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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Ishami ry’indwara z'umutima, ibitaro bya Fondasiyo ya Poliambulanza, Brescia, Ishami rya Cardiologiya, Kaminuza Gatolika y’umutima Mutagatifu wa Roma, Ubutaliyani Abstract: Ibiyobya bwenge byangiza (DES) , nubwo itangizwa ryibisekuru bya kabiri DES bisa nkaho byahinduye iki kintu ugereranije nigisekuru cya mbere DES, impungenge zikomeye ziracyafite impungenge zishobora gutinda ziterwa no guterwa stent, nka stent trombose (ST) no kwanga stent.Stenosis (ISR) .ST nikintu gishobora guteza impanuka cyagabanutse cyane binyuze muburyo bwiza bwo gutondeka, gushushanya udushya, hamwe no kuvura antiplatelet. Uburyo nyabwo busobanura ko bwabayeho burimo gukorwaho iperereza, kandi mubyukuri, ibintu byinshi birashinzwe. ISR muri BMS yabanje gufatwa nkigihugu gihamye hamwe n’impanuka za mbere z’ubushakashatsi bwakozwe mu gihe cy’amezi 6. imikurire ya neointimal mugihe kirekire cyo kuyikurikirana, ibintu bizwi nka "gutinda gufata". Kumva ko ISR ari indwara yubuvuzi isa neza kandi iherutse kuvuguruzwa nibimenyetso byerekana ko abarwayi bafite ISR bashobora kwandura syndromes ikaze.ikoreshwa kenshi kugirango irangize coronary angiography yo kwisuzumisha no gutwara inzira zintera.Intracoronary optique coherence tomografiya kuri ubu ifatwa nkubuhanga bwo kwerekana amashusho bugezweho. Ugereranije na ultrasound ultrasound, itanga igisubizo cyiza (byibuze inshuro 10), ituma imiterere irambuye yimiterere yubuso bwindwara ya endosike iterwa na disiki ya endosike ya Diyosezi. na DES. Kubwibyo, neo-atherosclerose yabaye umuntu wambere ukekwaho gutera indwara yo gutinda kwa stent.Ijambo ryibanze: coronary stent, stent trombose, restenosis, neoatherosclerose
Kwivanga kwa coronary (PCI) hamwe no guterwa stent nuburyo bukoreshwa cyane mukuvura indwara zifata imitsi yimitsi, kandi tekinike ikomeje kugenda itera imbere.1 Nubwo imiti yangiza ibiyobyabwenge (DES) igabanya imipaka yimyenda yicyuma (BMSs), ingorane zitinze nka stent trombose (ST) hamwe na stent restenosis (ISR)., impungenge zikomeye ziracyahari.2-5
Niba ST ari ibintu bishobora guteza impanuka, kumenya ko ISR ari indwara isa naho iherutse kuvuguruzwa n'ibimenyetso byerekana syndrome ikaze ya coronary (ACS) ku barwayi ba ISR.4.
Uyu munsi, intracoronary optique coherence tomografiya (OCT) 6-9 ifatwa nkubuhanga bugezweho bwo gufata amashusho, butanga igisubizo cyiza kuruta ultrasound ultrasound (IVUS).
Mu 1964, Charles Theodore Dotter na Melvin P Judkins basobanuye angioplasti ya mbere.Mu 1978, Andreas Gruntzig yakoze ballon ya mbere ya angioplasty (angioplasti ya ballon ishaje);bwari uburyo bwo kuvura impinduramatwara ariko bukagira imbogamizi zo gufunga imiyoboro ikaze no kuruhuka.13 Ibi byatumye havumburwa stent ya coronary: Puel na Sigwart bohereje stent ya mbere ya coronary mu 1986, batanga stent kugirango birinde gufunga ubwato bukaze no gutinda kwa systolike.14 Nubwo izo stent zambere zabujije kwangirika gutunguranye kwi bwato, byateje ibyangiritse bikabije. osis Inyigisho ya 16, yashyigikiye umutekano wa stent hamwe nubuvuzi bubiri bwa antiplatelet (DAPT) hamwe na / cyangwa uburyo bukwiye bwo kohereza.17,18 Nyuma yibi bigeragezo, habaye ubwiyongere bukomeye bwumubare wa PCI zakozwe.
