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U-Marta 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 Isifinyezo : Imikhawulo ye-Drug Stents) inciphisa i-Drug Stents) ukungenelela kwe-coronary.Kodwa-ke, nakuba ukwethulwa kwe-DES yesizukulwane sesibili kubonakala kunciphise lesi simo uma kuqhathaniswa ne-DES yesizukulwane sokuqala, ukukhathazeka okuphawulekayo kusasele mayelana nezinkinga ezingenzeka sekwephuzile zokufakelwa kwe-stent njenge-stent thrombosis (ST) kanye nokukhishwa kwe-stent, i-stenosis (SSI).I-ST isenzakalo esingaba yinhlekelele eye yancishiswa kakhulu ngokufakwa okulungiselelwe kwe-stent, imiklamo emisha ye-stent, kanye nokwelashwa okumbaxambili kwe-antiplatelet.Indlela okuyiyona echaza ukwenzeka kwayo isaphenywa, futhi kunezici ezimbalwa ezinomthelela.I-ISR ku-BMS ngaphambili yayibhekwa njengesimo esizinzile esinenani eliphakeme lokuqala le-intimal hyperplasia (ezinyangeni ze-6) elandelwa isikhathi sokuhlehla esingaphezu konyaka we-1.Ngokuphambene, kokubili izifundo zomtholampilo kanye ne-histological ze-DES zibonise ubufakazi bokukhula okuqhubekayo kwe-neointimal esikhathini eside sokulandelela, into eyaziwa ngokuthi "isenzo sokubanjwa sekwephuzile".Umbono wokuthi i-ISR iyisimo somtholampilo esibucayi muva nje uphikiswe ubufakazi bokuthi iziguli ezine-ISR zingase zibe ne-acute coronary syndromes.I-Intracoronary imaging iyindlela ehlaselayo yokuhlonza ama-atherosclerotic plaque ane-stent kanye nezimpawu zokuphulukiswa komkhumbi ngemva kokuqina, futhi kuvame ukusetshenziselwa ukuqedela ukuxilonga i-coronary angiography nokwenza izinqubo zokungenelela.I-Intracoronary optical coherence tomography okwamanje ibhekwa njengendlela ethuthuke kakhulu yokucabanga. inikeza, uma kuqhathaniswa ne-ultrasound ye-intravascular, ukulungiswa okungcono (okungenani> izikhathi ezingu-10), okuvumela ukucaciswa okuningiliziwe kwesakhiwo esingaphezulu sodonga lomkhumbi. inikeza, uma kuqhathaniswa ne-ultrasound ye-intravascular, ukulungiswa okungcono (okungenani> izikhathi ezingu-10), okuvumela ukucaciswa okuningiliziwe kwesakhiwo esingaphezulu sodonga lomkhumbi. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, >10 раз), что позволяет деавальшенсы ру стенки сосуда. inikeza, uma kuqhathaniswa ne-ultrasound ye-intravascular, ukulungiswa okungcono (okungenani> izikhathi ezingu-10), okuvumela ukucaciswa okuningiliziwe kwesakhiwo sobuso bodonga lomkhumbi.与血管内超声相比，它提供了更好的分辨率（至面少> 10 倍），允许详细表征血的管时。与血管内超声相比，它提供了更好的分辨率（至面少> 10），允许详细表征血管壁。Uma kuqhathaniswa ne-ultrasound ye-intravascular, inikeza isisombululo esingcono (okungenani izikhathi ezingu-10), okuvumela ukucaciswa okuningiliziwe kwesakhiwo sobuso bodonga lomkhumbi.Ucwaningo lwe-invivo imaging oluhambisana nokutholwe kwe-histological luphakamisa ukuthi ukuvuvukala okungapheli kanye/noma ukungasebenzi kahle kwe-endothelial kungase kubangele i-neoatherosclerosis ethuthukisiwe ku-HMS ne-DES.Ngakho-ke, i-neoatherossteosis isiphenduke umsolwa oyinhloko ku-pathogenesis yokwehluleka kwe-stent sekwephuzile.Amagama abalulekile: i-coronary stent, i-stent thrombosis, i-restenosis, i-neoatherosclerosis.
I-Stent percutaneous coronary intervention (PCI) iyindlela esetshenziswa kakhulu yokwelapha isifo se-coronary artery esinezimpawu, futhi inqubo iyaqhubeka nokuvela.1 Nakuba i-drug eluting stents (DES) inciphisa ukulinganiselwa kwama-stent stents (UES), izinkinga sekwephuzile ezifana ne-stent thrombosis (ST) kanye ne-stent restenosis (ISR) zingenzeka ngokufakwa okuqinile, futhi kusele ukukhathazeka okukhulu.2-5
Uma i-ST iyisenzakalo esingase sibe yinhlekelele, ukwamukelwa ukuthi i-ISR iyisifo esibucayi muva nje kuye kwaba nenselele ngobufakazi be-acute coronary syndrome (ACS) ezigulini ezine-ISR.ezine
Namuhla, i-intracoronary optical coherence tomography (OCT)6-9 ibhekwa njengendlela yesimanjemanje yokucabanga enikeza ukuxazulula okungcono kune-intravascular ultrasound (IVUS).Ucwaningo lwe-invivo imaging10-12 oluhambisana nokutholwe kwe-histological lubonisa indlela “entsha” yokusabela kwemithambo ngemva kokufakelwa okuqinile nge-de novo “neoatherosclerosis” ngaphakathi kwe-BMS ne-DES.
