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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Sashen Ilimin Zuciya, Asibitin Gidauniyar Poliambulanza, Brescia, 2 Sashen Ilimin Zuciya, Jami'ar Katolika ta Zuciya Mai Tsarki ta Rome, Italiya Takaitawa: Magungunan Stents masu rufi (DES) suna rage iyakokin amfani da stents na ƙarfe marasa siffa (BMS) bayan an yi musu tiyatar zuciya ta hanyar tiyatar zuciya ta hanyar fata. Duk da haka, yayin da gabatar da DES na ƙarni na biyu ya rage wannan lamari idan aka kwatanta da DES na ƙarni na farko, akwai damuwa mai yawa game da yiwuwar rikice-rikicen dasa stent a ƙarshen lokaci kamar su stent thrombosis (ST) da cire stent, stenosis (SSI). ST wani lamari ne mai yuwuwar bala'i wanda aka rage sosai ta hanyar ingantaccen dasa stent, sabbin ƙira na stent, da maganin hana platelet guda biyu. Ana binciken ainihin hanyar da ke bayyana faruwarsa, kuma hakika akwai dalilai da yawa da ke da alhakin hakan. A da, an yi la'akari da ISR a cikin BMS a matsayin yanayi mai dorewa tare da farkon kololuwar hyperplasia na ciki (a cikin watanni 6) sannan kuma lokacin komawa baya na fiye da shekara 1. Sabanin haka, binciken asibiti da na tarihi na DES sun nuna shaidar ci gaban neointimal mai ɗorewa a cikin dogon lokaci na bibiya, wani lamari da aka sani da abin da ya faru na "kamawa a ƙarshe". Kwanan nan an karyata ra'ayin cewa ISR wani yanayi ne mai sauƙi na asibiti wanda shaida ta nuna cewa marasa lafiya da ISR na iya kamuwa da cututtukan zuciya mai tsanani. Hoton intracoronary wata dabara ce mai cin zarafi don gano plaques na atherosclerotic da alamun warkar da jijiyoyin jini bayan stenting, kuma galibi ana amfani da shi don kammala binciken angiography na zuciya da kuma yin hanyoyin shiga tsakani. A halin yanzu ana ɗaukar hoton haɗin kai na gani a cikin coronary a matsayin mafi ci gaba a cikin hanyar hoto. Yana bayar da, idan aka kwatanta da na'urar duban dan tayi ta cikin jijiyoyin jini, mafi kyawun ƙuduri (aƙalla sau 10 sama da haka), wanda ke ba da damar cikakken bayanin tsarin saman bangon jijiyoyin jini. Yana bayar da, idan aka kwatanta da na'urar duban dan tayi ta cikin jijiyoyin jini, mafi kyawun ƙuduri (aƙalla sau 10 sama da haka), wanda ke ba da damar cikakken bayanin tsarin saman bangon jijiyoyin jini. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, > 10 разе), детально охарактеризовать поверхностную структуру стенки сосуда. Yana bayar da, idan aka kwatanta da na'urar duban dan tayi ta cikin jijiyoyin jini, mafi kyawun ƙuduri (aƙalla sau 10 sama da haka), wanda ke ba da damar cikakken bayanin tsarin saman bangon jijiyoyin jini.与血管内超声相比，它提供了更好的分辨率（至少> 10 倍）。与血管内超声相比，它提供了更好的分辨率（至少> 10）。Idan aka kwatanta da na'urar duban dan tayi ta cikin jijiyoyin jini, tana samar da mafi kyawun ƙuduri (aƙalla sau 10), wanda ke ba da damar cikakken bayanin tsarin saman bangon jijiyoyin jini.Nazarin hotunan da aka gudanar a cikin jiki wanda ya yi daidai da binciken histological ya nuna cewa kumburi na yau da kullun da/ko rashin aikin endothelial na iya haifar da ci gaba da neoatherosclerosis a cikin HMS da DES. Don haka, neoatherosclerosis ya zama babban abin zargi a cikin cututtukan da ke haifar da gazawar stent na ƙarshe. Kalmomi masu mahimmanci: stent na zuciya, stent thrombosis, restenosis, neoatherosclerosis.
Tsarin tiyatar zuciya ta hanyar amfani da stented percutaneous coronary intervention (PCI) ita ce hanyar da aka fi amfani da ita wajen magance cututtukan jijiyoyin zuciya masu alamun cutar, kuma dabarar tana ci gaba da bunƙasa. 1 Duk da cewa magungunan cire stent (DES) suna rage iyakokin stents marasa rufi (UES), matsaloli na ƙarshen lokaci kamar su thrombosis na stent (ST) da kuma stent restenosis (ISR) na iya faruwa tare da dasa stent, kuma akwai damuwa mai tsanani. 2-5
Idan ST wani lamari ne mai yuwuwar faruwa, yarda cewa ISR cuta ce mai sauƙi, kwanan nan an ƙalubalanci shaidar cutar zuciya mai tsanani (ACS) ga marasa lafiya da ke da ISR.
A yau, ana ɗaukar hoton da ke haɗa ido da ido ta hanyar intracoronary optical coherence tomography (OCT) 6-9 a matsayin wani nau'in hoto na zamani wanda ke ba da mafi kyawun ƙuduri fiye da na'urar duban dan tayi ta cikin jijiyoyin jini (IVUS). Nazarin hotunan da aka yi a cikin jini10-12 wanda ya yi daidai da binciken histological ya nuna wata hanyar "sabon" hanyar amsawar jijiyoyin jini bayan an dasa stent tare da de novo "neoatherosclerosis" a cikin BMS da DES.
