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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Dhipatimendi reCardiology, Poliambulanza Foundation Hospital, Brescia, 2 Dhipatimendi reCardiology, Catholic University of the Sacred Heart yeRome, Italy Abstract: Drug-Eluting simbi Stemize (BMS) mushure mekupindira kwepercutaneous coronary intervention.Zvisinei, kunyange zvazvo kuiswa kwechizvarwa chechipiri cheDES kunoratidzika kunge kwakagadzirisa chiitiko ichi chichienzaniswa nechizvarwa chekutanga cheDES, kunetseka kwakakomba kunoramba kuri pamusoro pezvinobvira kunonoka kunonoka kwekuiswa kwe stent, zvakadai se stent thrombosis (ST) uye stent resection. Stenosis (ISR) .ST chiitiko chinogona kuitika chakanyanya kuderedzwa kuburikidza nekugadzirisa stenting, novel stent designs, uye dual antiplatelet therapy.Iyo nzira chaiyo inotsanangura kuitika kwayo iri kuongororwa, uye zvechokwadi, zvinhu zvakawanda zvine mhosva.ISR muBMS yakamboonekwa sechinhu chakadzikama nekutanga kwepamusoro peatimal hyperplasia (at 6 months) gore.Kusiyana, zvose zvidzidzo zvekliniki uye histological zveDESs zvakaratidza uchapupu hwekuramba huripo neointimal kukura panguva yekutevera kwenguva refu, chiitiko chinozivikanwa se "late catch-up" chiitiko.Maonero ekuti ISR ​​inongova yakashata yekliniki mamiriro ezvinhu achangobva kupikiswa nehuchapupu hwokuti varwere vane ISR vanogona kukudziridza acute coronary syndromes. plaques uye zvinhu zve post-stent midziyo kuporesa; inowanzoshandiswa kupedza diagnostic coronary angiography uye drive interventional procedures.Intracoronary optical coherence tomography ikozvino inoonekwa seyepamusoro-soro yekufungidzira nzira.Inofananidzwa ne intravascular ultrasound, inopa kugadzirisa zviri nani (kanenge> 10 times), zvichibvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro emudziyo. Kunonoka-nhanho neo-atherosclerosis mukati meBMS neDES. Naizvozvo, neo-atherosclerosis ndiyo yakava mufungidziri mukuru wepathogenesis yekunonoka stent kukundikana. Keywords: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
Percutaneous coronary intervention (PCI) ine stent implantation ndiyo inonyanya kushandiswa nzira yekurapa kwechiratidzo checonary artery disease, uye nzira yacho inoramba ichichinja.1 Kunyange zvazvo mishonga-eluting stents (DES) inoderedza miganhu ye-bare-metal stents (BMSs), kunonoka kwematambudziko akadai se stent thrombosis (SRST) uye stent thrombosis. kuiswa kwe stent. , zvinonetsa zvakakomba zvichiripo.2-5
Kana ST iri chiitiko chinogona kutyisa, kuziva kuti ISR ​​chirwere chinotyisa chichangobva kupikiswa nehuchapupu hweacute coronary syndrome (ACS) muvarwere veISR.4
Nhasi, intracoronary optical coherence tomography (OCT) 6-9 inoonekwa seyazvino-ye-the-art imaging technique, inopa kugadzirisa zviri nani pane intravascular ultrasound (IVUS)."In vivo" zvidzidzo zvekufungidzira, 10-12 inopindirana nezvakaitika kare, inoratidza "itsva" nzira yekupindura kwevascular MS mushure mekuita stent implantation, neDES novoa.
Muna 1964, Charles Theodore Dotter naMelvin P Judkins vakatsanangura yekutanga angioplasty.Muna 1978, Andreas Gruntzig akaita bharumu rekutanga angioplasty (plain old balloon angioplasty); yakanga iri shanduko yekurapa asi yakanga ine zvipingamupinyi zvekuvhara kwemudziyo wakaoma uye restenosis.13 Izvi zvakafambisa kuwanikwa kwecoronary stents: Puel naSigwart vakashandisa iyo yekutanga coronary stent mu1986, vachipa stent kudzivirira kuvharwa kwemudziyo wakaoma uye kunonoka systolic retraction.14 Kunyange zvazvo aya ekutanga stents akadzivirira kuputika kwemudziyo, kuvharwa kwakakomba, kwakakonzera kuputika kwemudziyo. miedzo miviri inokosha, Belgian-Dutch Stent Trial 15 uye Stent Restenosis Chidzidzo 16, yakatsigira kuchengetedzwa kwe stenting ne dual antiplatelet therapy (DAPT) uye / kana nzira dzakakodzera dzekushandisa.17,18 Mushure memiedzo iyi, pane kuwedzera kukuru kwenhamba yePCIs yakaitwa.
