Javascript yakadzimwa mubrowser yako parizvino.Zvimwe zvewebhusaiti ino hazvishande kana JavaScript ikavharwa.
Bhalisa nemashoko ako chaiwo uye mushonga wekufarira, uye isu tichafananidza ruzivo rwaunopa nezvinyorwa mune yedu yakakura dhatabhesi uye email iwe kopi yePDF nekukasira.
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 Summary : the limitations of DrugStents mushure meDhipatimendi reStents) rinoshandiswa zvishoma nezvishoma ous coronary kupindira.Zvisinei, kunyange zvazvo kuiswa kwechizvarwa chechipiri cheDES kunoratidzika kunge kwakaderedza chiitiko ichi kana chichienzaniswa nechizvarwa chekutanga cheDES, kunetseka kwakanyanya kunoramba kuri pamusoro pezvinobvira kunonoka kukanganiswa kwe stent implantation yakadai se stent thrombosis (ST) uye stent resection, stenosis (SSI).ST chiitiko chinogona kuita njodzi icho chakaderedzwa zvakanyanya nekugadziriswa kwe stent kuisirwa, novel stent dhizaini, uye maviri maviri antiplatelet therapy.Iyo chaiyo nzira inotsanangura kuitika kwayo iri kuferefetwa, uye zvechokwadi zvinhu zvakati wandei zvine mhosva.ISR muBMS yaimboonekwa seyakadzikama ine yekutanga peak ye intimal hyperplasia (pamwedzi ye6) inoteverwa nenguva yekudzoreredza inopfuura 1 gore.Kusiyana neizvi, zvidzidzo zvekliniki uye histological zveDES zvakaratidza uchapupu hwekuramba huripo neointimal kukura pamusoro penguva yakareba yekutevera, chiitiko chinozivikanwa se "late catch-up" phenomenon.Pfungwa yekuti ISR ​​ine hutsinye hwekiriniki mamiriro achangobva kurambwa nehumbowo hwekuti varwere vane ISR vanogona kukura acute coronary syndromes.Intracoronary imaging inzira inoparadza yekuona stented atherosclerotic plaques uye zviratidzo zvemudziyo kuporeswa mushure mekuita stenting, uye inowanzoshandiswa kupedzisa diagnostic coronary angiography uye kuita maitiro ekupindira.Intracoronary optical coherence tomography ikozvino inoonekwa seyakanyanya yepamusoro yekufungidzira modhi. inopa, ichienzaniswa ne intravascular ultrasound, zviri nani kugadzirisa (kanenge> 10 nguva), zvichibvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro emudziyo. inopa, ichienzaniswa ne intravascular ultrasound, zviri nani kugadzirisa (kanenge> 10 nguva), zvichibvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro emudziyo. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, >10 раз), что позволяет деавальшение ру стенки сосуда. inopa, ichienzaniswa ne-intravascular ultrasound, sarudzo iri nani (inenge> 10 times), iyo inobvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro emudziyo.与血管内超声相比，它提供了更好的分辨率（至面少> 10 倍），允许论细表征征血的时候。与血管内超声相比，它提供了更好的分辨率（至少> 10），允许详细表征血管壁。Inofananidzwa ne-intravascular ultrasound, inopa sarudzo iri nani (kanenge ka10), iyo inobvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro emudziyo.In vivo imaging zvidzidzo zvinoenderana nezvakawanikwa zve histological zvinoratidza kuti kuzvimba kusingaperi uye/kana endothelial dysfunction inogona kukonzera advanced neoatherosclerosis muHMS neDES.Nekudaro, neoatherosclerosis yave yakanyanya kufungidzirwa mune pathogenesis yekunonoka stent kutadza.Mazwi akakosha: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
Stented percutaneous coronary intervention (PCI) ndiyo inonyanya kushandiswa nzira yekurapa kwechiratidzo checoronary artery chirwere, uye hunyanzvi hunoenderera mberi nekushanduka.1 Kunyange zvazvo mishonga eluting stents (DES) ichideredza miganhu yeuncoated stents (UES), matambudziko anonoka akadai se stent thrombosis (ST) uye mu stent restenosis (ISR) inogona kuitika ne stent implantation, uye kunetseka kwakanyanya kuripo.2-5
Kana ST iri chiitiko chinogona kutyisa, kubvuma kuti ISR ​​chirwere chisina kunaka chave chichangobva kupikiswa nehuchapupu hweacute coronary syndrome (ACS) kune varwere vane ISR.ina
Nhasi, intracoronary optical coherence tomography (OCT) 6-9 inoonekwa seye-state-of-the-art imaging modality inopa sarudzo iri nani pane intravascular ultrasound (IVUS).In vivo imaging zvidzidzo10-12 zvinoenderana nezvakawanikwa zve histological zvinoratidza "itsva" vascular response mechanism mushure mekusimwa kwe stent ne de novo "neoatherosclerosis" mukati meBMS neDES.