Nyamara, ikibazo cya iatrogène in-stent neointimal hyperplasia nyuma yo gushyirwa kwa BMS cyamenyekanye vuba, bituma ISR igera kuri 20% –30% by’ibikomere byavuwe.Mu 2001, DES yatangijwe19 kugira ngo hagabanuke icyifuzo cyo kuruhuka no kwisubiraho. .
Ibintu byose bifite aho bigarukira, kandi kuva mu 2005, impungenge z’umutekano wa "generation-yambere" DES zarazamutse, kandi stent-generation nshya nka 20,21 yaratejwe imbere kandi iratangizwa.22 Kuva icyo gihe, imbaraga zo kunoza imikorere ya stent ziyongereye vuba, kandi tekinoloji nshya, itangaje yakomeje kuvumburwa no kuzanwa ku isoko byihuse.
BMS ni mesh yoroheje ya wire.Nyuma yuburambe bwa mbere hamwe nu musozi wa "Urukuta", umusozi wa Gianturco-Roubin na Palmaz-Schatz umusozi, BMS nyinshi zitandukanye zirahari.
Ibishushanyo bitatu bitandukanye birashoboka: coil, tubular mesh hamwe nigituba cyerekanwe.Ibishushanyo mbonera byerekana insinga zicyuma cyangwa imirongo ikozwe muburyo buzunguruka;tubular mesh ishushanya ibiranga insinga zizingiye hamwe mesh kugirango zibe umuyoboro;Igishushanyo mbonera cyibikoresho bigizwe nigituba cyicyuma gikata lazeri cyakozwe.Ibikoresho biratandukanye mubigize (ibyuma bitagira umuyonga, nichrome, chrome ya cobalt), igishushanyo mbonera (imiterere itandukanye ya strut n'ubugari, diameter n'uburebure, imbaraga za radiyo, radiopacity) hamwe na sisitemu yo gutanga (kwagura cyangwa kwagura imipira).
Mubisanzwe, BMS nshya igizwe na cobalt-chromium ivanze, bivamo imirongo yoroheje hamwe nogutezimbere kugenda neza, bikomeza imbaraga za mashini.
Zigizwe nicyuma cyerekana ibyuma (mubisanzwe ibyuma bitagira umwanda) kandi bigashyirwaho na polymer ikuraho imiti igabanya ubukana hamwe na / cyangwa imiti igabanya ubukana.
Sirolimus (uzwi kandi ku izina rya rapamycin) yari yarakozwe mbere mu rwego rwo kurwanya antifungal.Uburyo bwibikorwa bukomoka ku guhagarika iterambere ry’ingirabuzimafatizo mu guhagarika inzibacyuho kuva mu cyiciro cya G1 kijya mu cyiciro cya S no kubuza imiterere ya neointima. Mu 2001, uburambe bwa "muntu-muntu" hamwe na SES bwerekanye ibisubizo bitanga icyizere, biganisha ku iterambere rya stent ya Cypher.23 Ibigeragezo binini bine byerekanaga ISR.
Paclitaxel yabanje kwemererwa kanseri yintanga, ariko imiti ikomeye ya cytostatike - imiti igabanya microtubules mugihe cya mitito, itera gufatwa kwingirangingo kandi ikabuza kwishyiriraho imitsi - bituma iba umusemburo wa Taxus Express PES. Ibigeragezo bya TAXUS V na VI byerekanaga ingaruka zigihe kirekire za PES mubyago byoroshye, bitwara ibyuma bitagira ubwonko byoroheje.25,26.
