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ʻO Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Keʻena o Cardiology, Poliambulanza Foundation Hospital, Brescia, 2 Keʻena o Cardiology, Ke Kulanui Katolika o ka Sacred Heart o Roma, Italia Pōkole: Hoʻemi nā Drug-Eluting Stents (DES) i nā palena o nā stents metala ʻōlohelohe (BMS) ma hope o ke komo ʻana o ka coronary percutaneous. Eia nō naʻe, ʻoiai ua hoʻohaʻahaʻa ka hoʻolauna ʻana o ka hanauna ʻelua o DES i kēia hanana i hoʻohālikelike ʻia me ka hanauna mua o DES, ke mau nei nā hopohopo koʻikoʻi e pili ana i nā pilikia hope o ka hoʻokomo ʻana o ka stent, e like me ka stent thrombosis (ST) a me ka stent resection. ʻO Stenosis (ISR). He hanana pōʻino paha ʻo ST i hoʻemi nui ʻia ma o ka stenting i hoʻomaikaʻi ʻia, nā hoʻolālā stent hou, a me ka lāʻau antiplatelet pālua. Ke noiʻi ʻia nei ke ʻano kikoʻī e wehewehe ana i kona hanana, a ʻoiaʻiʻo, he nui nā kumu e kuleana. Ua manaʻo mua ʻia ka ISR ma BMS he kūlana paʻa me kahi piko mua o ka hyperplasia intimal (ma 6 mau mahina) i ukali ʻia e kahi manawa regression o luna o 1 makahiki. I ka hoʻohālikelike ʻana, ua hōʻike nā haʻawina lapaʻau a me nā histological o DES i nā hōʻike o ka ulu mau ʻana o neointimal i ka wā o ka hahai lōʻihi, kahi hanana i ʻike ʻia ʻo ka hanana "hope catch-up". ʻO ka manaʻo he kūlana lapaʻau maikaʻi ʻole ʻo ISR ua hoʻopiʻi ʻia nei e nā hōʻike e hiki i nā maʻi me ISR ke hoʻomohala i nā syndromes coronary acute. ʻO ke kiʻi intracoronary kahi ʻenehana invasive e hiki ke ʻike i nā plaques atherosclerotic stent a me nā hiʻohiʻona o ka ho'ōla ʻana o ka moku post-stent; Hoʻohana pinepine ʻia ia e hoʻopau i ka angiography coronary diagnostic a hoʻokele i nā kaʻina hana interventional. ʻO ka tomography coherence optical intracoronary i kēia manawa i manaʻo ʻia ʻo ia ke ʻano hana kiʻi holomua loa. Ke hoʻohālikelike ʻia me ka ultrasound intravascular, hāʻawi ia i ka hoʻonā maikaʻi aʻe (ma ka liʻiliʻi he >10 mau manawa), e ʻae ana i ka wehewehe kikoʻī o ke ʻano o ka ʻili o ka paia o ka moku. "In vivo" nā haʻawina kiʻi e kūlike me nā ʻike histological e hōʻike ana e hiki i ka mumū mau a me/a i ʻole ka hana endothelial ke hoʻoulu i ka neo-atherosclerosis hope loa i loko o BMS a me DES. No laila, ua lilo ka neo-atherosclerosis i mea kānalua mua i ka pathogenesis o ka hāʻule ʻana o ka stent hope. Nā huaʻōlelo koʻikoʻi: stent coronary, stent thrombosis, restenosis, neoatherosclerosis
ʻO ke komo ʻana o ka coronary percutaneous (PCI) me ka hoʻokomo ʻana o ka stent ke kaʻina hana i hoʻohana nui ʻia no ka mālama ʻana i ka maʻi artery coronary symptomatic, a ke hoʻomau nei ke ʻano hana i ka ulu ʻana.1 ʻOiai ʻo nā stents drug-eluting (DES) e hōʻemi i nā palena o nā stents bare-metal (BMS), hiki ke loaʻa nā pilikia hope e like me ka stent thrombosis (ST) a me ka in-stent restenosis (ISR) me ka hoʻokomo ʻana o ka stent. , ke mau nei nā hopohopo koʻikoʻi.2-5
Inā he hanana pōʻino paha ʻo ST, ua hoʻopiʻi ʻia ka ʻike ʻana he maʻi maikaʻi ʻole ʻo ISR e nā hōʻike o ka maʻi coronary acute (ACS) i nā poʻe maʻi ISR.4
I kēia lā, ua manaʻo ʻia ʻo ka intracoronary optical coherence tomography (OCT) 6-9 ʻo ia ke ʻano hana kiʻi kiʻi o kēia manawa, e hāʻawi ana i ka hoʻonā maikaʻi aʻe ma mua o ka intravascular ultrasound (IVUS). "In vivo" imaging studies,10-12 e kūlike ana me nā ʻike histological, e hōʻike ana i kahi ʻano hana "hou" o ka pane vascular ma hope o ka hoʻokomo ʻana o ka stent, me ka de novo "neoatherosclerosis" i loko o BMS a me DES.