Muna 1964 Charles Theodore Dotter naMelvin P. Judkins vakatsanangura angioplasty yekutanga.Muna 1978, Andreas Grunzig akaita bharumu yekutanga angioplasty (iyo yekare yakajairika balloon angioplasty);yakanga iri kurapa kwechimurenga, asi zvakare yaive nezvakashata zveacute vascular kuvhara uye restenosis.13 Izvi zvakakonzera kuwanikwa kwemacoronary stents: Puel naSigwart vakaisa yekutanga coronary stent muna 1986, ichipa stent kudzivirira acute kuvharwa kwechikepe uye kunonoka systolic retraction.14 Kunyangwe aya ekutanga stents akadzivirira kuvharika kwechikepe, akakonzeresa kukuvara kwakanyanya kwekupedzisira uye kuzvimba.Munguva pfupi yapfuura, zvidzidzo zviviri zvakakosha, yeBelgian-Dutch Stent Chidzidzo 15 uye Stent Restenosis Chidzidzo 16, zvakakurudzira kuchengetedzwa kwemaviri antiplatelet therapy (DAPT) stenting uye/kana nzira dzakakodzera dzekutumira.17,18 Kutevera miedzo iyi, nhamba yePCIs yakaitwa yakawedzera zvakanyanya.
Zvisinei, dambudziko re iatrogenic in-stent neointima hyperplasia mushure mekuiswa kweBMS yakakurumidza kuonekwa, zvichiita kuti ISR ​​mu 20-30% yezvipembenene zvakarapwa.DES19 yakaunzwa muna 2001 kuti ideredze kudiwa kwerestenosis uye kushandazve.DES yakawedzera kuvimba kwevanoongorora moyo nekubvumira kurapwa kwenhamba inowedzera yezvironda zvakaoma izvo zvaimboonekwa sekuti zvinorapika ne coronary artery bypass grafting.Muna 2005, 80-90% yemaPCI ese akaperekedzwa neDES.
Zvese zvine zvipingamupinyi zvaro, uye kubvira 2005 kunetseka nezve kuchengetedzwa kwe "chizvarwa chekutanga" DES yakawedzera, chizvarwa chitsva stents senge 20,21 chakagadzirwa uye chakaunzwa.22 Kubva ipapo, kuedza kuvandudza kushanda kwemastents kwakakura nekukurumidza, uye matekinoroji matsva anofadza akaenderera mberi achiwanikwa uye nekukurumidza kuunzwa kumusika.
BMS ichubhu yakanaka yewaya mesh.Mushure mechiitiko chekutanga neWall mount, Gianturco-Roubin gomo uye Palmaz-Schatz gomo, akawanda akasiyana BMS ave kuwanikwa.
Zvitatu zvakasiyana dhizaini zviripo: nyoka, tubular mesh uye slotted chubhu.Magadzirirwo emakoiri anosanganisira waya dzesimbi kana mitsetse inoumba denderedzwa coil chimiro;mune tubular mesh dhizaini, waya yakakungurutswa pamwechete kuita mesh inoumba chubhu;slotted magadzirirwo anosanganisira simbi chubhu ari Laser akachekwa.Midziyo iyi inosiyana mukuumbwa (stainless simbi, nichrome, cobalt chrome), dhizaini (yakasiyana-siyana spacer maumbirwo nehupamhi, madhayamita nekureba, simba reradial, radiopacity), uye masisitimu ekutumira (kuzviwedzera kana bharumu-inokwidziridzwa).
Sekutonga, iyo BMS nyowani ine cobalt-chromium alloy, zvichikonzera kutetepa struts, kuvandudza kutyaira kwekutyaira uye kuchengetedza mechanical simba.
Iwo anoumbwa nesimbi stent chikuva (kazhinji simbi isina tsvina) uye akaputirwa nepolymer inoburitsa anti-proliferative uye/kana anti-inflammatory therapeutic agents.
Sirolimus (inozivikanwawo se rapamycin) yakatanga kugadzirwa seantifungal agent.Maitiro ayo ekuita anosanganiswa nekuvharira sero kutenderera kufambira mberi nekuvhara shanduko kubva kuG1 chikamu kuenda kuS chikamu uye inhibiting neointima kuumbwa.Muna 2001, chiitiko che "munhu wekutanga" neSES chakaratidza mhedzisiro inovimbisa, zvichitungamira mukugadzirwa kweCypher stent.23 Miedzo mikuru yakaratidza kushanda kwayo mukudzivirira IR.24
Paclitaxel yakatanga kubvumidzwa kurapwa kwegomarara reovarian, asi ine simba cytostatic zvimiro-mushonga unodzikamisa mamicrotubules panguva ye mitosis, unokonzeresa kusungwa kwesero, uye inhibits neointimal formation-ichiita musanganiswa weTaxus Express PES.Iyo TAXUS V uye VI miedzo yakaratidza kushanda kwenguva refu kwePES mune yakanyanya njodzi yakaoma yecoronary heart disease.25,26 Iyo yakatevera TAXUS Liberté yakaratidza chikuva chesimbi isina simbi kuti zvive nyore kuburitsa.
Humbowo hwakasimba kubva kuviri kwakarongeka ongororo uye meta-analys inoratidza kuti SES ine mukana wepamusoro pePES nekuda kwemitengo yakaderera yeIVR uye chinangwa chengarava revascularization (TVA), pamwe nemaitiro ekuwedzera acute myocardial infarction (AMI) muPES cohort.27.28
Zvishandiso zvechizvarwa chechipiri zvakadzikisira shaft ukobvu, yakagadziridzwa kuchinjika / kuburitsa, yakagadziridzwa polymer biocompatibility / zvinodhaka clearance profiles, uye yepamusoro reendothelialization kinetics.Mukuita kwazvino, aya ndiwo madhizaini epamusoro eDES uye makuru ecoronary stents akaiswa pasi rese.
