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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 Incamake: Ibicuruzwa byangiza ibiyobyabwenge byashyizwe ahagaragara (DES)Ariko, mugihe itangizwa ryibisekuru bya kabiri DES bigaragara ko byagabanije iki kintu ugereranije nigisekuru cya mbere DES, impungenge zikomeye ziracyafite impungenge ziterwa ningaruka zishobora gutinda ziterwa na stent nka stent trombose (ST) hamwe na stent resection, stenosis (SSI).ST ni ibintu bishobora guteza impanuka byagabanutse cyane mugushiraho uburyo bwiza bwo gushira, gushushanya udushya, hamwe no kuvura antiplatelet ebyiri.Uburyo nyabwo busobanura ibyabaye burimo gukorwaho iperereza, kandi mubyukuri ibintu byinshi birashinzwe.ISR muri BMS mbere yafatwaga nkigihugu gihamye gifite impinga ya hyperplasia yo hambere (kumezi 6) ikurikirwa nigihe cyo gusubira inyuma kirenze umwaka.Ibinyuranye, ubushakashatsi bw’amavuriro n’amateka ya DES bwerekanye ibimenyetso byerekana ko imikurire ikomeza kubaho mu gihe kirekire cyakurikiranwe, ikintu kizwi nka “gutinda gufata”.Igitekerezo kivuga ko ISR ari indwara y’ubuvuzi isa naho iherutse kuvuguruzwa n’ibimenyetso byerekana ko abarwayi bafite ISR bashobora kurwara syndromes ikaze.Imashusho ya Intracoronary nubuhanga butera kugirango tumenye icyapa cya aterosklerotike hamwe nibimenyetso byo gukira kw'imitsi nyuma yo gutera, kandi akenshi bikoreshwa mukurangiza imitekerereze ya coronary angiography no gukora inzira zo gutabara.Intracoronary optique coherence tomografiya ifatwa nkuburyo bugezweho bwo kwerekana amashusho. itanga, ugereranije na ultrasound ultrasound, gukemura neza (byibuze inshuro 10), itanga ibisobanuro birambuye biranga imiterere yimbere yurukuta rwubwato. itanga, ugereranije na ultrasound ultrasound, gukemura neza (byibuze inshuro 10), itanga ibisobanuro birambuye biranga imiterere yimbere yurukuta rwubwato. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере,> 10 раз), что позволяет чинно ох чизизовать поверхностную кюки скида. itanga, ugereranije na ultrasound ultrasound, ikemurwa neza (byibuze inshuro 10), itanga ibisobanuro birambuye kumiterere yubuso bwurukuta rwubwato.与 血管 内 超声 相比 ， 它 10 10 10 分辨率 10 10> 10 倍） ， 允许 详细 表征 壁 的 表面 表面。与 血管 内 超声 相比 ， 它 10 10 的 的 10 至少> 10） ， 允许 详细 表征 血管 壁 的 表面 结构。Ugereranije na ultrasound ultrasound, itanga igisubizo cyiza (byibuze inshuro 10), itanga ibisobanuro birambuye kumiterere yubuso bwurukuta rwubwato.Muri vivo amashusho yerekana amashusho ajyanye nubushakashatsi bwamateka yerekana ko gutwika karande hamwe na / cyangwa imikorere mibi ya endoteliyale bishobora gutera neoatherosclerose yateye imbere muri HMS na DES.Niyo mpamvu, neoatherosclerose yabaye umuntu ukekwaho kuba nyirabayazana yo gutera stent kunanirwa.Amagambo y'ingenzi: coronary stent, stent trombose, restenosis, neoatherosclerose.
Stent percutaneous coronary intervention (PCI) nuburyo bukoreshwa cyane mukuvura indwara zifata imitsi yimitsi, kandi tekinike ikomeje kugenda itera imbere.1 Nubwo ibiyobyabwenge biva mu biyobyabwenge (DES) bigabanya imipaka ya stent idafunze (UES), ingorane zitinze nko muri stent trombose (ST) no muri stent restenosis (ISR) zirashobora kubaho hamwe no gutera stent, kandi haracyari impungenge zikomeye.2-5
Niba ST ari ibintu bishobora guteza impanuka, kwemera ko ISR ari indwara isa naho iherutse kuvuguruzwa n'ibimenyetso byerekana syndrome ikaze ya coronary (ACS) ku barwayi barwaye ISR.bine
Uyu munsi, intracoronary optique coherence tomografiya (OCT) 6-9 ifatwa nkuburyo bugezweho bwo kwerekana amashusho butanga igisubizo cyiza kuruta ultrasound (IVUS).Mu bushakashatsi bwerekana amashusho ya vivo10-12 ijyanye nubushakashatsi bwamateka yerekana uburyo bushya bwo gusubiza imitsi "shyashya" nyuma yo guterwa stent hamwe na de novo "neoatherosclerose" muri BMS na DES.
