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UMarta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Department of Cardiology, Poliambulanza Foundation Hospital, Brescia, 2 Department of Cardiology, Catholic University of the Sacred Heart of Rome, Italy Isishwankathelo : Imida yeDrug Stents (i-Drug Stents) iyancipha i-Metal Stents ungenelelo lwe-coronary.Nangona kunjalo, ngelixa ukuqaliswa kwe-DES yesizukulwana sesibini kubonakala kunciphise le nto xa kuthelekiswa ne-DES yesizukulwana sokuqala, iinkxalabo ezibalulekileyo zihlala malunga neengxaki ezinokwenzeka emva kwexesha lokufakelwa kwe-stent ezifana ne-stent thrombosis (ST) kunye ne-stent resection, i-stenosis (SSI).I-ST sisiganeko esinokuba yintlekele esithe sancitshiswa kakhulu ngokufakelwa kakuhle kwe-stent, uyilo lwenoveli ye-stent, kunye nonyango oluphindwe kabini lwe-antiplatelet.Eyona ndlela ichaza ukwenzeka kwayo iphantsi kophando, kwaye ngenene izinto ezininzi zinoxanduva.I-ISR kwi-BMS ngaphambili yayibhekwa njengemeko ezinzileyo kunye nencopho yokuqala ye-intimal hyperplasia (kwiinyanga ze-6) elandelwa lixesha lokunciphisa elingaphezu kwe-1 unyaka.Ngokwahlukileyo, zombini izifundo zeklinikhi kunye nezifundo ze-histological ze-DES zibonise ubungqina bokukhula okuqhubekayo kwe-neointimal kwixesha elide lokulandelelana, into eyaziwa ngokuba yinto "yokubambisa kade".Ingcamango yokuba i-ISR yimeko yeklinikhi enobungozi isandul 'ukuchaswa bubungqina bokuba izigulane ezine-ISR zinokuhlakulela i-coronary syndromes enzima.I-Intracoronary imaging yindlela ehlaselayo yokuchonga amacwecwe ane-atherosclerotic kunye neempawu zokuphulukiswa kwenqanawa emva kokuqina, kwaye ihlala isetyenziselwa ukugqiba ukuxilongwa kwe-coronary angiography kunye nokwenza iinkqubo zokungenelela.I-Intracoronary optical coherence tomography okwangoku ithathwa njengeyona ndlela iphambili yokucinga. ibonelela, xa kuthelekiswa ne-ultrasound ye-intravascular, isisombululo esingcono (ubuncinci> amaxesha angama-10), ukuvumela ukubonakaliswa okucacileyo kwesakhiwo esingaphezulu sodonga lomkhumbi. ibonelela, xa kuthelekiswa ne-ultrasound ye-intravascular, isisombululo esingcono (ubuncinci> amaxesha angama-10), ukuvumela ukubonakaliswa okucacileyo kwesakhiwo esingaphezulu sodonga lomkhumbi. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, >10 раз), что позволяет деавалькенгей ру стенки сосуда. ibonelela, xa kuthelekiswa ne-intravascular ultrasound, isisombululo esingcono (ubuncinci> amaxesha angama-10), okuvumela ukucaciswa okucacileyo kwesakhiwo somphezulu wodonga lomkhumbi.与血管内超声相比，它提供了更好的分辨率（至面少> 10 倍），允许详细表征公管的与血管内超声相比，它提供了更好的分辨率（至面少> 10)Xa kuthelekiswa ne-intravascular ultrasound, ibonelela ngesisombululo esingcono (ubuncinci amaxesha angama-10), evumela ukucaciswa okucacileyo kwesakhiwo somphezulu wodonga lomkhumbi.Izifundo zokucinga nge-vivo ezihambelana neziphumo ze-histological zibonisa ukuba ukudumba okungapheliyo kunye / okanye ukungasebenzi kakuhle kwe-endothelial kunokubangela i-neoatherosclerosis ephezulu kwi-HMS kunye ne-DES.Ke, i-neoatherosclerosis iye yaba ngumrhanelwa ophambili kwi-pathogenesis yokungaphumeleli kwe-stent kade.Amagama aphambili: i-coronary stent, i-stent thrombosis, i-restenosis, i-neoatherosclerosis.
I-Stented percutaneous coronary intervention (PCI) yeyona nkqubo isetyenziswa kakhulu kunyango lwe-symptomatic coronary artery disease, kwaye ubuchule buyaqhubeka nokuvela.1 Nangona i-drug eluting stents (DES) inciphisa imida ye-stent stents (UES), iingxaki ezisemva kwexesha ezifana ne-stent thrombosis (ST) kunye ne-stent restenosis (ISR) zinokuthi zenzeke kunye nokufakelwa kwe-stent, kwaye iinkxalabo ezinzulu zihleli.2-5
Ukuba i-ST yinto enokuthi ibe yintlekele, ukwamkelwa ukuba i-ISR inesifo esincinci sisandul 'ukuphikiswa bubungqina be-acute coronary syndrome (ACS) kwizigulane ezine-ISR.ezine
Namhlanje, i-intracoronary optical coherence tomography (i-OCT) i-6-9 ithathwa njengeyona ndlela ye-imaging ye-state-of-art inikeza isisombululo esingcono kune-intravascular ultrasound (IVUS).Kwizifundo zokucinga nge-vivo10-12 ezihambelana neziphumo ze-histological zibonisa indlela "entsha" yokuphendula umthambo emva kokufakelwa kwe-stent kunye ne-de novo "neoatherosclerosis" ngaphakathi kwe-BMS kunye ne-DES.