Taxus Elements inotora iyi nhanho imwe mberi neiyo yakasarudzika yepolymer yakagadzirirwa yakanyanya kuburitswa yekutanga uye itsva platinamu-chromium spacer system inopa yakatetepa spacers uye yakawedzera radiopacity.Chidzidzo chePERSEUS 29 chakacherekedza mhedzisiro yakafanana pakati peElement neTaxus Express kwemwedzi inosvika gumi nemiviri.Nekudaro, hapana miyedzo yakakwana inoenzanisa yew zvinhu nezvimwe zvechizvarwa chechipiri DESs.
Iyo Endeavor Zotarolimus Coated Stent (ZES) yakavakirwa pane yakasimba cobalt-chromium stent chikuva chine kuchinjika kwepamusoro uye diki stent strut.Zotarolimus is sirolimus analogue ine yakafanana immunosuppressive mhedzisiro, asi nekuwedzera lipophilicity yekuvandudza nzvimbo mumudziyo wemudziyo.ZES inoshandisa nyowani phosphorylcholine polymer coating yakagadzirirwa kuwedzera biocompatibility uye kuderedza kuzvimba.Mishonga yakawanda inoshambidzwa muchikamu chekutanga chekukuvara, inoteverwa nekugadzirisa arterial.Mushure mekuedza kwekutanga kweENDEAVOUR, muyedzo wakatevera weENDEAVOR III wakaenzanisa ZES neSES, iyo yakaratidza kunonoka kunonoka kwe lumen uye HR asi mashoma akanyanya kuipa akashata zviitiko zvemoyo (MACEs) pane SES.30 Chidzidzo cheENDEAVOR IV chichienzanisa ZES nePES zvakare chakawana chiitiko chepamusoro cheSIS asi chiitiko chakaderera cheMI, zvichida nekuda kweiyo ST inowanikwa muboka reZES.31 Zvisinei, chidzidzo chePROTECT chakakundikana kuratidza mutsauko mu ST frequency pakati peEndeavor neCypher stents.32
Iyo Endeavor Resolute ishanduro yakagadziridzwa yeEndeavor stent ine itsva-layer polymer.Iyo itsva Resolute Kuvimbika (dzimwe nguva inodaidzwa sechizvarwa chechitatu DES) yakavakirwa papuratifomu nyowani ine yakakwirira yekuburitsa zvikwanisiro (iyo Integrity BMS papuratifomu) uye itsva, yakawanda biocompatible matatu-layer polymer iyo inogona kudzvanyirira yekutanga kuzvimba mhinduro uye elute yakawanda yemushonga mumazuva makumi matanhatu anotevera.Muedzo wakaenzanisa Resolute neXience V (everolimus eluting stent [EES]) wakaratidza kuti Resolute system yakashanda zvakaenzana maererano nekufa uye kutadza kwekukuvara kwechinangwa.33.34
Everolimus, a sirolimus derivative, iri zvakare cell cycle inhibitor inoshandiswa mukuvandudza EES Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform).Muyedzo weSPIRIT 35-37 wakaratidza migumisiro yakavandudzwa uye yakaderedza MACE neXience V kana ichienzaniswa nePES, nepo EXCELLENT muedzo wakaratidza kuti EES yakanga yakanaka seSES mukudzvinyirira kurasikirwa kwekupedzisira pamwedzi ye9 uye zviitiko zvekiriniki pamwedzi gumi nemiviri.38 Pakupedzisira, Xience stent yakaratidzwa kuva yepamusoro kune BMS mukugadzirisa kwe ST elevation myocardial infarction (MI).39
EPCs inhengo yemasero anotenderera anobatanidzwa muvascular homeostasis uye endothelial kugadzirisa.Kuwedzera kweEPC panzvimbo yekukuvara kwevascular kuchasimudzira kutangazve endothelialization, zvinogona kuderedza dambudziko re ST.EPC Biology's first foray mu stent design ndeye Genous stent, yakaputirwa neanti-CD34 antibodies, inokwanisa kusunga EPCs inotenderera kuburikidza nehematopoietic marker yayo kuwedzera endothelialization.Nepo zvidzidzo zvekutanga zvave zvichikurudzira, humbowo huchangobva kuitika hunonongedzera kumazinga eTVR akakwira.40
Tichifunga zvingango kanganisa mhedzisiro yepolymer-induced kunonoka kuporesa izvo zvine chekuita neST njodzi, bioresorbable polymers inopa mabhenefiti eDES nekudzivisa kushushikana kwenguva refu pamusoro pekushingirira kwepolymer.Parizvino, akasiyana bioresorbable masisitimu akabvumidzwa (semuenzaniso, Nobori neBiomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), asi zvinyorwa zvinotsigira mhedzisiro yavo yenguva refu ishoma.41
Bioabsorbable zvinhu zvine mukana we theoretical wekupa rutsigiro rwemakanika pakutanga kana elastic recoil inotariswa uye kuderedza njodzi dzenguva refu dzine chekuita nesimbi struts.Tekinoroji nyowani dzakatungamira mukugadzirwa kwelactic acid polymers (poly-l-lactic acid [PLLA]), asi akawanda stent masisitimu ari mukuvandudzwa, kunyangwe kuwana chiyero chakakodzera pakati pekudururwa kwezvinodhaka uye degradation kinetics inoramba iri dambudziko.Chidzidzo cheABSORB chakaratidza kuchengetedzeka uye kushanda kweeverolimus-yakavharwa PLLA stents.43 Ongororo yechizvarwa chechipiri Absorb stent yaive nani pane yapfuura ine yakanaka 2-year yekutevera.44 Chidzidzo chezvino cheABSORB II, muyedzo wekutanga wakasarudzika uchienzanisa Absorb stent neXience Prime stent, inofanira kupa rumwe ruzivo, uye yekutanga kuwanikwa mhedzisiro inovimbisa.45 Zvakadaro, mamiriro akakodzera, nzira yekudyara yakakwana, uye chimiro chekuchengetedza mucoronary artery chirwere chinoda kujekeswa.
