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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 Summary : the limitations of the DrugStents of minicuze kulowererapo kwa coronary.Komabe, ngakhale kuti kuyambitsidwa kwa DES ya m'badwo wachiwiri kukuwoneka kuti kwachepetsa izi poyerekeza ndi DES ya m'badwo woyamba, nkhawa zazikulu zimakhalabe zokhudzana ndi zovuta zomwe zingatheke mochedwa za kuikidwa kwa stent monga stent thrombosis (ST) ndi stent resection, stenosis (SSI).ST ndi chochitika chomwe chingakhale chowopsa chomwe chachepetsedwa kwambiri ndi kukhathamiritsa kwa stent, mapangidwe atsopano a stent, ndi chithandizo chapawiri cha antiplatelet.Njira yeniyeni yomwe imalongosola zochitika zake ikufufuzidwa, ndipo ndithudi pali zifukwa zingapo.ISR mu BMS poyamba inkaonedwa kuti ndi yokhazikika yokhala ndi chiwopsezo choyambirira cha intimal hyperplasia (pa miyezi 6) yotsatiridwa ndi nthawi yobwereranso yoposa chaka cha 1.Mosiyana ndi zimenezi, maphunziro a zachipatala ndi a histological a DES asonyeza umboni wa kukula kosalekeza kwa neointimal pa nthawi yayitali yotsatila, chinthu chodziwika bwino chotchedwa "mochedwa catch-up" phenomenon.Lingaliro lakuti ISR ​​ndi matenda owopsa kwambiri latsutsidwa posachedwa ndi umboni wakuti odwala omwe ali ndi ISR ​​akhoza kukhala ndi matenda aakulu a coronary.Intracoronary imaging ndi njira yowonongeka yodziwira zolembera za atherosclerotic ndi zizindikiro za kuchira kwa mitsempha pambuyo pa stenting, ndipo nthawi zambiri amagwiritsidwa ntchito pomaliza matenda a coronary angiography ndikuchita njira zothandizira.Intracoronary optical coherence tomography pakali pano imatengedwa kuti ndi njira yapamwamba kwambiri yojambula zithunzi. imapereka, poyerekeza ndi intravascular ultrasound, kusamvana bwino (osachepera> 10 nthawi), kulola kufotokozera mwatsatanetsatane mawonekedwe apamwamba a khoma la chotengera. imapereka, poyerekeza ndi intravascular ultrasound, kusamvana bwino (osachepera> 10 nthawi), kulola kufotokozera mwatsatanetsatane mawonekedwe apamwamba a khoma la chotengera. оно обеспечивает, внутрисосудистым УЗИ, лучшее разрешение (pa крайней мере, >10 раз), что позволяет деавалько озволяет ру стенки сосуда. imapereka, poyerekeza ndi intravascular ultrasound, chigamulo chabwino (osachepera> 10 nthawi), chomwe chimalola kufotokoza mwatsatanetsatane mawonekedwe a pamwamba pa khoma la chotengera.与血管内超声相比，它提供了更好的分辨率（至面少> 10 倍），允许论细表征血的话。与血管内超声相比，它提供了更好的分辨率（至面少> 10)Poyerekeza ndi intravascular ultrasound, imapereka chigamulo chabwino (nthawi zosachepera 10), chomwe chimalola kufotokozera mwatsatanetsatane kapangidwe kapamwamba ka khoma la chotengera.Kafukufuku woyerekeza mu vivo wogwirizana ndi zomwe adapeza akuwonetsa kuti kutupa kosatha komanso/kapena kusagwira bwino ntchito kwa endothelial kungayambitse neotherosclerosis mu HMS ndi DES.Chifukwa chake, neotherosulinosis yakhala ikukayikira kwambiri pathogenesis ya kulephera kwa stent mochedwa.Mawu ofunikira: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
Stented percutaneous coronary intervention (PCI) ndiyo njira yomwe imagwiritsidwa ntchito kwambiri pochiza matenda a symptomatic coronary artery, ndipo njirayo ikupitilizabe kusintha.1 Ngakhale mankhwala eluting stents (DES) kuchepetsa malire a uncoated stents (UES), mavuto mochedwa monga stent thrombosis (ST) ndi mu stent restenosis (ISR) akhoza kuchitika ndi stent implantation, ndipo nkhawa yaikulu idakalipo.2-5
Ngati ST ndi chochitika chomwe chingakhale choopsa, kuvomereza kuti ISR ​​ndi matenda osadziwika bwino posachedwapa kwatsutsidwa ndi umboni wa acute coronary syndrome (ACS) kwa odwala omwe ali ndi ISR.zinayi
Masiku ano, intracoronary optical coherence tomography (OCT) 6-9 imatengedwa ngati njira yamakono yojambula zithunzi yomwe imapereka njira yabwino kuposa intravascular ultrasound (IVUS).Maphunziro oyerekeza a mu vivo10-12 ogwirizana ndi zomwe adapeza akuwonetsa njira "yatsopano" yoyankhira mitsempha pambuyo pa kukhazikitsidwa kwa stent ndi de novo "neoatherosclerosis" mkati mwa BMS ndi DES.