Zvisinei, dambudziko re iatrogenic in-stent neointimal hyperplasia inotevera BMS kuiswa kwakakurumidza kuonekwa, zvichiita kuti ISR ​​mu 20% -30% yezvironda zvakarapwa. Muna 2005, 80% -90% yemaPCI ese akaperekedzwa neDES.
Zvose zvine zvipingamupinyi zvaro, uye kubvira 2005, kunetseka pamusoro pekuchengetedzwa kwe "chizvarwa chekutanga" DES chakasimuka, uye stents yechizvarwa chitsva chakadai se20,21 yakagadzirwa uye yakatangwa.22 Kubva ipapo, kuedza kwekuvandudza kushanda kwe stent kwakakura nokukurumidza, uye hutsva, hunoshamisa hutsva hwakaramba huchiwanikwa uye huchiendeswa kumusika nokukurumidza.
BMS iri mesh nhete waya chubhu.Mushure mechiitiko chekutanga ne "Wall" gomo, Gianturco-Roubin gomo uye Palmaz-Schatz gomo, akawanda akasiyana maBMS ave kuwanikwa.
Magadzirirwo matatu akasiyana anogoneka: coil, tubular mesh uye slotted chubhu.Makoiri madhizaini ane waya dzesimbi kana mitsetse yakaumbwa kuita denderedzwa coil chimiro; tubular mesh magadzirirwo anoratidza waya dzakaputirwa pamwechete mumambure kuita chubhu; slotted chubhu magadzirirwo anoumbwa nesimbi chubhu ari laser akachekwa made.Izvi midziyo inosiyana pakuumbwa (stainless simbi, nichrome, cobalt chrome), structural dhizaini (yakasiyana strut mapatani uye upamhi, madhayamita uye kureba, radial simba, radiopacity) uye kuendesa masisitimu (self-expanding or balloon-expandable) .
Kazhinji, iyo BMS itsva ine cobalt-chromium alloy, izvo zvinoguma neatete struts ane kuvandudzwa kwekufamba, kuchengetedza simba remuchina.
Iwo anosanganisira simbi stent chikuva (kazhinji simbi isina tsvina) uye yakaputirwa nepolymer inoburitsa anti-proliferative uye/kana anti-kuzvimba therapeutics.
Sirolimus (inozivikanwawo se rapamycin) yakatanga kugadzirwa se antifungal agent.Iyo nzira yekuita inobva pakuvharidzira kufambira mberi kwesero kuburikidza nekuvhara kushanduka kubva kuG1 chikamu kusvika kuS chikamu uye kuvharidzira neointima formation.Muna 2001, "yekutanga-mu-munhu" chiitiko neSES yakaratidza migumisiro inovimbisa yekuedza, kutungamirira kuCy23phe kufambira mberi kwayo. kushanda mukudzivirira ISR.makumi maviri nemana
Paclitaxel yakatanga kubvumirwa nekenza ye ovarian, asi ine simba cytostatic properties - mushonga unogadzirisa microtubules panguva ye mitosis, inotungamirira kusungwa kwesero kusungwa uye inhibits neointimal formation - ita kuti ive mubatanidzwa weTaxus Express PES.I TAXUS V uye VI miedzo yakaratidza kushanda kwenguva refu kwePES mune high-risk, TAX26, chirwere chetachiona chepamusoro-soro, TAXUS26 yakaoma. Liberté yakaratidza chikuva chesimbi isina simbi kuitira nyore kuburitsa.
Uchapupu hwakazara hunobva kuongororo mbiri dzakarongeka uye meta-kuongorora hunoratidza kuti SES ine mukana wepamusoro pePES nekuda kwekuderera kwemazinga eISR uye chinangwa chemudziyo revascularization (TVR), pamwe nemaitiro ekuwedzera acute myocardial infarction (AMI) muPES cohort. 27,28
Zvishandiso zvechizvarwa chechipiri zvakaderedza kukora, kuvandudza kuchinjika/kuburitswa, kukwidziridzwa kwepolymer biocompatibility/drug elution profiles, uye yakanakisa re-endothelialization kinetics.Muchiito chemazuva ano, ndiwo madhizaini epamusoro eDES uye mastents makuru ecoronary akaiswa pasi rose.