Ibimenyetso bifatika bivuye mu bushakashatsi bubiri hamwe na meta-isesengura byerekana ko SES ifite akarusho kuri PES bitewe n’igipimo cyo hasi cya ISR hamwe n’ubwonko bugamije kuvugurura imiyoboro (TVR), ndetse n’icyerekezo cyo kwiyongera kwa infiyite ikaze ya myocardial (AMI) mu itsinda rya PES.27,28
Ibikoresho byo mu gisekuru cya kabiri byagabanije umubyimba wa strut, byoroha guhinduka / gutanga, kuzamura polymer biocompatibilité / imyirondoro yo gukuraho ibiyobyabwenge, hamwe na kinetic ya re-endothelialisation nziza.Mu myitozo ya none, ni ibishushanyo mbonera bya DES byateye imbere hamwe na coronari nini yatewe ku isi yose.
Ibintu bya Taxus nibindi byateye imbere hamwe na polymer idasanzwe yagenewe gukora cyane kugirango irekurwe hakiri kare hamwe na sisitemu nshya ya platine-chromium strut itanga imirongo yoroheje kandi yongerewe imbaraga za radiopacity. Ikigeragezo cya PERSEUS 29 cyerekanye ibisubizo bisa hagati ya Element na Taxus Express mugihe cyamezi 12.Nyamara, ibigeragezo ugereranije nibintu bishya nibindi bisekuru bya DES birabura.
Zotarolimus-eluting stent (ZES) Endeavour ishingiye kumurongo ukomeye wa cobalt-chromium stent hamwe nubworoherane buhanitse hamwe nubunini buke bwa stent strut.Zotarolimus nikigereranyo cya sirolimusi ningaruka zisa na immunosuppressive ariko zongerewe imbaraga za lipophilicite kugirango zongere ibyiciro bya fosifilike ya polotike. gusana arterial.Nyuma yikigeragezo cyambere cya ENDEAVOR, urubanza rwa ENDEAVOR III rwakurikiyeho rwagereranije ZES na SES, rwerekanaga igihombo kinini cyatinze na ISR ariko ibintu bike byingutu byumutima-mitsi (MACE) ugereranije na SES .30 Urubanza rwa ENDEAVOR IV, rwagereranije ZES na PES, rwongeye kwerekana ko rwatsinzwe cyane na ZES mubiciro bya ST hagati ya Endeavour na Cypher stents.32
Endeavour Resolute ni verisiyo ishimishije ya stade ya Endeavour hamwe na polymer nshya igizwe n’ibice bitatu.Ubushakashatsi bushya bwa Resolute Integrity (rimwe na rimwe bwitwa DES yo mu gisekuru cya gatatu) bushingiye ku rubuga rushya rufite ubushobozi bwo gutanga ibintu byinshi (urubuga rwa Integrity BMS), kandi igitabo gishya, cyangiza biocompatible layer-layer polimeri, gishobora guhagarika ibisubizo bya mbere bya XL hamwe n’ibisubizo bya Elim. yerekanye kudasuzugura sisitemu ya Resolute mubijyanye nurupfu no gutsindwa kwibasirwa.33,34
Everolimus, inkomoko ya sirolimusi, nayo ni ingirabuzimafatizo ya selile ikoreshwa mugutezimbere Xience (Multi-link Vision BMS platform) / Promus (Platinum Chromium platform) EES. Ikigeragezo cya SPIRIT 35-37 cyerekanaga imikorere myiza kandi kigabanya MACE hamwe na Xience V ugereranije na PES, mugihe urubanza rwa EXCELLENT rwerekanaga ko EES yari idafite amezi 9. ent yerekanye ibyiza kurenza BMS mugushiraho ST-segment hejuru ya myocardial infarction (MI) .39
EPC ni agace kamwe ka selile izenguruka igira uruhare mumitsi ya homeostasis no gusana endoteliyale.Gutezimbere kwa EPC ahakomeretse imitsi bizafasha kongera kwandura endothelialisation hakiri kare, birashoboka ko byagabanya ibyago byambere bya biologiya ya ST.EPC mubushakashatsi bwa stent ni CD34 ya antibody ikozweho na genoside ya enterasiyo. yerekana ibiciro biri hejuru ya TVR.40