Ngo-1964 uCharles Theodore Dotter noMelvin P. Judkins bachaza i-angioplasty yokuqala.Ngo-1978, u-Andreas Grunzig wenza i-angioplasty yokuqala ye-balloon (i-angioplasty ye-balloon endala);bekuyindlela yokwelapha eguquguqukayo, kodwa futhi ibe nezinkinga zokuvaleka kwemithambo kanye ne-restenosis.13 Lokhu kwaholela ekutholakaleni kwama-coronary stents: U-Puel no-Sigwart bafaka i-coronary stent yokuqala ngo-1986, bahlinzeka nge-stent ukuvimbela ukuvalwa okunamandla komkhumbi kanye nokuhlehla kwe-systolic sekwephuzile.14 Nakuba la ma-stents okuqala avimbela ukuvaleka komkhumbi kungazelelwe, abangela ukulimala okukhulu kwe-endothelial nokuvuvukala.Muva nje, izifundo ezimbili eziyingqopha-mlando, i-Belgian-Dutch Stent Study 15 kanye ne-Stent Restenosis Study 16, ziye zakhuthaza ukuphepha kwe-double antiplatelet therapy (DAPT) stenting kanye/noma izindlela ezifanele zokuthunyelwa.17,18 Ukulandela lezi zivivinyo, inani lama-PCIs awenziwe lenyuke kakhulu.
Kodwa-ke, inkinga ye-iatrogenic in-stent neointima hyperplasia ngemva kokubekwa kwe-BMS yabonakala ngokushesha, okuholela ku-ISR ku-20-30% yezilonda eziphathwayo.I-DES19 yethulwa ngo-2001 ukuze kuncishiswe isidingo sokuphumula nokusebenza kabusha.I-DES ikhulise ukuzethemba kodokotela benhliziyo ngokuvumela ukwelashwa kwenani elikhulayo lezilonda eziyinkimbinkimbi ngaphambili ezazibhekwa njengokwelashwa ngokuxhunyelelwa kwe-coronary artery bypass.Ngo-2005, ama-80–90% awo wonke ama-PCI ayehambisana ne-DES.
Yonke into inezihibe zayo, futhi kusukela ngo-2005 ukukhathazeka ngokuphepha kwe-DES "yesizukulwane sokuqala" kwanda, ama-stents esizukulwane esisha afana ne-20,21 athuthukisiwe futhi ethulwa.22 Kusukela lapho, imizamo yokuthuthukisa ukusebenza kwama-stents ikhule ngokushesha, futhi ubuchwepheshe obusha obujabulisayo buye baqhubeka nokutholakala futhi bulethwa ngokushesha emakethe.
I-BMS iyishubhu ye-wire mesh enhle.Ngemva kokuhlangenwe nakho kokuqala nge-Wall mount, i-Gianturco-Roubin mount ne-Palmaz-Schatz mount, i-BMS eminingi ehlukene isiyatholakala.
Imiklamo emithathu ehlukene iyatholakala: i-serpentine, i-tubular mesh kanye ne-slotted tube.Imiklamo yekhoyili iqukethe izintambo zensimbi noma amapheshana akha umumo wekhoyili oyindilinga;emiklamo ye-tubular mesh, ucingo olugoqwe ndawonye lube yi-mesh lwakha ishubhu;imiklamo slotted aqukethe amashubhu ensimbi ukuthi laser cut.Lawa madivayisi ayahlukahluka ngokwakhiwa (insimbi engagqwali, i-nichrome, i-cobalt chrome), idizayini (umumo we-spacer nobubanzi, amadayamitha nobude, amandla eradial, radiopacity), kanye nezinhlelo zokulethwa (ezizandisayo noma ibhaluni-enwebekayo).
Njengomthetho, i-BMS entsha iqukethe ingxubevange ye-cobalt-chromium, okuholela kuma-struts azacile, ukusebenza okuthuthukisiwe kokushayela kanye nokugcina amandla emishini.
Ahlanganisa isiteji sensimbi esiqinile (imvamisa insimbi engagqwali) futhi ambozwe nge-polymer ekhulula ama-anti-proliferative kanye/noma ama-anti-inflammatory therapy.
I-Sirolimus (eyaziwa nangokuthi i-rapamycin) ekuqaleni yasungulwa njenge-ejenti ye-antifungal.Indlela yayo yokusebenza ihlotshaniswa nokuvimbela ukuqhubeka komjikelezo weseli ngokuvimbela uguquko ukusuka esigabeni se-G1 ukuya esigabeni se-S nokuvimbela ukwakheka kwe-neointima.Ngo-2001, isipiliyoni "somuntu wokuqala" nge-SES sibonise imiphumela ethembisayo, okuholela ekuthuthukisweni kwe-Cypher stent.23 Izinhlolo ezinkulu zikhombisile ukusebenza kahle kwazo ekuvimbeleni i-IR.24
I-Paclitaxel ekuqaleni yayigunyazwe ukwelashwa komdlavuza wesibeletho, kodwa izici zayo ezinamandla ze-cytostatic—umuthi uzinzisa ama-microtubules ngesikhathi se-mitosis, ubangela ukuboshwa komjikelezo wamangqamuzana, futhi unqande ukwakheka kwe-neointimal—uwenze inhlanganisela ye-Taxus Express PES.Ukuhlolwa kwe-TAXUS V kanye ne-VI kubonise ukusebenza kwesikhathi eside kwe-PES ku-high- risk complex complex coronary heart disease.25,26 I-TAXUS Liberté eyalandela ibonise inkundla yensimbi engagqwali ukuze kube lula ukuletha.
Ubufakazi obuqinile obuvela ekubuyekezweni okubili okuhlelekile nokuhlaziywa kwe-meta kubonisa ukuthi i-SES inenzuzo kune-PES ngenxa yamazinga aphansi e-IVR kanye ne-target vessel revascularization (TVA), kanye nokuthambekela ekukhuphukeni kwe-acute myocardial infarction (AMI) eqenjini le-PES.27.28
Amadivayisi esizukulwane sesibili anciphise ukujiya kwe-shaft, ukuguquguquka okuthuthukisiwe/ukulethwa, athuthukisiwe amaphrofayili e-polymer biocompatibility/ukususwa kwezidakamizwa, kanye ne-kinetics ye-reendothelialization ephakeme kakhulu.Ngokwenza kwamanje, lawa amadizayini e-DES athuthuke kakhulu kanye nama-coronary stents afakwe emhlabeni wonke.