Ngowe-1964 uCharles Theodore Dotter noMelvin P. Judkins bachaza i-angioplasty yokuqala.Ngo-1978, u-Andreas Grunzig wenza ibhaluni yokuqala ye-angioplasty (i-angioplasty endala yebhaluni eqhelekileyo);yayilunyango loguquko, kodwa nayo yayinokungalungi kokuvalwa kwemithambo ebukhali kunye ne-restenosis.I-13 Oku kwakhokelela ekufumaneni i-coronary stents: u-Puel no-Sigwart bafake i-coronary stent yokuqala kwi-1986, inikezela i-stent yokuthintela ukuvalwa kwenqanawa ebukhali kunye nokuhlehliswa kwe-systolic kade.14 Nangona ezi stents zakuqala zithintele ukuvaleka kwenqanawa ngequbuliso, zenza umonakalo omkhulu we-endothelial kunye nokudumba.Kutshanje, izifundo ezimbini ezibalulekileyo, iBelgian-Dutch Stent Study 15 kunye ne-Stent Restenosis Study 16, ziye zakhuthaza ukhuseleko lwe-antiplatelet therapy (DAPT) stenting kunye / okanye iindlela ezifanelekileyo zokuthunyelwa.I-17,18 Ukulandela olu vavanyo, inani le-PCIs ezenziweyo landa kakhulu.
Nangona kunjalo, ingxaki ye-iatrogenic in-stent neointima hyperplasia emva kokubekwa kwe-BMS kwachongwa ngokukhawuleza, okubangele i-ISR kwi-20-30% yezilonda eziphathwayo.I-DES19 yaziswa ngo-2001 ukunciphisa imfuno yokuphumla kunye nokusebenza kwakhona.I-DES iye yandisa ukuzithemba kweengcali ze-cardiologists ngokuvumela unyango lwenani elandayo lezilonda ezinzima ezazithathwa njengezinokunyangwa nge-coronary artery bypass grafting.Kwi-2005, i-80-90% yazo zonke ii-PCI zahamba kunye ne-DES.
Yonke into ineentsilelo zayo, kwaye ukususela ngo-2005 iinkxalabo malunga nokhuseleko "lwesizukulwana sokuqala" i-DES yanda, i-stents yesizukulwana esitsha njenge-20,21 iye yaphuhliswa kwaye yaziswa.22 Ukususela ngoko, iinzame zokuphucula ukusebenza kweestents ziye zakhula ngokukhawuleza, kwaye ubugcisa obutsha obuchulumancisayo buye baqhubeka bufunyanwa kwaye buziswa ngokukhawuleza emarikeni.
I-BMS yityhubhu enemesh entle.Emva kwamava okuqala ngeWall mount, Gianturco-Roubin mount kunye nePalmaz-Schatz mount, ezininzi ezahlukeneyo zeBMS ziyafumaneka ngoku.
Uyilo oluthathu olwahlukeneyo lukhoyo: inyoka, i-tubular mesh kunye ne-slotted tube.Uyilo lwekhoyili lubandakanya iingcingo zentsimbi okanye imicu eyenza imilo yekhoyili engqukuva;kuyilo lwe-tubular mesh, ucingo oluhlanganiswe ndawonye lube yi-mesh lwenza ityhubhu;uyilo slotted ziquka iityhubhu zentsimbi ukuba laser cut.Ezi zixhobo ziyahluka ekubunjweni (insimbi engenasici, i-nichrome, i-cobalt chrome), ukuyila (iindlela ezahlukeneyo ze-spacer shapes kunye nobubanzi, iidamitha kunye nobude, amandla e-radial, i-radiopacity), kunye neenkqubo zokuhambisa (i-self-expanding or balloon-expandable).
Njengomthetho, i-BMS entsha iqukethe i-cobalt-chromium alloy, ebangela ukuba i-struts encinci, ukuphuculwa kokuqhuba ukuqhuba kunye nokugcina amandla omatshini.
Ziquka i-platform ye-metal stent (ngokuqhelekileyo insimbi engenasici) kwaye ifakwe i-polymer ekhupha i-anti-proliferative kunye / okanye i-anti-inflammatory therapeutic agents.
I-Sirolimus (ekwabizwa ngokuba yi-rapamycin) yaphuhliswa ekuqaleni njenge-antifungal agent.Indlela yokusebenza kwayo inxulumene nokuthintela ukuqhubela phambili komjikelezo weseli ngokuthintela ukuguquka ukusuka kwisigaba se-G1 ukuya kwisigaba se-S kunye nokuvimbela ukubunjwa kwe-neointima.Kwi-2001, amava "abantu bokuqala" kunye ne-SES abonise iziphumo ezithembisayo, ezikhokelela ekuphuhlisweni kwe-stent Cypher.23 amalingo amakhulu abonakalise ukusebenza kwawo ekuthinteleni i-IR.24
I-Paclitaxel yayivunyiwe ekuqaleni kunyango lomhlaza we-ovarian, kodwa iipropathi zayo ezinamandla ze-cytostatic-ichiza lizinzisa i-microtubules ngexesha le-mitosis, libangela ukubanjwa komjikelo weseli, kwaye linqande ukubunjwa kwe-neointimal-yenza i-compound ye-Taxus Express PES.Uvavanyo lwe-TAXUS V kunye ne-VI lubonise ukusebenza kwexesha elide le-PES kwi-high-risk complex complex heart disease.I-25,26 I-TAXUS Liberté elandelayo ibonise iqonga lensimbi engenasici ukuze kube lula ukuhanjiswa.
Ubungqina obunamandla obuvela kwiingxelo ezimbini ezicwangcisiweyo kunye nohlalutyo lwe-meta lubonisa ukuba i-SES inenzuzo ngaphezu kwe-PES ngenxa yezinga eliphantsi le-IVR kunye ne-target ye-revascularization yenqanawa (TVA), kunye nomkhwa wokunyuka kwe-acute myocardial infarction (AMI) kwi-PES cohort.27.28
Izixhobo zesizukulwana sesibini ziye zanciphisa ubukhulu be-shaft, ukuphucula ukuguquguquka / ukuhanjiswa, ukuphuculwa kwe-polymer biocompatibility / iprofayili yokucoca iziyobisi, kunye ne-kinetics ephezulu yokubuyisela kwakhona.Kwinkqubo yangoku, ezi zezona ziyilo ze-DES eziphucukileyo kunye ne-coronary stents emiliselwe kwihlabathi liphela.