Urebye ingaruka zishobora kwangiza ziterwa na polymer iterwa no gutinda gukira, bifitanye isano ningaruka za ST, polyabers bioabsorbable itanga inyungu za DES, birinda impungenge zimaze igihe zerekeranye no gukomera kwa polymer. Kugeza magingo aya, sisitemu zitandukanye za bioabsorbable zemejwe (urugero: Nobori na Biomatrix, biolimus eluting stent, Synergy, EES, igihe kirekire, SES, Ultimaster, SES)
Bioabsorbable ibikoresho bifite inyungu zifatika zo kubanza gutanga inkunga yubukanishi mugihe harebwa uburyo bwa elastique recoil harebwa no kugabanya ingaruka zigihe kirekire zijyanye nigitereko cyicyuma gisanzwe.Ikoranabuhanga rishya ryatumye habaho iterambere rya polymers ishingiye kuri acide lactique (acide poly-l-lactique [PLLA]), ariko sisitemu nyinshi za stent ziri mu iterambere, nubwo kugena uburinganire bwiza hagati yikwirakwizwa ry’ibiyobyabwenge hamwe n’ibikorwa bya polotike ABL bikomeza kuba ikibazo. 43 Igisekuru cya kabiri Absorb stent ivugurura ryabaye iterambere ryambere ryabanje gukurikiranwa neza nimyaka 2.44 Urubanza rwa ABSORB II rukomeje, urubanza rwa mbere rwateganijwe ugereranije stent ya Absorb na stent ya Xience Prime, rugomba gutanga andi makuru, kandi ibisubizo byambere biboneka biratanga ikizere.45 Nyamara, uburyo bwiza, uburyo bwiza bwo gutera, hamwe numwirondoro wumutekano kugirango bikorwe neza.
Thrombose muri BMS na DES byombi bifite ingaruka mbi ku mavuriro.Mu gitabo cy’abarwayi bahabwa imiti ya DES, 47 24% by’abanduye indwara ya ST byaviriyemo urupfu, 60% byatewe na MI idapfa, na 7% biturutse kuri angina idahindagurika.
ST yateye imbere ishobora kugira ingaruka mbi ku mavuriro.Mu bushakashatsi bwa BASKET-LATE, amezi 6 kugeza kuri 18 nyuma yo gushyirwa kuri stent, ibipimo by’impfu z'umutima na MI bidahitana MI byari hejuru mu itsinda rya DES ugereranije no mu itsinda rya BMS (4.9% na 1.3%, uko bikurikirana). PES (0.7%)) yiyongereyeho indwara ya ST yatinze cyane ugereranije na BMS ku gipimo cya 0.2%, p = 0.028) .49 Ibinyuranye, mu isesengura ryakozwe na meta ririmo abarwayi 5108, 21% 60% byiyongera ku rupfu cyangwa MI byavuzwe na SES ugereranije na BMS (p = 0.03), mu gihe PES yari ifitanye isano no kwiyongera kwa 15% bidasanzwe (Gukurikirana amezi 9).
Kwiyandikisha kwinshi, ibigeragezo byateganijwe, hamwe na meta-gusesengura byakoze iperereza ku ngaruka ziterwa na ST nyuma yo guterwa kwa BMS na DES kandi bagaragaza ibisubizo bivuguruzanya.Mu gitabo cy’abarwayi 6.906 bakira BMS cyangwa DES, nta tandukaniro ryagaragaye mu mavuriro cyangwa ku bipimo bya ST mu gihe cy’umwaka umwe wakurikiranwe.48 Mu kindi gitabo cy’abarwayi ba 8.146 bagereranije na SES ya BES / 0.6%. ibyago byo gupfa na MI hamwe na DES yo mu gisekuru cya mbere ugereranije na BMS, 21 hamwe nubundi meta-isesengura ry’abarwayi 4.545 batoranijwe kuri SES cyangwa Nta tandukaniro ryigeze ribaho mu kwandura indwara ya ST hagati ya PES na BMS mu myaka 4 ikurikiranwa.50 Ubundi bushakashatsi bwakozwe ku isi bwerekanye ko ibyago byiyongera kuri ST na MI ku barwayi bakira DEST yo mu gisekuru cya mbere nyuma yo guhagarika DAPT.51.