A shekarar 1964, Charles Theodore Dotter da Melvin P. Judkins sun bayyana angioplasty na farko. A shekarar 1978, Andreas Grunzig ya yi angioplasty na balan-balan na farko (tsohon angioplasty na balan-balan na gargajiya); magani ne mai sauyi, amma kuma yana da rashin amfani da rufewar jijiyoyin jini mai tsanani da kuma sake yin tiyata. 13 Wannan ya haifar da gano angioplasty na zuciya: Puel da Sigwart sun sanya angioplasty na zuciya na farko a shekarar 1986, suna ba da angioplasty don hana rufewar jijiyoyin jini mai tsanani da kuma komawa baya a ƙarshen systolic. 14 Duk da cewa waɗannan angioplasty na farko sun hana rufewar jijiyoyin kwatsam, sun haifar da mummunan lalacewar endothelial da kumburi. Kwanan nan, bincike guda biyu masu muhimmanci, Nazarin Stent na Belgium-Holland 15 da Nazarin Stent Restenosis 16, sun ba da shawarar amincin angioplasty na biyu (DAPT) da/ko hanyoyin turawa masu dacewa. 17,18 Bayan waɗannan gwaje-gwajen, adadin PCI da aka yi ya ƙaru sosai.
Duk da haka, an gano matsalar iatrogenic in-stent neointima hyperplasia bayan sanya BMS cikin gaggawa, wanda ya haifar da ISR a cikin kashi 20-30% na raunukan da aka yi wa magani. An gabatar da DES19 a shekara ta 2001 don rage buƙatar sake yin tiyata da sake yin tiyata. DES ya ƙara wa likitocin zuciya kwarin gwiwa ta hanyar ba da damar maganin ƙarin raunuka masu rikitarwa waɗanda a da ake ganin za a iya magance su ta hanyar dashen jijiyoyin zuciya. A shekara ta 2005, kashi 80-90% na dukkan PCI suna tare da DES.
Komai yana da nasa matsalolin, kuma tun daga shekarar 2005 damuwa game da amincin "ƙarni na farko" DES ta ƙaru, an ƙirƙiro kuma an gabatar da sabbin stents kamar 20,21. 22 Tun daga lokacin, ƙoƙarin inganta aikin stents ya bunƙasa cikin sauri, kuma an ci gaba da gano sabbin fasahohi masu ban sha'awa kuma an kawo su kasuwa cikin sauri.
BMS bututu ne mai kyau na raga na waya. Bayan ƙwarewa ta farko da aka yi da Wall mount, Gianturco-Roubin mount da Palmaz-Schatz mount, yanzu ana samun BMS daban-daban.
Akwai ƙira uku daban-daban: serpentine, bututun raga da bututun rami. Tsarin na'urar ya ƙunshi wayoyi na ƙarfe ko tsiri waɗanda ke samar da siffar na'urar zagaye; a cikin ƙirar raga mai siffar bututu, waya da aka naɗe tare a cikin raga tana samar da bututu; ƙirar da aka naɗe ta ƙunshi bututun ƙarfe waɗanda aka yanke ta hanyar laser. Waɗannan na'urori sun bambanta a cikin abun da ke ciki (bakin ƙarfe, nichrome, cobalt chrome), ƙira (siffofi da faɗi daban-daban na spacer, diamita da tsayi, ƙarfin radial, radiation), da tsarin isarwa (mai faɗaɗa kai ko mai faɗaɗa balan-balan).
A matsayinka na mai mulki, sabon BMS ya ƙunshi ƙarfe mai kama da cobalt-chromium, wanda ke haifar da siraran struts, inganta aikin tuƙi da kuma riƙe ƙarfin injina.
Sun ƙunshi wani dandamali na ƙarfe (yawanci bakin ƙarfe) kuma an shafa su da wani abu mai ƙarfi wanda ke fitar da magungunan hana yaɗuwa da/ko kumburi.
An fara ƙirƙirar Sirolimus (wanda aka fi sani da rapamycin) a matsayin maganin fungal. Tsarin aikinsa yana da alaƙa da toshe ci gaban zagayowar ƙwayoyin halitta ta hanyar toshe canjin yanayin daga matakin G1 zuwa matakin S da kuma hana samuwar neointima. A shekara ta 2001, ƙwarewar "ɗan adam na farko" tare da SES ta nuna sakamako mai kyau, wanda ya haifar da haɓakar stent na Cypher. 23 Manyan gwaje-gwaje sun nuna ingancinsa wajen hana IR. 24
An fara amincewa da Paclitaxel don maganin ciwon daji na ovarian, amma ƙarfinsa na cytostatic - maganin yana daidaita microtubules yayin mitosis, yana haifar da dakatarwar zagayowar ƙwayoyin halitta, kuma yana hana samuwar neointimal - ya sanya shi mahaɗin Taxus Express PES. Gwaje-gwajen TAXUS V da VI sun nuna ingancin PES na dogon lokaci a cikin cututtukan zuciya masu haɗari mai haɗari. 25,26 TAXUS Liberté na gaba ya nuna dandamalin bakin ƙarfe don sauƙin isarwa.