Mu 1964 Charles Theodore Dotter ndi Melvin P. Judkins anafotokoza angioplasty yoyamba.Mu 1978, Andreas Grunzig anachita buluni woyamba angioplasty (wakale ochiritsira baluni angioplasty);chinali chithandizo chosinthira, koma chinalinso ndi zovuta za kutseka kwa mitsempha yoopsa ndi restenosis.13 Izi zidapangitsa kuti atulutsidwe ma coronary stents: Puel ndi Sigwart adayika stent yoyamba ya coronary mu 1986, ndikupereka stent kuti apewe kutseka kwachombo komanso mochedwa systolic retraction.14 Ngakhale kuti ma stents oyambirirawa analepheretsa kutsekedwa kwadzidzidzi kwa chombocho, anawononga kwambiri endothelial ndi kutupa.Posachedwapa, maphunziro awiri odziwika bwino, Belgian-Dutch Stent Study 15 ndi Stent Restenosis Study 16, adalimbikitsa chitetezo cha dual antiplatelet therapy (DAPT) stenting ndi/kapena njira zoyenera zotumizira.17,18 Pambuyo pa mayeserowa, chiwerengero cha PCI chomwe chinachitidwa chinawonjezeka kwambiri.
Komabe, vuto la iatrogenic in-stent neointima hyperplasia pambuyo poika BMS linadziwika mwamsanga, zomwe zinachititsa ISR mu 20-30% ya zilonda zochiritsidwa.DES19 idayambitsidwa mu 2001 kuti achepetse kufunikira kwa restenosis ndi kuyambiranso.DES yawonjezera chidaliro cha akatswiri amtima mwa kulola kuchiza kuchuluka kwa zilonda zovuta zomwe poyamba zinkawoneka kuti zingathe kuchiritsidwa ndi kulumikiza kwa mitsempha ya m'mitsempha.Mu 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 yawonjezeka, ma stents atsopano monga 20,21 apangidwa ndikuyambitsidwa.22 Kuyambira pamenepo, zoyesayesa zowongolera magwiridwe antchito a stents zakula mwachangu, ndipo matekinoloje atsopano osangalatsa apitilira kupezeka ndikubweretsedwa pamsika.
BMS ndi chubu chabwino cha waya.Nditakumana koyamba ndi Wall mount, Gianturco-Roubin phiri ndi Palmaz-Schatz phiri, BMS zambiri zosiyanasiyana zilipo.
Mapangidwe atatu osiyanasiyana alipo: serpentine, tubular mesh ndi slotted chubu.Mapangidwe a coil amakhala ndi mawaya achitsulo kapena mizere yomwe imapanga mawonekedwe ozungulira;mu mapangidwe a mauna a tubular, waya wokulungidwa pamodzi kukhala mauna amapanga chubu;zojambulajambula zimakhala ndi machubu achitsulo omwe amadulidwa ndi laser.Zipangizozi zimasiyanasiyana malinga ndi kapangidwe kake (chitsulo chosapanga dzimbiri, nichrome, cobalt chrome), kapangidwe kake (kapangidwe kosiyanasiyana ka spacer ndi m'lifupi, mainchesi ndi utali, mphamvu ya radial, radiopacity), ndi machitidwe operekera (odzikulitsa okha kapena baluni-owonjezera).
Monga lamulo, BMS yatsopano imakhala ndi cobalt-chromium alloy, zomwe zimapangitsa kuti zikhale zowonda kwambiri, kuyendetsa bwino galimoto ndikusunga mphamvu zamakina.
Amakhala ndi chitsulo chosungunula chachitsulo (kawirikawiri chitsulo chosapanga dzimbiri) ndipo amakutidwa ndi polima yomwe imatulutsa anti-proliferative and/kapena anti-inflammatory treatment agents.
Sirolimus (yomwe imadziwikanso kuti rapamycin) idapangidwa ngati antifungal wothandizira.Kachitidwe kake kakuchitapo kanthu kumalumikizidwa ndi kutsekereza kupitilira kwa ma cell poletsa kusintha kuchokera ku gawo la G1 kupita ku gawo la S ndikuletsa mapangidwe a neointima.Mu 2001, "munthu woyamba" ndi SES adawonetsa zotsatira zabwino, zomwe zidatsogolera ku chitukuko cha Cypher stent.23 Mayesero akuluakulu awonetsa mphamvu zake popewa IR.24
Paclitaxel idavomerezedwa poyambirira kuti ikhale yochizira khansa ya ovarian, koma mphamvu yake ya cytostatic - mankhwalawa amakhazikika ma microtubules panthawi ya mitosis, amachititsa kuti ma cell amangidwe, ndikuletsa mapangidwe a neointimal - amapanga gulu la Taxus Express PES.Mayesero a TAXUS V ndi VI adawonetsa mphamvu ya nthawi yayitali ya PES pazovuta zazikulu za matenda a mtima.25,26 TAXUS Liberté yotsatira inali ndi nsanja yachitsulo chosapanga dzimbiri kuti iperekedwe mosavuta.
Umboni wamphamvu kuchokera ku ndemanga ziwiri zotsatizana ndi kusanthula kwa meta zikusonyeza kuti SES ili ndi mwayi kuposa PES chifukwa cha kuchepa kwa IVR ndi chandamale chombo revascularization (TVA), komanso chikhalidwe cha kuwonjezeka kwa acute myocardial infarction (AMI) mu gulu la PES.27.28
Zida za m'badwo wachiwiri zachepetsa makulidwe a shaft, kusinthasintha / kutulutsidwa, kupititsa patsogolo mbiri ya polymer biocompatibility / chilolezo chamankhwala, komanso ma kinetics apamwamba a reendothelialization.M'machitidwe apano, awa ndi mapangidwe apamwamba kwambiri a DES ndi ma stents akuluakulu omwe amabzalidwa padziko lonse lapansi.