I ka makahiki 1964, ua wehewehe ʻo Charles Theodore Dotter lāua ʻo Melvin P Judkins i ka angioplasty mua. I ka makahiki 1978, ua hana ʻo Andreas Gruntzig i ka angioplasty balloon mua (plain old balloon angioplasty); he lāʻau lapaʻau kipi akā he mau hemahema o ka pani ʻana o nā kīʻaha koko a me ka restenosis.13 Ua alakaʻi kēia i ka ʻike ʻana o nā stents coronary: Ua hoʻolaha ʻo Puel lāua ʻo Sigwart i ka stent coronary mua i ka makahiki 1986, e hāʻawi ana i kahi stent e pale aku i ka pani ʻana o nā kīʻaha koko a me ka retraction systolic hope.14 ʻOiai ua pale kēia mau stents mua i ka pani koke ʻana o ka kīʻaha koko, ua hoʻopilikia nui lākou i ka endothelial a me ka mumū. Ma hope mai, ʻelua mau hoʻokolohua koʻikoʻi, ʻo ka Belgian-Dutch Stent Trial 15 a me ka Stent Restenosis Study 16, i kākoʻo i ka palekana o ka stenting me ka dual antiplatelet therapy (DAPT) a/a i ʻole nā ​​​​ʻano hana hoʻolaha kūpono.17,18 Ma hope o kēia mau hoʻokolohua, ua nui ka piʻi ʻana o ka helu o nā PCI i hana ʻia.
Eia nō naʻe, ua ʻike koke ʻia ka pilikia o ka iatrogenic in-stent neointimal hyperplasia ma hope o ke kau ʻana o BMS, e hopena ana i ka ISR ma 20%–30% o nā lesions i mālama ʻia. I ka makahiki 2001, ua hoʻolauna ʻia ʻo DES19 e hōʻemi i ka pono no ka restenosis a me ka reintervention. Ua hoʻonui nā DES i ka hilinaʻi o nā cardiologists, e ʻae ana i ka nui o nā lesions paʻakikī e mālama ʻia i manaʻo mua ʻia e hoʻoponopono ʻia e ka coronary artery bypass grafting. I ka makahiki 2005, ua hele pū ʻia ʻo 80%–90% o nā PCI āpau e DES.
Loaʻa nā hemahema o nā mea āpau, a mai ka makahiki 2005, ua piʻi aʻe nā hopohopo e pili ana i ka palekana o ka DES "hanauna mua", a ua hoʻomohala ʻia a hoʻolauna ʻia nā stents hanauna hou e like me 20,21.22 Mai ia manawa, ua ulu wikiwiki nā hana e hoʻomaikaʻi i ka hana stent, a ua hoʻomau ʻia ka ʻike ʻia ʻana o nā ʻenehana hou a kupanaha a lawe koke ʻia i ka mākeke.
He ʻuea lahilahi ʻupena ka BMS. Ma hope o ka ʻike mua ʻana me ka mauna "Wall", ka mauna Gianturco-Roubin a me ka mauna Palmaz-Schatz, loaʻa nā ʻano BMS like ʻole he nui.
ʻEkolu mau hoʻolālā like ʻole: coil, tubular mesh a me ka slotted tube. Hōʻike nā hoʻolālā coil i nā uea metala a i ʻole nā ​​​​ʻāpana i hana ʻia i loko o ke ʻano coil poepoe; hōʻike nā hoʻolālā tubular mesh i nā uea i ʻōwili pū ʻia i loko o kahi mesh e hana i kahi paipu; ʻO nā hoʻolālā paipu slotted i loaʻa nā paipu metala i hana ʻia me ka laser. ʻOkoʻa kēia mau mea hana i ka haku mele (stainless steel, nichrome, cobalt chrome), hoʻolālā kūkulu (nā ʻano strut like ʻole a me nā laulā, nā diameters a me nā lōʻihi, ka ikaika radial, radiopacity) a me nā ʻōnaehana hāʻawi (hoʻonui ponoʻī a i ʻole balloon-expandable).
Ma keʻano laulā, ʻo ka BMS hou he cobalt-chromium alloy, ka mea e hopena i nā struts lahilahi me ka hoʻomaikaʻi ʻana i ka hoʻokele ʻana, e mālama ana i ka ikaika mechanical.
Hana ʻia lākou me kahi kahua stent metala (ʻo ke kila kila maʻamau) a uhi ʻia me kahi polymer e pale aku i nā therapeutics anti-proliferative a/a i ʻole anti-inflammatory.
Ua hoʻolālā mua ʻia ʻo Sirolimus (i ʻike ʻia hoʻi ʻo rapamycin) ma ke ʻano he mea antifungal. ʻO kāna ʻano hana e pili ana i ka pale ʻana i ka holomua o ke kaʻina hana cell ma ke kāohi ʻana i ka hoʻololi ʻana mai ka pae G1 a i ka pae S a me ka pale ʻana i ka hoʻokumu ʻana o neointima. I ka makahiki 2001, ua hōʻike ka ʻike "mua-i-kanaka" me SES i nā hopena hoʻohiki, e alakaʻi ana i ka hoʻomohala ʻana o ka stent Cypher.23 Ua hōʻike nā hoʻokolohua nui i kona pono i ka pale ʻana i ka ISR. iwakāluakūmāhā
Ua ʻāpono mua ʻia ʻo Paclitaxel no ka maʻi ʻaʻai ovarian, akā ʻo kona mau waiwai cytostatic ikaika - hoʻopaʻa ka lāʻau i nā microtubules i ka wā mitosis, alakaʻi i ka hopu ʻana o ke kaʻina hana cell a kāohi i ka hoʻokumu ʻana o neointimal - e hoʻolilo iā ia i hui no Taxus Express PES. Ua hōʻike nā hoʻokolohua TAXUS V a me VI i ka pono lōʻihi o PES i nā maʻi artery coronary kiʻekiʻe a paʻakikī.25,26 Ua hōʻike ʻia ka TAXUS Liberté ma hope aku i kahi kahua kila kila no ka lawe maʻalahi.
