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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 of Rome, Italy Abstract: Drug-Eluting metals (DMSB) zvishoma nezvishoma taneous 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 kukanganiswa kwe stent implantation, zvakadai se stent thrombosis (ST) uye stent resection.Stenosis (ISR) .St chiitiko chinogona kuderedzwa zvakanyanya kuburikidza neyekuchinjisa. .In kusiyanisa, zvese zvechiriniki uye huro dzeruzivo rwekukura zvakaratidzirwa pakurarama kweiyo ISR. Placotle Plaques uye maficha ekupora-stent mudziyo kupora;inowanzoshandiswa kupedzisa diagnostic coronary angiography uye drive interventional procedures.Intracoronary optical coherence tomography parizvino inoonekwa seyakanyanya kukwirira nzira yekufungidzira.Kuenzaniswa ne intravascular ultrasound, inopa sarudzo iri nani (inenge> 10 times), zvichibvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro emudziyo. -atherosclerosis mukati meBMS uye DES. Naizvozvo, neo-atherosclerosis yave inonyanya kufungidzirwa mune pathogenesis yekunonoka stent kukundikana. Keywords: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
Percutaneous Coronary Kupindira (PCI) Nekusimbiswa kwehunyanzvi ndeyekuti kurapwa kwezviratidzo zveConery ., 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 muna 1986, vachipa stent kudzivirira kuvharwa kwemudziyo wakaoma uye kunonoka systolic retraction.14 Kunyange zvazvo aya ekutanga stents akadzivirira kuputika kwechikepe uye kuvharwa kwevhu kwakakomba, kuvharwa kwevhu kwakakonzera kuvharwa kwemhepo. , 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 yePCI yakaitwa.
Zvisinei, dambudziko re iatrogenic in-stent neointimal hyperplasia inotevera BMS kuiswa kwakakurumidza kuonekwa, zvichiita kuti ISR ​​mu 20% -30% yezvironda zvakarapwa. 2005, 80% -90% yePCI yese yakaperekedzwa 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, chiitiko che "kutanga-mu-munhu" neSES chakaratidza migumisiro inovimbisa yekuedza kweCy23phe kumigumisiro yekubudirira kwayo. ing ISR.makumi maviri nemana
Paclitaxel yakatanga kubvumidzwa nekenza ye ovarian, asi ine simba cytostatic properties - mushonga unodzikamisa microtubules panguva mitosis, unotungamirira 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 muchirwere chetachiona chepamusoro-soro, TAXUS26. chikuva chesimbi isina tsvina 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 kuchinjika kwepamusoro uye diki stent strut size.Zotarolimus is a sirolimus analogi ine yakafanana immunosuppressive effects asi yakawedzera lipophilicity kuti iwedzere midziyo yemudhuri.ZES inoshandisa minimize biocomize biocomize biocomer inogadzirwa novel. Kuzvimba.Mishonga yakawanda inobudiswa panguva yekukuvara kwekutanga, inoteverwa nekugadzirisa arterial.Pashure pekuedza kwekutanga ENDEAVOUR, muedzo wakatevera weENDEAVOR III wakaenzanisa ZES neSES, iyo yakaratidza kurasikirwa kukuru kwekupedzisira kwe lumen uye ISR asi zvishomanana zvakanyanya kuipa kwezviitiko zvemoyo (MACE) kupfuura SES .30 The ENDEAVOUR IV muedzo, iyo yakaenzanisa yakawanikwa yeZES icide, asi yakaderera muchiitiko che PESMI, iyo yakaenzaniswa neZES yakaderera, asi yakaderera muchiitiko chePSEMI, muyedzo wePSMI. kubva kuST yepamusoro 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 reaction over the most layer three-layer respond0 the first-layer respond0 muedzo uchienzanisa Resolute ne Xience V (everolimus-eluting stent [EES]) yakaratidza kusaderera kweResolute system maererano nerufu uye chinangwa chekukundikana kwekukuvara.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 zvichienzaniswa nePES, nepo EXfenin muedzo wakanonoka kusvika kuSECELLES wakanonoka kuyedza. mwedzi uye zviitiko zvechipatara pamwedzi 12.38 Pakupedzisira, Xience stent yakaratidza zvakanakira pamusoro peBMS mukugadzirisa kwe ST-segment elevation myocardial infarction (MI) .39
EPCs inhengo yemasero anotenderera anobatanidzwa muvascular homeostasis uye endothelial repair.Kuwedzerwa kweEPCs panzvimbo yekukuvara kwevascular kuchasimudzira kutangazve endothelialization, zvingaita kuderedza dambudziko rekutanga kuedza kweST.EPC biology mumunda we stent design ndiyo CD34 antibody-coated yeGenous binding stent, inokwanisa kuburitsa Genous stent, inokwanisa kusimuka Thelialization.Kunyange zvazvo zvidzidzo zvekutanga zvaikurudzira, uchapupu huchangobva kuitika hunoratidza huwandu hweTVR.40.