I-Taxus Elements iqhubekisela phambili lesi sinyathelo esisodwa nge-polymer eyingqayizivele edizayinelwe ukukhishwa kwangaphambi kwesikhathi okuphezulu kanye nesistimu entsha ye-platinum-chromium spacer ehlinzeka ngezikhala ezincane kanye ne-radiopacity eyengeziwe.Ucwaningo lwe-PERSEUS 29 luphawule imiphumela efanayo phakathi kwe-Element ne-Taxus Express kuze kube yizinyanga eziyi-12.Nokho, azikho izivivinyo ezanele eziqhathanisa ama-elementi e-yew namanye ama-DES esizukulwane sesibili.
I-Endeavor Zotarolimus Coated Stent (ZES) isuselwe kuplathifomu ye-cobalt-chromium stent enamandla enokuguquguquka okuphezulu kanye ne-stent strut encane.I-Zotarolimus iyi-analogue ye-sirolimus enemiphumela efanayo ye-immunosuppressive, kodwa ngokunyuka kwe-lipophilicity ukuze kuthuthukiswe indawo odongeni lomkhumbi.I-ZES isebenzisa i-phosphorylcholine polymer coating entsha eklanyelwe ukukhulisa ukuhambisana kwezinto eziphilayo kanye nokunciphisa ukuvuvukala.Izidakamizwa eziningi zigezwa esigabeni sokuqala sokulimala, kulandelwa ukulungiswa kwe-arterial.Ngemuva kohlolo lokuqala lwe-ENDAVOUR, uhlolo olwalandela lwe-ENDEAVOUR III luqhathanise i-ZES ne-SES, ebonise ukulahleka kwelume sekwephuzile okuphezulu kanye ne-HR kodwa izehlakalo ezimbi ezimbi kakhulu zenhliziyo (MACEs) kune-SES.30 Ucwaningo lwe-ENDEAVOR IV oluqhathanisa i-ZES ne-PES luphinde lwathola izehlakalo eziphezulu ze-SIS kodwa izehlakalo eziphansi ze-MI, mhlawumbe ngenxa ye-ST evame kakhulu eqenjini le-ZES.I-31 Nokho, ucwaningo lwe-PROTECT lwehlulekile ukukhombisa umehluko ku-ST frequency phakathi kwe-Endeavor kanye ne-Cypher stents.32
I-Endeavor Resolute inguqulo ethuthukisiwe ye-Endeavor stent ene-polymer entsha enezendlalelo ezintathu.I-Resolute Integrity entsha (ngezinye izikhathi ebizwa ngokuthi i-DES yesizukulwane sesithathu) isekelwe kunkundla entsha enamandla okulethwa aphezulu (inkundla ye-Integrity BMS) kanye ne-polymer entsha enezendlalelo ezintathu ehambisana ne-biocompatible engacindezela impendulo yokuqala yokuvuvukala futhi ikhiphe umuthi omningi ezinsukwini ezingama-60 ezilandelayo.Uhlolo oluqhathanisa i-Resolute ne-Xience V (everolimus eluting stent [EES]) lubonise ukuthi uhlelo lwe-Resolute lwalusebenza ngokulinganayo mayelana nokufa kanye nokwehluleka kwesilonda esiqondiwe.33.34
I-Everolimus, okuphuma ku-sirolimus, futhi iyisivimbeli somjikelezo wamaseli esetshenziswa ekuthuthukisweni kwe-EES Xience (i-Multi-link Vision BMS platform)/Promus (iplatinum Chromium).Uhlolo lwe-SPIRIT 35-37 lubonise imiphumela ethuthukisiwe futhi lwehlisa i-MACE nge-Xience V uma kuqhathaniswa ne-PES, kuyilapho uhlolo lwe-EXCELLENT lubonise ukuthi i-EES yayiyinhle njenge-SES ekucindezeleni ukulahlekelwa sekwephuzile ezinyangeni eziyi-9 kanye nemicimbi yomtholampilo ezinyangeni eziyi-12.38 Ekugcineni, i-Xience stent iboniswe ukuthi iphakeme kune-BMS esimweni se-ST elevation myocardial infarction (MI).39
Ama-EPC ayisethi engaphansi yamaseli ajikelezayo abandakanyeka ku-homeostasis ye-vascular kanye nokulungiswa kwe-endothelial.Ukwenyuka kwe-EPC endaweni yokulimala kwe-vascular kuzokhuthaza ukuvuselelwa kabusha kwe-endothelialization, okungenzeka kunciphise ingozi ye-ST.Ukungena kokuqala kwe-EPC Biology ekwakhiweni okuqinile yi-Genous stent, embozwe ngamasosha omzimba alwa ne-CD34, ekwazi ukubopha ama-EPC ajikelezayo ngokusebenzisa omaka bayo be-hematopoietic ukuze kuthuthukiswe ukubola kabusha kwe-endothelialization.Nakuba izifundo zokuqala bezilokhu zikhuthaza, ubufakazi bamuva bukhomba amazinga aphezulu e-TVR.40
Njengoba kunikezwe imiphumela engaba yingozi yokuphulukisa ukubambezeleka okubangelwa i-polymer ehlotshaniswa nengozi ye-ST, ama-polymers atholakalayo ahlinzeka ngezinzuzo ze-DES ngokugwema ukukhathazeka isikhathi eside mayelana nokuphikelela kwe-polymer.Kuze kube manje, izinhlelo ezihlukahlukene ze-bioresorbable zivunyelwe (isb, i-Nobori ne-Biomatrix, i-biolimus eluting stent, i-Synergy, i-EES, i-Ultimaster, i-SES), kodwa izincwadi ezisekela imiphumela yazo yesikhathi eside zilinganiselwe.41
Izinto ezisetshenziswa yi-Bioabsorbable zinenzuzo yethiyori yokuhlinzeka ngosekelo lwemishini ekuqaleni lapho ukunwebeka okunwebekayo kucatshangelwa futhi kuncishiswe ubungozi besikhathi eside obuhlobene nezinsimbi zensimbi ezikhona.Ubuchwepheshe obusha buye baholela ekuthuthukisweni kwama-polymer e-lactic acid (i-poly-l-lactic acid [PLLA]), kodwa izinhlelo eziningi ze-stent zisathuthuka, nakuba ukuthola ibhalansi ekahle phakathi kwe-lution yezidakamizwa kanye ne-degradation kinetics kuseyinselele.Ucwaningo lwe-ABSORB lubonise ukuphepha nokusebenza kahle kwamastenti e-PLLA ahlanganiswe nge-everolimus.43 Ukubuyekezwa kwesizukulwane sesibili i-Absorb stent ibingcono kuneyangaphambili enokulandelela okuhle kweminyaka emi-2.44 Ucwaningo lwamanje lwe-ABSORB II, isilingo sokuqala esingahleliwe esiqhathanisa i-Absorb stent ne-Xience Prime stent, kufanele sinikeze idatha eyengeziwe, futhi imiphumela yokuqala etholakalayo iyathembisa.45 Kodwa-ke, izimo ezifanele, indlela yokufakelwa kahle, kanye nephrofayili yokuphepha ku-coronary artery disease idinga ukucaciswa.