Taxus Elements inoenderera mberi nepolymer yakasiyana-siyana yakagadzirirwa kuwedzera kusunungurwa kwekutanga uye itsva platinum-chromium strut system inopa struts yakaonda uye yakagadziridzwa radiopacity.The PERSEUS trial 29 yakacherechedza migumisiro yakafanana pakati peElement neTaxus Express kusvika kumwedzi 12.Zvisinei, miedzo iri kuenzanisa yew-yew elements nedzimwe DES yechipiri lageneration.
Zotarolimus-eluting stent (ZES) Endeavor inobva pane yakasimba cobalt-chromium stent papuratifomu ine flexibility yakakwirira uye diki stent strut size.Zotarolimus is a sirolimus analogue ine ma immunosuppressive effects akafanana asi yakawedzera lipophilicity kuti iwedzere midziyo yemudhuri.ZES inoshandisa pholymize inogadzirwa novelline pholymery inogadzirwa novelline. biocompatibility uye kuderedza kuputika.Mishonga yakawanda inobudiswa panguva yekukuvara kwekutanga, inoteverwa nekugadzirisa arterial.Pashure pekutanga kweENDEAVOUR muedzo, muedzo wakatevera weENDEAVOUR III wakaenzanisa ZES neSES, iyo yakaratidza kurasikirwa kukuru kwekupedzisira kwe lumen uye ISR asi zvishomanana zvakanyanya kuipa kwezviitiko zvemwoyo (MACE) kupfuura SES .30 The ENDEAVOR, iyo yakawana chiyero cheZIVSR, iyo yakaenzanisa zvakare nePASSR muyedzo, iyo ENDEAVOUR, yakaenzaniswa nePISR. chiitiko chakaderera che AMI, sezviri pachena kubva kune yakanyanyisa ST muboka reZES.31 Zvisinei, chirongwa chePROTECT chakakundikana kuratidza kusiyana kwe ST rates pakati peEndeavor neCypher stents.32
Endeavor Resolute ishanduro yakavandudzwa yeEndeavor stent ine itsva-layer polymer.Iyo itsva Resolute Integrity (dzimwe nguva inonzi DES yechizvarwa chechitatu) inobva papuratifomu itsva ine hukuru hwekutakura hunogona (the Integrity BMS platform), uye novel, yakawanda biocompatible three-layer response over inflammatory the first-layer response over the first-layer response. Mazuva 60. Muedzo uchienzanisa Resolute ne Xience V (everolimus-eluting stent [EES]) yakaratidza kusaderera kweResolute system maererano nerufu uye chinangwa chekukundikana kwechirwere.33,34
Everolimus, inobva kune sirolimus, inonziwo cell cycle inhibitor inoshandiswa mukugadzirwa kweXience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform) EES.The SPIRIT trial 35-37 yakaratidza kuvandudzwa kwekushanda uye yakaderedza MACE neXience V ichienzaniswa nePES, nepo EXFECELLES yakaratidza kuti EXFECELLES muyedzo yakanga isina kuedzwa. kunonoka kurasikirwa pamwedzi 9 uye zviitiko zvechipatara pamwedzi 12. 38 Pakupedzisira, Xience stent yakaratidza zvakanakira BMS mukugadzirisa kwe ST-segment elevation myocardial infarction (MI) .39.