I-Taxus Elements ithatha eli nyathelo elinye ukuya phambili ngepolymer ekhethekileyo eyenzelwe ukukhutshwa kwangoko kunye neplatinam-chromium spacer system entsha ebonelela ngezikhewu ezibhityileyo kunye nokwanda kwe-radiopacity.Uphononongo lwe-PERSEUS 29 luphawule iziphumo ezifanayo phakathi kwe-Element kunye neTaxus Express ukuya kuthi ga kwiinyanga ezili-12.Nangona kunjalo, akukho zilingo zaneleyo zokuthelekisa izinto zeyew kunye nezinye isizukulwana sesibini se-DES.
I-Endeavor Zotarolimus Coated Stent (ZES) isekelwe kwiqonga elinamandla le-cobalt-chromium stent kunye nokuguquguquka okuphezulu kunye ne-stent strut encinci.I-Zotarolimus yi-analogue ye-sirolimus enemiphumo efanayo ye-immunosuppressive, kodwa ngokunyuka kwe-lipophilicity ukuphucula indawo kwindawo eludongeni lwenqanawa.I-ZES isebenzisa i-phosphorylcholine polymer coating entsha eyenzelwe ukunyusa ukuhambelana kwe-biocompatibility kunye nokunciphisa ukuvuvukala.Uninzi lwamachiza luhlanjwa kwisigaba sokuqala sokulimala, kulandelwa ukulungiswa kwe-arterial.Emva kolingo lokuqala lwe-ENDEAVOUR, ulingo olwalandelayo lwe-ENDEAVOR III luthelekisa i-ZES kunye ne-SES, ebonise ilahleko ephezulu kade ye-lumen kunye ne-HR kodwa zimbalwa iziganeko ezibi kakhulu ze-cardiovascular (MACEs) kune-SES.I-30 Uphononongo lwe-ENDEAVOR IV oluthelekisa i-ZES kunye ne-PES kwakhona lufumene izehlo eziphezulu ze-SIS kodwa iziganeko ezisezantsi ze-MI, mhlawumbi ngenxa ye-ST eqhelekileyo kwiqela le-ZES.31 Nangona kunjalo, isifundo se-PROTECT asiphumelelanga ukubonisa umahluko kwi-ST frequency phakathi kwe-Endeavour kunye ne-Cypher stents.32
I-Endeavor Resolute yinguqulelo ephuculweyo ye-stent ye-Endeavor ene-polymer entsha yoluhlu oluthathu.I-Resolute Integrity entsha (ngamanye amaxesha ibizwa ngokuba yi-DES yesizukulwana sesithathu) isekelwe kwiqonga elitsha elinamandla okuhanjiswa okuphezulu (iqonga le-Integrity BMS) kunye ne-polymer entsha, ehambelana ne-biocompatible enokuthi icinezele impendulo yokuqala yokuvuvukala kunye ne-elute ngaphezulu kwechiza kwiintsuku ezingama-60 ezizayo.Ulingo oluthelekisa i-Resolute kunye ne-Xience V (everolimus eluting stent [EES]) lubonise ukuba inkqubo yeResolute yayisebenza ngokulinganayo malunga nokufa kunye nokusilela kwesilonda ekujoliswe kuso.33.34
I-Everolimus, i-sirolimus derivative, nayo i-cell cycle inhibitor esetyenziselwa ukuphuhliswa kwe-EES Xience (i-Multi-link Vision BMS platform) / Promus (iplatinam Chromium platform).Ulingo lwe-SPIRIT 35-37 lubonise iziphumo eziphuculweyo kunye nokunciphisa i-MACE kunye ne-Xience V xa kuthelekiswa ne-PES, ngelixa ulingo lwe-EXCELLENT lubonise ukuba i-EES yayilungile njenge-SES ekucinezeleni ukulahleka kade kwiinyanga ze-9 kunye neziganeko zeklinikhi kwiinyanga ze-12.38 Ekugqibeleni, i-Stent ye-Xience ibonakaliswe ukuba iphezulu kune-BMS ekumiseni i-ST elevation myocardial infarction (MI).39
Ii-EPC ziyi-subset yeeseli ezijikelezayo ezibandakanyekayo kwi-vascular homeostasis kunye nokulungiswa kwe-endothelial.Ukunyuka kwe-EPC kwindawo yokulimala kwe-vascular kuya kukhuthaza ukuphinda kuphele kwakhona, kunokunciphisa umngcipheko we-ST.I-EPC Biology yokuqala yokungena kuyilo lwe-stent yi-stent ye-Genous, egqunywe ngamajoni omzimba achasene ne-CD34, ekwaziyo ukubophelela ii-EPC ezijikelezayo kusetyenziswa iziphawuli zayo ze-hematopoietic ukomeleza ukuphinda ukuphelisa.Nangona izifundo zokuqala ziye zakhuthaza, ubungqina bamva nje bukhomba kumazinga aphezulu e-TVR.40
Ukunikezelwa kweziphumo ezinokuba yingozi zokuphulukisa ukulibaziseka kwe-polymer ehambelana nomngcipheko we-ST, iipolymers ze-bioresorbable zibonelela ngeenzuzo ze-DES ngokuphepha iinkxalabo ezihlala ixesha elide malunga nokuphikelela kwe-polymer.Ukuza kuthi ga ngoku, iinkqubo ezahlukeneyo ze-bioresorbable zivunyiwe (umzekelo, i-Nobori kunye ne-Biomatrix, i-biolimus eluting stent, i-Synergy, i-EES, i-Ultimaster, i-SES), kodwa uncwadi oluxhasa iziphumo zabo zexesha elide lulinganiselwe.41
Izinto eziphathekayo ze-Bioabsorbable zinenzuzo yethiyori yokubonelela ngenkxaso yomatshini ekuqaleni xa i-elastic recoil ithathelwa ingqalelo kwaye inciphisa iingozi zexesha elide ezinxulumene ne-metal struts.Ubuchwephesha obutsha buye bakhokelela ekuphuhlisweni kweepolima ze-lactic acid (i-poly-l-lactic acid [PLLA]), kodwa iinkqubo ezininzi ze-stent zisekuphuhlisweni, nangona ukufumana ibhalansi efanelekileyo phakathi kokuchithwa kweziyobisi kunye ne-degradation kinetics kuhlala kungumngeni.Uphononongo lwe-ABSORB lubonise ukhuseleko kunye nokusebenza kakuhle kwe-everolimus-coated PLLA stents.43 Uhlaziyo lwesizukulwana sesibini i-Absorb stent yayingcono kuneyangaphambili enolandelelwano oluhle lweminyaka emi-2.44 Uphononongo lwangoku lwe-ABSORB II, ulingo lokuqala olungenamkhethe oluthelekisa i-Absorb stent kunye ne-Xience Prime stent, kufuneka lunike idatha eyongezelelweyo, kwaye iziphumo zokuqala ezikhoyo zithembisa.45 Nangona kunjalo, iimeko ezifanelekileyo, ubuchule obufanelekileyo bokufakelwa, kunye neprofayili yokhuseleko kwi-coronary artery disease kufuneka icaciswe.