I-Thrombosis kukho kokubili i-BMS ne-DES inemiphumela emibi yomtholampilo.Ebhukwini leziguli ezifakwe i-DES, ama-47 24% e-ST aholele ekufeni, ama-60% kwi-MI engabulali, kanye no-7% kwi-angina engazinzile.I-PCI ye-ST ephuthumayo ngokuvamile ayilungile, futhi iphindeka ku-12% wamacala.48
I-ST Enwetshiwe inemiphumela yomtholampilo engase ibe mibi.Ocwaningweni lwe-BASKET-LATE, izinyanga eziyi-6-18 ngemuva kokubekwa kwe-stent, amazinga okufa kwenhliziyo kanye ne-MI engabulali ayephezulu eqenjini le-DES kuneqembu le-SMP (4.9% kanye ne-1.3%, ngokulandelana).20 Ukuhlaziywa kwe-meta yezifundo eziyisishiyagalolunye lapho iziguli ze-5261 zihlelwe ngokungahleliwe ku-SES, i-PES, noma i-BMS ibonise ukuthi ngemva kweminyaka engu-4 yokulandelela, i-SES (0.6% ngokumelene no-0%, p = 0.025) kanye ne-PES (0.7%) ) yandisa isigameko se-ST sekwephuzile kakhulu uma kuqhathaniswa ne-BMS ngo-0.2%, p.49 Ngokuphambene, ekuhlaziyweni kwe-meta okuhlanganisa iziguli ze-5108, i-21 i-60% yokunyuka kwesihlobo sokufa noma i-MI yabikwa nge-SES uma kuqhathaniswa ne-BMS (p = 0.03), kuyilapho i-PES ihlotshaniswa nokunyuka okungabalulekile kwe-15% (bheka - kufika ezinyangeni ezingu-9 kuya eminyakeni engu-3).
Amarejistri amaningi, ukuhlola okungahleliwe, nokuhlaziywa kwemeta kuhlole ubungozi obuhlobene be-ST ngemva kokufakwa kwe-BMS ne-DES futhi kubike imiphumela engqubuzanayo.Kurejista yeziguli ze-6906 eziphathwe nge-BMS noma i-DES, kwakungekho umehluko emiphumeleni yomtholampilo noma amanani e-ST ku-1 unyaka wokulandela.48 Kwenye indawo yokubhalisa yeziguli ezingu-8146, ingozi yokuphikelela kwe-ST ngokweqile itholakale ingu-0.6% ngonyaka uma iqhathaniswa ne-BMS.I-49 Ukuhlaziywa kwe-meta yezifundo eziqhathanisa ne-SES noma i-PES nama-SMP abonise ingozi eyengeziwe yokufa kanye ne-MI ene-DES yesizukulwane sokuqala uma kuqhathaniswa nama-SMPs, i-21 kanye nokunye ukuhlaziywa kwe-meta yeziguli ze-4545 okungahleliwe ku-SES noma i-ST phakathi kwe-PES ne-BMS eminyakeni engu-4 yokulandelela.I-50 Ezinye izifundo zomhlaba wangempela zibonise ingozi eyengeziwe ye-ST ne-MI eqhubekayo ezigulini eziphathwa nge-DES yesizukulwane sokuqala ngemva kokuqedwa kwe-DAPT.51
Njengoba kunikezwe idatha engqubuzanayo, ukuhlaziya okuhlanganisiwe okuningana kanye nokuhlaziywa kwe-meta ngokuhlangene kunqume ukuthi i-DES ne-SGM yesizukulwane sokuqala azizange zihluke kakhulu engcupheni yokufa noma i-MI, kodwa i-SES ne-PES ibe nengozi eyengeziwe ye-ST evamile kakhulu uma kuqhathaniswa ne-SGM.Ukuze kubuyekezwe ubufakazi obutholakalayo, i-US Food and Drug Administration (FDA) yaqoka iphaneli yochwepheshe53 eyakhipha isitatimende esiqaphela ukuthi i-DES yesizukulwane sokuqala iyasebenza njengoba ibhaliwe nokuthi ubungozi bezigaba ezithuthuke kakhulu ze-ST buncane, kodwa abukhulu., Ukwanda okuphawulekayo.Ngenxa yalokho, i-FDA kanye nenhlangano batusa ukwelula isikhathi se-DAPT sibe unyaka ongu-1, nakuba kunobufakazi obuncane bokusekela lesi simangalo.