EPCs iboka remasero anotenderera anobatanidzwa muvascular homeostasis uye endothelial repair.Kuwedzerwa kweEPCs panzvimbo yekukuvara kwevascular kuchakurudzira kutanga kwekupedzisira endothelialization, zvingaita kuderedza dambudziko rekutanga kuedza kwe ST.EPC biology mumunda we stent design ndiyo CD34 antibody-coated yeGenous bipotic stent, inokwanisa kuisa chiratidzo cheGenous bipotic stent. wedzera re-endothelialization.Kunyange zvazvo zvidzidzo zvekutanga zvaikurudzira, uchapupu huchangobva kuitika hunoratidza huwandu hwepamusoro hweTVR.40
Tichifunga zvingangokanganisa mhedzisiro yepolymer-induced kunonoka kuporesa, iyo inosanganiswa nenjodzi yeST, bioabsorbable polymers inopa mabhenefiti eDES, kudzivirira kushushikana kwenguva refu pamusoro pepolymer persistence.Kusvika parizvino, akasiyana bioabsorbable masisitimu akatenderwa (eg Nobori neBiomatrix, biolimus eluting stent, EESl masters, Synergy yavo), mabhuku eSylrgy migumisiro yenguva refu ishoma.41
Bioabsorbable zvinhu zvine theoretical advantage yekutanga kupa mechanical support apo elastic recoil inofungidzirwa uye kuderedza njodzi dzenguva refu dzine chokuita nesimbi iripo struts.New technologies yakatungamirira kukugadzirwa kwelactic acid-based polymers (poly-l-lactic acid [PLLA]), asi dzakawanda stent systems dziri mukuvandudza, kunyange zvazvo kugadzirisa kuenzana kweBBS uye kusara kwehutano hwakanaka. muedzo wakaratidza kuchengeteka uye kushanda kweeverolimus-eluting PLLA stents.43 Chizvarwa chechipiri Absorb stent revision yakanga iri kuvandudzwa pamusoro pekare nekutevera kwakanaka kwegore re 2.44 Kuenderera mberi kweABSORB II kuedza, kuedza kwekutanga kusingaenzaniswi kuenzaniswa neAbsorb stent kune Xience Prime stent, inofanira kutanga kupa mamwe madhigirii anowanikwa, kunyange zvakadaro promising 45 data. implantation technique, uye chengetedzo profile for coronary maronda inoda kujekeswa zviri nani.
Thrombosis mune zvose BMS neDES ine migumisiro yakaipa yekliniki.Mubhuku revarwere vanogamuchira kuiswa kweDES, 47 24% yematambudziko e ST yakaguma nekufa, 60% kubva kune isingaurayiwi MI, uye 7% kubva kune angina isina kugadzikana.PCI mukukurumidzira ST inowanzova yakaderera, nekudzokorora mu12% yematambudziko.48
Muchidzidzo cheBASKET-LATE, 6 kusvika kumwedzi ye18 mushure mekuiswa kwe stent, mazinga ekufa kwemwoyo uye asina kuuraya MI akanga akakwirira muboka reDES kupfuura muboka reBMS (4.9% uye 1.3%, maererano) 20 Meta-analysis yevane 5, PES2, 9, 5, 5, 20, 20. BMS, yakashuma kuti pamakore mana ekutevera, SES (0.6% vs 0%, p = 0.025) uye PES (0.7%)) yakawedzera chiitiko chekupedzisira kwe ST kana ichienzaniswa neBMS ne0.2%, p = 0.028) .49 Kusiyana neizvi, mune meta-analysis inosanganisira 5,108 varwere, 0% ES MI yakashumwa nekufa kwevarwere, 0% ES 21 yakashumwa neBMS. (p = 0.03), nepo PES yakabatanidzwa ne15% isiri-yakakosha kuwedzera (Kutevera 9 mwedzi kusvika kumakore matatu).
Nhamba dzakawanda dzekunyoresa, miedzo yakarongeka, uye meta-analyse yakatsvaga njodzi ye ST mushure meBMS uye DES kudyarwa uye yakashuma migumisiro inopesana.Muzvinyorwa zvevarwere ve6,906 vanogamuchira BMS kana DES, pakanga pasina misiyano mumigumisiro yekliniki kana ST rates panguva ye1-gore kutevera-up.48 Mune imwe registry yevarwere ve8 yakawanikwa, mungozi yevarwere ve8. 0.6% / gore kana ichienzaniswa neBMS.49 Meta-analysis yekuedza kuenzanisa SES kana PES neBMS yakaratidza kuwedzera kwehuwandu hwekufa uye MI nezera rekutanga reDES kana ichienzaniswa neBMS, 21 uye imwe meta-analysis ye4,545 varwere randomized kuSES kana Pakanga pasina misiyano muchiitiko che ST pakati pemakore 450-MS-up yakawedzera-yakawedzera zvidzidzo zveBMS-pasi rose. njodzi yepamusoro ST uye MI kune varwere vanowana chizvarwa chekutanga cheDES mushure mekuregererwa kweDAPT.51
Zvichipa humbowo hunopesana, dzakawanda dzakabatanidzwa kuongorora uye meta-kuongorora pamwe chete dzakasarudza kuti chizvarwa chekutanga cheDES neBMS chakanga chisina kusiyana zvakanyanya munjodzi yekufa kana MI, asi SES nePES zvaive nengozi yakawedzerwa yeST yepamusoro zvikuru kana ichienzaniswa neBMS. Kuongorora Uchapupu huripo, US Food and Drug Administration (FDA) yakagadza nyanzvi yepaneru53 iyo yakabudisa chirevo ichibvuma kuti chizvarwa chekutanga cheDES chakashanda kune zviratidzo zvepa-label uye kuti njodzi yeST yepamusoro yakanga iri duku asi duku. Kuwedzera kwakakosha.Nekuda kweizvozvo, FDA nesangano rinokurudzira kuwedzera nguva yeDAPT kusvika 1 gore, kunyangwe paine data diki kutsigira kudai.