Hōʻike nā hōʻike hoʻoholo hope loa mai nā loiloi ʻōnaehana ʻelua a me nā meta-analyses he pono ko SES ma mua o PES ma muli o nā helu haʻahaʻa o ISR a me ka revascularization kīʻaha pahuhopu (TVR), a me kahi ʻano e hoʻonui ai i ka myocardial infarction acute (AMI) i ka hui PES. 27,28
Ua hoʻemi nā hāmeʻa hanauna ʻelua i ka mānoanoa o ke strut, hoʻomaikaʻi i ka maʻalahi/lawe ʻana, hoʻonui i nā ʻano biocompatibility polymer/drug elution, a me nā kinetics re-endothelialization maikaʻi loa. I ka hana o kēia wā, ʻo lākou nā hoʻolālā DES holomua loa a me nā stents coronary nui i hoʻokomo ʻia ma ka honua holoʻokoʻa.
ʻO Taxus Elements kahi holomua hou me kahi polymer kū hoʻokahi i hoʻolālā ʻia e hoʻonui i ka hoʻokuʻu mua ʻana a me kahi ʻōnaehana strut platinum-chromium hou e hāʻawi ana i nā struts lahilahi a me ka radiopacity i hoʻonui ʻia. Ua ʻike ka hoʻokolohua PERSEUS 29 i nā hopena like ma waena o Element a me Taxus Express a hiki i 12 mau mahina. Eia nō naʻe, ua nele nā ​​​​hoʻokolohua e hoʻohālikelike ana i nā mea yew me nā DES hanauna ʻē aʻe.
Hoʻokumu ʻia ka zotarolimus-eluting stent (ZES) Endeavor ma luna o kahi kahua stent cobalt-chromium ikaika me ka maʻalahi kiʻekiʻe a me ka liʻiliʻi o ka nui o ka stent strut. ʻO Zotarolimus kahi analog sirolimus me nā hopena immunosuppressive like akā hoʻonui ʻia ka lipophilicity e hoʻonui i ka localization paia kīʻaha. Hoʻohana ʻo ZES i kahi uhi polymer phosphorylcholine hou i hoʻolālā ʻia e hoʻonui i ka biocompatibility a hōʻemi i ka mumū. Hoʻokuʻu ʻia ka hapa nui o nā lāʻau i ka wā ʻeha mua, a ukali ʻia e ka hoʻoponopono arterial. Ma hope o ka hoʻāʻo ENDEAVOR mua, ua hoʻohālikelike ka hoʻāʻo ENDEAVOR III ma hope iā ZES me SES, kahi i hōʻike i ka nalowale lumen hope a me ISR akā ʻoi aku ka liʻiliʻi o nā hanana cardiovascular koʻikoʻi (MACE) ma mua o SES.30 Ua ʻike hou ka hoʻāʻo ENDEAVOR IV, kahi i hoʻohālikelike iā ZES me PES, i kahi hanana kiʻekiʻe o ISR, akā he hanana haʻahaʻa o AMI, mai ST holomua loa i ka hui ZES.31 Eia naʻe, ʻaʻole i hōʻike ka hoʻāʻo PROTECT i kahi ʻokoʻa ma nā helu ST ma waena o nā stents Endeavor a me Cypher.32
ʻO Endeavor Resolute kahi mana i hoʻomaikaʻi ʻia o ka stent Endeavor me kahi polymer ʻekolu-papa hou. ʻO ka Resolute Integrity hou (i kekahi manawa i kapa ʻia ʻo ke kolu o ka hanauna DES) ua hoʻokumu ʻia ma kahi kahua hou me nā hiki ke hoʻouna kiʻekiʻe (ka paepae Integrity BMS), a me kahi polymer ʻekolu-papa hou, ʻoi aku ka biocompatible, hiki ke kāohi i ka pane mumū mua a elute i ka hapa nui o ka lāʻau lapaʻau i nā lā 60 e hiki mai ana. Ua hōʻike kahi hoʻokolohua e hoʻohālikelike ana iā Resolute me Xience V (everolimus-eluting stent [EES]) i ka haʻahaʻa ʻole o ka ʻōnaehana Resolute ma ke ʻano o ka make a me ka hāʻule ʻana o ka lesion target.33,34
ʻO Everolimus, kahi hua o sirolimus, he mea hoʻopaʻa i ke kaʻina hana cell i hoʻohana ʻia i ka hoʻomohala ʻana o Xience (Multi-link Vision BMS platform) / Promus (Platinum Chromium platform) EES. Ua hōʻike ka hoʻokolohua SPIRIT 35-37 i ka hana i hoʻomaikaʻi ʻia a ua hoʻemi ʻia ka MACE me Xience V i hoʻohālikelike ʻia me PES, ʻoiai ua hōʻike ka hoʻokolohua EXCELLENT ʻaʻole ʻoi aku ka haʻahaʻa o EES i ka SES i ka hoʻopau ʻana i ka pohō hope ma 9 mau mahina a me nā hanana lapaʻau ma 12 mau mahina.38 ʻO ka hope loa, ua hōʻike ka stent Xience i nā pono ma luna o BMS ma ke ʻano o ka ST-segment elevation myocardial infarction (MI).39