Shaida mai ƙarfi daga bita guda biyu da kuma nazarin meta-nazari sun nuna cewa SES tana da fa'ida fiye da PES saboda ƙarancin IVR da sake fasalin jijiyoyin jini (TVA), da kuma yanayin ƙaruwar bugun zuciya mai tsanani (AMI) a cikin ƙungiyar PES. 27.28
Na'urorin ƙarni na biyu suna da ƙarancin kauri na shaft, ingantaccen sassauci/samun isarwa, ingantattun bayanan polymer biocompatibility/clearance na miyagun ƙwayoyi, da kuma ingantaccen tsarin sake dawowa. A aikace, waɗannan su ne mafi kyawun ƙira na DES da manyan stents na zuciya da aka dasa a duk duniya.
Taxus Elements ya ɗauki wannan mataki gaba tare da wani polymer na musamman da aka tsara don mafi girman fitarwa da wuri da kuma sabon tsarin spacer platinum-chromium wanda ke samar da spacers masu siriri da kuma ƙara yawan radiation. Binciken PERSEUS 29 ya lura da irin wannan sakamako tsakanin Element da Taxus Express na tsawon watanni 12. Duk da haka, babu isassun gwaje-gwaje da ke kwatanta abubuwan yew da sauran ƙarni na biyu DES.
An gina Endeavor Zotarolimus Coated Stent (ZES) akan wani dandamali mai ƙarfi na cobalt-chromium stent tare da sassauci mafi girma da ƙaramin stent strut. Zotarolimus analog ne na sirolimus tare da irin wannan tasirin hana garkuwar jiki, amma tare da ƙaruwar lipophilicity don inganta wurin zama a bangon jijiyoyin jini. ZES yana amfani da sabon murfin polymer na phosphorylcholine wanda aka tsara don haɓaka daidaiton biocompatibility da rage kumburi. Yawancin magunguna ana wanke su a matakin farko na rauni, sannan a gyara jijiyoyin jini. Bayan gwajin ENDEAVOR na farko, gwajin ENDEAVOR III na gaba ya kwatanta ZES da SES, wanda ya nuna asarar lumen mafi girma da HR amma ƙarancin munanan abubuwan da suka faru na zuciya da jijiyoyin jini (MACEs) fiye da SES. 30 Binciken ENDEAVOR IV wanda ya kwatanta ZES da PES ya sake gano cewa akwai SIS mafi girma amma ƙarancin faruwar MI, wataƙila saboda ST da aka saba gani a cikin ƙungiyar ZES. 31 Duk da haka, binciken PROTECT ya kasa nuna bambanci a cikin mitar ST tsakanin Endeavor da Cypher stents. 32
Endeavor Resolute wani ingantaccen sigar Endeavor stent ne wanda aka yi da sabon polymer mai matakai uku. Sabuwar Resolute Integrity (wani lokacin ana kiranta da DES na ƙarni na uku) ta dogara ne akan sabon dandamali mai ƙarfin isarwa (dandalin Integrity BMS) da sabon polymer mai matakai uku mai jituwa wanda zai iya danne martanin kumburi na farko da kuma fitar da ƙarin maganin a cikin kwanaki 60 masu zuwa. Wani gwaji da aka kwatanta Resolute da Xience V (everolimus eluting stent [EES]) ya nuna cewa tsarin Resolute yana da tasiri daidai gwargwado dangane da mace-mace da gazawar raunuka da aka yi niyya. 33.34
Everolimus, wani sirolimus da aka samo daga sirolimus, shi ma wani maganin hana zagayowar ƙwayoyin halitta ne da ake amfani da shi wajen haɓaka EES Xience (dandalin Multi-link Vision BMS)/Promus (dandalin Platinum Chromium). Gwajin SPIRIT 35-37 ya nuna ingantattun sakamako da rage MACE tare da Xience V idan aka kwatanta da PES, yayin da gwajin EXCELLENT ya nuna cewa EES yana da kyau kamar SES wajen rage asarar da aka yi a ƙarshen watanni 9 da kuma abubuwan da suka faru na asibiti a watanni 12. 38 A ƙarshe, an nuna cewa Xience stent ya fi BMS kyau a yanayin ST elevation myocardial infarction (MI). 39
EPCs wani ɓangare ne na ƙwayoyin da ke zagayawa waɗanda ke da hannu a cikin gyaran jijiyoyin jini da gyaran endothelial. Ƙara yawan EPC a wurin da jijiyoyin jini suka ji rauni zai haɓaka sake dawo da endothelialization da wuri, wanda zai iya rage haɗarin ST. Shirin farko na EPC Biology game da ƙirar stent shine Genous stent, wanda aka lulluɓe da ƙwayoyin rigakafi na anti-CD34, wanda ke da ikon ɗaure EPCs masu zagayawa ta hanyar alamun hematopoietic don haɓaka sake dawo da endothelialization. Duk da cewa binciken farko ya ƙarfafa gwiwa, shaidu na baya-bayan nan sun nuna yawan TVR. 40
Ganin illolin da ka iya haifar da jinkirin warkarwa da polymer ke haifarwa wanda ke da alaƙa da haɗarin ST, polymers masu narkewa suna ba da fa'idodin DES ta hanyar guje wa damuwa da suka daɗe game da dorewar polymer. Zuwa yanzu, an amince da tsarin bioresorbable daban-daban (misali, Nobori da Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), amma wallafe-wallafen da ke tallafawa sakamakonsu na dogon lokaci suna da iyaka. 41
Kayan da za a iya shaƙa su da rai suna da fa'idar nazari wajen samar da tallafi na injiniya da farko lokacin da aka yi la'akari da komawar roba da kuma rage haɗarin dogon lokaci da ke tattare da struts na ƙarfe da ake da su. Sabbin fasahohi sun haifar da haɓaka polymers na lactic acid (poly-l-lactic acid [PLLA]), amma ana ci gaba da haɓaka tsarin stent da yawa, kodayake samun daidaito mai kyau tsakanin fitar da magani da lalatawar kinetics ya kasance ƙalubale. Binciken ABSORB ya nuna aminci da ingancin stents na PLLA da aka shafa da everolimus. 43 Gyaran stent na ƙarni na biyu na Absorb ya fi na baya kyau tare da kyakkyawan bin diddigin shekaru 2. 44 Binciken ABSORB II na yanzu, gwajin farko da aka yi bazuwar da aka kwatanta stent na Absorb da Xience Prime stent, ya kamata ya samar da ƙarin bayanai, kuma sakamakon farko da ake da shi yana da kyau. 45 Duk da haka, ya kamata a fayyace yanayin da ya dace, dabarun dasawa mafi kyau, da kuma bayanin aminci a cikin cututtukan jijiyoyin zuciya.