Mu 1964, Charles Theodore Dotter na Melvin P. Judkins basobanuye angioplasti ya mbere.Mu 1978, Andreas Grunzig yakoze ballon ya mbere angioplasty (ballon ya kera isanzwe ya angioplasty);bwari uburyo bwo kuvura impinduramatwara, ariko kandi bwari bufite imbogamizi zo gufunga imitsi ikaze no kuruhuka.13 Ibi byatumye havumburwa stent ya coronary: Puel na Sigwart bashyizeho stent ya mbere ya coronary mu 1986, itanga stent kugirango ikumire imiyoboro ikaze kandi itinda gusubira inyuma.14 Nubwo izo stent zambere zabujije gufunga ubwato butunguranye, byateje kwangirika kwa endoteliyale no gutwika.Vuba aha, ubushakashatsi bubiri bwibanze, Ubushakashatsi bw’Ababiligi n’Ubuholandi 15 n’Ubushakashatsi bwa Stent Restenosis 16, bwashyigikiye umutekano w’ubuvuzi bubiri bwa antiplatelet (DAPT) bwo gutera hamwe / cyangwa uburyo bukwiye bwo kohereza.17,18 Nyuma yibi bigeragezo, umubare wa PCI wakozwe wiyongereye cyane.
Nyamara, ikibazo cya iatrogenic muri-stent neointima hyperplasia nyuma yo gushyira BMS kumenyekana vuba, bigatuma ISR muri 20-30% y ibikomere bivurwa.DES19 yatangijwe mu 2001 kugirango igabanye gukenera restenosis no kongera gufungura.DES yongereye icyizere cyinzobere mu bijyanye n’umutima yemerera kuvura umubare w’ibikomere byiyongera byafatwaga nkaho bivurwa hakoreshejwe imitsi ya koronariyeri.Muri 2005, 80-90% ya PCI zose zaherekejwe na DES.
Ibintu byose bifite aho bigarukira, kandi kuva 2005 impungenge zerekeye umutekano w "igisekuru cya mbere" DES yariyongereye, stent nshya nka 20,21 yaratejwe imbere kandi iratangizwa.22 Kuva icyo gihe, imbaraga zo kunoza imikorere ya stent zateye imbere byihuse, kandi tekinolojiya mishya ishimishije yakomeje kuvumburwa kandi izanwa ku isoko vuba.
BMS numuyoboro mwiza wa mesh.Nyuma yuburambe bwa mbere hamwe na Wall mount, Gianturco-Roubin umusozi na Palmaz-Schatz umusozi, BMS nyinshi zitandukanye zirahari.
Ibishushanyo bitatu bitandukanye birahari: inzoka, mesh tubari na tube ya slotted.Igishushanyo mbonera kigizwe ninsinga zicyuma cyangwa imirongo ikora uruziga ruzengurutse;mubishushanyo mbonera ya tubular, insinga yazungurutswe muri mesh ikora umuyoboro;Ibishushanyo mbonera bigizwe nigituba cyicyuma gikata laser.Ibi bikoresho biratandukanye mubigize (ibyuma bidafite ingese, nichrome, chrome ya cobalt), igishushanyo (imiterere itandukanye ya spacer nubugari, diameter n'uburebure, imbaraga za radiyo, radiopacity), hamwe na sisitemu yo gutanga (kwaguka cyangwa kwagura imipira).
Nkuko bisanzwe, BMS nshya igizwe na cobalt-chromium ivanze, bivamo imirongo yoroheje, kunoza imikorere yo gutwara no kugumana imbaraga za mashini.
Zigizwe nicyuma cya stent (mubisanzwe ibyuma bitagira umwanda) kandi bisizwe hamwe na polymer irekura imiti igabanya ubukana kandi / cyangwa imiti igabanya ubukana.
Sirolimus (izwi kandi ku izina rya rapamycin) mu ntangiriro yakozwe nka antifungal antifungal.Uburyo bwibikorwa byabwo bujyanye no guhagarika ingirabuzimafatizo zigenda zihagarika inzibacyuho kuva mu cyiciro cya G1 kijya mu cyiciro cya S no kubuza imiterere ya neointima.Muri 2001, uburambe bwa "muntu wambere" hamwe na SES bwerekanye ibisubizo bitanga icyizere, biganisha ku iterambere rya stent ya Cypher.23 Ibigeragezo binini byagaragaje akamaro kayo mukurinda IR.24
Paclitaxel yabanje kwemererwa kuvura 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.Igeragezwa rya TAXUS V na VI ryerekanye ingaruka ndende za PES mu ndwara zikomeye z'umutima.25,26 TAXUS Liberté yakurikiyeho yagaragazaga ibyuma bidafite ingese kugirango byoroherezwe gutangwa.
Ibimenyetso bifatika bivuye mu bushakashatsi bubiri butunganijwe hamwe na meta-isesengura byerekana ko SES ifite akarusho kuri PES bitewe n’igipimo cyo hasi cya IVR hamwe n’intego yo kuvugurura imitsi (TVA), ndetse n’icyerekezo cyo kwiyongera k'indwara ikaze ya myocardial infarction (AMI) mu itsinda rya PES.27.28
Ibikoresho byo mu gisekuru cya kabiri byagabanije umubyimba wa shaft, byoroha guhinduka / gutanga, kunoza polymer biocompatibilité / imyirondoro yo gukuraho ibiyobyabwenge, hamwe na kinetic ya reendothelialisation.Mubikorwa byubu, ibi nibishushanyo mbonera bya DES bigezweho hamwe na coronary stent yatewe kwisi yose.