Tichifunga nezve zvinogona kukuvadza zvinokonzerwa nepolymer-induced kunonoka kuporesa, iyo inobatanidza nengozi yeST, bioabsorbable polymers inopa zvikomborero zveDES, kudzivisa kushushikana kwenguva refu pamusoro pepolymer persistence.Kusvika iye zvino, maitiro akasiyana-siyana ekugadzirisa bioabsorbable akatenderwa (eg Nobori neBiomatrix, biolimus eluting stent, Esl-masters stent, ESl- , zvinyorwa zvavo zvenguva refu, Synergy). 41
Bioabsorbable materials ine theoretical advantage yekutanga kupa mechanical support apo elastic recoil inofungidzirwa uye kuderedza njodzi dzenguva refu dzine chokuita nesimbi iripo struts.New technologies yakatungamirira mukugadzirwa kwelactic acid-based polymers (poly-l-lactic acid [PLLA]), asi dzakawanda stent systems dziri mukuvandudza, kunyange zvazvo kugadzirisa kudzvinyirirwa kweBBS uye kuchengeteka kunoramba kuripo. uye kushanda kweeverolimus-eluting PLLA stents.43 Chizvarwa chechipiri Absorb stent revision yakanga iri kuvandudzwa pamusoro pekare nekutevera kwakanaka kwemakore 2.44 Kuenderera mberi kweABSORB II kuedza, kuedza kwekutanga kusingaenzaniswi kuenzanisa Absorb stent ne Xience Prime stent, inofanira kupa mamwe mashoko, uye yekutanga kuchengetedzwa kwepromisi yekona, uye yekutanga inowanika yekumisikidza nzira, uye yekutanga inowanika yekumisikidza nzira. ry maronda anoda 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, SES , 5, 20, 5, 20, 5, 20, 5, 20, 20 pamakore e4 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, mune meta-analysis inosanganisira 5,108 varwere, 21 a 60% P ES yakataurwa kana 60% MI inofananidzwa neBSS yakashumwa nekufa kwe 60%. yakabatanidzwa ne15% kuwedzera kusingakoshi (Kutevera-mwedzi 9 kusvika kumakore 3).
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 ye0 146 % yakawanikwa, njodzi ye 0% yevarwere ve8. 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 yevarwere ve4,545 randomized kuSES kana Pakanga pasina mutsauko muchiitiko cheST pakati pePES neBMS pamakore makumi mashanu ekutanga-kugamuchira njodzi-yekutanga-yepamusoro-soro yevarwere vane 50 yekudzidza kwekutanga kweSTMI uye 4 makore ekutanga-kugamuchira njodzi yepasi rose. chizvarwa 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 yakaderedza zvakanyanya kujekesa / zvichida ST uye MI zvichienzaniswa nePES, SES, uye ZES mushure memwedzi we21 metanat-6 muPalmerini, 7 mwedzi yePalmerini, 7 metaana-analysis yakaratidza 17,101 mwedzi. Varwere ve5 avo CoCr-EES yakanga yakaderera zvakanyanya kare, kunonoka, 1- uye 2-year definite ST kana ichienzaniswa 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 kwakanga kusiri muKukosha kare uye pamazuva makumi matatu (odds 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 % ES 0.9- ESpa 0.6 ESpa , PCI 9, ES 6 , ESPA 6, 95 ES 6, 95 ESPA). , 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 kupinda mukati nekuda kwenecrotic core (NC) prolapse, misodzi yepakati mukureba kwakasimba, kuparadzanisa kwechipiri nemararamiro akasara, kana kuti kuderera kwepamusoro kuderera. Optimal stenting, kusakwana kusina kukwana, uye kuwedzera kusina kukwana60 Kurapa regimen ne antiplatelet zvinodhaka hazvibatsiri zvakanyanya mukutanga kwe STD panguva yekurapa kwe ST. muedzo kuenzanisa BMS neDES Rates yakanga yakafanana (<1%) .61 Nokudaro, kutanga kweST kunoratidzika kunge kwakabatana zvikuru nepamusoro pezvipembenene zvekurapa 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 kunge yakaoma zvikuru.Zvave zvichiratidzwa kuti humwe hutano hwevarwere hunogona kunge huri pangozi yehutano hwepamusoro uye hwepamusoro zvikuru ST: chirwere cheshuga mellitus, ACS panguva yekuvhiyiwa kwekutanga, kukundikana kwerenal, kukwegura, zera rekutanga reAccardial, kuderedzwa kwezviitiko zvekutanga zveD30, accardial fraction yeD30 yemazuva ekutanga edjeverse. ES, maitiro akasiyana-siyana, akadai sekukura kwemidziyo miduku, bifurcations, chirwere chepolyvascular, calcification, zvachose occlusion, stents refu, inoratidzika seyakabatana