Taxus Elements ikupita patsogolo ndi polima yapadera yopangidwira kutulutsidwa koyambirira komanso kachipangizo katsopano ka platinamu-chromium komwe kamapereka ma spacers ocheperako komanso kuchuluka kwa ma radiopacity.Kafukufuku wa PERSEUS 29 adawona zotsatira zofanana pakati pa Element ndi Taxus Express mpaka miyezi 12.Komabe, palibe mayesero okwanira kuyerekeza zinthu za yew ndi ma DES ena am'badwo wachiwiri.
Endeavor Zotarolimus Coated Stent (ZES) idakhazikitsidwa pa nsanja yolimba ya cobalt-chromium stent yokhala ndi kusinthasintha kwakukulu komanso stent yaying'ono.Zotarolimus ndi analogue ya sirolimus yofanana ndi immunosuppressive zotsatira, koma ndi kuchuluka kwa lipophilicity kuti ipititse patsogolo kukhazikika kwa khoma la chotengera.ZES imagwiritsa ntchito zokutira zatsopano za phosphorylcholine polima zopangidwira kukulitsa kuyanjana kwachilengedwe ndikuchepetsa kutupa.Mankhwala ambiri amatsukidwa mu gawo loyambirira la kuvulala, ndikutsatiridwa ndi kukonzanso kwa mitsempha.Pambuyo pa kuyesa koyamba kwa ENDEAVOUR, kuyesa kotsatira kwa ENDEAVOR III kuyerekeza ZES ndi SES, zomwe zinawonetsa kutayika kwa lumen mochedwa kwambiri komanso HR koma zochitika zowopsa zamtima (MACEs) zocheperako kuposa SES.30 Kafukufuku wa ENDEAVOR IV kuyerekeza ZES ndi PES adapezanso kuchuluka kwa SIS koma kuchepa kwa MI, mwina chifukwa cha ST yofala kwambiri mu gulu la ZES.31 Komabe, phunziro la PROTECT linalephera kusonyeza kusiyana kwa ST pafupipafupi pakati pa Endeavor ndi Cypher stents.32
Endeavor Resolute ndi mtundu wowongoka wa Endeavor stent wokhala ndi polima watsopano wosanjikiza zitatu.Resolute Integrity yatsopano (yomwe nthawi zina imatchedwa DES ya m'badwo wachitatu) imachokera pa nsanja yatsopano yokhala ndi mphamvu zoperekera zowonjezera (pulatifomu ya Integrity BMS) ndi polima yatsopano yamitundu itatu yomwe imatha kupondereza kuyankha kotupa koyambirira ndikuchotsa mankhwala ambiri m'masiku 60 otsatira.Mlandu woyerekeza Resolute ndi Xience V (everolimus eluting stent [EES]) udawonetsa kuti Resolute system inali yothandiza kwambiri pankhani ya kufa komanso kulephera kwa zilonda zam'tsogolo.33.34
Everolimus, chochokera ku sirolimus, ndi choletsa ma cell cycle inhibitor chomwe chimagwiritsidwa ntchito popanga EES Xience (Multi-link Vision BMS platform)/Promus (platinamu Chromium platform).Kuyesa kwa SPIRIT 35-37 kunawonetsa zotsatira zabwino ndikuchepetsa MACE ndi Xience V poyerekeza ndi PES, pomwe kuyesa kwa EXCELLENT kunawonetsa kuti EES inali yabwino ngati SES popondereza kutayika mochedwa pa miyezi 9 ndi zochitika zachipatala pamiyezi 12.38 Pomaliza, stent ya Xience yasonyezedwa kuti ndi yapamwamba kuposa BMS poika ST elevation myocardial infarction (MI).39
EPCs ndi kagawo kakang'ono ka maselo ozungulira omwe amakhudzidwa ndi vascular homeostasis ndi endothelial kukonza.Kuwonjezeka kwa EPC pamalo ovulala kwa mitsempha kudzalimbikitsa kubwezeretsanso koyambirira, zomwe zingathe kuchepetsa chiopsezo cha ST.EPC Biology yoyambira kupanga stent ndi Genous stent, yokutidwa ndi ma anti-CD34 antibodies, omwe amatha kumanga ma EPC ozungulira kudzera pa zolembera za hematopoietic kuti apititse patsogolo endothelialization.Ngakhale kuti maphunziro oyambirira akhala akulimbikitsa, umboni waposachedwapa umasonyeza kuti TVR ikukwera.40
Poganizira zowononga zomwe zingachitike chifukwa cha kuchedwa kwa machiritso opangidwa ndi ma polima omwe amalumikizidwa ndi chiwopsezo cha ST, ma polima opangidwa ndi bioresorbable amapereka zabwino za DES popewa nkhawa zomwe zakhala zikuchitika kwanthawi yayitali za kulimbikira kwa polima.Mpaka pano, machitidwe osiyanasiyana a bioresorbable avomerezedwa (mwachitsanzo, Nobori ndi Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), koma mabuku omwe amathandiza zotsatira zawo za nthawi yayitali ndi ochepa.41
Zipangizo zomwe zimatha kukhala ndi bioabsorbable zili ndi mwayi wongoyerekeza wopereka chithandizo chamakina poyambilira pomwe zotanuka zimaganiziridwa ndikuchepetsa kuopsa kwanthawi yayitali komwe kumakhudzana ndi zitsulo zomwe zilipo kale.Ukadaulo watsopano wapangitsa kuti pakhale ma polima a lactic acid (poly-l-lactic acid [PLLA]), koma machitidwe ambiri a stent akukula, ngakhale kupeza bwino pakati pa kutulutsa mankhwala osokoneza bongo ndi kuwonongeka kwa kinetics kumakhalabe kovuta.Kafukufuku wa ABSORB adawonetsa chitetezo ndi mphamvu ya ma stents a PLLA okhala ndi everolimus.43 Kukonzanso kwa m'badwo wachiwiri wa Absorb stent kunali kwabwino kuposa kwam'mbuyo komwe kumatsatira zaka ziwiri.44 Kafukufuku waposachedwa wa ABSORB II, kuyesa koyamba kosasinthika kuyerekeza Absorb stent ndi Xience Prime stent, kuyenera kupereka zowonjezera, ndipo zotsatira zoyamba zopezeka zikulonjeza.45 Komabe, mikhalidwe yabwino, njira yabwino yokhazikitsira, ndi mbiri yachitetezo mu matenda a mitsempha yamagazi iyenera kufotokozedwa.