ʻO nā EPC kahi ʻāpana o nā pūnaewele e kaapuni ana i komo i ka homeostasis vascular a me ka hoʻoponopono endothelial. ʻO ka hoʻonui ʻana o nā EPC ma kahi o ka ʻeha vascular e paipai i ka re-endothelialization mua, e hōʻemi ana paha i ka pilikia o ST. ʻO ka hoʻāʻo mua a ka biology EPC ma ke kahua o ka hoʻolālā stent ʻo ia ka CD34 antibody-coated Genous stent, hiki ke hoʻopaʻa i nā EPC e kaapuni ana ma o kāna mau māka hematopoietic e hoʻoikaika i ka re-endothelialization. ʻOiai ua hoʻoikaika nā haʻawina mua, kuhikuhi nā hōʻike hou i nā helu kiʻekiʻe o TVR.40
Ke noʻonoʻo nei i nā hopena maikaʻi ʻole o ka ho'ōla lohi ʻana i hoʻokomo ʻia e ka polymer, kahi e pili ana me ka pilikia o ST, hāʻawi nā polymers bioabsorbable i nā pono o DES, e pale ana i nā hopohopo lōʻihi e pili ana i ka hoʻomau ʻana o ka polymer. A hiki i kēia lā, ua ʻae ʻia nā ʻōnaehana bioabsorbable like ʻole (e like me Nobori lāua ʻo Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), akā ua kaupalena ʻia nā palapala e kākoʻo ana i kā lākou hopena lōʻihi.41
Loaʻa i nā mea bioabsorbable ka pono theoretical o ka hāʻawi mua ʻana i ke kākoʻo mechanical ke noʻonoʻo ʻia ka recoil elastic a me ka hōʻemi ʻana i nā pilikia lōʻihi e pili ana me nā struts metala e kū nei. Ua alakaʻi nā ʻenehana hou i ka hoʻomohala ʻana o nā polymers lactic acid-based (poly-l-lactic acid [PLLA]), akā he nui nā ʻōnaehana stent e hoʻomohala ʻia nei, ʻoiai ʻo ka hoʻoholo ʻana i ke kaulike kūpono ma waena o ka elution lāʻau a me nā kinetics degradation he mea paʻakikī ia. Ua hōʻike ka hoʻokolohua ABSORB i ka palekana a me ka pono o nā stents PLLA everolimus-eluting.43 ʻO ka hoʻoponopono hou ʻana o ka stent Absorb hanauna ʻelua he hoʻomaikaʻi ma mua o ka mea ma mua me kahi hahai maikaʻi 2 makahiki.44 ʻO ka hoʻokolohua ABSORB II e hoʻomau nei, ʻo ka hoʻokolohua randomized mua e hoʻohālikelike ana i ka stent Absorb i ka stent Xience Prime, pono e hāʻawi i ka ʻikepili hou aku, a ʻo nā hopena mua i loaʻa he mea hoʻohiki.45 Eia nō naʻe, pono e wehewehe maikaʻi ʻia ke ʻano kūpono, ke ʻano hoʻokomo kūpono, a me ka ʻikepili palekana no nā lesions coronary.
ʻO ka Thrombosis ma BMS a me DES he mau hopena lapaʻau maikaʻi ʻole. Ma kahi papa inoa o nā maʻi e loaʻa ana i ka hoʻokomo ʻana o DES,47 24% o nā hihia ST i hopena i ka make, 60% mai ka MI make ʻole, a me 7% mai ka angina paʻa ʻole. ʻO ka PCI i ka ST ulia pōpilikia he suboptimal maʻamau, me ka hoʻi hou ʻana ma 12% o nā hihia.48
Loaʻa i ka ST holomua nā hopena lapaʻau maikaʻi ʻole. Ma ke aʻo ʻana o BASKET-LATE, 6 a 18 mau mahina ma hope o ke kau ʻana o ka stent, ʻoi aku ka kiʻekiʻe o ka make ʻana o ka puʻuwai a me ka MI make ʻole i ka hui DES ma mua o ka hui BMS (4.9% a me 1.3%, kēlā me kēia).20 Ua hōʻike ʻia kahi meta-analysis o ʻeiwa mau hoʻokolohua, kahi i hoʻokaʻawale ʻia ai nā maʻi 5,261 i SES, PES, a i ʻole BMS, i ka 4 mau makahiki o ka hahai ʻana, ua hoʻonui ʻo SES (0.6% vs 0%, p = 0.025) a me PES (0.7%)) i ka nui o ka ST hope loa i hoʻohālikelike ʻia me BMS ma 0.2%, p = 0.028).49 I ka hoʻohālikelike ʻana, ma kahi meta-analysis e komo pū ana me 5,108 mau maʻi, 21 ua hōʻike ʻia kahi piʻi pili o 60% i ka make a i ʻole MI me SES i hoʻohālikelike ʻia me BMS (p = 0.03), ʻoiai ua pili ʻo PES me ka piʻi ʻole o 15% (Hahai 9 mau mahina a 3 mau makahiki).