Urebye ibimenyetso bivuguruzanya, isesengura ryinshi hamwe na meta-isesengura hamwe byemeje ko ibisekuru bya mbere DES na BMS bitatandukanye cyane mubyago byurupfu cyangwa MI, ariko SES na PES bari bafite ibyago byinshi byo kwandura ST cyane ugereranije na BMS.Kugira ngo dusuzume ibimenyetso bihari, Ikigo cy’Amerika gishinzwe ibiryo n’ibiyobyabwenge (FDA) cyashyizeho itsinda ry’impuguke53 ryasohoye itangazo ryemeza ko DES yo mu gisekuru cya mbere yagize akamaro ku bimenyetso byerekana kandi ko ibyago byo kwandura ST byateye imbere ari bito ariko bito.Ubwiyongere bukomeye. Nkigisubizo, FDA nishyirahamwe birasaba kongera igihe cya DAPT kugeza kumwaka 1, nubwo hari amakuru make yo gushyigikira iki kirego.
Nkuko byavuzwe haruguru, DES yo mu gisekuru cya kabiri ifite imiterere igezweho yo gushushanya yatejwe imbere.CoCr-EESs yakoze ubushakashatsi bwimbitse ku mavuriro.Mu isesengura ryakozwe na Baber et al, 54 harimo abarwayi 17,101, CoCr-EES yagabanije cyane ST na MI isobanutse neza ugereranije na PES, SES, na ZES nyuma y’amezi 21. Byarangiye, Palmerini et al. Imyaka 2 isobanutse ya ST ugereranije nizindi DES zahujwe.55 Ubushakashatsi nyabwo bwerekanye ko igabanuka ryibyago bya ST hamwe na CoCr-EES ugereranije nabasekuruza ba mbere DES.56
Re-ZES yagereranijwe na CoCr-EES mu manza za RESOLUTE-AC na TWENTE.33,57 Nta tandukaniro rikomeye ryagaragaye mu rupfu, infirasi ya myocardial, cyangwa ST isobanutse hagati ya stent zombi.
Mu rusobe meta-isesengura ry’abarwayi 50.844 harimo 49 RCTs, 58CoCr-EES yajyanye no kwandura cyane indwara zanduye kurusha BMS, igisubizo nticyagaragaye mu zindi DES;kugabanuka ntabwo byari Byingenzi gusa hakiri kare no muminsi 30 (igipimo kidasanzwe [OR] 0.21, 95% intera yicyizere [CI] 0.11-0.42) kandi no mumwaka 1 (OR 0.27, 95% CI 0.08-0.74) nimyaka 2 (OR 0.35, 95% CI 0.17–0.69) .Gereranije na PES, SES, na ZES, CoCr-EES.
ST yo hambere ifitanye isano nibintu bitandukanye.Gukoresha plaque morphologie hamwe numutwaro wa trombus bigaragara ko bigira ingaruka kubisubizo nyuma ya PCI;59 Kwinjira cyane byatewe no kugabanuka kwa nerotic (NC), amarira yo hagati mu burebure bwa stent, gutandukana kwa kabiri hamwe n’imisigarira isigaye, cyangwa kugabanuka gukomeye Optimal stenting, apposition ituzuye, hamwe no kwaguka kwuzuye60 Uburyo bwo kuvura imiti ya antiplatelet ntabwo bugira ingaruka zikomeye kubibazo bya ST hakiri kare: Ibipimo bya ST bikabije hamwe na subacute ST mugihe cya DAPT. kuba cyane cyane bifitanye isano no kuvura ibikomere byo kuvura nibintu byo kubaga.