Njengoba kushiwo ngaphambili, i-DES yesizukulwane sesibili iye yathuthukiswa ngezici zokuklama ezithuthukisiwe.I-CoCr-EES yenze ucwaningo olunzulu lwezokwelapha.Ekuhlaziyweni kwe-meta okwenziwa ngu-Baber et al.54 weziguli eziyi-17,101, i-CoCr-EES yehlise kakhulu i-ST eqondile/engenzeka kanye ne-MI uma kuqhathaniswa ne-PES, i-SES, ne-ZES ezinyangeni ezingama-21.Ekugcineni, i-Palmerini et al ibonise ekuhlaziyweni kwe-meta yeziguli ze-16,775 ukuthi i-CoCr-EES ine-ST echazwe ngaphambilini ephansi kakhulu, ephuzile, engu-1- kanye ne-2 ngonyaka uma kuqhathaniswa namanye ama-DES ahlanganisiwe.Izifundo ze-Real-life ezingama-55 zibonise ukuncipha kwengozi ye-ST nge-CoCr-EES uma kuqhathaniswa ne-DES yesizukulwane sokuqala.56
I-Re-ZES yaqhathaniswa ne-CoCr-EES ocwaningweni lwe-RESOLUTE-AC kanye ne-TWENTE.33,57 Kwakungekho umehluko omkhulu ekufeni, i-myocardial infarction, noma ingxenye ye-ST echazwe phakathi kwama-stents amabili.
Ekuhlaziyweni kwe-meta yenethiwekhi yeziguli ze-50,844, kuhlanganise ne-49 RCTs, i-58 CoCr-EES ihlotshaniswa nesigameko esiphansi kakhulu se-ST echazwe kune-BMS, ukutholakala okungabonakali namanye ama-DES;ukwehla kwakungekhona kuphela “ekuqalekeni okukhulu” nangemva kwezinsuku ezingama-30 (58).isilinganiso sezinto ezingafani [NOMA] 0.21, 95% isikhawu sokuzithemba [CI] 0.11-0.42) kanye nonyaka ongu-1 (NOMA 0.27, 95% CI 0.08-0.74) neminyaka engu-2 (NOMA 0.35, 95% CI 0.17–0.69).Uma kuqhathaniswa ne-PES, i-SES, ne-ZES, i-CoCr-EES yayihlotshaniswa nenani eliphansi le-ST onyakeni ongu-1.
I-ST yasekuqaleni ihlotshaniswa nezici ezihlukahlukene. I-morphology ye-plaque ephansi kanye nomthwalo we-thrombus kubonakala kuthonya umphumela ngemva kwe-PCI; Ukungena kwe-59 okujulile kwe-struts nge-necrotic core (NC) prolapse, ukudabuka okude okuphakathi ngaphakathi kwe-stent, i-suboptimal stenting ene-dissections enqenqemeni esele noma i-stenosis enqenqemeni ephawulekayo, i-apposition engaphelele, kanye nokwenyuka kwe-STD kwe-incomplete engaphelele. uhlobo lwezidakamizwa ze-antiplatelet alithinti kakhulu izehlakalo ze-ST zakuqala: esivivinyweni esingahleliwe esiqhathanisa nama-BMS nama-DES, amanani e-ST acute ne-subacute ngesikhathi se-DAPT ayefana (<1%).61 Ngakho, i-ST yakuqala ibonakala ihlobene ngokuyinhloko nezilonda eziphathwayo ezingaphansi kanye nezici zenqubo. I-morphology ye-plaque ephansi kanye nomthwalo we-thrombus kubonakala kuthonya umphumela ngemva kwe-PCI; Ukungena kwe-59 okujulile kwe-struts nge-necrotic core (NC) prolapse, ukudabuka okude okuphakathi ngaphakathi kwe-stent, i-suboptimal stenting ene-dissections enqenqemeni esele noma i-stenosis enqenqemeni ephawulekayo, i-apposition engaphelele, kanye nokwenyuka kwe-STD kwe-incomplete engaphelele. uhlobo lwezidakamizwa ze-antiplatelet aluthonyeli kakhulu ukwenzeka kwe-ST yokuqala: esivivinyweni esingahleliwe esiqhathanisa nama-BMS nama-DES, amanani e-ST acute ne-subacute ngesikhathi se-DAPT ayefana (<1%) .61 Ngakho, i-ST yakuqala ibonakala ihlobene ngokuyinhloko nezilonda eziphathwayo ezingaphansi kanye nezici zenqubo. I-Морфология лежащей в основе бляшки and тромбоз, по-видимому, влияют на исход после ЧКВ;59 более глубокая пенетразаконся врасположение дра (NC), длинного медиального разрыва внутри стента, субоптимального стентирования с остаточными краевыми расслоениями или значитеральномым i-neполным расширением имплантированного стента может увеличить риск ST.60 на частоту раннего ST: в рандомизированном исследовании, сравнивающем BMS ne-DES, частота острого и подострого ST во время DAPT была оди1назвой, 60%, 6. , по-видимому, в первую очередь связана с лежащими в основе пролеченными поражениями и процедурными факторами. I-morphology ye-plaque ephansi kanye ne-thrombosis ibonakala ithonya umphumela ngemva kwe-PCI; Ukungena kwe-59 okujulile kwe-strut ngenxa ye-necrotic nucleus (NC) prolapse, izinyembezi ezikude ezingaphakathi ngaphakathi kwe-stent, i-suboptimal stenting ne-residual marginal delaminations noma i-marginal stenosis ephawulekayo, ingozi engaphelele kanye nokwenyuka kwe-STD kungakhuphula i-implate6. uhlobo lwezidakamizwa ze-antiplatelet akuthinti kakhulu ukwenzeka kwe-ST yokuqala: esivivinyweni esingahleliwe esiqhathanisa ne-BMS ne-DES, isigameko se-ST esibucayi nesincane ngesikhathi se-DAPT sasifana (<1%) .61 Ngakho, i-ST yokuqala ibonakala ihlobene ngokuyinhloko nezilonda eziphathwayo ezingaphansi kanye nezici zenqubo.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着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 期闥急急性的亚会1%)潜在 的 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 内侧的 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 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 发生 发生 发生 发生 发生 发生生 发生率相似(<1%） .61I-morphology ye-plaque eyisisekelo kanye ne-thrombosis ibonakala ithonya imiphumela ngemva kwe-PCI;I-59 Ukungena okujulile kwe-strut ngenxa ye-necrotic nucleus (NC) prolapse, ukuqhuma okuphakathi ngobude obuqinile, ukuhlukaniswa kwesibili ngamaphethelo asele, noma ukunciphisa umkhawulo obalulekile Ukuqina okuphezulu, ukufakwa okungaphelele, nokwandiswa okungaphelele60 I-Antiplatelet regimen ayinayo umphumela obalulekile we-STDA ekuhlolweni kokuqala kwe-STDA. i-BMS ne-DES.zihlobene ngokuyinhloko nezilonda zokwelapha ezicashile kanye nezici zokuhlinzwa.