Ua noiʻi nā papa inoa he nui, nā hoʻokolohua randomized, a me nā meta-analyses i ka pilikia pili o ST ma hope o ka hoʻokomo ʻana o BMS a me DES a ua hōʻike i nā hopena kūʻē. Ma kahi papa inoa o 6,906 mau maʻi e loaʻa ana iā BMS a i ʻole DES, ʻaʻohe ʻokoʻa i nā hopena lapaʻau a i ʻole nā ​​​​helu ST i ka wā o ka hahai ʻana o 1 makahiki.48 Ma kahi papa inoa ʻē aʻe o 8,146 mau maʻi, ua ʻike ʻia ka pilikia o ka ST keu mau he 0.6%/makahiki i hoʻohālikelike ʻia me BMS.49 Ua hōʻike ʻia kahi meta-analysis o nā hoʻokolohua e hoʻohālikelike ana iā SES a i ʻole PES me BMS i ka piʻi ʻana o ka pilikia o ka make a me MI me ka hanauna mua DES i hoʻohālikelike ʻia me BMS, 21 a me kekahi meta-analysis o 4,545 mau maʻi i randomized i SES a i ʻole ʻAʻohe ʻokoʻa i ka hanana o ST ma waena o PES a me BMS ma 4 mau makahiki o ka hahai ʻana.50 Ua hōʻike nā haʻawina honua maoli ʻē aʻe i ka piʻi ʻana o ka pilikia o ST a me MI holomua i nā maʻi e loaʻa ana iā DES hanauna mua ma hope o ka hoʻopau ʻana o DAPT.51
Ma muli o nā hōʻike kūʻē, ua hoʻoholo kekahi mau loiloi i hōʻuluʻulu ʻia a me nā meta-analyses i ʻole ʻokoʻa nui ka hanauna mua o DES a me BMS i ka pilikia o ka make a i ʻole MI, akā ua ʻoi aku ka nui o ka pilikia o SES a me PES i ka ST holomua loa i hoʻohālikelike ʻia me BMS. No ka nānā ʻana i nā hōʻike i loaʻa, ua koho ka US Food and Drug Administration (FDA) i kahi panela loea53 nāna i hoʻopuka i kahi ʻōlelo e ʻae ana he kūpono ka hanauna mua o DES no nā hōʻailona ma ka lepili a he liʻiliʻi akā liʻiliʻi ka pilikia o ka ST holomua loa. He piʻi nui. ʻO ka hopena, ua ʻōlelo ka FDA a me ka hui e hoʻolōʻihi i ka manawa DAPT i 1 makahiki, ʻoiai he liʻiliʻi ka ʻikepili e kākoʻo i kēia koi.
E like me ka mea i ʻōlelo ʻia ma mua, ua hoʻomohala ʻia ka lua o ka hanauna DES me nā hiʻohiʻona hoʻolālā holomua. Ua hana ʻia nā CoCr-EES i nā haʻawina lapaʻau ākea loa. Ma kahi meta-analysis e Baber et al,54 me 17,101 mau maʻi, ua hōʻemi nui ʻo CoCr-EES i ka ST a me MI maopopo/probable i hoʻohālikelike ʻia me PES, SES, a me ZES ma hope o 21 mau mahina. ʻO ka hope loa, ua hōʻike ʻo Palmerini et al i kahi meta-analysis o 16,775 mau maʻi ua emi nui ka CoCr-EES i ka wā mua, hope, 1- a me 2-makahiki ST maopopo i hoʻohālikelike ʻia me nā DES ʻē aʻe i hui pū ʻia.55 Ua hōʻike nā haʻawina honua maoli i ka emi ʻana o ka pilikia ST me CoCr-EES i hoʻohālikelike ʻia me ka hanauna mua DES.56
Ua hoʻohālikelike ʻia ʻo Re-ZES me CoCr-EES ma nā hoʻokolohua RESOLUTE-AC a me TWENTE.33,57 ʻAʻohe ʻokoʻa koʻikoʻi i ka nui o ka make, ka myocardial infarction, a i ʻole ST maopopo ma waena o nā stents ʻelua.
Ma kahi meta-analysis pūnaewele o 50,844 mau maʻi me 49 RCTs, ua pili ʻo 58CoCr-EES me kahi hanana haʻahaʻa loa o ST maopopo ma mua o BMS, kahi hopena i ʻike ʻole ʻia ma nā DES ʻē aʻe; ʻaʻole wale ka emi ʻana ma Significant early a ma 30 mau lā (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.11-0.42) a ma 1 makahiki hoʻi (OR 0.27, 95% CI 0.08-0.74) a me 2 mau makahiki (OR 0.35, 95% CI 0.17–0.69). Ke hoʻohālikelike ʻia me PES, SES, a me ZES, ua pili ʻo CoCr-EES me kahi hanana haʻahaʻa o ST ma 1 makahiki.
Pili ka ST mua i nā kumu like ʻole. ʻIke ʻia ka morphology plaque ma lalo a me ke kaumaha thrombus e hoʻohuli i nā hopena ma hope o ka PCI; 59 ʻOi aku ka hohonu o ka komo ʻana o ka strut ma muli o ka necrotic core (NC) prolapse, nā waimaka medial i nā lōʻihi stent, ka dissection lua me nā palena koena, a i ʻole ka palena koʻikoʻi e hoʻohaʻahaʻa ana ʻO ka stenting maikaʻi loa, ka apposition piha ʻole, a me ka hoʻonui piha ʻole60 ʻAʻole pili nui ka regimen lapaʻau me nā lāʻau antiplatelet i ka hanana o ka ST mua: ʻo ka hanana o ka ST acute a me ka subacute i ka wā o DAPT i kahi hoʻokolohua randomized e hoʻohālikelike ana i ka BMS me DES Ua like nā helu (<1%).61 No laila, ʻike ʻia ka ST mua e pili nui ana i nā lesions therapeutic ma lalo a me nā kumu ʻoki.