Thrombosis mu BMS ndi DES ali ndi zotsatira zoyipa zachipatala.M’kaundula wa odwala oikidwa ndi DES, 47 24% ya STS inachititsa imfa, 60% mu MI yosapha, ndi 7% mu angina wosakhazikika.PCI ya ST yofulumira nthawi zambiri imakhala yocheperako, ndikubwerezanso mu 12% ya milandu.48
Kuwonjezeka kwa ST kumakhala ndi zotsatira zoyipa zachipatala.Mu phunziro la BASKET-LATE, miyezi ya 6-18 pambuyo pa kuikidwa kwa stent, chiwerengero cha imfa ya mtima ndi MI yosapha anali apamwamba mu gulu la DES kusiyana ndi gulu la SMP (4.9% ndi 1.3%, motsatira).20 Meta-analysis ya maphunziro asanu ndi anayi omwe odwala 5261 adasinthidwa ku SES, PES, kapena BMS adawonetsa kuti pambuyo pa zaka 4 zotsatiridwa, SES (0.6% motsutsana ndi 0%, p = 0.025) ndi PES (0.7%)) adachulukitsa zochitika za ST mochedwa kwambiri poyerekeza ndi BMS ndi 0.2%, 2% .49 Mosiyana ndi zimenezi, mu meta-analysis kuphatikizapo odwala 5108, 21 ndi 60% kuwonjezeka kwa chiwerengero cha imfa kapena MI inanenedwa ndi SES poyerekeza ndi BMS (p = 0.03), pamene PES inagwirizanitsidwa ndi kuwonjezeka kosafunikira kwa 15% (onani - mpaka miyezi 9 mpaka zaka 3).
Ma registries ambiri, mayesero osasinthika, ndi kusanthula kwa meta adawunika chiwopsezo cha ST pambuyo pa BMS ndi DES implantation ndipo awonetsa zotsatira zotsutsana.Mu kaundula wa odwala 6906 omwe amathandizidwa ndi BMS kapena DES, panalibe kusiyana kwa zotsatira zachipatala kapena ST rates pa 1 chaka chotsatira.48 M'kaundula wina wa odwala 8146, chiopsezo chopitilira ST chowonjezera chinapezeka kuti ndi 0.6% pachaka poyerekeza ndi BMS.49 Meta-kufufuza kafukufuku woyerekeza SES kapena PES ndi SMPs anasonyeza chiwopsezo chowonjezereka cha imfa ndi MI ndi DES ya m'badwo woyamba poyerekeza ndi SMPs, 21 ndi meta-analysis ina ya odwala 4545 osasinthika ku SES kapena ST pakati pa PES ndi BMS pa zaka 4 zotsatila.50 Maphunziro ena enieni awonetsa chiopsezo chowonjezeka cha ST ndi MI mwa odwala omwe amathandizidwa ndi DES ya m'badwo woyamba atasiya DAPT.51
Poganizira zotsutsana zotsutsana, kuwunika kophatikizana ndi kusanthula kwa meta pamodzi kunatsimikizira kuti DES ndi SGM ya m'badwo woyamba sizinasiyane kwambiri pachiwopsezo cha imfa kapena MI, koma SES ndi PES zinali ndi chiopsezo chowonjezereka cha ST yofala kwambiri poyerekeza ndi SGM.Kuti muwonenso umboni womwe ulipo, bungwe la US Food and Drug Administration (FDA) linasankha gulu la akatswiri53 lomwe linapereka mawu ozindikira kuti DES ya m'badwo woyamba ndi yothandiza monga momwe zalembedwera komanso kuti chiopsezo cha magawo apamwamba kwambiri ST ndi ochepa, koma osati aakulu., Kuwonjezeka kwakukulu.Zotsatira zake, a FDA ndi mayanjano amalimbikitsa kukulitsa nthawi ya DAPT mpaka chaka cha 1, ngakhale pali umboni wochepa wotsimikizira izi.
Monga tanena kale, m'badwo wachiwiri wa DES wapangidwa ndi mawonekedwe opangidwa bwino.CoCr-EES yachita kafukufuku wozama kwambiri wazachipatala.Mu meta-analysis ndi Baber et al.54 mwa odwala 17,101, CoCr-EES inachepetsa kwambiri chotsimikizika / chotheka ST ndi MI poyerekeza ndi PES, SES, ndi ZES pa miyezi 21.Pomaliza, Palmerini et al adawonetsa mu meta-analysis ya odwala 16,775 kuti CoCr-EES ili ndi kuchepa kwambiri koyambirira, mochedwa, 1- ndi 2-year yofotokozedwa ST poyerekeza ndi DES ina yophatikizidwa.Maphunziro a 55 Real-life awonetsa kuchepa kwa chiopsezo cha ST ndi CoCr-EES poyerekeza ndi DES ya m'badwo woyamba.56
Re-ZES idafanizidwa ndi CoCr-EES mu RESOLUTE-AC ndi maphunziro a TWENTE.33,57 Panalibe kusiyana kwakukulu mu imfa, myocardial infarction, kapena kutanthauzira gawo la ST pakati pa ma stents awiri.