Namuhla, kugxilwe ku-ST sekwephuzile/sekwephuze kakhulu.Nakuba izici zenqubo nezobuchwepheshe zibonakala zidlala indima enkulu ekuthuthukisweni kwe-ST ebukhali nencane, indlela yezenzakalo ze-thrombotic ebambezelekile ibonakala iyinkimbinkimbi kakhulu.Kuye kwaphakanyiswa ukuthi izici ezithile zesiguli zingase zibe yingozi ye-ST eqhubekayo futhi ethuthuke kakhulu: isifo sikashukela, i-ACS ngesikhathi sokuhlinzwa kokuqala, ukwehluleka kwezinso, ukuguga, ukunciphisa ingxenye ye-ejection, izenzakalo ezinkulu ezimbi zenhliziyo phakathi kwezinsuku ezingu-30 zokuhlinzwa kokuqala.Ku-BMS ne-DES, okuguquguqukayo kwezinqubo ezifana nosayizi womkhumbi omncane, ama-bifurcations, isifo se-multivascular, i-calcification, i-occlusion ephelele, ama-stents amade abonakala ehlotshaniswa nengozi ye-ST eqhubekayo.I-62,63 Ukusabela okungalungile ekwelashweni kwe-antiplatelet kuyingozi enkulu ye-DES thrombosis 51 eqhubekayo.Le mpendulo ingase ibe ngenxa yokungalandeli kwesiguli, ukwehlisa umthamo womthamo, ukusebenzisana kwezidakamizwa, izifo ezithinta ukusabela kwezidakamizwa, i-polymorphism yofuzo yezinga le-receptor (ikakhulukazi ukumelana ne-clopidogrel), kanye nokwenza kusebenze ezinye izindlela zokwenza iplatelet isebenze.I-stent neoatherosclerosis ibhekwa njengendlela ebalulekile yokwehluleka kwe-stent sekwephuzile, okuhlanganisa sekwephuzile i-ST64 (isigaba "I-Stent Neoatherosclerosis").I-endothelium eqinile ihlukanisa udonga lomkhumbi olune-thrombosed kanye nezigxobo ze-stent egazini futhi ikhiphe izinto ezilwa ne-antithrombotic kanye ne-vasodilatory.I-DES idalula udonga lomkhumbi emithini evimbela ukwanda kanye nenkundla yokukhishwa kwezidakamizwa, enemiphumela ehlukahlukene ekwelapheni nasekusebenzeni kwe-endothelial, ngengcuphe ye-thrombosis sekwephuzile.Ucwaningo lwe-Pathological lwe-65 lubonise ukuthi ama-polymers esizukulwane sokuqala se-DES anamandla angaba nomthelela ekuvuvukeni okungapheli, ukufakwa kwe-fibrin okungapheli, ukuphulukiswa okungahambi kahle kwe-endothelial, futhi ngenxa yalokho kwanda ingozi ye-thrombosis.3 I-hypersensitivity ephuzile ku-DES ibonakala ingenye indlela eholela ku-ST.Virmani et al.[66] kubika okutholakele kwe-postmortem ngemva kwe-ST ebonisa ukunwetshwa kwe-aneurysm engxenyeni ye-stent ngokusabela kwe-hypersensitivity yendawo ehlanganisa i-T-lymphocytes nama-eosinophils;lokhu okutholakele kungase kubonise ithonya lama-polymers angabhubhi.67 Ukungahambi kahle kwe-stent kungase kubangelwe ukunwetshwa kwe-stent okuncane noma kwenzeke ezinyangeni ezimbalwa ngemva kwe-PCI.Nakuba ukungahambi kahle kwezinqubo kuyisici esiyingozi se-ST ebukhali nesabisayo, ukubaluleka komtholampilo kokutholwa kwe-stent malapposition kungase kuncike ekulungisweni kabusha kwe-arterial okunamandla noma ukuphulukiswa okulibaziseka okubangelwa izidakamizwa, kodwa ukuhambisana kwakho komtholampilo kuyaphikisana.68
Imiphumela yokuvikela ye-DES yesizukulwane sesibili ingase ihlanganise i-endothelialization esheshayo futhi eqinile, kanye nokwehluka kwe-stent alloy nesakhiwo, ukushuba kwe-strut, izakhiwo ze-polymer, kanye nohlobo lwezidakamizwa ezilwa nokuvuvukala, umthamo, kanye ne-kinetics.
Uma kuqhathaniswa ne-CoCr-EES, izacile (81 µm) ze-cobalt-chromium stent scaffolds, i-antithrombotic fluoropolymers, okuqukethwe kwe-polymer ephansi, nokulayishwa kwezidakamizwa kungase kube nomthelela emazingeni aphansi e-ST.Ucwaningo lokuhlola lubonise ukuthi i-thrombosis kanye ne-platelet deposition iphansi kakhulu kuma-stents ane-fluoropolymer-coated kunama-stents angamboziwe.69 Ukuthi amanye ama-DES esizukulwane sesibili anezakhiwo ezifanayo kufanele afunde okwengeziwe.