Thrombosis a cikin BMS da DES yana da mummunan sakamako na asibiti. A cikin rajistar marasa lafiya da aka yi wa DES, 47% na shari'o'in ST sun haifar da mutuwa, 60% a cikin MI mara mutuwa, da 7% a cikin angina mara tabbas. PCI don gaggawar ST yawanci ba shi da kyau, tare da sake dawowa a cikin 12% na shari'o'in. 48
Extended ST yana da mummunan sakamako na asibiti. A cikin binciken BASKET-LATE, watanni 6-18 bayan sanya stent, ƙimar mace-macen zuciya da MI mara mutuwa sun fi yawa a cikin ƙungiyar DES fiye da na ƙungiyar SMP (4.9% da 1.3%, bi da bi). 20 Wani bincike na bincike tara inda aka bazu ga marasa lafiya 5261 zuwa SES, PES, ko BMS ya nuna cewa bayan shekaru 4 na bin diddigin, SES (0.6% idan aka kwatanta da 0%, p = 0.025) da PES (0.7%) sun ƙara yawan kamuwa da cutar ST a ƙarshen lokaci idan aka kwatanta da BMS da 0.2%, p = 0.028). 49 Sabanin haka, a cikin wani bincike na meta wanda ya haɗa da marasa lafiya 5108, an ruwaito 21 cewa an samu karuwar mace-mace ko MI da kashi 60% tare da SES idan aka kwatanta da BMS (p = 0.03), yayin da PES ke da alaƙa da ƙaruwa mara mahimmanci na 15% (duba - har zuwa watanni 9 zuwa shekaru 3).
Rijista da yawa, gwaje-gwajen da bazuwar, da kuma nazarin meta-nazari sun binciki haɗarin kamuwa da cutar ST bayan dasa BMS da DES kuma sun ba da rahoton sakamako masu karo da juna. A cikin rajistar marasa lafiya 6906 da aka yi wa magani da BMS ko DES, babu wani bambanci a cikin sakamakon asibiti ko ƙimar ST a shekara 1 na bin diddigin cutar. 48 A cikin wani rajistar marasa lafiya 8146, an gano haɗarin yawan ST mai ɗorewa ya kai 0.6% a kowace shekara idan aka kwatanta da BMS. 49 Wani nazari na meta-nazari na nazarin da aka kwatanta SES ko PES tare da SMPs ya nuna ƙaruwar haɗarin mace-mace da MI tare da DES na ƙarni na farko idan aka kwatanta da SMPs, 21 da wani nazari na meta-nazari na marasa lafiya 4545 da aka bazu ga SES ko ST tsakanin PES da BMS a cikin shekaru 4 na bin diddigin cutar. 50 Sauran nazarin gaske sun nuna ƙaruwar haɗarin ci gaba da ST da MI a cikin marasa lafiya da aka yi wa magani da DES na ƙarni na farko bayan dakatar da DAPT. 51
Ganin bayanai masu karo da juna, an tattara bincike da nazari da dama tare da gano cewa DES da SGM na ƙarni na farko ba su bambanta sosai ba a cikin haɗarin mutuwa ko MI, amma SES da PES suna da ƙaruwar haɗarin kamuwa da cutar ST idan aka kwatanta da SGM. Don sake duba shaidar da ake da ita, Hukumar Abinci da Magunguna ta Amurka (FDA) ta naɗa wani kwamitin ƙwararru53 wanda ya fitar da sanarwa inda ya amince da cewa DES na ƙarni na farko yana da tasiri kamar yadda aka yiwa alama kuma haɗarin kamuwa da cutar ST mai ci gaba ƙanana ne, amma ba babba ba. , Babban ƙaruwa. Sakamakon haka, FDA da ƙungiyar sun ba da shawarar tsawaita lokacin DAPT zuwa shekara 1, kodayake babu wata shaida da za ta goyi bayan wannan iƙirarin.