Uyu munsi, intego yibanze yibanze kuri ST itinze / itinze cyane.Niba ibintu byuburyo bwa tekiniki bisa nkibifite uruhare runini mugutezimbere ST ikaze kandi itagaragara, uburyo bwo gutinda kwa trombotique busa nkaho bugoye.Byavuzwe ko ibiranga abarwayi bimwe na bimwe bishobora kuba ingaruka ziterwa na ST yateye imbere kandi yateye imbere cyane nka diyabete mellitus, ACS mugihe cyo kubagwa kwa mbere, kugabanuka kwa kanseri ya DMS, ingano yubwato buto, bifurcations, indwara ya polyvasculaire, calcisation, gufunga byose, stent ndende, bigaragara ko bifitanye isano ningaruka zo kwandura ST.62,63 Igisubizo kidahagije kijyanye no kuvura antiplatelet nikintu gikomeye gishobora gutera indwara ya DES trombose yateye imbere 51 .Iki gisubizo gishobora guterwa no kutagira umurwayi, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza indwara, kwanduza imiti, kwanduza indwara, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza imiti, kwanduza indwara, kwanduza imiti, kwanduza indwara, kwanduza imiti, kwanduza indwara, kwanduza indwara, kwanduza imiti, kwanduza indwara, kwanduza imiti, kwanduza indwara, kwanduza imiti, kwanduza imiti, kwanduza indwara. inzira.Mu-stent neoatherosclerose ifatwa nkuburyo bwingenzi bwo kunanirwa kwa stent, harimo na nyuma ya ST64 (igice cyitwa "In-stent neoatherosclerose"). ibyago byo gutinda kwa trombose.65 Ubushakashatsi bw’ubuvuzi bwerekana ko polymers ziramba zo mu gisekuru cya mbere DES zishobora kugira uruhare mu gutwika indwara zidakira, kwanduza fibrine idakira, gukira indwara ya endoteliyale, ndetse n’ingaruka zo kwiyongera kwa trombose.3 Gutinda gukabije kwa DES bigaragara ko ari ubundi buryo buganisha kuri ST. ophils;ibi bivumbuwe birashobora kwerekana ingaruka za polymers zidashobora kwangirika.67 Malapposition ya stent irashobora guterwa no kwaguka kwa stoptimal stent cyangwa ikabaho nyuma y amezi nyuma ya PCI. Nubwo malapposition yuburyo bukwiye ari ingaruka ziterwa na ST ikaze kandi idahwitse, akamaro k’amavuriro yo kwandura stent irashobora guterwa no gukira kwa arteriire cyangwa guterwa no gutinda gukira.68.
Ingaruka zo gukingira igisekuru cya kabiri DES zirashobora kuba zirimo endothelialisiyasi yihuse kandi idahwitse, kimwe no gutandukana kwa stent alloy hamwe nimiterere, umubyimba wa strut, imitungo ya polymer, nubwoko bwibiyobyabwenge bya antiproliferative, dose, na kinetics.
Ugereranije na CoCr-EES, inini (81 µm) cobalt-chromium stent struts, antithrombotic fluoropolymers, polymer nkeya, hamwe no gupakira ibiyobyabwenge bishobora kugira uruhare runini mu kwandura indwara ya ST.Ubushakashatsi bwakozwe bwerekanye ko trombose hamwe na platine yatewe na fluoropolymer yometse ku bindi bisobanuro.6.