Ama-coronary stents athuthukisa impumelelo yokuhlinzwa yokungenelela kwe-coronary uma kuqhathaniswa ne-traditional percutaneous transluminal coronary angioplasty (PTCA), enezinkinga zemishini (i-vascular occlusion, dissection, njll.) kanye nezinga eliphezulu le-restenoses (kufika ku-40-50% wamacala).Ekupheleni kweminyaka yawo-1990, cishe ama-70% ama-PCI enziwa ngokufakwa 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%，在特特约為20%，在特特特生光约给生亲统云安營。然而，尽管技术、技术和药物治疗取得了进步，但BMSNokho, naphezu kwentuthuko kwezobuchwepheshe, amasu, kanye nokwelapha, ingozi restenosis kulandela ukufakelwa BMS cishe 20%, namazinga angaphezu kuka-40% emaqenjini athile amancane.71 Ngokuvamile, izifundo zomtholampilo zibonise ukuthi i-restenosis ngemva kokufakelwa kwe-BMS, efana nalokho okubonwa nge-PTCA evamile, ifinyelela phezulu ezinyangeni ezingu-3-6 futhi ixazulula ngonyaka we-1.72
I-DES iphinde yehlise amazinga e-ISR,73 nakuba lokhu kuncipha kuncike ku-angiographically nangokomtholampilo.I-DES polymer coating ikhulula ama-anti-inflammatory and anti-proliferative agents, ivimbela ukwakheka kwe-neointima, futhi ilibazise ukulungiswa kwemithambo ngezinyanga noma iminyaka.74 Ezifundweni zemitholampilo kanye nezamasiko, ukukhula okuqhubekayo kwe-neointima kuye kwabonwa esikhathini eside sokulandelela ngemva kokufakwa kwe-DES, into eyaziwa ngokuthi “ukubamba sekwephuzile” 75.
Ukulimala kwe-Vascular ngesikhathi se-PCI kubangela inqubo eyinkimbinkimbi yokuvuvukala nokulungisa esikhathini esifushane kakhulu (amasonto kuya ezinyangeni), okuholela ekuqedeni kwe-endothelialization kanye ne-neointimal coverage.Ngokokubhekwa kwe-histopathological, i-neointimal hyperplasia (HMS ne-DES) ngemva kokufakwa kwe-stent ikakhulukazi yayihlanganisa amangqamuzana emisipha abushelelezi akhulayo ku-matrix engaphandle kwe-proteoglycan ecebile.70
Ngakho-ke, i-neointimal hyperplasia iyinqubo yokulungisa ehlanganisa izici ze-coagulation kanye nokuvuvukala, kanye namangqamuzana abangela ukwanda kwamaseli emisipha ebushelelezi kanye nokwakheka kwe-matrix ye-extracellular.Ngokushesha ngemva kwe-PCI, ama-platelet kanye ne-fibrin afakwa odongeni lomkhumbi futhi ahehe ama-leukocyte ngochungechunge lwama-molecule e-adhesion cell.Ama-leukocyte agingqikayo anamathela kumaplatelet anamathiselwe ngokusebenzisa ukuxhumana phakathi kwe-leukocyte integrin Mac-1 (CD11b/CD18) ne-platelet glycoprotein Ibα 53 noma i-fibrinogen ehambisana ne-platelet glycoprotein IIb/IIIa.76.77
Ngokusho kwedatha entsha, amaseli e-bone marrow progenitor abandakanyeka ekuphenduleni kwe-vascular kanye nezinqubo zokulungisa.Ukuhlanganisa i-EPC kusuka kumnkantsha wethambo kuya egazini le-peripheral kukhuthaza ukuvuselelwa kwe-endothelial kanye ne-neovascularization yangemva kokubeletha.Kubonakala sengathi i-bone marrow smooth muscle progenitor cells (SMPCs) ithuthela endaweni yokulimala kwemithambo, okuholela ekwandeni kwe-neointimal.78 Phambilini, amaseli e-CD34-positive ayebhekwa njengenani labantu elingaguquki lama-EPCs, ucwaningo olwengeziwe luye lwabonisa ukuthi i-CD34 surface antigen iyawabona ngempela ama-stem cells womnkantsha wamathambo anamandla okuhlukanisa abe ama-EPC nama-PBMC.Ukwehlukaniswa kwamaseli e-CD34-positive abe ohlwini lwe-EPC noma lwe-SMPC kuncike endaweni yendawo;izimo ze-ischemic zenza umehluko ku-phenotype ye-EPC, ekhuthaza ukuphindaphinda kwe-reendothelialization, kuyilapho izimo zokuvuvukala zenza umehluko ku-phenotype ye-SMPC, ekhuthaza ukwanda kwe-neointimal.79
Isifo sikashukela sandisa ingozi ye-ISR ngo-30-50% ngemva kokufakwa kwe-BMS, futhi izinga eliphezulu lokuphumula kwesifo sikashukela uma kuqhathaniswa neziguli ezingezona ezinesifo sikashukela nalo laqhubeka enkathini ye-DES.Izinqubo ezingaphansi kwalokhu kubuka cishe ziyizici eziningi, ezihlanganisa i-systemic (isb, ukuhlukahluka ekuphenduleni kokuvuvukala) kanye ne-anatomical (isb., imikhumbi emincane, izilonda ezinde, izifo ezisakazekayo, njll.), okwandisa ngokuzimela ingozi ye-ISR.70
Ububanzi bomkhumbi kanye nobude bokulimala buthinte ngokuzimele amazinga e-ISR, ngezilonda ezincane zobubanzi/ezinde ezikhuphula ngokuphawulekayo izinga lokuqina kwe-restenosis uma kuqhathaniswa nobukhulu obukhulu/izilonda ezimfushane.71
Amaplathifomu aqinile esizukulwane sokuqala abonise ama-stent stent aminyene kanye nama-ISR aphezulu uma kuqhathaniswa nezinkundla zesizukulwane sesibili eziqinile ezinama-struts azacile.