I kēia lā, ʻo kahi mea nui e kau nei ma ka ST hope/hope loa. Inā ʻike ʻia nā mea hana a me nā mea loea e pāʻani i kahi kuleana nui i ka hoʻomohala ʻana o ka ST ʻoi a me ka subacute, ʻike ʻia ka paʻakikī o ke ʻano o nā hanana thrombotic i hoʻopaneʻe ʻia. Ua manaʻo ʻia he mau mea pilikia paha kekahi mau ʻano o ka mea maʻi no ka ST holomua a holomua loa: diabetes mellitus, ACS i ka wā o ke ʻoki mua ʻana, ka hāʻule ʻana o ka renal, ka makahiki kiʻekiʻe, ka emi ʻana o ka hapa ejection, nā hanana cardiac ʻino nui i loko o 30 mau lā o ke ʻoki mua. No BMS a me DES, ʻo nā loli hana, e like me ka nui o nā kīʻaha liʻiliʻi, nā bifurcations, nā maʻi polyvascular, calcification, ka occlusion holoʻokoʻa, nā stents lōʻihi, ʻike ʻia e pili ana i ka pilikia o ka ST holomua.62,63 ʻO ka pane lawa ʻole i ka antiplatelet therapy he mea pilikia nui no ka thrombosis DES holomua 51. Hiki i kēia pane ke kumu o ka non-adherence o ka mea maʻi, ka underdosing, nā pilina lāʻau, nā comorbidities e pili ana i ka pane lāʻau, nā polymorphisms genetic ma ka pae receptor (ʻoi aku ka pale ʻana o clopidogrel), a me ka hoʻonui ʻana o nā ala hoʻāla platelet ʻē aʻe. Manaʻo ʻia ka neoatherosclerosis In-stent he ʻano hana koʻikoʻi o ka hopena. ʻO ka hāʻule ʻana o ka stent, me ka ST64 hope loa (ʻāpana "In-stent neoatherosclerosis"). Hoʻokaʻawale ka endothelium i hoʻopaʻa ʻia i ka paia o ke kīʻaha thrombosed a me nā struts stent mai ke kahe koko a hūnā i nā mea antithrombotic a me nā vasodilatory. Hōʻike ʻo DES i ka paia o ke kīʻaha i nā lāʻau antiproliferative a me kahi kahua eluting lāʻau me nā hopena ʻokoʻa ma ka ho'ōla endothelial a me ka hana, me ka pilikia o ka thrombosis hope.65 Hōʻike nā haʻawina pathological e hiki i nā polymers paʻa o ka DES hanauna mua ke kōkua i ka mumū mau, ka waiho ʻana o ka fibrin mau, ka hoʻōla endothelial maikaʻi ʻole, a me ka hoʻonui ʻia o ka thrombosis.3 ʻO ka hypersensitivity hope loa i DES me he mea lā he ʻano hana ʻē aʻe e alakaʻi ana iā ST. Ua hōʻike ʻo Virmani et al66 i nā ʻike post-mortem post-ST e hōʻike ana i ka hoʻonui ʻana o ka aneurysm ma ka ʻāpana stent me nā hopena hypersensitivity kūloko i haku ʻia me nā lymphocytes T a me nā eosinophils; hiki i kēia mau ʻike ke hōʻike i ka mana o nā polymers nonerodible.67 Hiki paha i ka malapposition stent ma muli o ka hoʻonui ʻana o ka stent suboptimal a i ʻole e hana ʻia i nā mahina ma hope o ka PCI. ʻOiai ʻo ka malapposition kaʻina hana he mea pilikia no ka ST acute a me subacute, ʻo ke koʻikoʻi lapaʻau o ka malapposition stent i loaʻa e hilinaʻi paha i ka hoʻoponopono hou ʻana o ka arterial aggressive a i ʻole ka hoʻōla lohi ʻana i hoʻoulu ʻia e ka lāʻau lapaʻau, akā he mea hoʻopaʻapaʻa kona koʻikoʻi lapaʻau.68
ʻO nā hopena palekana o ka lua o ka hanauna DES e komo pū me ka endothelialization wikiwiki a piha hoʻi, a me nā ʻokoʻa i ka stent alloy a me ke ʻano, ka mānoanoa o ke strut, nā waiwai polymer, a me ke ʻano lāʻau antiproliferative, ka nui, a me nā kinetics.
E pili ana iā CoCr-EES, ʻo nā struts stent cobalt-chromium lahilahi (81 µm), nā fluoropolymers antithrombotic, ka polymer haʻahaʻa, a me ka hoʻouka lāʻau lapaʻau e kōkua paha i ka emi ʻana o ka hanana o ST. Ua hōʻike nā haʻawina hoʻokolohua he haʻahaʻa loa ka thrombosis a me ka waiho ʻana o ka platelet o nā stents i uhi ʻia me ka fluoropolymer ma mua o nā stents bare-metal.69 Inā he mau waiwai like ko nā DES hanauna ʻē aʻe, pono e noiʻi hou ʻia.