Thrombosis mune zvese BMS uye DES ine yakaipa mhedzisiro yekiriniki.Mune registry yevarwere vakasimwa neDES, 47 24% yeST kesi zvakaguma nerufu, 60% mune isiri inouraya MI, uye 7% mune isina kugadzikana angina.PCI yekukurumidzira ST inowanzova suboptimal, nekudzokorora mu12% yezviitiko.48
Yakawedzerwa ST ine zvingangove zvakashata mhedzisiro yekiriniki.Muchidzidzo cheBASKET-LATE, mwedzi 6-18 mushure mekuiswa kwe stent, mazinga ekufa kwemoyo uye asina kuuraya MI akanga akakwirira muboka reDES kupfuura muboka reSMP (4.9% uye 1.3%, maererano).20 Meta-analysis yezvidzidzo zvipfumbamwe umo varwere ve5261 vakanga vasarudzwa kuSES, PES, kana BMS yakaratidza kuti mushure memakore mana ekutevera, SES (0.6% inopesana ne0%, p = 0.025) uye PES (0.7%)) yakawedzera chiitiko chekupedzisira kwe ST kana ichienzaniswa neBMS ne 0.2%.49 Kusiyana neizvi, mune meta-analysis inosanganisira varwere ve5108, 21 a 60% kuwedzera kwehuwandu hwekufa kana MI yakashumwa neSES yakaenzaniswa neBMS (p = 0.03), nepo PES yakabatanidzwa nekuwedzera kusingakoshi kwe15% (ona - kusvika kumwedzi 9 kusvika kumakore matatu).
Mazhinji maregistries, miedzo yakasarudzika, uye meta-analyse akaongorora njodzi yakaenzana yeST mushure meBMS uye DES kuisirwa uye vakashuma mhedzisiro inopesana.Mune registry yevarwere ve6906 vanobatwa neBMS kana DES, pakanga pasina misiyano mumigumisiro yekliniki kana ST rates pa1 gore rekutevera.48 Mune imwe registry yevarwere ve8146, njodzi yekuramba ichiwedzera ST yakawanikwa iri 0.6% pagore kana ichienzaniswa neBMS.49 Meta-analysis yezvidzidzo kuenzanisa SES kana PES neSMPs yakaratidza kuwedzera kwengozi yekufa uye MI nechizvarwa chekutanga cheDES kana ichienzaniswa neSMPs, 21 uye imwe meta-analysis yevarwere ve4545 randomized kuSES kana ST pakati pePES neBMS pamakore mana ekutevera.50 Zvimwe zvidzidzo zvepasi rose zvakaratidza kuwedzera kwengozi yekufambira mberi ST uye MI kune varwere vanobatwa nezera rekutanga reDES mushure mekuregererwa kweDAPT.51
Tichifunga nezve data inopokana, akati wandei akaongororwa uye meta-analyse pamwe akafunga kuti DES uye yekutanga-chizvarwa SGM haina kusiyana zvakanyanya munjodzi yekufa kana MI, asi SES nePES vaive nenjodzi yakawedzera ye ST yakajairika kana ichienzaniswa neSGM.Kuongorora humbowo huripo, US Food and Drug Administration (FDA) yakagadza nyanzvi yepaneru53 iyo yakapa chirevo ichiziva kuti chizvarwa chekutanga cheDES chinoshanda sezvakanyorwa uye kuti njodzi yematanho epamberi ST idiki, asi haina hombe., Kuwedzera kunokosha.Nekuda kweizvozvo, iyo FDA nemubatanidzwa inokurudzira kuwedzera nguva yeDAPT kusvika gore 1, kunyangwe paine humbowo hushoma hunotsigira ichi.
Sezvambotaurwa, chizvarwa chechipiri DES chakagadziridzwa neyakagadziridzwa dhizaini maficha.CoCr-EES yakaita tsvakiridzo yekiriniki yakanyanya.Mune meta-analysis naBaber et al.54 yevarwere ve17,101, CoCr-EES yakaderedza zvakanyanya kujekesa / zvichida ST uye MI zvichienzaniswa nePES, SES, uye ZES pamwedzi 21.Pakupedzisira, Palmerini et al vakaratidza mune meta-analysis yevarwere ve16,775 kuti CoCr-EES ine yakaderera zvakanyanya kutanga, kunonoka, 1- uye 2-gore yakatsanangurwa ST kana ichienzaniswa nedzimwe dzakabatanidzwa DES.55 Zvidzidzo zvehupenyu chaihwo zvakaratidza kuderedzwa kwengozi yeST neCoCr-EES kana ichienzaniswa nechizvarwa chekutanga cheDES.56
Re-ZES yakaenzaniswa neCoCr-EES mune RESOLUTE-AC uye TWENTE zvidzidzo.33,57 Pakange pasina misiyano yakakosha mukufa, myocardial infarction, kana yakatsanangurwa ST segment pakati pezviviri izvi.