Ibikoresho bya tagisi bifata iyindi ntambwe hamwe na polymer idasanzwe yagenewe kurekurwa hakiri kare hamwe na sisitemu nshya ya platine-chromium spacer itanga icyogajuru cyoroshye kandi ikongera radiyo.Ubushakashatsi bwa PERSEUS 29 bwerekanye ibisubizo bisa hagati ya Element na Taxus Express mugihe cyamezi 12.Ariko, nta bigeragezo bihagije ugereranya yew nibindi bisekuru bya kabiri DES.
Endeavour Zotarolimus Coated Stent (ZES) ishingiye kumurongo ukomeye wa cobalt-chromium stent hamwe nubworoherane buke hamwe na stent ntoya.Zotarolimus ni analogue ya sirolimus ifite ingaruka zisa na immunosuppressive, ariko hamwe na lipofilique yiyongera kugirango irusheho kuba hafi kurukuta rwubwato.ZES ikoresha fosiforicholine polymer nshya yashizweho kugirango igabanye ibinyabuzima byinshi kandi igabanye umuriro.Imiti myinshi yogejwe mugice cyambere cyimvune, ikurikirwa no gusana arterial.Nyuma yikigeragezo cya mbere cya ENDEAVOR, iburanisha ryakurikiyeho rya ENDEAVOR III ryagereranije ZES na SES, yerekanaga igihombo kinini cyatinze na HR ariko kikaba ari gito cyane kibi gikomeye cyumutima-mitsi (MACEs) kurusha SES.30 Ubushakashatsi bwa ENDEAVOR IV bugereranya ZES na PES bwongeye kubona umubare munini wa SIS ariko umubare muto wa MI, birashoboka ko biterwa na ST ikunze kugaragara mu itsinda rya ZES.31 Ariko, ubushakashatsi bwo GUKINGIRA bwananiwe kwerekana itandukaniro muri ST inshuro nyinshi hagati ya Endeavour na Cypher.32
Endeavour Resolute ni verisiyo nziza ya Endeavour stent hamwe na polymer nshya-eshatu.Ubusobanuro bushya bwa Resolute Integrity (rimwe na rimwe byitwa DES generation ya gatatu DES) bushingiye kumurongo mushya ufite ubushobozi bwo gutanga ibintu byinshi (platform ya Integrity BMS platform) hamwe na polymer nshya, biocompatible igizwe na polimeri eshatu zishobora guhagarika igisubizo cyambere cyo gutwika no gukuraho ibiyobyabwenge byinshi muminsi 60 iri imbere.Ikigeragezo kigereranya Resolute na Xience V (everolimus eluting stent [EES]) cyerekanye ko sisitemu ya Resolute yagize akamaro kanini mubijyanye nimpfu no kunanirwa kwibasirwa.33.34
Everolimus, inkomoko ya sirolimus, nayo ni ingirabuzimafatizo ya selile ikoreshwa mugutezimbere EES Xience (Multi-link Vision BMS platform) / Promus (Platinum Chromium platform).Ikigeragezo cya SPIRIT 35-37 cyerekanye umusaruro ushimishije kandi kigabanya MACE hamwe na Xience V ugereranije na PES, mugihe ikigeragezo CYIZA cyerekanaga ko EES yari nziza nka SES muguhashya igihombo cyatinze mumezi 9 nibikorwa byubuvuzi mumezi 12.38 Hanyuma, stent ya Xience yerekanwe ko iruta BMS mugushiraho infashanyo ya ST yo hejuru ya myocardial (MI).39
EPC ni agace ka selile izenguruka igira uruhare mumitsi ya homeostasis no gusana endoteliyale.Kwiyongera kwa EPC ahakomeretse imitsi bizamura re-endothelialisation hakiri kare, bishobora kugabanya ibyago bya ST.Ubuzima bwa EPC bwa mbere muburyo bwa stent ni stent ya Genous, yashizwemo na antibodiyide zirwanya CD34, zishobora guhuza EPC ikwirakwiza ikoresheje ibimenyetso byayo bya hematopoietic kugirango byongere re-endoteliyale.Mugihe ubushakashatsi bwambere bwashimishije, ibimenyetso biheruka byerekana ibiciro bya TVR.40
Bitewe n'ingaruka zishobora kwangiza ziterwa na polymer iterwa no gutinda gukira bifitanye isano na ST ibyago, polymers bioresorbable itanga inyungu za DES wirinda impungenge zimaze igihe ziterwa no gukomeza polymer.Kugeza ubu, sisitemu zitandukanye za bioresorbable zemejwe (urugero, Nobori na Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), ariko ibitabo bishyigikira ibisubizo byigihe kirekire ni bike.41
Bioabsorbable ibikoresho bifite inyungu zuburyo bwo gutanga ubufasha bwa mashini mugihe hambere harebwa elastique recoil no kugabanya ingaruka zigihe kirekire zijyanye nibyuma bihari.Ikoranabuhanga rishya ryatumye habaho iterambere rya polymers acide lactique (acide poly-l-lactique [PLLA]), ariko sisitemu nyinshi za stent ziratera imbere, nubwo kubona uburinganire bwiza hagati yo gukuraho ibiyobyabwenge no gutesha agaciro bikomeje kuba ingorabahizi.Ubushakashatsi bwa ABSORB bwerekanye umutekano nubushobozi bwa stent ya PLOL ya Everolimus.43 Kuvugurura igisekuru cya kabiri Absorb stent byari byiza kurenza ibyabanje hamwe nimyaka 2 ikurikirana.44 Ubu bushakashatsi bwa ABSORB II, ikigeragezo cyambere cyateganijwe ugereranije stent ya Absorb na stent ya Xience Prime, igomba gutanga amakuru yinyongera, kandi ibisubizo byambere biboneka biratanga ikizere.45 Ariko rero, ibintu byiza, tekinike nziza yo gutera, hamwe numwirondoro wumutekano mu ndwara zifata imitsi.