Hoʻomaikaʻi nā stent coronary i ka holomua o ke ʻoki ʻana o nā hana coronary i hoʻohālikelike ʻia me ka percutaneous transluminal coronary angioplasty (PTCA) kuʻuna, nona nā pilikia mechanical (vascular occlusion, dissection, etc.) a me nā helu restenosis kiʻekiʻe (a hiki i ka 40%–50% o nā hihia). I ka hopena o nā makahiki 1990, ua hana ʻia kokoke i ka 70% o nā PCI me ka hoʻokomo ʻana o BMS.70
Eia nō naʻe, ʻoiai ka holomua o ka ʻenehana, nā ʻenehana, a me nā lāʻau lapaʻau, ʻo ka pilikia o ka restenosis ma hope o ke kau ʻana o BMS ma kahi o 20%, me ka >40% i loko o nā hui liʻiliʻi kikoʻī.71 Ma keʻano holoʻokoʻa, ua hōʻike nā haʻawina lapaʻau e hōʻike ana ka restenosis ma hope o ke kau ʻana o BMS, e like me ka mea i ʻike ʻia me ka PTCA maʻamau, e piʻi ana i 3-6 mau mahina a hoʻopau ma hope o 1 makahiki.72
Hoʻemi hou aku ʻo DES i ka nui o ISR,73 ʻoiai ʻo kēia hōʻemi e pili ana i ka angiography a me ke kūlana lapaʻau. Hoʻokuʻu ka uhi polymer ma ka DES i nā mea anti-inflammatory a me nā anti-proliferative, kāohi i ka hoʻokumu ʻana o neointima, a hoʻopaneʻe i ke kaʻina hana hoʻoponopono vascular no nā mahina a i nā makahiki.74 ʻO ka ulu mau ʻana o neointimal i ka wā o ka hahai lōʻihi ma hope o ka hoʻokomo ʻana o DES, kahi hanana i ʻike ʻia ʻo "late catch-up", ua ʻike ʻia i nā haʻawina lapaʻau a me histological. 75
ʻO ka hōʻeha ʻana o ke koko i ka wā o ka PCI e hana i kahi kaʻina hana paʻakikī o ka mumū a me ka hoʻoponopono ʻana i kahi manawa pōkole (nā pule a i nā mahina), e alakaʻi ana i ka endothelialization a me ka uhi neointimal. Wahi a nā nānā histopathological, ʻo ka hyperplasia neointimal (BMS a me DES) ma hope o ka hoʻokomo ʻana o ka stent ua haku nui ʻia me nā cell muscle smooth proliferative i loko o kahi matrix extracellular waiwai proteoglycan.70
No laila, ʻo ka hyperplasia neointimal e hōʻike ana i kahi kaʻina hana hoʻoponopono e pili ana i ka coagulation a me nā mea mumū a me nā cell e hoʻoulu ai i ka hoʻonui ʻana o nā cell muscle laumania a me ka hoʻokumu ʻana o ka matrix extracellular. Ma hope koke o ka PCI, waiho nā platelets a me ka fibrin ma ka paia o ke kīʻaha a hoʻoulu i nā leukocytes ma o kahi moʻo o nā molekala hoʻopili cell. Hoʻopili nā leukocytes ʻōwili i nā platelets adherent ma o ka launa pū ʻana ma waena o ka leukocyte integrin Mac-1 (CD11b/CD18) a me ka platelet glycoprotein Ibα 53 a i ʻole fibrinogen i hoʻopaʻa ʻia i ka platelet glycoprotein IIb/IIIa.76,77
Wahi a ka ʻikepili e kū mai ana, pili nā pūnaewele progenitor i loaʻa mai ka iwi iwi i nā pane vascular a me nā kaʻina hana hoʻoponopono. ʻO ka hoʻoneʻe ʻana o nā EPC mai ka iwi iwi i loko o ke koko peripheral e paipai i ka hoʻoulu hou ʻana o ka endothelial a me ka neovascularization postnatal. Me he mea lā e neʻe ana nā pūnaewele progenitor muscle smooth marrow (SMPC) i kahi o ka hōʻeha vascular, e alakaʻi ana i ka hoʻonui ʻana o neointimal.78 Ma mua, ua manaʻo ʻia nā pūnaewele CD34-positive he heluna paʻa o EPC; ua hōʻike nā haʻawina hou aʻe ua ʻike maoli ka antigen surface CD34 i nā pūnaewele kumu iwi iwi undifferentiated me ka hiki ke hoʻokaʻawale i loko o EPC a me SMPC. ʻO ka transdifferentiation o nā pūnaewele CD34-positive i ka EPC a i ʻole ka laina SMPC e pili ana i ke kaiapuni kūloko; hoʻoulu nā kūlana ischemic i ka hoʻokaʻawale ʻana i ka phenotype EPC e paipai i ka re-endothelialization, ʻoiai nā kūlana mumū e hoʻoulu i ka hoʻokaʻawale ʻana i ka phenotype SMPC e paipai i ka hoʻonui ʻana o neointimal.79
Hoʻonui ka maʻi diabetes i ka pilikia o ISR ma 30% -50% ma hope o ke kau ʻana o BMS,80 a ʻo ke kiʻekiʻe o ka restenosis i nā maʻi maʻi diabetes i hoʻohālikelike ʻia me nā maʻi nondiabetic i hoʻomau ʻia i ka wā DES. ʻO nā ʻano hana e pili ana i kēia nānā ʻana he multifactorial paha, e pili ana i nā mea systemic (e.g., ʻokoʻa i ka pane inflammatory) a me nā anatomical (e.g., nā kīʻaha liʻiliʻi, nā lesions lōʻihi, nā maʻi diffuse, a me nā mea ʻē aʻe) e hoʻonui kūʻokoʻa i ka pilikia o ISR.70
Ua hoʻopilikia kūʻokoʻa ke anawaena o ka moku a me ka lōʻihi o ka lesion i ka hanana o ISR, me nā lesions liʻiliʻi/lōʻihi e hoʻonui nui ana i nā helu restenosis i hoʻohālikelike ʻia me nā lesions nui/pōkole.71
Ua hōʻike nā kahua stent o ka hanauna mua i nā struts stent mānoanoa a me nā helu ISR kiʻekiʻe i ka hoʻohālikelike ʻia me nā kahua stent o ka hanauna ʻelua me nā struts lahilahi.