Mune network meta-analysis yevarwere ve50,844, kusanganisira 49 RCTs, 58 CoCr-EES yakabatanidzwa nehuwandu hwakaderera hwechiitiko che ST yakatsanangurwa kupfuura BMS, kuwanikwa kusingaonekwi nedzimwe DES;kuderera kwacho kwakanga kusiri chete pa "zvakakosha kare" uye mushure memazuva makumi matatu (58).odds ratio [OR] 0.21, 95% nguva yekuvimba [CI] 0.11-0.42) uye pa1 gore (OR 0.27, 95% CI 0.08-0.74) uye makore maviri (OR 0.35, 95% CI 0.17-0.69).Kuenzaniswa nePES, SES, uye ZES, CoCr-EES yakabatanidzwa nechepasi ST rate pa1 gore.
Early ST inobatanidzwa nezvinhu zvakasiyana-siyana. Underlying plaque morphology uye thrombus mutoro unoratidzika kunge unokanganisa mhedzisiro mushure mePCI; 59 yakadzika struts inopinda ne necrotic core (NC) prolapse, kureba kwepakati kubvarura mukati meiyo stent, suboptimal stenting ine yasara edge dissections kana yakakosha edge stenosis, isina kukwana apposition, uye kuputika kweiyo incomplete yekuwedzera kwe STD. chirongwa chemishonga yeantiplatelet hachinyanyi kukanganisa kuitika kwekutanga ST: mukuedza kusinganzwisisiki kuenzanisa BMSs neDESs, zviyero zveacute uye subacute ST panguva yeDAPT yakanga yakafanana (<1%) .61 Saka, kutanga kwe ST kunoratidzika kunge kwakabatana zvikuru nehutachiona hwehutachiona uye nemaitiro ekugadzirisa. Underlying plaque morphology uye thrombus mutoro unoratidzika kunge unokanganisa mhedzisiro mushure mePCI; 59 yakadzika struts inopinda ne necrotic core (NC) prolapse, kureba kwepakati kubvarura mukati meiyo stent, suboptimal stenting ine yasara edge dissections kana yakakosha edge stenosis, isina kukwana apposition, uye kuputika kweiyo incomplete yekuwedzera kwe STD. chirongwa chemishonga yeantiplatelet hachinyanyi kukanganisa kuitika kwekutanga ST: mukuedza kusinganzwisisiki kuenzanisa BMSs neDESs, zviyero zveacute uye subacute ST panguva yeDAPT yakanga yakafanana (<1%) .61 Saka, kutanga kwe ST kunoratidzika kunge kwakabatana zvikuru nehutachiona hwehutachiona uye kune maitiro ekugadzirisa. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВ;59 более глубокая пенетрация изправя дра (NC), длинного медиального разрыва внутри стента, субоптимального стентирования с остаточными краевыми разрыва внутри стента, субоптимального стентирования с остаточными краевыми расслоениями или значительного 60 Терапевтический режим антитромбоцитарных увеличить риск ST.60 на частоту раннего ST: в рандомизированном исследовании, сравнивающем BMS и DES, частота острого и подострого ST во время DAPT была оди1назвой, Господь одингай, от песни. , в первую очередь связана с лежащими в основе пролеченными поражениями и процедурными факторами. Underlying plaque morphology uye thrombosis inoratidzika kuva inopesvedzera mhedzisiro mushure mePCI; 59 yakadzika strut kupinda nekuda kwenecrotic nucleus (NC) prolapse, kureba kwepakati kubvarura mukati me stent, suboptimal stenting ine yakasara marginal delaminations kana akakosha marginal stenosis, kusakwana apposition uye kuderera kwekuwedzera kwe STD inogona kuwedzera kusapera. chirongwa chemishonga yeantiplatelet hachibatsiri zvakanyanya kuitika kwekutanga ST: mukuedza kusinganzwisisiki kuenzanisa BMS neDES, chiitiko cheacute uye subacute ST panguva yeDAPT yakanga yakafanana (<1%) .61 Nokudaro, kutanga kwe ST kunoratidzika kunge kwakabatana zvikuru nehutachiona hwehutachiona uye maitiro ekugadzirisa zvinhu.潜在的斑块形态和血栓负荷似乎影响PCI 后的结果；59 坏死核心(NC) 脱垂导致的更深的更深的更深的更深的更深的更深的更深,内侧撕裂、具有残余边缘剥离或显边缘狭窄的次优支架、不完全并置和不完全并置和不完全并置和方案不会显着影响早期ST 的发生率：在一项比较BMS 与DES 的随机试验中，DAPT 期间急急性的亚会1%） .61 因此，早期ST 似主要与潜在的治疗病变和手术因素有关.潜在 斑块 形态 和血栓 似乎 影响 影响 pci 后 结果 ; ; ; ; ; ; ;导致的 支柱 穿透 , 内长的 内侧支架 , 不 完全 并置和 不 扩张 扩张 抗血 小板 板 扩张 抗血 小板 板 药 板 扩张 抗血 小板 药 板 药 板 完全 并置.影响 影响 早期的 ： 在 项 比较 比较 bms 与 des 中 , dapt 期间 急性 亚急性 石发生 发生发生 发生 发生 发生 发生 发生 发生 发生 发生 发生 发生 发生 发生生 发生率相似（<1%） .61Iyo yepasi peplaque morphology uye thrombosis inoratidzika kunge inokanganisa mhedzisiro mushure mePCI;59 Yakadzika strut kupindira nekuda kweiyo necrotic nucleus (NC) prolapse, kuputika kwepakati mukureba kwakasimba, yechipiri dissection ine yakasara margins, kana yakakosha margin kuderera Optimal stenting, isina kukwana apposition, uye kusakwana kwekuwedzera60 Antiplatelet regimen haina chinhu chakakosha muchiitiko che STDA mukutanga kutongwa kwekutanga kwe STDA. iri BMS uye DES.zvinonyanya kuenderana nezviri pasi pemaronda ekurapa uye zvinhu zvekuvhiya.