Kamar yadda aka ambata a baya, an haɓaka DES na ƙarni na biyu tare da ingantattun fasalulluka na ƙira. CoCr-EES ta yi bincike mafi zurfi a asibiti. A cikin wani bincike na meta da Baber et al.54 na marasa lafiya 17,101 suka yi, CoCr-EES ya rage tabbatacce/mai yiwuwa ST da MI idan aka kwatanta da PES, SES, da ZES a cikin watanni 21. A ƙarshe, Palmerini et al. sun nuna a cikin wani bincike na meta na marasa lafiya 16,775 cewa CoCr-EES yana da ƙarancin ST da aka ayyana da wuri, latti, shekaru 1 da 2 idan aka kwatanta da sauran DES da aka haɗa. 55 Nazarin rayuwa na gaske ya nuna raguwar haɗarin ST tare da CoCr-EES idan aka kwatanta da DES na ƙarni na farko. 56
An kwatanta Re-ZES da CoCr-EES a cikin nazarin RESOLUTE-AC da TWENTE. 33,57 Babu wani bambanci mai mahimmanci a cikin mace-mace, bugun zuciya, ko ɓangaren ST da aka ayyana tsakanin stent guda biyu.
A cikin wani bincike na cibiyar sadarwa na marasa lafiya 50,844, ciki har da RCTs 49, CoCr-EES 58 yana da alaƙa da ƙarancin yawan ST da aka ayyana fiye da BMS, wani binciken da ba a gani tare da wasu DES ba; raguwar ba wai kawai a "da wuri sosai" ba kuma bayan kwanaki 30 (58). rabon rashin daidaito [OR] 0.21, tazara ta amincewa da kashi 95% [CI] 0.11-0.42) da kuma a shekara 1 (OR 0.27, 95% CI 0.08-0.74) da shekaru 2 (OR 0.35, 95% CI 0.17–0.69). Idan aka kwatanta da PES, SES, da ZES, CoCr-EES yana da alaƙa da ƙarancin ƙimar ST a shekara 1.
Farkon ST yana da alaƙa da dalilai daban-daban. Tsarin plaque da nauyin thrombus da alama suna yin tasiri ga sakamakon bayan PCI;59 zurfin struts shigar ta hanyar necrotic core (NC) prolapse, dogon tsagewar tsakiya a cikin stent, rashin ingantaccen stent tare da ragowar gefen ko babban stenosis na gefen, rashin cikakken shigarwa, da kuma rashin cikakken faɗaɗa stent da aka dasa na iya ƙara haɗarin ST.60 Tsarin magani na magungunan antiplatelet ba ya yin tasiri sosai ga faruwar farkon ST: a cikin gwaji da aka yi bazuwar da aka kwatanta BMSs da DESs, ƙimar ST mai tsanani da subacute a lokacin DAPT sun yi kama da juna (<1%).61 Don haka, farkon ST yana da alaƙa da raunukan da aka yi wa magani da kuma abubuwan da suka shafi tsari. Tsarin plaque da nauyin thrombus da alama suna yin tasiri ga sakamakon bayan shigar PCI;59 zurfin struts ta hanyar shigar da ƙwayar necrotic core (NC) prolapse, dogon tsagewar tsakiya a cikin stent, rashin ingantaccen stent tare da ragowar gefen ko babban stenosis na gefen, rashin cikakken shigarwa, da kuma faɗaɗawar stent da aka dasa na iya ƙara haɗarin ST.60 Tsarin magani na magungunan antiplatelet ba ya yin tasiri sosai ga faruwar farkon ST: a cikin gwaji da aka yi bazuwar da aka kwatanta BMSs da DESs, ƙimar ST mai tsanani da subacute a lokacin DAPT sun yi kama da juna (<1%) .61 Don haka, farkon ST yana da alaƙa da raunukan da aka yi wa magani da kuma abubuwan da suka shafi tsari. Морфология лежащей основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВ;59 пенетрация распорок из-за пролапса некротического ядра (NC), стентирования с остаточными краевыми расслоениями или значительным неполным расширением имплантированного стента может препаратов не оказывает существеного влияния на частоту раннего ST: в рандомизированом исследовании, частота острого и подострого ST время DAPT была одинаковой (<1%) первую очередь связана с лежащими основе пролеченными Tsarin plaque da thrombosis na ƙasa da ƙasa sun bayyana suna tasiri ga sakamako bayan PCI;59 zurfin shigar strut saboda raguwar necrotic nucleus (NC), dogon tsagewa a cikin stent, rashin ingantaccen stent tare da ragowar gefen gefe ko babban stenosis na gefe, rashin cikakken shigarwa da kuma rashin cikakken faɗaɗa stent da aka dasa na iya ƙara haɗarin ST.60 Tsarin magani na magungunan antiplatelet ba ya shafar yawan faruwar farkon ST: a cikin gwaji da aka yi bazuwar da aka kwatanta BMS da DES, yawan faruwar ST mai tsanani da kuma subacute a lokacin DAPT iri ɗaya ne (<1%) .61 Don haka, farkon ST ya bayyana yana da alaƙa da raunukan da aka yi wa magani da abubuwan da suka shafi tsari.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)脱垂导致的更深的支柱穿透、支架内长的内侧撕裂、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扩张60 抗血小板药物的治疗方案不会显着影响早期ST期间急性和亚急性ST 的发生率相似（<1%） .61 因此，早期ST似乎主要与潜在的治疗病变和手术因素有关。潜在 的 斑块 形态 和 血栓 似乎 影响 影响 pci 后 结果核心 核心边缘 狭窄 次 次 次 不 完全 并置和 不抗血 小板 药物 的 治疗 方案 不 显着 影响期间 急性 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 发生率相伈（<1%） .61Tsarin plaque da thrombosis na ƙasa da ƙasa sun bayyana suna yin tasiri ga sakamako bayan PCI; 59 Zurfin shigar strut saboda raguwar ƙwayoyin necrotic (NC), tsagewar tsakiya a tsawon stent, rabuwa ta biyu tare da ragowar gefuna, ko raguwar gefuna mai mahimmanci Mafi kyawun stenting, cikakken shigarwa, da faɗaɗawa mara cika60 Tsarin hana platelet ba shi da wani tasiri mai mahimmanci akan farkon faruwar ST: faruwar ST mai tsanani da kuma subacute a lokacin DAPT a cikin gwaji na bazuwar da aka kwatanta BMS da DES. galibi suna da alaƙa da raunukan magani da abubuwan tiyata.