I-Thrombosis kwi-BMS kunye ne-DES ineziphumo ezibi zeklinikhi.Kwirejista yezigulane ezifakwe kwi-DES, i-47 24% yeemeko ze-ST zibangele ukufa, i-60% kwi-MI engabulali, kunye ne-7% kwi-angina engazinzanga.I-PCI ye-ST engxamisekileyo idla ngokuba yi-suboptimal, kunye nokuphindaphinda kwi-12% yamatyala.48
Ukwandiswa kwe-ST kuneziphumo ezibi kakhulu zeklinikhi.Kwisifundo se-BASKET-LATE, iinyanga ze-6-18 emva kokubekwa kwe-stent, izinga lokufa kwentliziyo kunye ne-MI engabulaliyo yayiphezulu kwiqela le-DES kuneqela le-SMP (4.9% kunye ne-1.3%, ngokulandelanayo).I-20 I-meta-analysis yezifundo ezisithoba apho izigulane ze-5261 zifakwe kwi-SES, i-PES, okanye i-BMS ibonise ukuba emva kweminyaka eyi-4 yokulandelelana, i-SES (0.6% ngokubhekiselele ku-0%, p = 0.025) kunye ne-PES (0.7%) yandisa iziganeko ze-ST kakhulu emva kwexesha xa kuthelekiswa ne-BMS nge-0.2%, i-2%, i-2%).49 Ngokwahlukileyo koko, kwi-meta-analysis kubandakanywa izigulane ze-5108, i-21 i-60% yokunyuka kwesihlobo sokufa okanye i-MI yabikwa nge-SES xa kuthelekiswa ne-BMS (p = 0.03), ngelixa i-PES idibaniswe nokunyuka okungabalulekanga kwe-15% (jonga - ukuya kwiinyanga ze-9 ukuya kwi-3 iminyaka).
Iirejista ezininzi, iimvavanyo ezingahleliwe, kunye nohlalutyo lwe-meta luye lwavavanya umngcipheko we-ST emva kokufakelwa kwe-BMS kunye ne-DES kwaye baye babika iziphumo eziphikisanayo.Kwirejista yezigulane ze-6906 eziphathwe nge-BMS okanye i-DES, kwakungekho nantlukwano kwiziphumo zeklinikhi okanye amazinga e-ST kwi-1 unyaka wokulandelelana.48 Kwesinye irejistri yezigulane ze-8146, umngcipheko we-ST oqhubekayo ufunyenwe u-0.6% ngonyaka xa kuthelekiswa ne-BMS.I-49 i-meta-analysis yezifundo ezithelekisa i-SES okanye i-PES kunye ne-SMPs ibonise umngcipheko wokufa kunye ne-MI kunye ne-DES yesizukulwana sokuqala xa kuthelekiswa ne-SMPs, i-21 kunye nolunye uhlalutyo lwe-meta yezigulane ze-4545 ezifakwe kwi-SES okanye i-ST phakathi kwe-PES kunye ne-BMS kwiminyaka eyi-4 yokulandelelana.I-50 Olunye uphando lwehlabathi lwangempela lubonise umngcipheko ophezulu we-ST kunye ne-MI kwizigulane eziphathwa nge-DES yesizukulwana sokuqala emva kokuyeka i-DAPT.51
Ukunikezelwa kwedatha ephikisanayo, uhlalutyo oluninzi oludibeneyo kunye nohlalutyo lwe-meta ngokudibeneyo lunqume ukuba i-DES kunye ne-SGM yesizukulwana sokuqala ayizange ihluke kakhulu kumngcipheko wokufa okanye i-MI, kodwa i-SES kunye ne-PES babenomngcipheko owongezelelweyo we-ST eqhelekileyo xa kuthelekiswa ne-SGM.Ukuphonononga ubungqina obukhoyo, i-US Food and Drug Administration (i-FDA) yamisela iphaneli yeengcali53 ekhuphe ingxelo eqaphela ukuba isizukulwana sokuqala se-DES sisebenza kakuhle njengoko sibhaliwe kwaye umngcipheko wezigaba eziphambili kakhulu ze-ST zincinci, kodwa azinkulu., Ukwanda okuphawulekayo.Ngenxa yoko, i-FDA kunye nombutho uncoma ukwandisa ixesha le-DAPT ukuya kwi-1 unyaka, nangona kukho ubungqina obuncinane bokuxhasa eli bango.