Sezvambotaurwa, chizvarwa chechipiri cheDES chine maitiro ekugadzirwa kwepamusoro zvakagadziridzwa.CoCr-EESs yakave yakanyatsoongorora zvidzidzo zvekliniki.Mu meta-analysis naBaber et al, 54 kusanganisira varwere ve17,101, CoCr-EES yakaderedzwa zvakanyanya kujekesa / zvichida ST uye MI zvichienzaniswa nePES, SES, uye ZES mushure memwedzi ye21 metanat-analyse muPalmerini-analysis mushure memwedzi ye21 yePalmerini. Varwere ve16,775 avo CoCr-EES yakanga yakaderera zvakanyanya kare, kunonoka, 1- uye 2-gore rechokwadi ST zvichienzaniswa nedzimwe dzakabatanidzwa DES.55 Zvidzidzo zvepasi rose zvakaratidza kuderedzwa kwe ST ngozi neCoCr-EES zvichienzaniswa nechizvarwa chekutanga DES.56
Re-ZES yakaenzaniswa neCoCr-EES muRESOLUTE-AC uye TWENTE miedzo.33,57 Pakanga pasina misiyano yakakura muchiitiko chekufa, myocardial infarction, kana ST yakananga pakati pemastents maviri.
Mune network meta-analysis yevarwere ve50,844 kusanganisira 49 RCTs, 58CoCr-EES yakabatanidzwa nechiitiko chakanyanya kuderera che ST chaiyo kupfuura BMS, chigumisiro chisina kuonekwa mune imwe DES; kuderedzwa kwaisangova muKukosha kwekutanga uye pamazuva makumi matatu (odd ratio [OR] 0.21, 95% nguva yekuvimba [CI] 0.11-0.42) uyewo mugore re 1 (OR 0.27, 95% CI 0.08-0.74) uye 2 makore (OR 0.35% 7Com 0.9-0 . PES, SES, uye ZES, CoCr-EES yakabatanidzwa nehuwandu hwe ST pa 1 gore.
Early ST inobatana nezvikonzero zvakasiyana-siyana.Pasi peplaque morphology uye mutoro we thrombus unoratidzika kunge unokonzera migumisiro mushure mePCI; 59 Yakadzika strut kupinza nekuda kwenecrotic core (NC) prolapse, misodzi yepakati mukureba kwakasimba, yechipiri dissection ine yakasara margins, kana yakakosha margin kupfupika Optimal stenting, isina kukwana apposition, uye isina kukwana kuwedzera60 Kurapa regimen ne antiplatelet zvinodhaka hazvikonzeri zvakanyanya kuuraya kwe ST panguva yekutanga zvinodhaka. DAPT mukuedza kusinganzwisisiki kuenzanisa BMS neDES Rates yakafanana (<1%).61 Nokudaro, kutanga kwe ST kunoratidzika kunge kwakabatana zvikuru nehutachiona hwehutachiona uye zvinhu zvekuvhiya.