A yau, an fi mai da hankali kan ST a ƙarshen/ƙarshen. Duk da cewa abubuwan da suka shafi tsari da fasaha suna taka muhimmiyar rawa wajen haɓaka ST mai tsanani da kuma subacute, hanyar da ke haifar da jinkirin faruwar thrombosis ta bayyana a matsayin mafi rikitarwa. An ba da shawarar cewa wasu halaye na marasa lafiya na iya zama abubuwan haɗari ga ST mai ci gaba da ci gaba: ciwon suga mellitus, ACS a lokacin tiyatar farko, gazawar koda, tsufa, raguwar ɗigon fitarwa, manyan abubuwan da suka faru na zuciya a cikin kwanaki 30 na tiyatar farko. Ga BMS da DES, masu canjin tsari kamar ƙaramin girman tasoshin jini, bifurcations, cututtukan jijiyoyin jini da yawa, calcification, cikakken toshewar ƙwaya, dogayen stents suna da alaƙa da haɗarin ST mai ci gaba. 62,63 Rashin amsawa ga maganin hana platelet babban abin haɗari ne ga ci gaba da thrombosis na DES 51. Wannan martanin na iya kasancewa saboda rashin bin ƙa'idodin marasa lafiya, ƙarancin allurai, hulɗar magunguna, abubuwan da ke shafar amsawar magani, polymorphism na matakin masu karɓa (musamman juriyar clopidogrel), da kunna wasu hanyoyin don kunna platelet. Ana ɗaukar Stent neoatherosclerosis a matsayin wata hanya mai mahimmanci don gazawar stent na ƙarshe, gami da ƙarshen ST64 (sashe na "Stent Neoatherosclerosis"). Endothelium ɗin da ba shi da matsala yana raba bangon jijiyoyin jini da sandunan stent daga jini kuma yana fitar da abubuwan hana thrombosis da vasodilatory. DES yana fallasa bangon jijiyoyin jini ga magungunan hana yaduwa da dandamalin sakin magani, tare da tasirin daban-daban akan warkarwa da aikin endothelial, tare da haɗarin thrombosis na ƙarshe. 65 Nazarin cututtuka sun nuna cewa ƙarfin polymers na DES na ƙarni na farko na iya ba da gudummawa ga kumburi na yau da kullun, ajiyar fibrin na yau da kullun, rashin warkar da endothelial, da kuma ƙaruwar haɗarin thrombosis. 3 Rashin lafiyar DES na ƙarshe ya bayyana a matsayin wata hanya da ke haifar da ST. Virmani et al. [66] sun ba da rahoton binciken bayan mutuwa bayan ST yana nuna faɗaɗa aneurysm a cikin sashin stent tare da halayen rashin lafiyar gida wanda ya ƙunshi T-lymphocytes da eosinophils; waɗannan binciken na iya nuna tasirin polymers marasa lalacewa. 67 Rashin daidaiton stent na iya faruwa ne saboda faɗaɗa stent ɗin da ba shi da kyau ko kuma ya faru watanni da yawa bayan PCI. Kodayake rashin daidaituwar tsari abu ne mai haɗari ga ST mai tsanani da kuma mai tsanani, mahimmancin rashin daidaituwar stent da aka samu a asibiti na iya dogara ne akan sake fasalin jijiyoyin jini mai tsanani ko jinkirin warkarwa da miyagun ƙwayoyi suka haifar, amma mahimmancin sa na asibiti yana da ce-ce-ku-ce. 68
Tasirin kariya na DES na ƙarni na biyu na iya haɗawa da saurin endothelialization, da kuma bambance-bambance a cikin ƙarfe da tsari na stent, kauri na strut, halayen polymer, da nau'in maganin hana yaduwa, kashi, da motsi.
Idan aka kwatanta da CoCr-EES, siraran stent na cobalt-chromium (81 µm), magungunan hana thrombosis, ƙarancin sinadarin polymer, da kuma yawan magunguna na iya taimakawa wajen rage yawan ST. Nazarin gwaji ya nuna cewa zubar jini da platelet sun yi ƙasa sosai a cikin stent da aka shafa da fluoropolymer fiye da na stent da ba a shafa ba. 69 Ko wasu DES na ƙarni na biyu suna da irin wannan halaye ya cancanci ƙarin nazari.