Nhasi, tarisiro ndeyekunonoka / kunonoka kwazvo ST.Kunyange zvazvo maitiro uye maitiro ehutano anoita seanoita basa guru mukugadzirwa kweacute uye subacute ST, nzira yekunonoka kwezviitiko zve thrombotic inoratidzika kuva yakaoma zvikuru.Zvave zvichiratidzwa kuti humwe hutano hwevarwere hunogona kunge huri mungozi yekufambira mberi uye yakanyanya kufambira mberi ST: chirwere cheshuga mellitus, ACS panguva yekuvhiyiwa kwekutanga, kukanganisa kwerenal, kukwegura, kuderedzwa kwechikamu chejection, zviitiko zvikuru zvemoyo zvakashata mukati memazuva makumi matatu ekuvhiyiwa kwekutanga.Nokuda kweBMS neDES, maitiro ekugadzirisa akadai sekukura kwechikepe, bifurcations, chirwere chemultivascular, calcification, kuvharwa kwakakwana, stents yakareba inoratidzika inobatanidza nengozi yekufambira mberi ST.62,63 Kupindura kusina kunaka kune antiplatelet therapy ndiyo ngozi huru yekufambira mberi kweDES thrombosis 51.Mhinduro iyi inogona kunge yakakonzerwa nekusateerera kwemurwere, kuderedzwa, kusangana kwezvinodhaka, comorbidities inokanganisa mhinduro yezvinodhaka, receptor-level genetic polymorphism (kunyanya clopidogrel resistance), uye kushandiswa kweimwe nzira yeplatelet activation.Stent neoatherosclerosis inoonekwa seyakakosha nzira yekunonoka stent kutadza, kusanganisira kunonoka ST64 (chikamu "Stent Neoatherosclerosis").Iyo intact endothelium inoparadzanisa madziro emudziyo ane thrombosed uye stent posts kubva muropa uye inoburitsa antithrombotic uye vasodilatory zvinhu.DES inofumura madziro emudziyo kune anti-proliferative zvinodhaka uye dhizaini-kuburitsa chikuva, ine mhedzisiro inosiyana pakurapa uye endothelial basa, ine njodzi yekunonoka thrombosis.65 Zvidzidzo zvepathological zvakaratidza kuti mapolymer echizvarwa chekutanga akasimba eDES anogona kubatsira mukuzvimba kusingaperi, kusingaperi fibrin deposition, kupora endothelial kupora, uye nekudaro kuwedzera njodzi yethrombosis.3 Kunonoka hypersensitivity kuDES inoita seimwe nzira inotungamira kuST.Virmani et al.[66] yakashuma zvakawanikwa mushure mekunge ST ichiratidza kuwedzera kweaneurysm muchikamu che stent nemunharaunda hypersensitivity reactions inosanganisira T-lymphocytes uye eosinophils;izvi zvakawanikwa zvinogona kuratidza pesvedzero yemapolima asingagoneki.67 Stent misfit inogona kunge yakakonzerwa nekuwedzera stent kana kuitika mwedzi yakati wandei mushure mePCI.Kunyange zvazvo procedural malapposition iri ngozi yeacute uye subacute ST, kukosha kwekliniki yekuwana stent malapposition inogona kuvimba nehutsinye hwekugadzirisa arterial kana zvinodhaka-induced kunonoka kuporesa, asi kukosha kwayo kwekliniki kunokakavadzana.68
Izvo zvinodzivirira zvechizvarwa chechipiri DES zvinogona kusanganisira kukurumidza uye zvakanyanya kusimba endothelialization, pamwe nekusiyana kwe stent alloy uye chimiro, strut ukobvu, polymer zvivakwa, uye antiproliferative mushonga rudzi, dose, uye kinetics.
Kuenzaniswa neCoCr-EES, yakaonda (81 µm) cobalt-chromium stent scaffolds, antithrombotic fluoropolymers, yakaderera polymer yemukati, uye kurodha zvinodhaka zvinogona kubatsira kudzikira ST mitengo.Ongororo dzekuyedza dzakaratidza kuti thrombosis uye platelet deposition yakadzikira zvakanyanya mu fluoropolymer-yakavharwa stents pane isina kuvharwa stents.69 Kuti mamwe maDES echizvarwa chechipiri ane zvivakwa zvakafanana anokodzera kumwe kudzidza.