Thrombose muri BMS na DES ifite ingaruka mbi zamavuriro.Mu gitabo cy’abarwayi batewe na DES, 47 24% by’abanduye indwara ya ST byaviriyemo urupfu, 60% muri MI idapfa, na 7% muri angina idahindagurika.PCI kubintu byihutirwa ST mubisanzwe ni suboptimal, hamwe nibisubiramo 12% byimanza.48
Kwagura ST bifite ingaruka mbi zamavuriro.Mu bushakashatsi bwa BASKET-LATE, amezi 6-18 nyuma yo gushyirwaho stent, ibipimo by'impfu z'umutima na MI bidahitana MI byari hejuru mu itsinda rya DES kuruta mu itsinda rya SMP (4.9% na 1.3%).20 Isesengura ryakozwe n’ubushakashatsi icyenda aho abarwayi 5261 batoranijwe kuri SES, PES, cyangwa BMS ryerekanye ko nyuma yimyaka 4 ikurikiranwa, SES (0,6% na 0%, p = 0.025) na PES (0.7%)) byongereye ubwandu bwa ST yatinze cyane ugereranije na BMS kuri 0.2%, p = 0.028).49 Ibinyuranye, mu isesengura ryakozwe 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 kudasanzwe kwa 15% (reba - kugeza ku mezi 9 kugeza ku myaka 3).
Kwiyandikisha kwinshi, ibigeragezo byateganijwe, hamwe na meta-gusesengura byasuzumye ingaruka ziterwa na ST nyuma yo kwimurwa kwa BMS na DES kandi byatanze ibisubizo bivuguruzanya.Mu gitabo cy’abarwayi 6906 bavuwe na BMS cyangwa DES, nta tandukaniro ryigeze riva mu mavuriro cyangwa ku bipimo bya ST mu mwaka 1 wabikurikiranye.48 Mu kindi gitabo cy’abarwayi 8146, ibyago byo gukomeza kwandura ST byagaragaye ko ari 0,6% ku mwaka ugereranije na BMS.49 Meta-isesengura ryubushakashatsi bugereranya SES cyangwa PES na SMPs ryerekanye ibyago byinshi byo guhitanwa nimpfu na MI hamwe na DES yo mu gisekuru cya mbere ugereranije na SMP, 21 nubundi meta-isesengura ry’abarwayi 4545 batoranijwe na SES cyangwa ST hagati ya PES na BMS mu myaka 4 ikurikiranwa.50 Ubundi bushakashatsi bwakozwe ku isi bwerekanye ibyago byinshi byo kwandura ST na MI ku barwayi bavuwe na DES yo mu gisekuru cya mbere nyuma yo guhagarika DAPT.51
Urebye amakuru avuguruzanya, isesengura ryinshi hamwe na meta-isesengura hamwe byemeje ko DES hamwe nigisekuru cya mbere SGM itatandukanye cyane mubyago byurupfu cyangwa MI, ariko SES na PES bari bafite ibyago byinshi byo kwandura ST ugereranije na SGM.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 ikora neza nkuko yanditse kandi ko ibyago byo mu byiciro byateye imbere cyane ari bito, ariko atari binini., Kwiyongera gukomeye.Kubera iyo mpamvu, FDA n’ishyirahamwe birasaba kongera igihe cya DAPT kugeza ku mwaka 1, nubwo hari ibimenyetso bike byemeza iki kirego.