Njengoko bekutshiwo ngaphambili, isizukulwana sesibini i-DES siphuhlisiwe ngeempawu zoyilo eziphuculweyo.I-CoCr-EES yenze olona phando lubanzi lwezonyango.Kwi-meta-analysis ngu-Baber et al.54 yezigulane ze-17,101, i-CoCr-EES yanciphisa kakhulu i-ST eqinisekileyo / enokwenzeka kunye ne-MI xa kuthelekiswa ne-PES, i-SES, kunye ne-ZES kwiinyanga ze-21.Ekugqibeleni, i-Palmerini et al ibonise kwi-meta-analysis yezigulane ze-16,775 ukuba i-CoCr-EES ine-ST ephantsi kakhulu, emva kwexesha, i-1 kunye ne-2 yeminyaka echazwe kwi-ST xa kuthelekiswa nezinye i-DES ezidibeneyo.Izifundo ze-55 zobomi bokwenene zibonise ukunciphisa umngcipheko we-ST kunye ne-CoCr-EES xa kuthelekiswa ne-DES yesizukulwana sokuqala.56
I-Re-ZES yathelekiswa ne-CoCr-EES kwi-RESOLUTE-AC kunye nezifundo ze-TWENTE.33,57 Kwakungekho nantlukwano ebalulekileyo ekufeni, i-myocardial infarction, okanye i-ST echazwe inxalenye phakathi kwee-stents ezimbini.
Kwi-intanethi ye-meta-analysis yezigulane ze-50,844, kubandakanywa ne-49 RCTs, i-58 CoCr-EES idibaniswe nesiganeko esisezantsi kakhulu se-ST echazwe kune-BMS, ukufunyaniswa okungabonwanga kunye nezinye i-DES;ukwehla kwakungekho kuphela “kungethuba kakhulu” kwaye emva kweentsuku ezingama-30 (58).i-odds ratio [OR] 0.21, i-95% yexesha lokuzithemba [CI] 0.11-0.42) kunye nomnyaka we-1 (OKANYE 0.27, 95% CI 0.08-0.74) kunye ne-2 iminyaka (OKANYE 0.35, 95% CI 0.17-0.69).Xa kuthelekiswa ne-PES, i-SES, kunye ne-ZES, i-CoCr-EES idibaniswe nezinga eliphantsi le-ST kwi-1 ngonyaka.
I-ST yasekuqaleni inxulunyaniswa nezinto ezahlukeneyo. Isiseko se-plaque morphology kunye nomthwalo we-thrombus ubonakala unefuthe kwisiphumo emva kwe-PCI;I-59 i-struts enzulu yokungena nge-necrotic core (NC) i-prolapse, ukukrazula okude phakathi kwe-stent, i-suboptimal stenting kunye ne-dissections edge edge okanye i-stenosis ebalulekileyo, umngcipheko ongaphelelanga, kunye nokwandisa umngcipheko we-STD. i-regimen yezidakamizwa ze-antiplatelet ayinakuchaphazela kakhulu iziganeko ze-ST yokuqala: kwisilingo esingenasiphelo esithelekisa ii-BMS kunye ne-DES, amaxabiso e-ST acute kunye ne-subacute ST ngexesha le-DAPT ayefana (<1%). Isiseko se-plaque morphology kunye nomthwalo we-thrombus ubonakala unefuthe kwisiphumo emva kwe-PCI;I-59 i-struts enzulu yokungena nge-necrotic core (NC) i-prolapse, ukukrazula okude phakathi kwe-stent, i-suboptimal stenting kunye ne-dissections edge edge okanye i-stenosis ebalulekileyo, umngcipheko ongaphelelanga, kunye nokwandisa umngcipheko we-STD. i-regimen yezidakamizwa ze-antiplatelet ayinakuchaphazela kakhulu iziganeko ze-ST yokuqala: kwisilingo esingenasiphelo esithelekisa ii-BMS kunye ne-DES, amaxabiso e-ST acute kunye ne-subacute ST ngexesha le-DAPT ayefana (<1%) .61 Ngoko, i-ST yokuqala ibonakala ihambelana ngokuyinhloko nezilonda eziphathwayo eziphantsi kunye neenkqubo zenkqubo. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВ;59 более глубокая пенетразапокс дра (NC), длинного медиального разрыва внутри стента, субоптимального стентирования с остаточными краевыми расслоениями или значительновый Ией и неполным расширением имплантированного стента может увеличить риск ST.60 на частоту раннего ST: в рандомизированном исследовании, сравнивающем BMS kunye neDES, частота острого и подострого ST во время DAPT была оди1назвой, STEP. , по-видимому, в первую очередь связана с лежащими в основе пролеченными поражениями и процедурными факторами. Isiseko se-plaque morphology kunye ne-thrombosis ibonakala inempembelelo kwisiphumo emva kwe-PCI; Ukungena kwe-59 enzulu ngenxa ye-necrotic nucleus (NC) prolapse, ukukrazula okude phakathi kwe-stent, i-suboptimal stenting kunye ne-residual marginal delaminations okanye i-stenosis ebalulekileyo ye-marginal, i-apposition engaphelelanga kunye nokwandisa umngcipheko we-STD ongagqibekanga. i-regimen yezidakamizwa ze-antiplatelet ayichaphazeli kakhulu iziganeko ze-ST zakuqala: kwisilingo esingenasiphelo esithelekisa i-BMS kunye ne-DES, iziganeko ze-ST ezibukhali kunye ne-subacute ngexesha le-DAPT zazifana (<1%) .61 Ngaloo ndlela, i-ST yokuqala ibonakala ihambelana ngokuyinhloko nezilonda eziphathwayo eziphantsi kunye nezinto zenkqubo.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内侧撕裂、具有残余边缘剥离或显着的边缘狭窄的次优支架、不完全并缘剥离或显着的边缘狭窄的次优支架、方案不会显着影响早期ST 的发生率：在一项比较BMS 与DES , 1% ()潜在 斑块 形态 和血栓 影响 影响 pci 后 结果 ； ; ; ; ; ; ; ;导致的 支柱 穿透 , 内长的 内侧 , 具有支架 , 不 完全 并置和 不影响 影响 早期的 : 在 项 比较 比较 bms 与 des 中 , dapt 期间 急性 亚急怑 的 石发生发生 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%） .61I-morphology ye-plaque ephantsi kunye ne-thrombosis ibonakala inempembelelo kwiziphumo emva kwe-PCI;I-59 Ukungena kwe-strut ejulile ngenxa ye-necrotic nucleus (NC) ye-prolapse, i-medial rupture in ubude be-stent, i-dissection yesibini kunye nemida eshiyekileyo, okanye i-margin ephawulekayo yokunciphisa I-Optim stenting, i-apposition engagqibekanga, kunye nokwandiswa okungagqibekanga60 I-Antiplatelet irejimeni ayinayo impembelelo ebalulekileyo kwi-STDA kwi-STDA yovavanyo olubalulekileyo kwi-STDA. kwi-BMS kunye ne-DES.zinxulumene ikakhulu nezilonda zonyango kunye nezinto zotyando.