nenjodzi yepamusoro-soro ST.62,63 Kusakwana kwemhinduro kune antiplatelet therapy ndiyo ngozi huru yeDES thrombosis yepamusoro 51 .Iyi mhinduro inogona kunge yakakonzerwa nemurwere kusateerera, kukanganiswa kwezvinodhaka, genetics kupindirana kwemaitiro, genetics, genetic receptor. (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 thrombosed mudziyo rusvingo uye stent stent kubva kune antidithrombotic rusvingo uye secretessose mudziyo weantithrombotic uye secretessoseti yeantithrombosis yeropa uye secretessoDE yemidziyo yeropa. zvinodhaka uye dhizaini-eluting platform ine zvakasiyana-siyana pakuguma kwekuporesa uye kushanda, ine ngozi yekupedzisira thrombosis.65 Zvidzidzo zvepathological zvinoratidza kuti mapolymers akasimba ezera rekutanga reDES anogona kuita kuti kuve nekuputika kusingaperi, kusingaperi fibrin deposition, kushaya simba kwekupedzisira kwekupedzisira, uye zvakakonzera kuwedzera kwengozi ye thrombosis.3 Kunonoka kune hypertemrma6 nzira yekuwana post-6ST yakashuma kuDES-post-menoor inonzi post-menoor inonzi STES inoratidzika. kuratidza 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 procedural malapposition inokonzera njodzi yeacute uye subacute ST, kukosha kwekliniki yekuwana stent malapposition inogona kuvimba nehutsinye arterial remodeling remodeling kana kunonoka kuporesa zvinodhaka 6, kunonoka kurapa zvinodhaka.
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 zvinodhaka zvinogona kuita kuti chiitiko chakaderera cheST. Zvidzidzo zvekuongorora zvakaratidza kuti thrombosis uye platelet deposition yefluoropolymer-coated-coated-yakaderera kupfuura mamwe maDyster-coated akaderera eD9 stents akanyanya kuderera. vane zvimiro 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.
Kuenderera mberi kunoderedza chiitiko cheIRR, 73 Kunyangwe kuderedzwa uku kweAngiography nemwedzi nemakore.74 Kuwedzera Kwemwedzi, uye Kuwedzera Kwekudzivirira Kwemakore. Bata-kumusoro ", yakaonekwa muClinical uye Hwuneal 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 kugadzirisa kunosanganisira coagulation uye kuputika zvinhu pamwe chete nemasero anokonzera kutsetseka kwemasero emasero uye extracellular matrix formation.Pakarepo mushure mePCI, platelets uye fibrin deposit pamadziro emudziyo uye kutsvaga leukocyte kuburikidza nemutsara we cell adhesion molecules.Rolling leukocyte platelets kuburikidza neCD-1CD inonamatira kune adherent1CD leukocytes. 8) uye platelet glycoprotein Ibα 53 kana fibrinogen yakasungwa kune platelet 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 muropa reperipheral kunokurudzira endothelial regeneration uye postnatal neovascularization.Zvinoratidzika kuti mapfupa emapfupa anofambisa masero emagetsi emagetsi (SMPC) anotamira kunzvimbo yekukuvara kwevascular, kutungamirira kuCD4 prolifeed7 yakanzi yakagadziriswa masero. huwandu hweEPCs;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 ne30% -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 akawanda, anosanganisira systemic (semuenzaniso, kushanduka kwechirwere chinoputika, chirwere chiduku, dhayamita, dhayamita, anagtomi, dhayamita refu, dhayamita refu) uye diki. iyo inowedzera yakazvimirira 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 ne intimal regression nekuwedzerwa lumen makore akawanda mushure mekudyara kwakasimba; 71 smooth muscle cell maturation yakave yakaratidza kunonoka matrix maturation. .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 muhutachiona hwema coronary arteries Histological morphology ye block ine foamy macrophages uye cholesterol crystals. Uyezve, pakuenzanisa BMS neDES, musiyano mukuru munguva yekuvandudzwa kweatherosclerosis itsva yakaonekwa. 2 makore gare gare uye yakaramba iine zvisingawanzo kuwanikwa kusvikira makore 4. Uyezve, DES stenting yezvipembenene zvisina kugadzikana zvakadai se-thin-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 muBMS, zvichida nekuda kwekupfuura kwakasiyana.
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.