Nkuko byavuzwe haruguru, igisekuru cya kabiri DES yatejwe imbere hamwe nuburyo bunoze bwo gushushanya.CoCr-EES yakoze ubushakashatsi bwimbitse mubuvuzi.Mu isesengura ryakozwe na Baber et al.54 ku barwayi 17,101, CoCr-EES yagabanije cyane ST / MI isobanutse neza / bishoboka ugereranije na PES, SES, na ZES mu mezi 21.Hanyuma, Palmerini n'abandi berekanye muri meta-isesengura ry’abarwayi 16.775 ko CoCr-EES ifite hasi cyane ku buryo bugaragara hakiri kare, bitinze, 1- na 2 ans byasobanuwe na ST ugereranije nizindi DES zahujwe.55 Ubushakashatsi nyabwo bwerekanye ko igabanuka ryibyago bya ST hamwe na CoCr-EES ugereranije na DES yo mu gisekuru cya mbere.56
Re-ZES yagereranijwe na CoCr-EES mubushakashatsi bwa RESOLUTE-AC na makumyabiri.33,57 Nta tandukaniro rikomeye ryagaragaye mu rupfu, infirasiyo ya myocardial, cyangwa igice cya ST cyasobanuwe hagati ya stent zombi.
Mu rusobe meta-isesengura ry’abarwayi 50.844, harimo 49 RCTs, 58 CoCr-EES yahujwe no kuba umubare muto ugaragara wa ST wasobanuwe kurusha BMS, ubushakashatsi butabonetse hamwe n’abandi DES;kugabanuka ntabwo byari "hakiri kare cyane" na nyuma yiminsi 30 (58).Ikigereranyo kidasanzwe [OR] 0.21, 95% intera yicyizere [CI] 0.11-0.42) no kumwaka 1 (OR 0.27, 95% CI 0.08-0.74) nimyaka 2 (OR 0.35, 95% CI 0.17–0.69).Ugereranije na PES, SES, na ZES, CoCr-EES yahujwe nigipimo cyo hasi cya ST kumwaka 1.
ST yo hambere ifitanye isano nibintu bitandukanye. Imiterere ya plaque morphologie hamwe numutwaro wa trombus bisa nkibishobora kugira ingaruka kubisubizo nyuma ya PCI; 59 byimbitse byinjira byinjira muri nerotic core (NC) gusenyuka, amarira maremare yo hagati muri stent, stoptimal stent hamwe no gutandukana kwuruhande rwibisigisigi cyangwa stenosis ikomeye, kwifata kutuzuye, kugereranya kwangirika kwimiti ya STMS 60. hamwe na DES, ibipimo bya ST ikaze na subacute ST mugihe cya DAPT byari bisa (<1%). 61 Rero, ST yo hambere isa nkaho ifitanye isano cyane cyane nibikomere bivurwa biterwa nimpamvu zikurikirana. Imiterere ya plaque morphologie hamwe numutwaro wa trombus bisa nkibishobora kugira ingaruka kubisubizo nyuma ya PCI; 59 byimbitse byinjira byinjira muri nerotic core (NC) gusenyuka, amarira maremare yo hagati muri stent, stoptimal stent hamwe no gutandukana kwuruhande rwibisigisigi cyangwa stenosis ikomeye, kwifata kutuzuye, kugereranya kwangirika kwimiti ya STMS 60. hamwe na DES, igipimo cya ST ikaze na subacute ST mugihe cya DAPT byari bisa (<1%) .61 Rero, ST yo hambere isa nkaho ifitanye isano cyane cyane nibisebe bivurwa hamwe nibintu bikurikirana. Морфогия лежащnzi иа Пролапа па па па па па па па па па па и Краевым Расслоениями ки ки ки апп Ожеличить Риска ST60 Го ST: в Рандо THEPированн унаниваниваюстострого одинаровой (<1%) .61 Так Им Обром обром, Ран Ми. Indangantego ya plaque morphologie na trombose bigaragara ko bigira ingaruka kumusubizo nyuma ya PCI; 59 byimbitse byimbaraga zatewe na nerotic nucleus (NC) gusenyuka, amarira maremare yo hagati muri stent, stoptimal stent hamwe na mariginal mariginal stenosis, kwifata kutuzuye hamwe no kwaguka kutuzuye kwa stent yatewe no kwanduza indwara ya ST.60. MS na DES, indwara ya ST ikaze na subacute ST mugihe cya DAPT yari imwe (<1%) .61 Rero, ST yo hambere isa nkaho ifitanye isano cyane cyane nibikomere bivurwa hamwe nibintu bikurikirana.潜在 的 斑块 形态 和 负荷 似乎 影响 PCI 后 的 结果 ； 59 坏死 核心 (NC) 脱垂 导致 的 更深 的 支柱 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张 扩张方案 不会 显 着 影响 ST 的 发生 率 率 在 一项 比较 BMS 与 DES 的 随机 试验 中 ， DAPT 期间 急性 和 亚 急性 ST 的 发生 率 （1潜在 的 斑块 形态 ci ci ci pci 后 结果 ； ； ； ci ； 坏 死 导致 导致 、 着 着 次 着 次 次 次 次 次 次 次 狭窄 次 次 次的 的 的 的 ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms ms发生 发生 发生 发生 发生 发生 发生 发生 发生 发生 发生 发生 （1 1 1 1 1 <1%） .61Icyapa cyibanze cya morfologiya na trombose bigaragara ko bigira ingaruka kubisubizo nyuma ya PCI;59 Kwinjira cyane cyane bitewe na nucleus nucleus (NC) gusenyuka, guturika hagati yuburebure bwa stent, gutandukana kwa kabiri hamwe n’imisigarira isigaye, cyangwa kugabanuka gukabije kwa Optimal stenting, apposition ituzuye, no kwaguka kutuzuye60 Gahunda ya Antiplatelet nta ngaruka nini igira kuri ST hakiri kare: kwandura ST gukabije na subacute ST mugihe cya DAPT.bifitanye isano cyane cyane no kuvura ibikomere hamwe nibintu byo kubaga.