Eia kekahi, ua pili ka nui o ka restenosis i ka lōʻihi o ka stent, me ka lōʻihi o ka stent >35 mm kokoke i ʻelua manawa ka lōʻihi ma mua o kēlā mau mea <20 mm. Ua hoʻokani pū kekahi ke anawaena lumen liʻiliʻi loa o ka stent i kahi hana koʻikoʻi: ua wānana kahi anawaena lumen liʻiliʻi loa i ka piʻi nui ʻana o ka pilikia o ka restenosis.81,82
ʻO ka mea maʻamau, ua manaʻo ʻia ka hyperplasia intimal ma hope o ke kau ʻana o BMS he paʻa, me kahi kiʻekiʻe mua ma waena o 6 mau mahina a me 1 makahiki, ukali ʻia e kahi manawa mālie hope. Ua hōʻike mua ʻia kahi kiʻekiʻe mua o ka ulu ʻana o intimal, ukali ʻia e ka regression intimal me ka hoʻonui ʻana o ka lumen i kekahi mau makahiki ma hope o ke kau ʻana o stent;71 ua manaʻo ʻia ka ulu ʻana o nā cell muscle laumania a me nā hoʻololi i loko o ka matrix extracellular e like me nā ʻano hana hiki ke hana no ka regression neointimal hope.83 Eia nō naʻe, ua hōʻike nā haʻawina me ka hahai lōʻihi lōʻihi i kahi pane triphasic ma hope o ke kau ʻana o BMS, me ka restenosis mua, ka regression waena, a me ka restenosis lumen hope.84
I ka wā DES, ua hōʻike mua ʻia ka ulu ʻana o ka neointimal hope ma hope o ke kau ʻana o SES a i ʻole PES i nā hiʻohiʻona holoholona.85 Ua hōʻike kekahi mau haʻawina IVUS i ka emi mua ʻana o ka ulu ʻana o ka intimal i ukali ʻia e ka hopu ʻana i ka wā ma hope o ke kau ʻana o SES a i ʻole PES, ma muli paha o ke kaʻina hana mumū e hoʻomau nei.86
ʻOiai ke "paʻa" i hāʻawi mau ʻia i ka ISR, ma kahi o hoʻokahi hapakolu o nā maʻi BMS ISR e loaʻa iā ACS.4
Aia ka nui o nā hōʻike e hōʻike ana he hoʻoulu ka mumū mau a me/a i ʻole ka lawa ʻole o ka endothelial i ka neoatherosclerosis holomua i loko o BMS a me DES (ʻo ia hoʻi ka hanauna mua o DES), ʻo ia paha kahi ʻano hana koʻikoʻi no ka ISR holomua a i ʻole ST holomua. Ua hōʻike ʻo Inoue et al. 87 i nā ʻike histological mai nā laʻana autopsy ma hope o ke kau ʻana o nā stents coronary Palmaz-Schatz, e hōʻike ana e hiki i ka mumū peri-stent ke hoʻolalelale i nā loli atherosclerotic indolent hou i loko o ka stent. Ua hōʻike ʻia nā haʻawina ʻē aʻe10 ʻo ka ʻiʻo restenotic i loko o ka BMS, ma luna o 5 mau makahiki, he atherosclerosis hou e kū mai ana, me ka mumū peri-stent a i ʻole; Hōʻike nā laʻana mai nā hihia ACS i nā palaki palupalu maʻamau i loko o nā aʻa coronary maoli. ʻO ke ʻano histological o ka poloka me nā macrophages foamy a me nā kristal cholesterol. Eia kekahi, i ka hoʻohālikelike ʻana iā BMS a me DES, ua ʻike ʻia kahi ʻokoʻa koʻikoʻi i ka manawa e hoʻomohala ai i ka atherosclerosis hou. Ua hoʻomaka nā loli atherosclerotic mua loa i ka infiltration macrophage foamy 4 mau mahina ma hope o ka hoʻokomo ʻana o SES, ʻoiai ua hana ʻia nā loli like i nā lesions BMS i 2 mau makahiki ma hope mai a ua noho mau ia he ʻike kakaikahi a hiki i 4 mau makahiki. Eia kekahi, ʻo ka DES stenting no nā lesions paʻa ʻole e like me ka thin-cap fibroatherosclerosis (TCFA) a i ʻole ka haki ʻana o ka intimal he manawa pōkole ia e hoʻomohala ai i hoʻohālikelike ʻia me BMS. No laila, ʻike ʻia ka neoatherosclerosis he mea maʻamau a hana mua ʻia ma ka hanauna mua o DES ma mua o BMS, malia paha ma muli o kahi pathogenesis ʻokoʻa.
ʻAʻole pono e aʻo ʻia ka hopena o ka lua o ka hanauna DES a i ʻole DES i ka hoʻomohala ʻana; ʻoiai kekahi mau nānā ʻana o ka lua o ka hanauna DESs88 e hōʻike ana i ka emi ʻana o ka mumū, ua like ka nui o ka neoatherosclerosis me ko ka hanauna mua, akā pono nō ka noiʻi hou aku.