Nhasi, kunyanya kutarisa kunonoka / kunonoka zvikuru ST.Kana maitiro uye maitiro ehutano anoita seanoita basa guru mukugadzirwa kweacute uye subacute ST, nzira yekunonoka kwezviitiko zve thrombotic inoratidzika kuva yakaoma zvikuru.Yakave yakaratidza kuti humwe hutano hwevarwere hunogona kunge huri pangozi yehutano hwepamusoro uye hwepamusoro hwe ST: chirwere cheshuga mellitus, ACS panguva yekuvhiyiwa kwekutanga, kukundikana kwerenal, kukwegura, zera rekutanga, kuderedzwa kwezviitiko zvekutanga zve30 cardiac. kuvhiyiwa.Kune BMS neDES, maitiro akasiyana-siyana, akadai sehukuru hwemidziyo, bifurcations, chirwere chepolyvascular, calcification, kuvharika kwese, stents refu, inoratidzika seyakabatana nehuwandu hwepamusoro hwe ST.62,63 Kusakwana kwemhinduro kune antiplatelet therapy ndiyo inokonzera ngozi yepamusoro yeDES thrombosis 51. Iyi mhinduro inogona kunge yakanamatira, kupindirana kwezvinodhaka, pasi pekusagadzikana kwezvinodhaka, kupindirana kwezvinodhaka. mhinduro, genetic polymorphisms padanho rekugamuchira (kunyanya clopidogrel resistance), uye kukwidziridzwa kweimwe platelet activation pathways.In-stent neoatherosclerosis inoonekwa seyakakosha nzira yekunonoka stent kukundikana, kusanganisira kunonoka ST64 (chikamu "In-stent neoatherosclerosis") .Iyo intact endothelium inoparadzanisa thrombotentththrombosis yemidziyo yeropa uye yakavanzika yemidziyo yeropa uye yakavanzika yeropa. vasodilatory substances.DES inoratidzira rusvingo rwemudziyo kune antiproliferative zvinodhaka uye zvinodhaka-eluting platform nemigumisiro yakasiyana-siyana pakuguma kwekuporesa uye kushanda, ine ngozi yekupera kwekupedzisira thrombosis.65 Zvidzidzo zvepathological zvinoratidza kuti mapolymers akasimba ezera rekutanga reDES anogona kuita kuti kuve nekuputira kusingaperi, kusingaperi fibrin deposition, kusava nehanya kwe hypersensitive , uye DES hypersensitivity kunowedzera, uye DES yakawedzera ngozi. kuva imwe nzira inotungamirira ku ST.Virmani et al66 yakashuma post-mortem post-ST zvakawanikwa zvichiratidza kuwedzera kweaneurysm pane stent segment nemunharaunda hypersensitivity reactions inoumbwa neT lymphocytes uye eosinophils; izvi zvakawanikwa zvinogona kuratidza simba remapolymers asingasviki.67 Stent malapposition inogona kunge yakakonzerwa nekuwedzera kwekuwedzera kwe stent kana kuitika mwedzi mushure mePCI.Kunyange zvazvo nzira yekufambisa iine ngozi kune acute uye subacute ST, kukosha kwekliniki yekuwana stent malapposition inogona kuvimba nehutsinye hwekugadzirisa arterial remodeling kana kunonoka kuporesa zvinodhaka zvinodhaka. nharo.68
Izvo zvinodzivirira zvechizvarwa chechipiri DES zvinogona kusanganisira kukurumidza uye intact endothelialization, pamwe nekusiyana kwe stent alloy uye chimiro, strut thick, polymer properties, uye antiproliferative drug type, dose, uye kinetics.
Zvinei neCoCr-EES, nhete (81 µm) cobalt-chromium stent stent, antithrombotic fluoropolymers, low polymer, uye kurodha kwezvinodhaka zvinogona kuita kuti chiitiko chakaderera cheST. Ongororo dzekuongorora dzakaratidza kuti thrombosis uye platelet deposition yefluoropolymer-coated-yakadzika kupfuura mamwe stether6 akaderera kupfuura mamwe ma-stether6. chizvarwa chechipiri DES vane zvivakwa zvakafanana vanokodzera kumwe kudzidza.
Coronary stents inovandudza kuvhiyiwa kwekubudirira kwekupindira kwekoroni kana ichienzaniswa neyechinyakare percutaneous transluminal coronary angioplasty (PTCA), iyo ine mechanical complications (vascular occlusion, dissection, etc.) uye yakakwirira restenosis rates (kusvika ku40% -50% yematambudziko). Pakazosvika 1990s, inenge 70% yePCIs yakaitwa neBMS implantation.70
Zvisinei, pasinei nekufambira mberi mune teknolojia, maitiro, uye marapirwo ezvokurapa, njodzi ye restenosis mushure mekudyarwa kweBMS inenge 20%, ne> 40% muzvikamu zvakasiyana-siyana.71 Kakawanda, zvidzidzo zvekliniki zvakaratidza kuti restenosis mushure mekusimwa kweBMS, yakafanana neyo yakaonekwa ne PTCA yakajairwa, inokwira pamwedzi 3-6 uye inogadzirisa mushure me1 gore.72.