Uyu munsi, icyibandwaho ni gutinda / gutinda cyane ST.Mugihe ibintu byuburyo bwa tekiniki bisa nkibifite uruhare runini mugutezimbere ST ikaze kandi itagaragara, uburyo bwibintu byatinze bya trombotic bigaragara ko bigoye.Byagaragaye ko ibiranga abarwayi bimwe na bimwe bishobora kuba ingaruka ziterwa na ST igenda itera imbere kandi itera imbere cyane: diyabete mellitus, ACS mugihe cyo kubagwa bwa mbere, kunanirwa kw'impyiko, gusaza, kugabanya igice cyo gusohora, ibintu bikomeye bibi byumutima bitarenze iminsi 30 nyuma yo kubagwa bwa mbere.Kuri BMS na DES, impinduka zikurikirana nkubunini bwubwato buto, gutandukana, indwara zifata imitsi myinshi, kubara, gufunga byuzuye, stent ndende bigaragara ko ifitanye isano ningaruka zo kwandura ST.62,63 Igisubizo kibi cyo kuvura antiplatelet nikintu gikomeye gishobora gutera DES trombose igenda itera imbere 51.Iki gisubizo gishobora guterwa no kutubahiriza abarwayi, kunywa ibiyobyabwenge, guhuza ibiyobyabwenge, ingaruka ziterwa no gufata ibiyobyabwenge, polymorphism yo mu rwego rwa reseptor (cyane cyane kurwanya clopidogrel), no gukora izindi nzira zo gukora platine.Stent neoatherosclerose ifatwa nkuburyo bwingenzi bwo kunanirwa gutinda kwa stent, harimo na nyuma ya ST64 (igice “Stent Neoatherosclerose”).Endotelium idahwitse itandukanya urukuta rw'imitsi hamwe na poste ya stent kuva mumaraso kandi ikarekura antithrombotic na vasodilatory.DES igaragaza urukuta rw'imitsi imiti igabanya ubukana hamwe na porogaramu irekura ibiyobyabwenge, bigira ingaruka zitandukanye ku mikorere yo gukiza no kurangiza, hamwe na trombose yatinze.65 Ubushakashatsi bw’ubuvuzi bwerekanye ko imbaraga za DES polymers zo mu gisekuru cya mbere zishobora kugira uruhare mu gutwika indwara zidakira, kubika fibrine idakira, gukira nabi kwa endoteliyale, bityo bikaba byongera ibyago byo kurwara trombose.3 Gutinda cyane kuri DES bigaragara ko ari ubundi buryo buganisha kuri ST.Virmani n'abandi.66ibi bivumbuwe birashobora kwerekana ingaruka za polymers zidashobora kurimburwa.67 Imyitwarire idahwitse irashobora guterwa no kwaguka kwa stoptimal cyangwa kugaragara nyuma y'amezi menshi PCI.Nubwo malapposition ikurikirana ari ibintu bishobora gutera indwara ya ST ikaze kandi idasobanutse, akamaro k’amavuriro yo kwandura stent malapposition gashobora guterwa no kuvugurura imiyoboro ikaze cyangwa guterwa no gutinda gukira, ariko akamaro k’amavuriro ntikivugwaho rumwe.68
Ingaruka zo gukingira DES-generation ya kabiri DES irashobora gushiramo endothelialisation yihuse kandi idahwitse, kimwe no gutandukanya stent alloy hamwe nimiterere, uburebure bwa strut, imiterere ya polymer, hamwe nubwoko bwibiyobyabwenge bya antiproliferative, dose, na kinetics.
Ugereranije na CoCr-EES, inanutse (81 µm) cobalt-chromium stent scaffolds, fluoropolymers antithrombotic, ibirimo polymer nkeya, hamwe no gupakira ibiyobyabwenge bishobora kugira uruhare mukugabanuka kwa ST.Ubushakashatsi bwakozwe bwerekanye ko trombose hamwe na platine yoherejwe biri hasi cyane muri stente ya fluoropolymer kuruta muri stent idafunze.69 Niba ikindi gisekuru cya kabiri DES ifite imitungo isa ikwiye gukomeza kwiga.
