperplasia (BMS ndi DES) pambuyo pa kukhazikitsidwa kosasunthika kunali makamaka kumapangidwa ndi proliferative proliferative smooth matrix 7 cell cell.
Choncho, neointimal hyperplasia imayimira kukonzanso komwe kumaphatikizapo coagulation ndi zinthu zotupa komanso maselo omwe amachititsa kuti minofu ikhale yosalala komanso mapangidwe a matrix a extracellular.Atangotha ​​​​PCI, mapulateleti ndi fibrin deposit pa khoma la chombo ndikulemba ma leukocyte kupyolera mu mndandanda wa ma cell adhesion molecules.Rolling leukocytes platelets through1CD-international platelets attach1CD-contact1CD 8) ndi mapulateleti glycoprotein Ibα 53 kapena fibrinogen womangidwa ku platelet glycoprotein IIb/IIIa.76,77
Malingana ndi deta yomwe ikubwera, maselo amtundu wa mafupa omwe amachokera ku mafupa amakhudzidwa ndi mayankho a mitsempha ndi kukonzanso njira.Kusonkhanitsa kwa EPCs kuchokera ku mafupa a mafupa kupita ku magazi ozungulira kumapangitsa kuti endothelial regeneration ndi postnatal neovascularization. kuchuluka kwa ma EPC;kafukufuku wina wasonyeza kuti CD34 pamwamba antigen kwenikweni amazindikira osadziwika fupa tsinde maselo ndi luso kusiyanitsa EPCs ndi SMPCs.Transdifferentiation wa CD34-positive maselo ku EPC kapena SMPC mzere kumadalira malo am'deralo;Mikhalidwe ya ischemic imapangitsa kusiyana kwa EPC phenotype kulimbikitsa kubwezeretsanso endothelialization, pamene kutupa kumapangitsa kusiyana kwa phenotype ya SMPC kulimbikitsa kufalikira kwa neointimal.79
Matenda a shuga amawonjezera chiopsezo cha ISR ndi 30% -50% pambuyo pa kuikidwa kwa BMS, 80 komanso kuchuluka kwa restenosis kwa odwala omwe ali ndi matenda a shuga poyerekeza ndi odwala omwe alibe matenda a shuga amakhalanso opitirira mu nthawi ya DES.Njira zomwe zimayang'ana izi ndizowonjezereka, zomwe zimakhudza machitidwe (mwachitsanzo, kusinthasintha kwa kuyankha kotupa, matenda ang'onoang'ono, matenda ang'onoang'ono, ang'onoang'ono). zomwe zimachulukitsa paokha Zowopsa za ISR.70
Kutalika kwa chotengera ndi kutalika kwa zilonda zinakhudza zochitika za ISR, ndi zilonda zazing'ono zapakati / zazitali zomwe zimachulukitsa kwambiri restenosis poyerekeza ndi zilonda zazikulu / zazifupi.71
Mapulatifomu a m'badwo woyamba adawonetsa ma stent stent ndi ma ISR apamwamba kwambiri poyerekeza ndi nsanja zam'badwo wachiwiri zokhala ndi zingwe zoonda.
Kuonjezera apo, chiwopsezo cha restenosis chinali chokhudzana ndi kutalika kwa stent, ndi kutalika kwa stent> 35 mm pafupifupi kawiri kuposa <20 mm. Chomaliza chochepa cha lumen m'mimba mwake chinathandizanso kwambiri: gawo laling'ono lomaliza la lumen linanena kuti chiopsezo chowonjezeka cha restenosis.81,82
Mwachizoloŵezi, intimal hyperplasia yotsatira BMS implantation imaonedwa kuti ndi yokhazikika, ndi nsonga yoyambirira pakati pa miyezi 6 ndi 1 chaka, ndikutsatiridwa ndi nthawi yochedwa. .83 Komabe, maphunziro omwe ali ndi nthawi yayitali akuwonetsa kuyankha katatu pambuyo pa kuyika kwa BMS, ndi kupuma koyambirira, kutsika kwapakatikati, ndi kuchedwa kwa lumen restenosis.84
Mu nthawi ya DES, kukula kwa neointimal mochedwa kunasonyezedwa potsatira SES kapena PES implantation mu zitsanzo za nyama.85 Kafukufuku wambiri wa IVUS wasonyeza kuchepetsedwa koyambirira kwa kukula kwapamtima komwe kumatsatiridwa ndi kugwidwa mochedwa pakapita nthawi pambuyo pa SES kapena PES implantation, mwinamwake chifukwa cha kutupa kosalekeza.86
Ngakhale kuti "kukhazikika" komwe kumatchedwa ISR, pafupifupi gawo limodzi mwa magawo atatu a odwala BMS ISR amapanga ACS.4
Pali umboni wowonjezereka wosonyeza kuti kutupa kosatha ndi / kapena endothelial insufficiency imapangitsa kuti neatherosclerosis ipite patsogolo mkati mwa BMS ndi DES (makamaka DES ya m'badwo woyamba), yomwe ingakhale njira yofunikira ya ISR yapamwamba kapena ST.Inoue et al.87 inanena kuti zotsatira za histological kuchokera ku zitsanzo za autopsy pambuyo pa kuikidwa kwa Palmaz-Schatz coronary stents, kutanthauza kuti kutupa kwapang'onopang'ono kungapangitse kusintha kwatsopano kwa atherosclerotic mkati mwa stent.Zitsanzo zochokera ku milandu ya ACS zimasonyeza zowonongeka zowonongeka m'mitsempha yamtundu wa mitsempha Histological morphology ya chipika chokhala ndi foamy macrophages ndi makristasi a kolesteroloni. Kuphatikiza apo, poyerekeza BMS ndi DES, kusiyana kwakukulu pa nthawi ya chitukuko cha atherosclerosis yatsopano kunadziwika. Zaka za 2 pambuyo pake ndipo anakhalabe osowa kwambiri mpaka zaka 4. Komanso, DES stenting kwa zilonda zosakhazikika monga thin-cap fibroatherosclerosis (TCFA) kapena intimal rupture ali ndi nthawi yaifupi ya chitukuko poyerekeza ndi BMS.Choncho, neatherosclerosis ikuwoneka ngati yofala kwambiri ndipo imapezeka kale m'badwo woyamba wa DES kusiyana ndi BMS, mwinamwake chifukwa cha kusiyana kosiyana.
Zotsatira za DES ya m'badwo wachiwiri kapena DES mu chitukuko zikuyenera kuphunziridwa;ngakhale zowona zomwe zilipo za m'badwo wachiwiri wa DESs88 zikuwonetsa kutupa kocheperako, zochitika za neoatherosclerosis ndizofanana ndi za m'badwo woyamba, koma kafukufuku wopitilira akufunikabe.