Namhlanje, kugxilwe kwi-ST kade/emva kakhulu.Nangona izinto zenkqubo kunye nezobugcisa zibonakala zidlala indima enkulu ekuphuhliseni i-ST ebukhali kunye ne-subacute, indlela yokulibaziseka kweziganeko ze-thrombotic ibonakala inzima kakhulu.Kuye kwacetyiswa ukuba iimpawu ezithile zesigulane zinokuba yimingcipheko ye-ST ehamba phambili kunye neyona nto iphezulu kakhulu: isifo sikashukela, i-ACS ngexesha lotyando lokuqala, ukungaphumeleli kwezintso, ubudala obudala, ukunciphisa iqhekeza le-ejection, iziganeko ezinkulu ezimbi zenhliziyo phakathi kweentsuku ze-30 zokuhlinzwa kokuqala.Kwi-BMS kunye ne-DES, iinguqu zenkqubo ezifana nobukhulu besitya esincinci, i-bifurcations, isifo se-multivascular, i-calcification, i-occlusion epheleleyo, i-stents ende ibonakala ihambelana nomngcipheko we-ST ehamba phambili.I-62,63 Ukuphendula okungalunganga kunyango lwe-antiplatelet ngumngcipheko omkhulu we-DES thrombosis ye-51 eqhubekayo.Le mpendulo inokuba ngenxa yokungathotyelwa kwesigulane, ukuthoba ngaphantsi, ukusebenzisana kweziyobisi, i-comorbidities echaphazela impendulo yeziyobisi, i-polymorphism ye-receptor-level genetic (ingakumbi ukumelana ne-clopidogrel), kunye nokusebenza kwezinye iindlela zokuvula iplatelet.I-Stent neoatherosclerosis ithathwa njengesixhobo esibalulekileyo sokungaphumeleli kwe-stent kade, kubandakanywa ne-ST64 kade (icandelo elithi "Stent Neoatherosclerosis").I-endothelium engaguqukiyo yahlula udonga lwe-thrombosed isitya kunye nezithuba ze-stent ukusuka kwigazi kwaye ifihla izinto ze-antithrombotic kunye ne-vasodilatory.I-DES iveza udonga lwenqanawa kwiziyobisi ezichasayo kunye neqonga lokukhutshwa kweziyobisi, elineempembelelo ezahlukeneyo ekuphulukiseni nasekusebenzeni kwe-endothelial, kunye nomngcipheko we-thrombosis kade.Izifundo ze-65 ze-Pathological zibonise ukuba i-polymers ye-DES yesizukulwana sokuqala esomeleleyo sinokufaka isandla ekudumbeni okungapheliyo, ukufakwa kwe-fibrin engapheliyo, ukuphiliswa kakubi kwe-endothelial, kwaye ngenxa yoko ukonyuka komngcipheko we-thrombosis.I-3 i-hypersensitivity yasemva kwexesha kwi-DES ibonakala iyenye indlela ekhokelela kwi-ST.Virmani et al.[66] ingxelo yokufunyaniswa kwe-postmortem emva kokuba i-ST ibonisa ukwandiswa kwe-aneurysm kwicandelo le-stent kunye neempendulo ze-hypersensitivity zendawo ezibandakanya i-T-lymphocytes kunye ne-eosinophils;ezi ziphumo zingabonisa impembelelo yeepolima ezingenakonakala.67 Ukungalungelwa kakuhle kwestent kusenokuba ngenxa yokwandiswa kwestent kuncinci okanye kwenzeke iinyanga ezininzi emva kwePCI.Nangona i-procedural malapposition is a risk factor for acute and subacute ST, ukubaluleka kweklinikhi ye-stent malapposition efunyenweyo inokuxhomekeka ekuhlaziyweni kwe-arterial enobudlova okanye ukuphulukiswa okulibaziseka okubangelwa ngamachiza, kodwa ukufaneleka kwayo kweklinikhi kuyaphikisana.68
Iziphumo zokukhusela ze-DES zesizukulwana sesibini zingabandakanya ukukhawuleza kunye nokuphela kwe-endothelialization, kunye nokungafani kwe-stent alloy kunye nesakhiwo, ubukhulu be-strut, izakhiwo ze-polymer, kunye nohlobo lweziyobisi ezichasayo, umthamo, kunye ne-kinetics.
Xa kuthelekiswa ne-CoCr-EES, i-cobalt-chromium stent scaffolds encinci (81 µm), i-antithrombotic fluoropolymers, umxholo wepolymer ephantsi, kunye nokulayishwa kweziyobisi kunokufaka isandla kumazinga aphantsi e-ST.Uphononongo lovavanyo lubonise ukuba i-thrombosis kunye ne-platelet deposition isezantsi kakhulu kwizitenti ezigqunywe nge-fluoropolymer kunezitenti ezingafakwanga.69 Ingaba ezinye ii-DES zesizukulwana sesibini zineepropati ezifanayo zifanele ukuphononongwa ngakumbi.