Mu intaneti meta-analysis ya odwala 50,844, kuphatikizapo 49 RCTs, 58 CoCr-EES inagwirizanitsidwa ndi chiwerengero chochepa kwambiri cha ST kuposa BMS, zomwe sizinawonedwe ndi DES zina;kuchepa sikunali kokha "koyambirira kwambiri" komanso pambuyo pa masiku 30 (58).zovuta chiŵerengero [OR] 0.21, 95% nthawi yodalirika [CI] 0.11-0.42) ndi chaka chimodzi (OR 0.27, 95% CI 0.08-0.74) ndi zaka 2 (OR 0.35, 95% CI 0.17-0.69).Poyerekeza ndi PES, SES, ndi ZES, CoCr-EES idalumikizidwa ndi chiwongola dzanja chochepa cha ST pa 1 chaka.
ST yoyambirira imagwirizana ndi zinthu zosiyanasiyana. Pansi pa plaque morphology ndi katundu wa thrombus zikuwoneka kuti zimakhudza zotsatira pambuyo pa PCI; 59 zozama zakuya zolowera ndi necrotic core (NC) prolapse, misozi yaitali yapakati mkati mwa stent, suboptimal stenting ndi zotsalira za m'mphepete mwa stenosis, kusakwanira kokwanira, ndi kuwonjezereka kwa incomplete ya ST. regimen ya mankhwala a antiplatelet sichimakhudza kwambiri zochitika za ST yoyambirira: mu mayesero osadziwika bwino poyerekeza ndi BMSs ndi DESs, mitengo ya ST yovuta kwambiri ndi subacute pa nthawi ya DAPT inali yofanana (<1%).61 Choncho, ST yoyambirira ikuwoneka kuti ikugwirizana kwambiri ndi zilonda zowonongeka zowonongeka ndi ndondomeko. Pansi pa plaque morphology ndi katundu wa thrombus zikuwoneka kuti zimakhudza zotsatira pambuyo pa PCI; 59 zozama zakuya zolowera ndi necrotic core (NC) prolapse, misozi yaitali yapakati mkati mwa stent, suboptimal stenting ndi zotsalira za m'mphepete mwa stenosis, kusakwanira kokwanira, ndi kuwonjezereka kwa incomplete ya ST. regimen ya mankhwala a antiplatelet sichimakhudza kwambiri zochitika za ST yoyambirira: mu mayesero osadziwika bwino poyerekeza ndi BMSs ndi DESs, mitengo ya ST yovuta kwambiri ndi subacute pa DAPT inali yofanana (<1%) .61 Choncho, ST yoyambirira ikuwoneka kuti ikugwirizana kwambiri ndi zilonda zam'mimba zomwe zimagwiritsidwa ntchito komanso ndondomeko. Морфология лежащей в основе бляшки ndi тромбоз, по-видимому, влияют на исход ЧКВ; 59 более глубокая пенетразаконское дра (NC), длинного медиального разрыва внутри стента, субоптимального стентирования с остаточными краевыми разрыва внутри стента, субоптимального стентирования с остаточными краевыми разрыва внутри стента, субоптимального стентирования с остаточными краевыми расслоениями или значительновым ndi ukadaulo wapadziko lonse lapansi womwe umapereka mwayi wopezeka pa ST.60 ndikuwongolera magwiridwe antchito amtundu wapadziko lonse. на частоту раннего ST: в рандомизированном исследовании, сравнивающем BMS ndi DES, частота острого и подострого ST во время DAPT была оди1назвой, 10 . , по-видимому, в первую очередь связана с лежащими в основе пролеченными поражениями ndi процедурными факторами. Pansi pa plaque morphology ndi thrombosis zimawoneka kuti zimakhudza zotsatira pambuyo pa PCI; 59 kulowa kwakuya kwapakati chifukwa cha necrotic nucleus (NC) prolapse, kung'ambika kwapakatikati mkati mwa stent, suboptimal stenting ndi zotsalira zam'mbali zam'mphepete kapena m'mphepete mwa stenosis, kusakwanira kwapang'onopang'ono ndi kufalikira kwa STD kuwonjezereka kosakwanira. regimen ya mankhwala a antiplatelet sichimakhudza kwambiri zochitika za ST yoyambirira: mu mayesero osadziwika bwino poyerekeza ndi BMS ndi DES, zochitika za ST yovuta ndi subacute pa nthawi ya DAPT zinali zofanana (<1%) .61 Choncho, ST yoyambirira ikuwoneka kuti ikugwirizana makamaka ndi zilonda zomwe zimagwiritsidwa ntchito pansi ndi ndondomeko.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) 脱垂导致、锯深的更深的更深的更内侧撕裂、具有残余边缘剥离或显着边缘狭窄的次优支架、不完全并置和不完全并置和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 期间急生生的亚和1%)潜在的 斑块 形态 和血栓 似乎 影响 影响 pci 后 结果 ; ; ; ; ; ; ; ; ; ;导致的 支柱 穿透 , 内长的 内侧支架 , 不 完全 并置和 不影响 影响 早期的 ： 在 项 比较 比较 bms 与 des 中 , dapt 期间 急性 亚急性 矔发生 发生发生 发生 发生 发生 发生 发生 发生 发生 发生生 发生率相似（<1%） .61Zomwe zili pansi pa plaque morphology ndi thrombosis zikuwoneka kuti zimakhudza zotsatira pambuyo pa PCI;59 Kulowera kozama kwambiri chifukwa cha necrotic nucleus (NC) prolapse, kuphulika kwapakati mu kutalika kwa stent, kugawanika kwachiwiri ndi malire otsalira, kapena kuchepetsedwa kwakukulu kwa malire Kukhazikika bwino, kuyika kosakwanira, ndi kufalikira kosakwanira60 Antiplatelet regimen alibe zotsatira zowononga pa nthawi ya STDA yoyesedwa ndi mayesero oyambirira a STDA. BMS ndi DES.zimagwirizana makamaka ndi zotupa zochiritsira zomwe zimapangidwira komanso zochitika za opaleshoni.
