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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) intervention.Nyamara, nubwo itangizwa ryigisekuru cya kabiri DES isa nkaho yahinduye iki kintu ugereranije nicyiciro cya mbere DES, impungenge zikomeye ziracyakomeza kubyerekeranye ningaruka zishobora gutinda ziterwa na stent, nka stent trombose (ST) no kwanga stent. Stenosis (ISR) .ST nikintu gishobora guteza impanuka cyagabanutse cyane binyuze muburyo bwiza bwo gutera intambwe, gushushanya udushya, hamwe no kuvura antiplatelet. Uburyo nyabwo busobanura uko bwabayeho burimo gukorwaho iperereza, kandi mubyukuri, ibintu byinshi birashinzwe. ISR muri BMS yabanje gufatwa nkigihugu gihamye hamwe n’impanuka ya mbere y’ubuvuzi bukabije mu gihe cy’amezi 6. yerekanye ibimenyetso byerekana imikurire idahwitse mugihe gikurikiranwa igihe kirekire, ibintu bizwi nka "gutinda gufata". Kumva ko ISR ari indwara y’ubuvuzi isa nkaho iherutse kuvuguruzwa n’ibimenyetso 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 bugezweho bwo gufata amashusho. Ugereranije na ultrasound ultrasound, itanga igisubizo cyiza (byibuze inshuro 10), ituma imiterere irambuye yerekana imiterere yubuso bwurukuta rwumuvuduko. neo-atherosclerose muri BMS 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 koronariyeri (PCI) hamwe no gutera stent nuburyo bukoreshwa cyane mukuvura indwara zifata imitsi ya coronary arteriire, kandi tekinike ikomeje kugenda itera imbere.1 Nubwo imiti ikuramo ibiyobyabwenge (DES) igabanya imipaka yimyenda yicyuma (BMSs), ingorane zitinze nka stent trombose (ST) hamwe na stent stentose. , 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 ubwato bukaze 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 sisitolike.14 Nubwo izo stent zambere zabuzaga gufunga gutunguranye kwi bwato, byateje ikibazo cya endothelia hamwe na inflamma. Inyigo ya Stent Restenosis 16, yashyigikiye umutekano wo gutera 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’ibisebe byavuwe.Mu 2001, DES yatangijwe19 kugira ngo hagabanuke icyifuzo cyo kuruhuka no kuvura indwara. baherekejwe na DES.
Ibintu byose bifite aho bigarukira, kandi kuva 2005, impungenge zumutekano w "D-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 tekinolojiya mishya, 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 imiterere ya cytostatike ikomeye - 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, byoroheje byerekana imiyoboro ya TAUS.
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 buto bwa stent strut.Zotarolimus nikigereranyo cya sirolimusi ningaruka zisa na immunosuppressive ariko zongerewe lipofilicite kugirango zongere imbaraga zo gutwika imitsi. icyiciro cyimvune, gikurikirwa no gusana arterial.Nyuma yikigereranyo cya mbere cya ENDEAVOR, ikizamini cya ENDEAVOR III cyakurikiyeho cyagereranije ZES na SES, cyerekanaga igihombo kinini cyatinze na ISR ariko kikaba cyaragize ingaruka nke zikomeye zifata umutima-mitsi (MACE) kurusha SES .30 Urubanza rwa ENDEAVOR IV, rwagereranije na ZES hamwe na PES, rwongeye kubona indwara nyinshi za ISR AM, ariko zaragaragaye cyane muri ISR, ikigeragezo cyo GUKINGIRA cyananiwe kwerekana itandukaniro ryibiciro bya ST hagati ya Endeavour na Cypher.32
Endeavour Resolute ni verisiyo ishimishije ya stade ya Endeavour hamwe na polymer nshya igizwe n’ibice bitatu.Ibisubizo bishya bya Resolute Integrity (rimwe na rimwe byitwa DES yo mu gisekuru cya gatatu) bishingiye ku rubuga rushya rufite ubushobozi bwo gutanga ibintu byinshi (urubuga rwa Integrity BMS), hamwe n’igitabo, biocompatible bilayibice bitatu bya polimeri, gishobora guhagarika ibisubizo bya mbere bya Xol hamwe no kugabanya iminsi myinshi ya Xol. [EES]) yerekanye ubudashyikirwa bwa sisitemu ya Resolute mubijyanye nurupfu no gutsindwa kwangirika.33,34
Everolimus, ikomoka kuri 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 rwatanze ukwezi kwa 9. Hanyuma, Xience stent yerekanye ibyiza kurenza BMS mugushiraho ST-segment hejuru ya myocardial infarction (MI) .39
EPC ni agace ka selile izenguruka igira uruhare mu mitsi ya homeostasis no gusana endoteliyale.Gutezimbere kwa EPC ahakomeretse imitsi y'amaraso bizatera kongera kwandura hakiri kare, bishobora kugabanya ibyago byo kwandura ibinyabuzima bya ST.EPC bwa mbere mu rwego rwo gushushanya stent ni CD34 ya antibody ikozweho na genoside ya enterineti. byari bishimishije, ibimenyetso biheruka kwerekana 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 ubufasha bwubukanishi mugihe harebwa uburyo bwa elastique recoil harebwa no kugabanya ingaruka zigihe kirekire zifitanye isano nicyuma gisanzwe.Ikoranabuhanga rishya ryatumye habaho iterambere rya polymers ishingiye kuri acide lactique (poly-l-lactique acide [PLLA]), ariko sisitemu nyinshi za stent ziri mu majyambere, nubwo kugena uburinganire bwiza hagati yikwirakwizwa ryibiyobyabwenge hamwe no kwangirika kwa kinote. PLLA stents.43 Igisekuru cya kabiri Absorb stent ivugurura ryabaye iterambere ryayibanjirije hamwe nimyaka 2 yakurikiranwe.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 gushira hamwe, hamwe nibisobanuro byumutekano 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.