I-coronary stents iphucula ukuphumelela kokuhlinzwa kwe-coronary interventions xa kuthelekiswa ne-traditional percutaneous transluminal coronary angioplasty (PTCA), eneengxaki zomatshini (i-vascular occlusion, dissection, njl.) kunye nezinga eliphezulu le-restenoses (ukuya kwi-40-50% yamatyala).Ekupheleni kwe-1990s, phantse i-70% ye-PCIs yenziwa ngokufakelwa kwe-BGM.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%，在特牠约為20%，在特牠。然而，尽管技术、技术和药物治疗取得了进步，但BMSNangona kunjalo, ngaphandle kokuhambela phambili kweteknoloji, ubuchule, kunye nonyango, umngcipheko wokubuyisela emva kokufakelwa kwe-BMS malunga ne-20%, kunye namazinga adlula i-40% kumaqela amancinci athile.71 Ngokubanzi, izifundo zeklinikhi zibonise ukuba i-restenosis emva kokufakelwa kwe-BMS, efana neyokubonwa nge-PTCA eqhelekileyo, iphakamileyo kwiinyanga ze-3-6 kwaye isombulule kwi-1 ngonyaka.72
I-DES iphinde yehlise amazinga e-ISR,73 nangona oku kuncitshiswa kuxhomekeke kwi-angiographical kunye neklinikhi.I-DES i-polymer coating ikhupha i-anti-inflammatory and anti-proliferative agents, inqanda ukubunjwa kwe-neointima, kwaye ilibazise ukulungiswa kwemithambo ngeenyanga okanye iminyaka.74 Kwizifundo zeklinikhi kunye ne-histological, ukukhula okuqhubekayo kwe-neointima kuye kwabonwa kwixesha elide lokulandelwa emva kokufakelwa kwe-DES, into eyaziwa ngokuba "yi-late catch-up" 75.
Ukulimala kwe-Vascular ngexesha le-PCI kubangela inkqubo eyinkimbinkimbi yokuvuvukala kunye nokulungiswa kwexesha elifutshane (iiveki ukuya kwiinyanga), okubangela ukupheliswa kwe-endothelialization kunye neointimal coverage.Ngokoqwalaselo lwe-histopathological, i-neointimal hyperplasia (i-HMS kunye ne-DES) emva kokufakelwa kwe-stent ikakhulu yayibandakanya iiseli zemisipha ezigudileyo kwi-proteoglycan-rich extracellular matrix.70
Ngaloo ndlela, i-neointimal hyperplasia yinkqubo yokulungisa ebandakanya i-coagulation kunye nezinto ezivuthayo, kunye neeseli ezenza ukwanda kweeseli ze-muscle kunye nokwakheka kwe-matrix ye-extracellular.Ngokukhawuleza emva kwe-PCI, iiplatelet kunye ne-fibrin zifakwe kwindonga yenqanawa kwaye zitsala i-leukocytes ngokusebenzisa uchungechunge lwee-molecule ze-cell adhesion.I-leukocyte eqengqelekayo iqhotyoshela kwiiplatelets eziqhotyoshelweyo ngokusebenzisa intsebenziswano phakathi kwe-leukocyte integrin Mac-1 (CD11b / CD18) kunye neplatelet glycoprotein Ibα 53 okanye i-fibrinogen ehambelana ne-platelet glycoprotein IIb / IIIa.76.77
Ngokutsho kwedatha entsha, iiseli ze-bone marrow progenitor zibandakanyeka kwiimpendulo ze-vascular kunye neenkqubo zokulungisa.Ukuhlanganiswa kwe-EPC ukusuka kwithambo lethambo ukuya kwigazi le-peripheral kukhuthaza ukuvuselelwa kwe-endothelial kunye ne-postnatal neovascularization.Kubonakala ngathi i-bone marrow smooth muscle progenitor cells (SMPCs) ifudukela kwindawo yokulimala kwe-vascular, okubangelwa ukwanda kwe-neointimal.78 Ngaphambili, iiseli ze-CD34-positive zazithathwa njengenani elimiselweyo le-EPCs, uphando olongezelelweyo lubonise ukuba i-CD34 surface antigen ngokwenene iyaqaphela iiseli ze-stem zomongo ezingahlukanisiweyo ezikwaziyo ukwahlula kwii-EPC kunye nee-PBMCs.Ukutshintshwa kweeseli ze-CD34-positive kwi-EPC okanye i-SMPC yomgca kuxhomekeke kwimeko yendawo;iimeko ze-ischemic zibangela ukuhlukana ngokubhekiselele kwi-phenotype ye-EPC, ekhuthaza ukuphindaphinda kwakhona, ngelixa iimeko ezivuthayo zibangela ukuhlukana kwi-phenotype ye-SMPC, ekhuthaza ukwanda kwe-neointimal.79
Isifo sikashukela sonyusa umngcipheko we-ISR nge-30-50% emva kokufakelwa kwe-BMS, kwaye izinga eliphezulu le-restenosis kwi-diabetic xa kuthelekiswa nezigulane ezingenasifo seswekile nazo zaqhubeka kwixesha le-DES.Iindlela eziphantsi kolu qwalaselo kusenokwenzeka ukuba zininzi, kubandakanywa nenkqubo (umzekelo, ukuguquguquka kwempendulo yokuvuvukala) kunye ne-anatomical (umzekelo, iinqanawa ezincinci, izilonda ezinde, izifo ezisasazekayo, njl. njl.), eziye zandisa ngokuzimeleyo ingozi ye-ISR.70
Ubukhulu besitya kunye nobude be-lesion buchaphazele ngokuzimeleyo imilinganiselo ye-ISR, kunye ne-diameter encinci / izilonda ezide zonyusa kakhulu amazinga e-restenosis xa kuthelekiswa nobukhulu obukhulu / amanxeba amafutshane.71
Amaqonga eqonga esizukulwana sokuqala abonise ii-stent stent struts ezityebileyo kunye nee-ISR eziphezulu xa kuthelekiswa neqonga lesibini lesibini elinemitya emincinci.