Coronary stents inovandudza kubudirira kwekuvhiya kwemaitiro ekupindira kana kuenzaniswa netsika yepercutaneous transluminal coronary angioplasty (PTCA), iyo ine mechanical complications (vascular occlusion, dissection, etc.) uye yakakwirira ye restenoses (kusvika ku40-50% yematambudziko).Pakupera kwema1990, inenge 70% yePCIs yakaitwa neBGM implantation.70
然而，尽管技术、技术和药物治疗取得了进步，但BMS 植入后再狭窄的风险约為20%，在特耀约為20%)然而，尽管技术、技术和药物治疗取得了进步，但BMSZvisinei, pasinei nekufambira mberi mune teknolojia, maitiro, uye marapirwo, njodzi yerestenosis inotevera kuisirwa kweBMS inenge 20%, nemitengo inopfuura 40% mune mamwe mapoka maduku.71 Kazhinji, zvidzidzo zvechipatara zvakaratidza kuti restenosis mushure mekudyara kweBMS, yakafanana neyo inoonekwa ne PTCA yakajairika, inokwira pamwedzi 3-6 uye inogadzirisa mugore re1.72
DES inowedzera kuderedza ISR mazinga, 73 kunyange zvazvo kuderedzwa uku kuri angiographically uye kuchipatara kunoenderana.Iyo DES polymer coating inoburitsa anti-inflammatory uye anti-proliferative agents, inhibits neointima kuumbwa, uye inonoke kugadzirisa vascular nemwedzi kana makore.74 Muzvidzidzo zvekiriniki uye histological, kuenderera mberi neointima kukura kwave kuchicherechedzwa pamusoro penguva yakareba yekutevera mushure mekuisirwa kweDES, chiitiko chinozivikanwa se "kunonoka kubata-up" 75.
Kukuvara kweVascular panguva yePCI kunokonzera nzira yakaoma yekuzvimba uye kugadzirisa pane imwe nguva pfupi (mavhiki kusvika kumwedzi), zvichiita kuti endothelialization uye neointimal coverage.Zvinoenderana nekuongorora kwe histopathological, neointimal hyperplasia (HMS neDES) mushure mekusimwa kwakasimba kwainyanya kuve nekuwedzera kwakatsetseka kwetsandanyama maseru mune proteoglycan-rich extracellular matrix.70
Saka, neointimal hyperplasia inzira yekugadzirisa inosanganisira coagulation uye kuzvimba zvinhu, pamwe nemasero anokonzera kutsetseka kwemhasuru sero kuwedzera uye extracellular matrix kuumbwa.Pakarepo mushure mePCI, maplatelet uye fibrin zvinoiswa pamadziro emudziyo uye zvinokwezva leukocytes kuburikidza nenhevedzano yemasero adhesion mamorekuru.Rolling leukocytes inonamatira kumaplatelet akabatanidzwa kuburikidza nekubatana pakati pe leukocyte integrin Mac-1 (CD11b / CD18) uye platelet glycoprotein Ibα 53 kana fibrinogen inobatanidza neplatelet glycoprotein IIb/IIIa.76.77
Zvinoenderana nedata nyowani, masero emapfupa emapfupa anobatanidzwa mukuita kwevascular uye kugadzirisa maitiro.Kufambiswa kweEPC kubva mumwongo kuenda kuropa remukati kunokurudzira endothelial regeneration uye postnatal neovascularization.Zvinoita sekuti pfupa repfupa rakatsetseka masero eprogenitor masero (SMPCs) anotamira kunzvimbo yekukuvara kwevascular, zvichiita kuti neointimal kuwedzera.78 Kare, masero eCD34-positive aionekwa sehuwandu hwevanhu veEPCs, zvimwe zvidzidzo zvakaratidza kuti CD34 surface antigen zvechokwadi inocherechedza masero emapfupa emapfupa asina kuparadzaniswa ane kukwanisa kusiyanisa kuva EPCs uye PBMCs.Transdifferentiation yeCD34-positive masero muEPC kana SMPC mutsara zvinoenderana nenharaunda yenzvimbo;ischemic mamiriro ezvinhu anokonzera kusiyanisa kune EPC phenotype, iyo inokurudzira reendothelialization, asi mamiriro ekuputika anokonzera kusiyanisa kune SMPC phenotype, iyo inokurudzira kuwedzera neointimal.79
Chirwere cheshuga chinowedzera njodzi yeISR ne30-50% mushure mekusimwa kweBMS, uye chiyero chepamusoro chekuregererwa kwechirwere cheshuga chichienzaniswa nevarwere vasina chirwere cheshuga chakaramba chiripo munguva yeDES.Nzira dziri pasi pekucherechedza uku dzinogona kunge dzakasiyana-siyana, kusanganisira systemic (semuenzaniso, kusiyanisa mumhinduro yekuputika) uye anatomical (semuenzaniso, midziyo miduku, maronda akareba, chirwere chinopararira, nezvimwewo), izvo zvinozvimiririra zvinowedzera ngozi yeISR.70
Dhayamita yemudziyo uye kureba kwemaronda zvakazvimiririra zvakakanganisa ISR mazinga, ane diki dhayamita / kureba maronda anowedzera zvakanyanya restenosis mazinga achienzaniswa neakakura dhayamita / mapfupi maronda.71
Chizvarwa chekutanga stent mapuratifomu airatidza gobvu stent struts uye yakakwira ISRs zvichienzaniswa neyechipiri chizvarwa stent mapuratifomu ane matete struts.