Indwara ya Coronary itezimbere uburyo bwo kubaga ibikorwa bya coronary ugereranije na gakondo ya percutaneous transluminal coronary angioplasty (PTCA), ifite ibibazo byubukanishi (imitsi y'amaraso, gutandukana, nibindi) hamwe nigipimo kinini cya restenose (kugeza 40-50% byimanza).Mu mpera z'imyaka ya za 90, hafi 70% ya PCI zakozwe hakoreshejwe BGM.70
然而 ， 尽管 技术 、 技术 和 MS MS MS 了 进步 MS BMS 植入 后再 狭窄 的 风险 约为 20% ， 在 特定 亚 组 中 发生 率> 40%。MS ， 尽管 技术 、 技术 和 MS MS MS MS BMSNubwo, nubwo iterambere ryateye imbere mu ikoranabuhanga, tekinike, no kuvura, ibyago byo kuruhuka nyuma yo guterwa BMS bigera kuri 20%, ibiciro birenga 40% mu matsinda amwe.Muri rusange, ubushakashatsi ku mavuriro bwerekanye ko restenosis nyuma yo guterwa BMS, bisa nkibigaragara hamwe na PTCA isanzwe, igera ku mezi 3-6 kandi igakemuka mu mwaka 1.72
DES irongera kugabanya igipimo cya ISR, 73 nubwo uku kugabanuka gutandukanijwe na clinique.DES polymer coating irekura anti-inflammatory na anti-proliferative, ikabuza imiterere ya neointima, kandi igatinda gusana imitsi amezi cyangwa imyaka.74 Mu bushakashatsi bw’ubuvuzi n’amateka, ubwiyongere bwa neointima bwagaragaye mu gihe kirekire cyakurikiranwe nyuma yo gushyirwaho DES, ikintu kizwi nka “gutinda gufata” 75.
Gukomeretsa kw'amaraso mugihe cya PCI bitera inzira igoye yo gutwika no gusana mugihe gito ugereranije (ibyumweru ukwezi), bikavamo endothelialisation hamwe na neointimal.Dukurikije ubushakashatsi bwakozwe na histopathologique, hyperplasia ya neointimal (HMS na DES) nyuma yo guterwa stent ahanini yari igizwe ningirabuzimafatizo zigenda ziyongera muri matrike ya proteoglycan ikungahaye cyane.70
Niyo mpamvu, hyperplasia ya neointimal ni inzira yo gusana irimo ibintu byo gutwika no gutwika, kimwe na selile zitera imikurire yimitsi yimitsi hamwe na matrix idasanzwe.Ako kanya nyuma ya PCI, platine na fibrin bishyirwa kurukuta rwubwato kandi bikurura leukocytes binyuze murukurikirane rwa molekile zifata selile.Kuzunguruka leukocytes yomeka kuri platine ifatanye binyuze mumikoranire hagati ya leukocyte integrin Mac-1 (CD11b / CD18) na platine glycoprotein Ibα 53 cyangwa fibrinogen ifitanye isano na platine glycoproteine ​​IIb / IIIa.76.77
Dukurikije amakuru mashya, ingirabuzimafatizo zo mu magufa zigira uruhare mu myitwarire y’imitsi no mu bikorwa byo gusana.Gukangurira EPC kuva mu magufa kugera ku maraso ya periferique bitera kuvugurura endoteliyale no kuvuka kwa neovascularization.Bigaragara ko amagufwa ya magufa yoroshye ya progenitor selile (SMPCs) yimukira ahakomeretse imitsi, bikaviramo kwiyongera kwa neointimal.78 Mbere, selile nziza ya CD34 yafatwaga nkabaturage bahamye ba EPC, ubushakashatsi bwakozwe bwerekanye ko antigen yo hejuru ya CD34 yemera rwose ingirabuzimafatizo zidafite amagufwa zifite ubushobozi bwo gutandukanya EPC na PBMCs.Guhindura CD34-selile nziza mumirongo ya EPC cyangwa SMPC biterwa nibidukikije byaho;imiterere ya ischemic itera itandukaniro kuri fenotype ya EPC, iteza imbere reendothelialisation, mugihe imiterere yumuriro itera itandukaniro ryerekanwa na SMPC phenotype, iteza ikwirakwizwa rya neointimal.79
Diyabete yongerera ibyago ISR 30-50% nyuma yo gushyirwaho BMS, kandi umuvuduko mwinshi wa restenosis muri diyabete ugereranije n’abarwayi badafite diyabete nawo wakomeje mu gihe cya DES.Uburyo bushingiye kuri uku kwitegereza bushobora kuba butandukanye, harimo sisitemu (urugero, guhinduka mubisubizo byumuriro) hamwe na anatomique (urugero, imiyoboro mito, ibikomere birebire, indwara ikwirakwizwa, nibindi), byigenga byigenga ibyago bya ISR.70
Diameter ya Vessel hamwe nuburebure bwa lesion 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 ndende hamwe na ISR yo hejuru ugereranije na generation ya kabiri stent platform hamwe na tronc yoroheje.