Masiku ano, chidwi chili pa ST mochedwa / mochedwa kwambiri.Ngakhale kuti njira zoyendetsera ntchito ndi zamakono zikuwoneka kuti zikuthandizira kwambiri pa chitukuko cha ST yovuta kwambiri, njira yochepetsera zochitika za thrombotic imakhala yovuta kwambiri.Zakhala zikuwonetsa kuti zizindikiro zina za odwala zingakhale zoopsa za ST yopita patsogolo komanso yapamwamba kwambiri: matenda a shuga, ACS pa nthawi ya opaleshoni yoyamba, kulephera kwa aimpso, ukalamba, kuchepetsa kachigawo kakang'ono ka ejection, zochitika zazikulu za mtima wamtima mkati mwa masiku a 30 kuyambira opaleshoni yoyamba.Kwa BMS ndi DES, zosintha zamachitidwe monga kukula kwa chotengera chaching'ono, bifurcations, matenda amitundu yambiri, calcification, occlusion kwathunthu, ma stents aatali akuwoneka kuti akugwirizana ndi chiopsezo cha ST.62,63 Kuyankha kolakwika kwa mankhwala a antiplatelet ndi chiopsezo chachikulu cha thrombosis ya DES 51 yopita patsogolo.Kuyankha uku kumatha kukhala chifukwa chakusamvera kwa odwala, kuchepera, kuyanjana ndi mankhwala, zovuta zomwe zimakhudza kuyankha kwamankhwala, ma receptor-level genetic polymorphism (makamaka clopidogrel resistance), ndi kuyambitsa kwa njira zina zoyambitsa mapulateleti.Stent neoatherosulinosis imawonedwa ngati njira yofunikira pakulephereka kwa stent mochedwa, kuphatikiza mochedwa ST64 (gawo la "Stent Neoatherosclerosis").Endothelium yomwe ili bwino imalekanitsa khoma la chotengera cha thrombosed ndi stent posts kuchokera m'magazi ndikutulutsa antithrombotic ndi vasodilatory.DES imawulula khoma la chotengera ku mankhwala oletsa kuchulukirachulukira komanso nsanja yotulutsa mankhwala, yokhala ndi zotsatira zosiyanasiyana pa machiritso ndi ntchito yomaliza, yokhala ndi chiopsezo chakumapeto kwa thrombosis.65 Kafukufuku wamatenda awonetsa kuti ma polima amphamvu a m'badwo woyamba wa DES amatha kuthandizira kutupa kosatha, kuyika kwa fibrin kosatha, kuchira koyipa kwa endothelial, komanso kukulitsa chiwopsezo cha thrombosis.3 Mochedwa hypersensitivity kwa DES zikuwoneka ngati njira ina yotsogolera ku ST.Virmani et al.[66] inanena kuti zotsatira za postmortem pambuyo pa ST kusonyeza kuwonjezeka kwa aneurysm mu gawo la stent ndi machitidwe a hypersensitivity amderalo omwe ali ndi T-lymphocytes ndi eosinophils;zomwe zapezazi zitha kuwonetsa chikoka cha ma polima osawonongeka.67 Stent misfit ikhoza kukhala chifukwa chakukula pang'onopang'ono kwa stent kapena kumachitika miyezi ingapo pambuyo pa PCI.Ngakhale kuti njira yowonongeka ndiyomwe imayambitsa chiopsezo cha ST Acute and subacute ST, kufunikira kwachipatala kwa kupezeka kwa stent malapposition kungadalire kukonzanso kwamphamvu kwa mitsempha kapena kuchedwa kuchira chifukwa cha mankhwala, koma kufunika kwake kwachipatala kumatsutsana.68
Zotsatira zoteteza za m'badwo wachiwiri wa DES zingaphatikizepo endothelialization yofulumira komanso yowonjezereka, komanso kusiyana kwa stent alloy ndi mapangidwe, makulidwe a strut, katundu wa polima, ndi mtundu wa mankhwala osokoneza bongo, mlingo, ndi kinetics.
Poyerekeza ndi CoCr-EES, zowonda (81 µm) za cobalt-chromium stent scaffolds, antithrombotic fluoropolymers, zotsika polima, komanso kuthira mankhwala kungathandize kuchepetsa mitengo ya ST.Kafukufuku woyeserera wawonetsa kuti thrombosis ndi kuyika kwa mapulateleti ndizotsika kwambiri pama stenti okutidwa ndi fluoropolymer kuposa ma stenti osakutidwa.69 Kaya ma DES am'badwo wachiwiri ali ndi katundu wofanana akuyenera kuphunzitsidwanso.