DES inowedzera kuderedza kuitika kweISR,73 kunyange zvazvo kuderedzwa uku kunoenderana neangiography uye kliniki yekugadziriswa.Kufukidzwa kwepolymer paDES kunobudisa anti-inflammatory and anti-proliferative agents, inhibits neointima formation, uye kunonoka kugadzirisa kwevascular kumwedzi kusvika kumakore.74 Kuramba kuripo neointimal kukura munguva yakareba yekutevera-up mushure me "DESlate catch-upplant" inozivikanwa se "phenomenon-implantation" yekliniki inozivikanwa se "DEStenomeup" yakaonekwa uye kliniki. histological zvidzidzo. 75
Kukuvadzwa kweVascular panguva yePCI inogadzira nzira yakaoma yekuputika nekugadzirisa munguva shoma shoma (mavhiki kusvika kumwedzi), zvichiita kuti endothelialization uye neointimal coverage.Maererano nekuongorora kwe histopathological, neointimal hyperplasia (BMS neDES) mushure mekudyara kwe stent yainyanya kuumbwa neproliferative proliferative smooth matrix masero matrix.
Nokudaro, neointimal hyperplasia inomiririra nzira yekugadzirisa inosanganisira coagulation uye kuputika kwezvinhu pamwe chete nemasero anokonzera kutsetseka kwemasero emasero uye extracellular matrix formation.Pakarepo mushure mePCI, maplatelet uye fibrin deposit pamadziro emudziyo uye kutora leukocytes kuburikidza nemutsara we cell adhesion molecules.Rolling leukocytes leukocytes inobata kune adherent integrate1 (CD11b/CD18) uye platelet glycoprotein Ibα 53 kana fibrinogen yakasungwa kuplatelet glycoprotein IIb/IIIa.76,77
Maererano nemashoko ari kubuda, bone marrow-derived progenitor cells anobatanidzwa mumhinduro dzevascular uye kugadzirisa maitiro.Kuunganidza kweEPCs kubva kumapfupa emapfupa kusvika kuropa remukati kunokurudzira endothelial regeneration uye postnatal neovascularization.Zvinoratidzika kuti pfupa rinoputika masero emuscle progenitor cells (SMPC) anotamira kunzvimbo yekukuvara kwevascular, zvichiita kuti CD48 iwedzere kukura, masero eCD37 aifungidzirwa. kuve vanhu vakatarwa veEPCs; zvimwe zvidzidzo zvakaratidza kuti CD34 surface antigen inonyatso cherechedza masero emakumbo emapfupa asina kuparadzaniswa ane simba rekusiyanisa muEPCs uye SMPCs.Transdifferentiation yeCD34-positive cells kuEPC kana SMPC mutsara unoenderana nenharaunda yenzvimbo; ischemic mamiriro ezvinhu anokonzera kusiyanisa kune EPC phenotype kukurudzira re-endothelialization, asi mamiriro ekuputika anokonzera kusiyanisa kune SMPC phenotype kukurudzira neointimal proliferation.79
Chirwere cheshuga chinowedzera njodzi yeISR ne 30% -50% mushure mekudyara kweBMS, 80 uye chiitiko chepamusoro che restenosis muvarwere vane chirwere cheshuga kana vachienzaniswa nevarwere vasina chirwere cheshuga vakaenderera mberi munguva yeDES.Maitirwo ari pasi pekucherechedza uku angangodaro akasiyana-siyana, anosanganisira systemic (semuenzaniso, kusiyanisa mumhepo inoputika, dhayamita refu, anagtomi, madiki madiki, dhiyabhorosi, dhayamita refu, anagtomio refu chirwere, etc.) zvinhu zvinowedzera zvakasununguka Ngozi yeISR.70
Kureba kwemudziyo uye kureba kwechirwere zvakazvimiririra zvakakanganisa kuitika kweISR, nediki dhayamita / kureba zvipembenene zvakanyanya kuwedzera restenosis mazinga kana zvichienzaniswa nehupamhi hukuru / mapfupi maronda.71
Mapuratifomu echizvarwa chekutanga airatidza kusimba kwakasimba uye mareti epamusoro eISR akaenzaniswa neyechipiri-chizvarwa stent mapuratifomu ane matete struts.