Ngaphezu kwalokho, izehlakalo ze-restenosis zihlotshaniswa nobude be-stent, obucishe buphindeke kabili ubude be-stent>35 mm uma kuqhathaniswa nalabo abangu-<20 mm. Ngaphezu kwalokho, izehlakalo ze-restenosis zihlotshaniswa nobude be-stent, obucishe buphindeke kabili ubude be-stent>35 mm uma kuqhathaniswa nalabo abangu-<20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента >35 мм по сравнению с длиной стента <20 мм. Ukwengeza, izinga le-restenosis lihlobene nobude be-stent, cishe ngokuphindwe kabili ubude be-stent> 35 mm uma kuqhathaniswa 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. Ukwengeza, imvamisa ye-restenosis incike kubude be-stent: ubude be-stent> 35 mm cishe buphindwe kabili kune-stent <20 mm.Ubukhulu bokugcina obuncane be-lumen be-stent bubuye badlala indima ebalulekile: ubuncane bokugcina obuncane be-lumen ububanzi bubikezele ingozi eyanda kakhulu ye-restenosis.81.82
Ngokwesiko, i-hyperplasia ye-intimal ngemva kokufakwa kwe-BMS ibhekwa njengezinzile, nenani eliphakeme langaphambi kwesikhathi phakathi kwezinyanga ezingu-6 nonyaka ongu-1 okulandelwa isikhathi sokulala sekwephuzile.Inani eliphakeme lokuqala lokukhula okusondelene okulandelwa ukuhlehla okusondelene nokukhulisa ilume eminyakeni embalwa ngemuva kokubikwa kokufakwa kwe-stent ngaphambilini;ukuvuthwa kwamaseli emisipha abushelelezi kanye nezinguquko ku-matrix engaphandle kwe-extracellular kuye kwahlongozwa njengezindlela ezingenzeka zokuhlehla kwe-neointima sekwephuzile.83 Kodwa-ke, izifundo zokulandelela isikhathi eside zibonise ukusabela okuthathu ngemva kokubekwa kwe-BMS nge-restenosis yakuqala, ukuhlehla okuphakathi, kanye ne-luminal restenosis sekwephuzile.84
Esikhathini se-DES, ukukhula sekwephuzile kwe-neointimal ekuqaleni kwaboniswa ngemva kokufakwa kwe-SES noma i-PES kumamodeli ezilwane.Izifundo ze-85 eziningana ze-IVUS zibonise ukuncishiswa kokuqala kokukhula okusondelene okulandelwa ukubanjwa sekwephuzile ngokuhamba kwesikhathi ngemva kokufakwa kwe-SES noma i-RPE, mhlawumbe ngenxa yenqubo yokuvuvukala eqhubekayo.86
Naphezu "kokuzinza" okuvame ukubizwa ngokuthi i-ISR, cishe ingxenye yesithathu yeziguli ezine-BMS ISR zithuthukisa i-ACS.ezine
Kunobufakazi obandayo bokuthi ukuvuvukala okungapheli kanye/noma ukungasebenzi kahle kwe-endothelial kudala i-neoatherosclerosis eqhubekayo ku-HCM ne-DES (ikakhulukazi i-DES yesizukulwane sokuqala), okungase kube indlela ebalulekile yokuthuthukiswa kwe-IR eqhubekayo noma i-ST eqhubekayo.U-Inoue et al [87] ubike okutholwe kwe-histological autopsy ngemuva kokufakwa kwe-coronary stents ye-Palmaz-Schatz, ephakamisa ukuthi ukuvuvukala okuzungeze i-stent kungase kubangele izinguquko ezintsha ze-atherosclerotic ezingenzi lutho ngaphakathi kwe-stent.Ezinye izifundo10 zibonise ukuthi izicubu ze-restenotic ngaphakathi kwe-CGM yeminyaka engu-5 iqukethe i-atherosclerosis yokuqala yakamuva noma ngaphandle kokuvuvukala kwe-peritoneal;ama-specimens avela ezimweni ze-ACS abonisa ama-plaque asengozini emithanjeni yenhliziyo yomdabu I-Histological block morphology enama-foamy macrophages namakristalu e-cholesterol.Ngaphezu kwalokho, lapho kuqhathaniswa ne-BMS ne-DES, umehluko omkhulu ngesikhathi sokuthuthukiswa kwe-atherosclerosis entsha waphawulwa.I-11,12 Izinguquko zokuqala ze-atherosclerotic ekungeneni kwe-foamy macrophage zaqala izinyanga ezingu-4 ngemva kokufakwa kwe-SES, kuyilapho izinguquko ezifanayo ezilonda ze-CGM zenzeke ngemva kweminyaka engu-2 futhi zahlala zingavamile ukuthola iminyaka engu-4.Ngaphezu kwalokho, i-DES stenting yezilonda ezingazinzile ezifana ne-fibroatherosclerosis encane ye-tegmental (TCFA) noma i-intimal rupture inesikhathi esifushane sokuthuthuka uma kuqhathaniswa ne-BMS.Ngakho-ke, i-neoatherosclerosis ibonakala ivame kakhulu futhi yenzeke ekuqaleni kwe-DES yesizukulwane sokuqala kune-BMS, mhlawumbe ngenxa ye-pathogenesis ehlukile.
Umthelela wesizukulwane sesibili i-DES noma i-DES ekuthuthukisweni kusazobhekwa;nakuba okunye ukubhekwa okukhona kwesizukulwane sesibili i-DES88 kuphakamisa ukuvuvukala okuncane, izehlakalo ze-neoatherosclerosis ziyefana uma ziqhathaniswa nesizukulwane sokuqala, kodwa izifundo ezengeziwe zisadingeka.