Ma coronary stents amapangitsa 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 restenoses (mpaka 40-50% ya milandu).Pofika kumapeto kwa zaka za m'ma 1990, pafupifupi 70% ya ma PCI anachitidwa ndi kuikidwa kwa BGM.70
然而，尽管技术、技术和药物治疗取得了进步，但BMS 植入后再狭窄的风险约為20%，在特特生甚麼给 20%然而，尽管技术、技术和药物治疗取得了进步，但BMSKomabe, ngakhale kupita patsogolo kwa umisiri, njira, ndi mankhwala, chiopsezo cha restenosis pambuyo pa kuikidwa kwa BMS ndi pafupifupi 20%, ndi mitengo yoposa 40% m'magulu ena.71 Kawirikawiri, maphunziro a zachipatala asonyeza kuti restenosis pambuyo pa kuikidwa kwa BMS, mofanana ndi zomwe zimawonedwa ndi PTCA wamba, zimafika pa miyezi 3-6 ndikutsimikiza pa chaka chimodzi.72
DES imachepetsanso mitengo ya ISR, 73 ngakhale kuchepetsedwa uku kumadalira angiographically komanso kuchipatala.DES polima yokutira imatulutsa anti-inflammatory and anti-proliferative agents, imalepheretsa mapangidwe a neointima, ndikuchedwetsa kukonzanso kwa mitsempha ndi miyezi kapena zaka.74 M'maphunziro azachipatala ndi histological, kukula kosalekeza kwa neointima kwawonedwa pakapita nthawi yayitali pambuyo pa kukhazikitsidwa kwa DES, chodabwitsa chotchedwa "kuchedwa kugwidwa" 75.
Kuvulala kwa mitsempha pa PCI kumayambitsa njira yovuta yotupa ndi kukonzanso kwa nthawi yochepa (masabata mpaka miyezi), zomwe zimapangitsa kuti endothelialization ndi neointimal coverage.Malinga ndi kuwunika kwa histopathological, neointimal hyperplasia (HMS ndi DES) pambuyo pa kuikidwa kwa stent makamaka kumakhala ndi ma cell osalala a minofu mu matrix olemera a proteoglycan.70
Choncho, neointimal hyperplasia ndi njira yokonzanso yomwe imaphatikizapo coagulation ndi kutupa zinthu, komanso maselo omwe amachititsa kuti maselo osalala azitha kufalikira komanso mapangidwe a extracellular matrix.Pambuyo pa PCI, mapulateleti ndi fibrin zimayikidwa pakhoma la chotengera ndikukopa ma leukocyte kudzera mumagulu angapo a ma cell adhesion.Ma leukocyte ogubuduza amamangiriridwa ku mapulateleti olumikizidwa kudzera mu kuyanjana kwa leukocyte integrin Mac-1 (CD11b/CD18) ndi kupatsidwa zinthu za m’mwazi glycoprotein Ibα 53 kapena fibrinogen yogwirizana ndi kupatsidwa zinthu za m’mwazi glycoprotein IIb/IIIa.76.77
Malingana ndi deta yatsopano, maselo otsogolera mafupa a mafupa amakhudzidwa ndi machitidwe a mitsempha ndi kukonza njira.Kulimbikitsa EPC kuchokera m'mafupa kupita ku magazi ozungulira kumalimbikitsa endothelial regeneration ndi postnatal neovascularization.Zikuoneka kuti mafupa osalala a minofu progenitor maselo (SMPCs) amasamukira ku malo a kuvulala kwa mitsempha, zomwe zimapangitsa kuti neointimal ichuluke.78 M'mbuyomu, maselo a CD34-positive ankatengedwa ngati chiwerengero chokhazikika cha EPCs, kafukufuku wina wasonyeza kuti CD34 surface antigen imazindikiradi maselo amtundu wa mafupa omwe amatha kusiyanitsa mu EPCs ndi PBMCs.Kusinthana kwa maselo abwino a CD34 kukhala mzere wa EPC kapena SMPC kumadalira chilengedwe;Mikhalidwe ya ischemic imapangitsa kusiyana kwa EPC phenotype, yomwe imalimbikitsa reendothelialization, pamene kutupa kumapangitsa kusiyana kwa phenotype ya SMPC, yomwe imalimbikitsa kufalikira kwa neointimal.79
Matenda a shuga amawonjezera chiopsezo cha ISR ndi 30-50% pambuyo pa kuikidwa kwa BMS, ndipo kuchuluka kwa restenosis kwa odwala matenda a shuga poyerekeza ndi odwala omwe alibe matenda a shuga kunapitirirabe mu nthawi ya DES.Njira zomwe zimayang'anira izi ndizochita zambiri, kuphatikizapo machitidwe (mwachitsanzo, kusinthasintha kwa kuyankha kotupa) ndi ma anatomical (mwachitsanzo, ziwiya zing'onozing'ono, zotupa zazitali, matenda opatsirana, ndi zina zotero), zomwe zimawonjezera chiopsezo cha ISR.70
Kutalika kwa chotengera ndi kutalika kwa zilonda kumakhudzanso mitengo ya ISR, yokhala ndi zilonda zazing'ono / zazitali zomwe zimachulukitsa kwambiri restenosis poyerekeza ndi zilonda zazikulu zam'mimba / zazifupi.71
Mapulatifomu a m'badwo woyamba adawonetsa ma stent stent ndi ma ISR apamwamba poyerekeza ndi nsanja za m'badwo wachiwiri wokhala ndi zingwe zoonda.