Stents na jijiyoyin zuciya suna inganta nasarar tiyatar jijiyoyin zuciya idan aka kwatanta da na gargajiya na percutaneous transluminal coronary angioplasty (PTCA), wanda ke da rikitarwa na injiniya (ƙullewar jijiyoyin jini, yankewa, da sauransu) da kuma yawan restenoses (har zuwa kashi 40-50% na lokuta). A ƙarshen shekarun 1990, kusan kashi 70% na PCI an yi su ne da dashen 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为20%，在特定亚组中发生率> 40%.然而，尽管技术、技术和药物治疗取得了进步，但BMSDuk da haka, duk da ci gaba a fasaha, dabaru, da jiyya, haɗarin restenosis bayan dasa BMS kusan kashi 20% ne, tare da ƙimar da ta wuce kashi 40% a wasu ƙananan ƙungiyoyi. 71 Gabaɗaya, binciken asibiti ya nuna cewa restenosis bayan dasa BMS, irin wanda aka gani tare da PTCA na al'ada, yana ƙaruwa a cikin watanni 3-6 kuma yana ƙarewa a shekara 1. 72
DES yana ƙara rage ƙimar ISR,73 kodayake wannan raguwar ya dogara ne akan angiographic da kuma a asibiti. Rufin polymer na DES yana fitar da magungunan hana kumburi da hana yaduwa, yana hana samuwar neointima, kuma yana jinkirta gyaran jijiyoyin jini da watanni ko shekaru.74 A cikin nazarin asibiti da na tarihi, an lura da ci gaban neointima mai ɗorewa a tsawon lokaci mai tsawo bayan dasa DES, wani abu da aka sani da "kamawa a ƙarshe"75.
Raunin jijiyoyin jini a lokacin PCI yana haifar da tsari mai rikitarwa na kumburi da gyarawa a cikin ɗan gajeren lokaci (makonni zuwa watanni), wanda ke haifar da endothelialization da rufewar neointimal. A cewar binciken histopathological, neointimal hyperplasia (HMS da DES) bayan dasa stent galibi ya ƙunshi ƙwayoyin tsoka masu santsi masu yaduwa a cikin matrix na extracellular mai arzikin proteoglycan. 70
Saboda haka, hyperplasia na neointimal tsari ne na gyara wanda ya shafi abubuwan da ke haifar da coagulation da kumburi, da kuma ƙwayoyin da ke haifar da yaduwar ƙwayoyin tsoka mai santsi da kuma samuwar matrix na extracellular. Nan da nan bayan PCI, ana ajiye platelets da fibrin a kan bangon jijiyoyin jini kuma suna jawo leukocytes ta hanyar jerin ƙwayoyin mannewar tantanin halitta. Kwayoyin leukocytes masu juyawa suna haɗuwa da platelets da aka haɗa ta hanyar hulɗa tsakanin leukocyte integrin Mac-1 (CD11b/CD18) da platelet glycoprotein Ibα 53 ko fibrinogen da ke da alaƙa da platelet glycoprotein IIb/IIIa. 76.77
A cewar sabbin bayanai, ƙwayoyin halittar ƙashi suna da hannu a cikin halayen jijiyoyin jini da kuma gyaran hanyoyin. Haɗakar EPC daga ƙashi zuwa jinin gefe yana haɓaka sake farfaɗowar endothelial da kuma sake farfaɗowar jijiyoyin jini bayan haihuwa. Da alama ƙwayoyin halittar tsoka mai santsi na ƙashi (SMPCs) suna ƙaura zuwa wurin da raunin jijiyoyin jini ya faru, wanda ke haifar da haɓakar ƙwayoyin halittar neointimal. 78 A baya, an ɗauki ƙwayoyin halittar CD34-positive a matsayin ƙayyadadden yawan EPCs, ƙarin bincike sun nuna cewa antigen na saman CD34 hakika yana gane ƙwayoyin halittar ƙashi marasa bambanci waɗanda ke da ikon bambancewa zuwa EPCs da PBMCs. Canza ƙwayoyin halittar CD34-positive zuwa cikin layin EPC ko SMPC ya dogara da yanayin gida; yanayin ischemic yana haifar da bambancewa zuwa ga yanayin EPC, wanda ke haɓaka sake farfaɗowa, yayin da yanayin kumburi ke haifar da bambancewa zuwa yanayin SMPC, wanda ke haɓaka haɓakar ƙwayoyin halittar neointimal. 79
Ciwon suga yana ƙara haɗarin kamuwa da cutar ISR da kashi 30-50% bayan an dasa BMS, kuma yawan kamuwa da cutar restenosis a cikin masu ciwon suga idan aka kwatanta da marasa lafiya marasa ciwon suga suma sun ci gaba a zamanin DES. Hanyoyin da ke ƙarƙashin wannan lura wataƙila suna da alaƙa da abubuwa da yawa, gami da tsarin jiki (misali, bambancin amsawar kumburi) da kuma tsarin jiki (misali, ƙananan tasoshin jini, raunuka masu tsayi, cututtukan da ke yaɗuwa, da sauransu), waɗanda ke ƙara haɗarin kamuwa da cutar ISR da kansu. 70
Diamita da tsawon raunukan jijiyoyin jini sun shafi ƙimar ISR daban-daban, tare da ƙananan raunuka/tsawon diamita sun ƙara yawan restenosis idan aka kwatanta da manyan raunuka/gajere. 71
Dandalin stent na ƙarni na farko sun nuna kauri stent struts da kuma ISR mafi girma idan aka kwatanta da dandamalin stent na ƙarni na biyu waɗanda ke da siraran struts.