Uyezve, chiitiko che restenosis chinosanganiswa nehurefu hwakatsetseka, hunenge hwakapetwa kaviri kune hurefu hwakareba> 35 mm kana ichienzaniswa neiyo <20 mm. Uyezve, chiitiko che restenosis chinosanganiswa nehurefu hwe stent, hunenge hwakapetwa kaviri kune hurefu hurefu> 35 mm kana ichienzaniswa neiyo <20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента >35 мм по сравнению с длиной стента <20 мм. Mukuwedzera, chiyero che restenosis chakabatana nekureba kwe stent, kunenge kupeta kaviri nehurefu hwe stent> 35 mm kana ichienzaniswa nehurefu hwe stent <20 mm.此外，再狭窄的发生率与支架长度有关，支架长度>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 стента: длина стента >35 мм почти в два раза больше, чем стента <20 мм. Mukuwedzera, kuwanda kwerestenosis kwaienderana nekureba kwe stent: kureba kwe stent> 35 mm inenge kaviri iyo ye stent <20 mm.Iyo yekupedzisira yakaderera lumen dhayamita ye stent yakaitawo basa rakakosha: diki yekupedzisira diki lumen dhayamita yakafanotaura njodzi yakawedzera zvakanyanya yekuzorora.81.82
Sechinyakare, intimal hyperplasia mushure mekuisirwa kweBMS inoonekwa seyakagadzikana, ine yekutanga peak pakati pemwedzi mitanhatu uye 1 gore inoteverwa nekunonoka kurara nguva.Peak yekutanga yekukura kwemukati inoteverwa ne intimal regression pamwe nekuwedzera lumen makore akati wandei mushure mekuiswa kwe stent kwakambotaurwa;maturation of smooth muscle cells uye shanduko muextracellular matrix yakatsanangurwa senzira dzinobvira dzekunonoka neointima regression.83 Zvisinei, zvidzidzo zvekutevera kwenguva refu zvakaratidza mhinduro katatu mushure mekuiswa kweBMS nekutanga restenosis, kuderera kwepakati, uye kupera kwe luminal restenosis.84
Munguva yeDES, kunonoka kukura neointimal kwakatanga kuratidzwa mushure meSES kana PES kuisirwa mumhando dzemhuka.85 Tsvakurudzo dzinoverengeka dzeIVUS dzakaratidza kukurumidza kunonoka kwekukura kwemukati kunoteverwa nekunonoka kubata nekufamba kwenguva mushure meSES kana RPE kuisirwa, zvichida nekuda kwekuenderera mberi kwekuzvimba.86
Pasinei ne "kugadzikana" kunowanzonzi kune ISR, inenge chikamu chimwe muzvitatu chevarwere vane BMS ISR vanogadzira ACS.ina
Pane humbowo hunowedzera hunoratidza kuti kusingaperi kuzvimba uye/kana endothelial insufficiency inokonzera kufambira mberi neoatherosclerosis muHCM neDES (kunyanya chizvarwa chekutanga cheDES), inogona kunge iri nzira yakakosha yekuvandudza IR inofambira mberi kana ST inofambira mberi.Inoue et al vakashuma histological autopsy zvakawanikwa mushure mekusimwa kwePalmaz-Schatz coronary stents, zvichiratidza kuti kuzvimba kwakatenderedza stent kunogona kukonzeresa shanduko nyowani dzeatherosclerotic mukati me stent.Zvimwe zvidzidzo10 zvakaratidza kuti restenotic tissue mukati me5-year CGM inosanganisira ichangopfuura inotanga atherosclerosis ine kana isina peritoneal inflammation;zvienzaniso kubva kumakesi eACS anoratidza akajairwa ari panjodzi mumitsipa yekoroni Histological block morphology ine foamy macrophages uye cholesterol makristasi.Mukuwedzera, pakuenzanisa BMS neDES, mutsauko mukuru munguva yekuvandudzwa kweatherosclerosis itsva yakaonekwa.11,12 Kuchinja kwekutanga kweatherosclerotic mu foamy macrophage infiltration yakatanga mwedzi 4 mushure mekudyara kweSES, asi kuchinja kwakafanana mumakumbo eCGM kwakaitika mushure memakore maviri uye yakaramba isingawanzowanikwi kusvika kumakore mana.Pamusoro pezvo, DES stenting yezvironda zvisina kugadzikana senge mutete tegmental fibroatherosclerosis (TCFA) kana intimal rupture ine nguva ipfupi yebudiriro kana ichienzaniswa neBMS.Nokudaro, neoatherosclerosis inoratidzika kuva yakawanda uye inoitika kare muchizvarwa chekutanga cheDES kupfuura muBMS, zvichida nekuda kwepathogenesis yakasiyana.
Mhedzisiro yechizvarwa chechipiri DES kana DES pabudiriro inoramba ichiongororwa;kunyangwe zvimwe zvakaonekwa zvechizvarwa chechipiri DES88 zvichiratidza kuzvimba kushoma, chiitiko cheatherosclerosis chakafanana kana chichienzaniswa nechizvarwa chekutanga, asi zvimwe zvidzidzo zvichiri kudikanwa.