Komanso, kuchuluka kwa restenosis kumalumikizidwa ndi kutalika kwa stent, pafupifupi kuwirikiza kawiri kutalika kwa stent> 35 mm poyerekeza ndi <20 mm. Komanso, kuchuluka kwa restenosis kumalumikizidwa ndi kutalika kwa stent, pafupifupi kuwirikiza kawiri kutalika kwa stent> 35 mm poyerekeza ndi <20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента >35 мм по сравнению с длиной стента <20 мм. Kuonjezera apo, mlingo wa restenosis umagwirizana ndi kutalika kwa stent, pafupifupi kuwirikiza ndi kutalika kwa stent> 35 mm poyerekeza ndi kutalika kwa stent <20 mm.此外，再狭窄的发生率与支架长度有关，支架长度>35 mm 的支架长度几乎是<20 mm 的两倍.此外，再狭窄的发生率与支架长度有关，支架长度>35 mm Кроме того, частота рестеноза зависела от длины стента: длина стента >35 мм почти в два раза больше, чем стента <20 мм. Kuonjezera apo, nthawi zambiri za restenosis zimatengera kutalika kwa stent: kutalika kwa stent> 35 mm ndi pafupifupi kawiri kuposa <20 mm.Chiwopsezo chochepa kwambiri cha lumen cha stent chinathandizanso kwambiri: kagawo kakang'ono komaliza ka lumen kamene kamaneneratu kuwonjezereka kwakukulu kwa chiwopsezo cha restenosis.81.82
Mwachikhalidwe, intimal hyperplasia pambuyo pa kuikidwa kwa BMS imaonedwa kuti ndi yokhazikika, ndi nsonga yoyambirira pakati pa miyezi 6 ndi 1 chaka ndikutsatiridwa ndi nthawi yopuma mochedwa.Chiwopsezo choyambirira cha kukula kwapamtima kotsatiridwa ndi kutsika kwapamtima ndi kukulitsa lumen patatha zaka zingapo kukhazikitsidwa kwa stent kunenedwa kale;kukhwima kwa maselo osalala a minofu ndi kusintha kwa matrix a extracellular kwaperekedwa ngati njira zomwe zingatheke kuti muchepetse neointima regression.83 Komabe, kafukufuku wotsatira nthawi yayitali wasonyeza kuyankha katatu pambuyo pa kuyika kwa BMS ndi kupuma koyambirira, kutsika kwapakatikati, ndi kuchedwa kwa luminal restenosis.84
Munthawi ya DES, kukula mochedwa kwa neointimal kudawonetsedwa pambuyo pa kukhazikitsidwa kwa SES kapena PES mumitundu yanyama.85 Kafukufuku wambiri wa IVUS wasonyeza kuchedwa koyambirira kwa kukula kwapamtima komwe kumatsatiridwa ndi kugwira mochedwa pakapita nthawi pambuyo pa SES kapena RPE implantation, mwinamwake chifukwa cha kutupa kosalekeza.86
Ngakhale "kukhazikika" komwe kumatchedwa ISR, pafupifupi gawo limodzi mwa magawo atatu a odwala omwe ali ndi BMS ISR amapanga ACS.zinayi
Pali umboni wowonjezereka wosonyeza kuti kutupa kosatha ndi/kapena kulephera kwa endothelial kumapangitsa kuti neatherosclerosis ipite patsogolo mu HCM ndi DES (makamaka DES ya m'badwo woyamba), yomwe ingakhale njira yofunikira pakupanga IR yopita patsogolo kapena ST.Inoue et al [87] adanenanso zomwe adapeza pambuyo pa kuikidwa kwa Palmaz-Schatz coronary stents, kutanthauza kuti kutupa mozungulira stent kungayambitse kusintha kwatsopano kwa atherosulinosis mkati mwa stent.Maphunziro ena10 awonetsa kuti minofu yopumira mkati mwa 5-year CGM imakhala ndi matenda a atherosulinosis omwe ali ndi kapena popanda kutupa kwa peritoneal;Zitsanzo za zochitika za ACS zimawonetsa zolembera zosatetezeka m'mitsempha yapamtima Histological block morphology yokhala ndi foamy macrophages ndi makristasi a cholesterol.Kuphatikiza apo, poyerekeza BMS ndi DES, kusiyana kwakukulu pa nthawi ya chitukuko cha atherosulinosis yatsopano kunadziwika.11,12 Kusintha koyambirira kwa atherosclerotic mu kulowetsedwa kwa foamy macrophage kunayamba miyezi 4 pambuyo pa kuikidwa kwa SES, pamene kusintha komweku kwa CGM kunachitika pambuyo pa zaka 2 ndipo kunakhalabe kosawerengeka mpaka zaka 4.Kuphatikiza apo, DES stenting for zilonda zosakhazikika monga thin tegmental fibroatherosclerosis (TCFA) kapena intimal rupture ili ndi nthawi yaifupi ya chitukuko poyerekeza ndi BMS.Chifukwa chake, neatherosclerosis ikuwoneka ngati yofala kwambiri ndipo imachitika kale mu DES ya m'badwo woyamba kuposa BMS, mwina chifukwa cha matenda osiyanasiyana.
Zotsatira za m'badwo wachiwiri wa DES kapena DES pa chitukuko zikuyenera kufufuzidwa;ngakhale zowona zomwe zilipo za m'badwo wachiwiri wa DES88 zikuwonetsa kutupa kocheperako, zochitika za neatherosclerosis ndizofanana poyerekeza ndi m'badwo woyamba, koma maphunziro owonjezera akufunikabe.