Byongeye kandi, indwara ya restenosis ifitanye isano n'uburebure bwa stent, hafi kwikuba kabiri uburebure bwa stent> mm 35 ugereranije nizo <20 mm. Byongeye kandi, indwara ya restenosis ifitanye isano nuburebure bwa stent, hafi kwikuba kabiri uburebure bwa stent> mm 35 ugereranije nizo <20 mm. Кроме того, частота рестеноза свяаза с длиной мата, поти удваиваясь при длине мта> 35 мим по сравнению с длиной марта <20 mm. Mubyongeyeho, igipimo cya restenosis kijyanye nuburebure bwa stent, hafi gukuba kabiri hamwe nuburebure bwa stent> mm 35 ugereranije nuburebure bwa stent <20 mm.此外 ， 再 狭窄 的 发生 率 与 35 长度 有关 ， 支架> mm 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 мата: длина мата> 35 мил поти в два раза больше, чем мата <20 mm. Mubyongeyeho, inshuro ya restenosis yaterwaga nuburebure bwa stent: uburebure bwa stent> mm 35 ni hafi inshuro ebyiri za stent <20 mm.Diameter ya nyuma ya diameter ya stent nayo yagize uruhare runini: ntoya ntoya ya nyuma ya diameter ya lumen yahanuye ko ibyago byo kwandura byiyongera cyane.81.82
Ubusanzwe, hyperplasia ntangarugero nyuma yo gushyirwaho kwa BMS ifatwa nkaho itajegajega, hamwe nimpinga hakiri kare hagati y amezi 6 numwaka 1 ikurikirwa nigihe cyo gusinzira.Impinga yambere yo gukura kwimbitse ikurikirwa no gusubira inyuma cyane hamwe no kwaguka kwa lumen nyuma yimyaka myinshi nyuma yo guterwa stent byavuzwe mbere;Gukura kwingirangingo zimitsi yoroshye hamwe nimpinduka muri matrice idasanzwe byasabwe nkuburyo bushoboka bwo gutinda kwa neointima.83 Nyamara, ubushakashatsi bwigihe kirekire bwakurikiranye bwerekanye igisubizo cya trafasique nyuma yo gushyirwa kwa BMS hamwe na restenosis kare, gusubira inyuma, no gutinda kwa luminal.84
Mugihe cya DES, gukura gutinze kwa neointimal kwerekanwe bwa mbere nyuma yo gushyirwaho SES cyangwa PES mubyitegererezo byinyamaswa.85 Ubushakashatsi bwinshi bwa IVUS bwerekanye ko hakiri kare gukura gukabije gukurikirwa no gutinda gufata igihe nyuma yo guterwa SES cyangwa RPE, bishoboka ko biterwa nuburyo bukomeza gutwikwa.86
Nubwo "ituze" risanzwe ryitirirwa ISR, hafi kimwe cya gatatu cyabarwayi bafite BMS ISR barwara ACS.bine
Hariho ibimenyetso byinshi byerekana ko gutwika karande hamwe na / cyangwa kubura endoteliyale bitera neoatherosclerose igenda itera imbere muri HCM na DES (cyane cyane DES yo mu gisekuru cya mbere), bishobora kuba inzira yingenzi yo guteza imbere iterambere rya IR cyangwa ST itera imbere.Inoue et al [87] yatangaje ibyavuye mu isuzuma ry’amateka nyuma yo gushyirwaho intanga za Palmaz-Schatz coronary, byerekana ko gutwika kuri stent bishobora gukurura impinduka nshya ziterwa na aterosklerotike muri stent.Ubundi bushakashatsi10 bwerekanye ko tissue restenotic mugihe cyimyaka 5 CGM igizwe na aterosclerose iherutse gutangira hamwe na peritoneal inflammation;Ingero zivuye muri ACS zerekana plaque zisanzwe zishobora kwibasirwa nimiyoboro ya koronari kavukire ya Histologiya ihagarika morphologie hamwe na macrophage ifuro hamwe na kristu ya cholesterol.Byongeye kandi, iyo ugereranije BMS na DES, hagaragaye itandukaniro rikomeye mugihe niterambere rya aterosklerose nshya.11,12 Impinduka za mbere za aterosklerotike mumyanya myinshi ya macrophage yinjiye yatangiye amezi 4 nyuma yo guterwa kwa SES, mugihe impinduka zimwe mubikomere bya CGM zabayeho nyuma yimyaka 2 kandi bikomeza kuba imbonekarimwe kugeza kumyaka 4.Byongeye kandi, DES stenting kubikomere bidahindagurika nka fibroatherosclerose yoroheje (TCFA) cyangwa guturika cyane bifite igihe gito cyo kwiteza imbere ugereranije na BMS.Niyo mpamvu, neoatherosclerose isa nkibisanzwe kandi bibaho kare mu gisekuru cya mbere DES kuruta muri BMS, bishoboka ko biterwa na virusi itandukanye.
Ingaruka z'igisekuru cya kabiri DES cyangwa DES ku iterambere ziracyashakishwa;nubwo bimwe mubisanzweho byerekeranye nigisekuru cya kabiri DES88 byerekana umuriro muke, indwara ya neoatherosclerose irasa nigisekuru cya mbere, ariko haracyakenewe ubundi bushakashatsi.