Ngaphezu koko, iziganeko ze-restenosis zihambelana nobude be-stent, phantse ngokuphindwe kabini ubude be-stent> 35 mm xa kuthelekiswa nalabo <20 mm. Ngaphezu koko, iziganeko ze-restenosis zihambelana nobude be-stent, phantse ngokuphindwe kabini ubude be-stent> 35 mm xa kuthelekiswa nalabo <20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента >35 мм по сравнению с длиной стента <20 мм. Ukongezelela, izinga le-restenosis lihambelana nobude be-stent, phantse ngokuphindwe kabini kunye nobude be-stent> 35 mm xa kuthelekiswa nobude be-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. Ukongezelela, i-frequency of restenosis ixhomekeke kubude be-stent: ubude be-stent> 35 mm buphantse kabini i-stent <20 mm.Ubuncinci bokugqibela bedayamitha ye-lumen ye-stent bukwadlale indima ebalulekileyo: ubuncinci bokugqibela obuncinci bedayamitha yelumen buqikelele umngcipheko owonyuka kakhulu wokungaphumli.81.82
Ngokwesiko, i-hyperplasia ye-intimal emva kokufakelwa kwe-BMS ithathwa njengezinzile, kunye nencopho yokuqala phakathi kweenyanga ze-6 kunye ne-1 unyaka olandelwa lixesha lokulala.Incopho yokuqala yokukhula kwe-intimal elandelwa kukuhla kwe-intimal kunye nokwandiswa kwelumen kwiminyaka eliqela emva kokufakwa kwe-stent kuye kwaxelwa ngaphambili;Ukuvuthwa kweeseli ze-muscle ezigudileyo kunye notshintsho kwi-matrix engaphandle kwe-extracellular kucetywayo njengeendlela ezinokwenzeka zokunciphisa i-neointima kade.I-83 Nangona kunjalo, izifundo zokulandelelana kwexesha elide ziye zabonisa impendulo ye-triphasic emva kokubekwa kwe-BMS kunye nokuphumla kwangaphambili, ukuhla okuphakathi, kunye ne-luminal restenosis.84
Ngexesha le-DES, ukukhula kade kwe-neointimal kwaqala kwaboniswa emva kokufakelwa kwe-SES okanye i-PES kwiimodeli zezilwanyana.Izifundo ze-85 ezininzi ze-IVUS zibonise ukuxhatshazwa kwangaphambili kokukhula kwe-intimal elandelwa kukubamba kade emva kwexesha emva kokufakelwa kwe-SES okanye i-RPE, mhlawumbi ngenxa yenkqubo eqhubekayo yokuvuvukala.86
Nangona "ukuzinza" ngokuqhelekileyo kubhekiselwa kwi-ISR, malunga nesithathu sezigulane ezine-BMS ISR ziphuhlisa i-ACS.ezine
Kukho ubungqina obuninzi bokuthi ukuvuvukala okungapheliyo kunye / okanye ukungabikho kokuphela kwe-endothelial kubangela i-neoatherosclerosis eqhubekayo kwi-HCM kunye ne-DES (ikakhulukazi i-DES yesizukulwana sokuqala), enokuthi ibe yindlela ebalulekileyo yokuphuhliswa kwe-IR eqhubekayo okanye i-ST eqhubekayo.U-Inoue et al unike ingxelo ngeziphumo ze-autopsy emva kokufakelwa kwe-Palmaz-Schatz coronary stents, ebonisa ukuba ukudumba okujikeleze i-stent kunokubangela utshintsho olutsha olungenamsebenzi lwe-atherosclerotic ngaphakathi kwi-stent.Olunye uphando lwe-10 lubonise ukuba izicubu ze-restenotic ngaphakathi kwe-CGM ye-5 yonyaka iqulethe i-atherosclerosis yakutshanje kunye okanye ngaphandle kokuvuvukala kwe-peritoneal;iisampulu ezivela kwiimeko ze-ACS zibonisa amacwecwe asemngciphekweni kwimithambo yendalo ye-coronary arteries Histological block morphology ene-foamy macrophages kunye ne-cholesterol crystals.Ukongezelela, xa kuthelekiswa ne-BMS kunye ne-DES, umehluko omkhulu ngexesha lokuphuhliswa kwe-atherosclerosis entsha yaphawulwa.I-11,12 Utshintsho lokuqala lwe-atherosclerotic kwi-foamy macrophage infiltration yaqala iinyanga ze-4 emva kokufakelwa kwe-SES, ngelixa utshintsho olufanayo kwizilonda ze-CGM zenzeke emva kweminyaka eyi-2 kwaye lwahlala lunqabileyo olufunyenweyo ukuya kwi-4 iminyaka.Ukongeza, i-DES stenting yezilonda ezingazinzanga ezifana ne-tegmental fibroatherosclerosis (TCFA) okanye i-intimal rupture inexesha elifutshane lophuhliso xa kuthelekiswa ne-BMS.Ngaloo ndlela, i-neoatherosclerosis ibonakala ixhaphake kakhulu kwaye yenzeke ngaphambili kwi-DES yesizukulwana sokuqala kune-BMS, mhlawumbi ngenxa ye-pathogenesis eyahlukileyo.
Impembelelo yesizukulwana sesibini se-DES okanye i-DES kuphuhliso isafuna ukuphononongwa;nangona uqwalaselo olukhoyo lwesizukulwana sesibini i-DES88 lucebisa ukudumba okuncinci, izehlo ze-neoatherosclerosis ziyafana xa kuthelekiswa nesizukulwana sokuqala, kodwa izifundo ezongezelelweyo zisafuneka.