Iterambere rya ST rishobora 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%), p = 0.025) na PES (0.7%)) byiyongereyeho indwara ya ST yatinze cyane ugereranije na BMS ku gipimo cya 0.2%, p = 0.028) .49 Ibinyuranye, mu isesengura ryakozwe na meta harimo 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% (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 ugereranije na SES / PES. BMS yerekanye ibyago byo guhitanwa nimpfu na MI hamwe na DES yo mu gisekuru cya mbere ugereranije na BMS, 21 nubundi meta-isesengura ry’abarwayi 4.545 batoranijwe kuri SES cyangwa Nta tandukanyirizo ryatewe na ST hagati ya PES na BMS mu myaka 4 yakurikiranwe.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 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. gutinda, 1- na 2-yimyaka isobanutse ST ugereranije nizindi DES zahujwe.55 Ubushakashatsi nyabwo kwisi bwerekanye ko igabanuka ryibyago bya ST hamwe na CoCr-EES ugereranije nibisekuru bya 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 gukabije Kugabanya uburyo bwiza bwo kwifata, kwifata kutuzuye, no kwaguka kutuzuye60 Uburyo bwo kuvura imiti ya antiplatelet ntabwo bugira ingaruka zikomeye ku mibereho ya ST yo hambere (ugereranije na ST) mu gihe cya DAPT. Rero, ST yo hambere isa nkaho ifitanye isano cyane cyane no kuvura ibikomere byo kuvura nibintu byo kubaga.
Uyu munsi, intego yibanze yibanze kuri ST yatinze / itinze cyane.Niba ibintu byuburyo bwa tekiniki bisa nkibifite uruhare runini mugutezimbere ST ikaze kandi itagaragara, uburyo bwibintu bitinze bya trombotique bigaragara ko bigoye cyane.Byavuzwe ko bimwe mubiranga abarwayi bishobora kuba ingaruka ziterwa na ST yateye imbere kandi yateye imbere cyane: indwara ya diabete mellitus, ACS mugihe cyo kubagwa kwa mbere, kugabanuka kwa kanseri, impinduka zuburyo bukoreshwa, nkubunini bwubwato buto, gutandukana, indwara ya polyvaskulaire, kubara, gufunga byose, stent ndende, bigaragara ko bifitanye isano ningaruka ziterwa na ST.62,63 Igisubizo kidahagije cyo kuvura antiplatelet nikintu gikomeye gishobora gutera indwara ya DES trombose yateye imbere 51 .Iki gisubizo gishobora guterwa no kutagira imiti, kwanduza imiti, kwanduza imiti, kwanduza ibiyobyabwenge resistance), hamwe no kugenzura izindi nzira zo gukora platine.Mu-stent neoatherosclerose ifatwa nkuburyo bwingenzi bwo kunanirwa kwa stent, harimo na nyuma ya ST64 (igice cyitwa "In-stent neoatherosclerose"). Ihuriro ryibiyobyabwenge bifite ingaruka zinyuranye mugukiza kwa endoteliyale no mumikorere, hamwe nimpanuka zo gutinda kwa trombose.65 Ubushakashatsi bw’ubuvuzi bwerekana ko polymers iramba yo mu gisekuru cya mbere DES ishobora kugira uruhare mu gutwika indwara zidakira, kwanduza fibrine idakira, gukira kwa endoteliyale, hamwe n’ingaruka ziyongera ziterwa na trombose. kwaguka kuri stent igice hamwe na hypersensitivite yaho igizwe na T lymphocytes na eosinofile; 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 yerekana inzira yo gusana irimo coagulation na inflammatory hamwe na selile zitera ikwirakwizwa ryimitsi yimitsi itunganijwe neza hamwe na matrix idasanzwe. Ako kanya nyuma ya PCI, platine na fibrin kubitsa kurukuta rwubwato hanyuma ugashakisha leukocytes ukoresheje urukurikirane rwa molekile zifata selile. Ibα ​​53 cyangwa fibrinogen ihambiriye kuri platine glycoproteine ​​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 gutinze.Hariho havuzwe ko hakiri kare imikurire yo gukura kwinshi nyuma yo guterwa kwa stente; gukurikirana byagaragaje igisubizo cya trafasique 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 zatewe na ACS zerekana plaque zisanzwe zishobora kwibasirwa nimiyoboro ya coronari kavukire Amateka ya morfologiya ya blokologiya hamwe na macrophage ifuro hamwe na kristu ya cholesterol. Byongeye kandi, iyo ugereranije na BMS na DES, hagaragaye itandukaniro rikomeye mugihe cyo guteza imbere aterosklerose nshya.11,12 Impinduka za mbere za aterosklerotike zatewe no kwandura kwa macrophage. kandi yagumye kuba ubushakashatsi budasanzwe kugeza kumyaka 4. Byongeye kandi, DES yibasiye ibikomere bidahindagurika nka thin-cap fibroatherosclerose (TCFA) cyangwa guturika kwimbitse bifite igihe gito cyo kwiteza imbere ugereranije na BMS.Ibyo rero, neoatherosclerose isa nkibisanzwe kandi bibaho hakiri kare 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.