Mukuwedzera, chiitiko chekuzorora chakanga chakabatana nekureba kwe stent, ne stent urefu> 35 mm inenge yakapetwa kaviri kupfuura iyo <20 mm. Iyo yekupedzisira stent mishoma lumen diameter yakaitawo basa rinokosha: shoma yekupedzisira shoma lumen diameter yakafanotaura kuwedzera kwakanyanya kwengozi ye restenosis.81,82
Nechinyakare, intimal hyperplasia inotevera BMS implantation inoonekwa seyakagadzikana, ine yekutanga peak pakati pemwedzi 6 uye 1 gore, inoteverwa neinononoka quiescent period.Nhepfenyuro yekutanga yekukura kwemukati yakambotaurwa, ichiteverwa nekudzoreredzwa kwemukati nekuwedzera lumen makore akati wandei mushure mekuisirwa stent; 71 yakatsetseka muscle cell maturation yakave yakaratidza kunonoka matrix maturation. neointimal regression .83 Zvisinei, zvidzidzo zvine nguva yakareba yekutevera zvakaratidza mhinduro katatu mushure mekuiswa kweBMS, nekutanga restenosis, kuderera kwepakati, uye kunonoka lumen restenosis.84
Munguva yeDES, kunonoka neointimal kukura kwakatanga kuratidzirwa kutevera SES kana PES kudyara mumhando dzemhuka.85 Zvidzidzo zvakawanda zveIVUS zvakaratidza kutanga kunonoka kwekukura kwemukati kunoteverwa nekunonoka kubata-nekufamba kwenguva mushure meSES kana PES kuiswa, zvichida nekuda kwekuenderera mberi kwekuputika.86
Pasinei ne "kugadzikana" kunowanzonzi kune ISR, inenge chikamu chimwe muzvitatu chevarwere veBMS ISR vanogadzira ACS.4
Pane humbowo hunowedzera hunoratidza kuti kusingaperi kuzvimba uye / kana endothelial insufficiency induces advanced neoatherosclerosis mukati meBMS neDES (kunyanya chizvarwa chekutanga DES), iyo inogona kunge iri nzira yakakosha yeISR yepamusoro kana yepamusoro ST.Inoue et al. 87 yakashuma histological zvakawanikwa kubva ku autopsy samples zvichitevera kuisirwa kwePalmaz-Schatz coronary stents, zvichiratidza kuti peri-stent kuzvimba kunogona kukurumidza kutsva indolent atherosclerotic shanduko mukati me stent.Zvimwe zvidzidzo10 zvakaratidza kuti restenotic tishu mukati meBMS, pamusoro pemakore mashanu, ine ichangobva kubuda; sampuli kubva kumatambudziko eACS anoratidza maitiro anowanzovhiringidza mumagetsi echiropa Histological morphology of the block ine foamy macrophages uye cholesterol crystals. Uyezve, pakuenzanisa BMS neDES, musiyano mukuru munguva yekuvandudzwa kweatherosclerosis itsva yakaonekwa. Zvipembenene zveBMS zvakaitika makore 2 gare gare uye zvakaramba zvisingawanzo kuwanikwa kusvikira makore 4. Uyezve, DES stenting yezvipembenene zvisina kugadzikana zvakadai setete-cap fibroatherosclerosis (TCFA) kana kuputika kwemukati kune nguva shoma yekukura kana ichienzaniswa neBMS.Saka, neoatherosclerosis inoratidzika kuva yakawanda uye inoitika kare muchizvarwa chekutanga cheDES kupfuura nekuda kweBMS, zvichida zvakasiyana-siyana.
Mhedzisiro yechizvarwa chechipiri DES kana DES mukusimudzira inoramba ichidzidzwa; kunyange zvazvo kumwe kucherechedzwa kuripo kwechizvarwa chechipiri DESs88 kunoratidza kuzvimba kushoma, chiitiko cheneoatherosclerosis chakafanana neicho chechizvarwa chekutanga, asi Kumwe kuongorora kuchiri kudikanwa.