Indwara ya Coronary itezimbere uburyo bwo kubaga ibikorwa byo kubaga kwa coronary ugereranije na gakondo ya percutaneous transluminal coronary angioplasty (PTCA), ifite ibibazo byubukanishi (imiyoboro y'amaraso, gutandukana, nibindi) hamwe nigipimo kinini cya restenosis (kugeza 40% - 50% byimanza).Mu mpera z'imyaka ya za 90, hafi 70% ya PCI zakozwe hakoreshejwe BMS.70
Nubwo, nubwo iterambere ryateye imbere mu ikoranabuhanga, tekiniki, no kuvura, ibyago byo kuruhuka nyuma yo guterwa kwa BMS bigera kuri 20%, hamwe na> 40% mu matsinda yihariye.71 Muri rusange, ubushakashatsi bw’amavuriro bwerekanye ko restenosis nyuma yo guterwa BMS, bisa n’ibyavuzwe na PTCA isanzwe, bikagera ku mezi 3-6 kandi bigakemuka nyuma y’umwaka 1.72
DES iragabanya kandi kwandura ISR, 73 nubwo uku kugabanuka guterwa na angiografiya hamwe nubuvuzi bwa clinique. Igipfundikizo cya polymer kuri DES kirekura imiti igabanya ubukana bwa anti-inflammatory na anti-proliferative, ikabuza imiterere ya neointima, kandi ikadindiza uburyo bwo gusana imitsi mu gihe cy’amezi kugeza ku myaka.75
Gukomeretsa kw'amaraso mugihe cya PCI bitanga inzira igoye yo gutwika no gusana mugihe gito ugereranije (ibyumweru ukwezi), biganisha kuri endothelialisation no gukwirakwizwa na neointimal. Dukurikije ubushakashatsi bwakozwe na histopathologique, hyperplasia ya neointimal (BMS na DES) nyuma yo guterwa stent yari igizwe ahanini ningirabuzimafatizo zikungahaye cyane muri matrike ya proteoglycan.
Niyo mpamvu, hyperplasia ya neointimal igereranya inzira yo gusana irimo coagulation na inflammatory hamwe na selile zitera ikwirakwizwa ryimitsi yimitsi itunganijwe neza hamwe na matrice idasanzwe. Ako kanya nyuma ya PCI, platine na fibrin kubitsa kurukuta rwubwato hanyuma ugashakisha leukocytes ukoresheje urukurikirane rwa molekile zifata selile. ogen ihambiriye kuri platine glycoprotein IIb / IIIa.76,77
Dukurikije imibare igaragara, ingirabuzimafatizo zikomoka ku magufa zigira uruhare mu gusubiza mu mitsi no mu bikorwa byo gusana.Gukangurira EPC kuva mu magufa kugera mu maraso ya periferique bitera kuvugurura endothelia no kuvuka kwa neovascularization.Bigaragara ko amagufwa yo mu magufa yoroheje ingirabuzimafatizo (SMPC) yimukira mu kibanza cy’imitsi ikabije ya CD7.ubundi bushakashatsi bwerekanye ko CD34 yubuso bwa antigen mubyukuri imenya utugingo ngengabuzima twa magufa marrow idafite ubushobozi bwo gutandukanya EPC na SMPC. Guhindura ingirabuzimafatizo za CD34 kumurongo wa EPC cyangwa SMPC biterwa nibidukikije byaho;imiterere ya ischemic itera itandukaniro kuri fenotipike ya EPC kugirango iteze imbere endothelialisation, mugihe imiterere yumuriro itera itandukaniro kuri phenotype ya SMPC kugirango iteze ikwirakwizwa rya neointimal.79
Diyabete yongerera ibyago ISR 30% - 50% nyuma yo gushyirwaho kwa BMS, 80 hamwe n’ikibazo kinini cyo kwandura abarwayi ba diyabete ugereranije n’abarwayi ba diyabete na bo bakomeje kubaho mu gihe cya DES.
Diameter ya Vessel hamwe nuburebure bwa lesion byigenga byagize ingaruka ku bwigenge bwa ISR, hamwe na diameter ntoya / ibikomere birebire byongera cyane igipimo cya restenosis ugereranije na diameter nini / ibikomere bigufi.71
Igisekuru cya mbere stent platform yerekanaga stent nini cyane hamwe nigipimo kinini cya ISR ugereranije nigisekuru cya kabiri stent platform hamwe na tronc yoroheje.