Bugu da ƙari, yawan kamuwa da cutar restenosis yana da alaƙa da tsawon stent, kusan ninki biyu idan aka kwatanta da tsawon stent da ya wuce mm 35 idan aka kwatanta da waɗanda suka wuce mm 20. Bugu da ƙari, yawan kamuwa da cutar restenosis yana da alaƙa da tsawon stent, kusan ninki biyu idan aka kwatanta da tsawon stent da ya wuce mm 35 idan aka kwatanta da waɗanda suka wuce mm 20. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь > 35 zance <20 мм. Bugu da ƙari, yawan restenosis yana da alaƙa da tsawon stent, kusan ninki biyu idan tsayin stent ya fi 35 mm idan aka kwatanta da tsawon stent sama da 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 的两关此外，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 больтам в два раза больтме , . Bugu da ƙari, yawan sake yin amfani da maganin ya dogara ne akan tsawon maganin: tsawon maganin da ya wuce mm 35 ya ninka na maganin da ya wuce mm 20 sau biyu.Mafi ƙarancin diamita na lumen na ƙarshe na stent shi ma ya taka muhimmiyar rawa: ƙaramin ƙaramin diamita na lumen na ƙarshe ya annabta ƙaruwar haɗarin restenosis. 81.82
A al'ada, ana ɗaukar hyperplasia ta intimal bayan dasa BMS a matsayin tsayayye, tare da farkon kololuwar tsakanin watanni 6 zuwa shekara 1 sannan kuma lokacin barci a ƙarshen lokaci. An bayar da rahoton farkon kololuwar girma ta intimal sannan kuma komawa baya tare da faɗaɗa lumen shekaru da yawa bayan dasa stent; an gabatar da shawarar balaga na ƙwayoyin tsoka masu santsi da canje-canje a cikin matrix na extracellular a matsayin hanyoyin da za su iya haifar da koma baya na neointima a ƙarshen lokaci. 83 Duk da haka, nazarin bin diddigin na dogon lokaci ya nuna amsawar triphasic bayan sanya BMS tare da restenosis da wuri, komawa baya na tsaka-tsaki, da kuma sake dawowa daga late luminal restenosis. 84
A zamanin DES, an fara nuna ci gaban neointimal a ƙarshen lokacin bayan an dasa SES ko PES a cikin samfuran dabbobi. 85 Nazarin IVUS da yawa sun nuna raguwar ci gaban intimal da wuri sannan kuma a makara bayan an dasa SES ko RPE, wataƙila saboda ci gaban kumburi da ke ci gaba.86
Duk da "kwanciyar hankali" da aka saba dangantawa da ISR, kusan kashi ɗaya bisa uku na marasa lafiya da ke da BMS ISR suna da ACS.
Akwai ƙarin shaida da ke nuna cewa kumburi na yau da kullun da/ko rashin isasshen endothelial yana haifar da ci gaba da neoatherosclerosis a cikin HCM da DES (galibi ƙarni na farko na DES), wanda zai iya zama muhimmiyar hanya don haɓaka ci gaba da IR ko ci gaba da ST. Inoue et al [87] sun ba da rahoton binciken gawarwakin jini bayan dasa ƙwayoyin zuciya na Palmaz-Schatz, suna nuna cewa kumburi a kusa da stent na iya haifar da sabbin canje-canje na atherosclerotic marasa ƙarfi a cikin stent. Wasu bincike10 sun nuna cewa kyallen restenotic a cikin shekaru 5 na CGM ya ƙunshi sabon atherosclerosis tare da ko ba tare da kumburin peritoneal ba; samfuran daga shari'o'in ACS suna nuna alamun plaques masu rauni a cikin jijiyoyin zuciya na asali Tsarin toshewar histological tare da macrophages kumfa da lu'ulu'u na cholesterol. Bugu da ƙari, lokacin kwatanta BMS da DES, an lura da babban bambanci a cikin lokaci ga ci gaban sabon atherosclerosis. 11,12 Sauye-sauyen atherosclerotic na farko a cikin kumfa mai shiga cikin macrophage sun fara ne watanni 4 bayan dasa SES, yayin da canje-canje iri ɗaya a cikin raunukan CGM suka faru bayan shekaru 2 kuma sun kasance abin da ba a saba gani ba har zuwa shekaru 4. Bugu da ƙari, DES stenting don raunuka marasa ƙarfi kamar siririn fibroatherosclerosis (TCFA) ko fashewar ciki yana da ɗan gajeren lokaci kafin ci gaba idan aka kwatanta da BMS. Don haka, neoatherosis ya fi yawa kuma yana faruwa da wuri a cikin ƙarni na farko na DES fiye da na BMS, wataƙila saboda wani nau'in pathogenesis daban.
Har yanzu ba a bincika tasirin DES ko DES na ƙarni na biyu akan ci gaba ba; kodayake wasu abubuwan da aka lura da su na ƙarni na biyu DES88 sun nuna ƙarancin kumburi, yawan kamuwa da cutar neoatherosclerosis iri ɗaya ne idan aka kwatanta da ƙarni na farko, amma har yanzu ana buƙatar ƙarin bincike.