Byongeye kandi, indwara ya restenosis yari ifitanye isano n'uburebure bwa stent, hamwe n'uburebure bwa stent> mm 35 hafi inshuro ebyiri zingana na ziriya <20 mm. Dimetero yanyuma ya stent ntoya ya lumen nayo yagize uruhare runini: diameter ntoya ya nyuma ya lumen yahanuye ko ibyago byo kwandura byiyongera cyane.81.82
Ubusanzwe, hyperplasia ntangarugero nyuma yo gushyirwaho kwa BMS ifatwa nkaho itajegajega, hamwe nimpinga ya mbere hagati y amezi 6 numwaka 1, ikurikirwa nigihe cyo gutinda gutinda.Impanuka yambere yo gukura kwimbere byavuzwe mbere, ikurikirwa no gusubira inyuma kwinshi hamwe no kwaguka kwa lumen nyuma yimyaka myinshi nyuma yo guterwa; igisubizo cyihuse nyuma yo gushyira BMS, hamwe na restenosis kare, gusubira inyuma, hamwe na lumen restenosis yatinze.84
Mugihe cya DES, gukura gutinze kwa neointimal kwerekanwe bwa mbere nyuma yo guterwa kwa SES cyangwa PES mubyitegererezo byinyamanswa.85 Ubushakashatsi bwinshi bwa IVUS bwerekanye ko hakiri kare gukura gukabije gukurikirwa no gutinda gufatwa nyuma yigihe cyo guterwa kwa SES cyangwa PES, bishoboka ko biterwa nuburyo bukomeza gutwikwa.86
Nubwo "ituze" risanzwe ryitirirwa ISR, hafi kimwe cya gatatu cyabarwayi ba BMS ISR barwara ACS.4
Hariho ibimenyetso byinshi byerekana ko gutwika karande hamwe na / cyangwa kutagira endoteliyale bitera neoatherosclerose yateye imbere muri BMS na DES (cyane cyane DES yo mu gisekuru cya mbere), bishobora kuba inzira yingenzi ya ISR yateye imbere cyangwa ST.Inoue nibindi.87 byatangajwe n’ubushakashatsi bwakozwe mu mateka yakozwe na autopsie nyuma yo gushyirwaho kwa cormazari ya Palmaz-Schatz, byerekana ko gutwika peri-stent bishobora kwihutisha impinduka nshya ya aterosklerotike idahwitse muri stent. Ubundi bushakashatsi10 bwerekanye ko tissue restenotic muri BMS, mu myaka 5, igizwe na aterosclerose nshya cyangwa idafite umuriro;Ingero zivuye mu manza za ACS zerekana plaque zisanzwe zishobora kwibasirwa na arterière kavukire ya Histologiya morphologie ya blokte hamwe na macrophage ifuro hamwe na kristu ya cholesterol. Byongeye kandi, iyo ugereranije na BMS na DES, hagaragaye itandukaniro rikomeye mugihe cyiterambere rya aterosklerose nshya.11,12 Impinduka zidasanzwe za Aterosclerotique zatewe no kwandura kwa mikoro ya SMS. kugeza ku myaka 4. Byongeye kandi, DES yibasiye ibikomere bidahungabana nka thin-cap fibroatherosclerose (TCFA) cyangwa guturika gukabije bifite igihe gito cyo kwiteza imbere ugereranije na BMS.Ibyo rero, neoatherosclerose isa nkibisanzwe kandi bibaho mbere muri DES yo mu gisekuru cya mbere kuruta muri BMS, bishoboka ko biterwa na virusi itandukanye.
Ingaruka zo mu gisekuru cya kabiri DES cyangwa DES mu iterambere ziracyakomeza kwigwa;nubwo bimwe mubisanzweho byerekeranye nigisekuru cya kabiri DESs88 byerekana umuriro muke, indwara ya neoatherosclerose isa niy'igihe cya mbere, ariko haracyakenewe ubundi bushakashatsi.