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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Chav Haujlwm Saib Xyuas Kab Mob Plawv, Tsev Kho Mob Poliambulanza Foundation, Brescia, 2 Chav Haujlwm Saib Xyuas Kab Mob Plawv, Catholic University of the Sacred Heart of Rome, Ltalis Abstract: Cov Stents Uas Muab Tshuaj Tua Kab Mob (DES) txo qhov kev txwv ntawm cov hlau tsis muaj hlau (BMS) tom qab kev cuam tshuam ntawm lub plawv. Txawm li cas los xij, txawm hais tias kev qhia txog DES tiam thib ob zoo li tau txo qhov xwm txheej no piv rau DES tiam thawj zaug, tseem muaj kev txhawj xeeb loj txog qhov teeb meem lig ntawm kev cog stent, xws li stent thrombosis (ST) thiab stent resection. Kev Mob Ntshav Stenosis (ISR). ST yog ib qho teeb meem loj heev uas tau raug txo qis los ntawm kev siv stenting zoo tshaj plaws, kev tsim stent tshiab, thiab kev kho mob ob zaug. Lub tshuab tseeb uas piav qhia txog nws qhov tshwm sim tseem tab tom tshawb nrhiav, thiab qhov tseeb, ntau yam yog lub luag haujlwm. ISR hauv BMS yav dhau los tau suav tias yog lub xeev ruaj khov nrog qhov siab tshaj plaws ntawm intimal hyperplasia (thaum 6 lub hlis) ua raws li lub sijhawm rov qab los ntawm ntau tshaj 1 xyoos. Hauv kev sib piv, ob qho kev tshawb fawb hauv tsev kho mob thiab histological ntawm DESs tau ua pov thawj ntawm kev loj hlob neointimal tas li thaum lub sijhawm saib xyuas ntev, ib qho xwm txheej hu ua "late catch-up phenomenon". Kev xav tias ISR yog ib qho mob tsis muaj teeb meem tau raug tawm tsam los ntawm cov pov thawj tias cov neeg mob uas muaj ISR yuav tsim cov kab mob coronary mob hnyav. Intracoronary imaging yog ib txoj hauv kev invasive uas tuaj yeem txheeb xyuas cov stented atherosclerotic plaques thiab cov yam ntxwv ntawm kev kho cov hlab ntsha tom qab stent; Nws feem ntau siv los ua kom tiav kev kuaj mob coronary angiography thiab tsav cov txheej txheem interventional. Intracoronary optical coherence tomography tam sim no suav hais tias yog cov txheej txheem imaging siab tshaj plaws. Piv rau intravascular ultrasound, nws muab kev daws teeb meem zoo dua (tsawg kawg >10 zaug), tso cai rau cov ntsiab lus ntxaws ntawm cov qauv ntawm phab ntsa ntawm cov hlab ntsha. "Hauv vivo" kev tshawb fawb imaging sib xws nrog cov kev tshawb pom histological qhia tias kev mob ntev thiab / lossis endothelial dysfunction yuav ua rau muaj kev mob neo-atherosclerosis theem kawg hauv BMS thiab DES. Yog li ntawd, neo-atherosclerosis tau dhau los ua tus neeg raug liam tseem ceeb hauv pathogenesis ntawm kev ua tsis tiav stent lig. Cov lus tseem ceeb: coronary stent, stent thrombosis, restenosis, neoatherosclerosis
Kev kho mob plawv los ntawm kev siv txoj hlab ntsha (PCI) nrog rau kev muab stent cog rau hauv yog txoj kev kho mob uas siv ntau tshaj plaws rau kev kho cov tsos mob ntawm cov kab mob plawv, thiab cov txheej txheem no tseem niaj hnub hloov zuj zus.1 Txawm hais tias cov stent uas muab tshuaj pleev rau hauv (DES) txo qhov kev txwv ntawm cov stent uas muab hlau tsis muaj dab tsi (BMSs), cov teeb meem lig xws li stent thrombosis (ST) thiab in-stent restenosis (ISR) yuav tshwm sim nrog kev muab stent cog rau hauv. , tseem muaj kev txhawj xeeb loj heev.2-5
Yog tias ST yog ib qho xwm txheej loj heev, qhov kev lees paub tias ISR yog ib yam kab mob tsis muaj teeb meem dab tsi tau raug tawm tsam los ntawm cov pov thawj ntawm tus mob plawv nres (ACS) hauv cov neeg mob ISR.
Niaj hnub no, kev siv tshuab intracoronary optical coherence tomography (OCT)6-9 yog suav tias yog cov txheej txheem thaij duab niaj hnub no, muab kev daws teeb meem zoo dua li kev siv tshuab ultrasound hauv lub plawv (IVUS). "Hauv vivo" kev tshawb fawb txog kev thaij duab,10-12 sib xws nrog cov kev tshawb pom histological, qhia txog "tshiab" ntawm cov hlab ntsha teb tom qab kev cog stent, nrog rau de novo "neoatherosclerosis" hauv BMS thiab DES.
Xyoo 1964, Charles Theodore Dotter thiab Melvin P Judkins tau piav qhia txog thawj qhov kev phais angioplasty. Xyoo 1978, Andreas Gruntzig tau ua thawj qhov kev phais angioplasty (balloon angioplasty yooj yim); nws yog ib qho kev kho mob tshiab tab sis muaj qhov tsis zoo ntawm kev kaw cov hlab ntsha sai thiab rov qab stenosis.13 Qhov no tau tsav txoj kev tshawb pom ntawm coronary stents: Puel thiab Sigwart tau xa thawj coronary stent hauv xyoo 1986, muab ib lub stent los tiv thaiv kev kaw cov hlab ntsha sai thiab lig systolic retraction.14 Txawm hais tias cov stents thawj zaug no tiv thaiv kev kaw ntawm cov hlab ntsha sai, lawv ua rau endothelial puas tsuaj loj heev thiab o. Tom qab ntawd, ob qhov kev sim tseem ceeb, Belgian-Dutch Stent Trial 15 thiab Stent Restenosis Study 16, tau tawm tswv yim txog kev nyab xeeb ntawm stenting nrog dual antiplatelet therapy (DAPT) thiab / lossis cov txheej txheem tsim nyog.17,18 Tom qab cov kev sim no, muaj kev nce ntxiv ntawm tus lej ntawm PCIs tau ua.
Txawm li cas los xij, qhov teeb meem ntawm iatrogenic in-stent neointimal hyperplasia tom qab BMS tso tau pom sai sai, ua rau ISR hauv 20% -30% ntawm cov qhov txhab kho. Xyoo 2001, DES tau qhia19 kom txo qhov xav tau restenosis thiab rov kho dua. DES tau ua rau cov kws kho mob plawv ntseeg siab ntxiv, tso cai rau ntau qhov mob nyuaj kho uas tau xav tias yuav daws tau los ntawm kev phais plawv bypass. Xyoo 2005, 80% -90% ntawm tag nrho PCIs tau nrog DES.
Txhua yam muaj nws qhov tsis zoo, thiab txij li xyoo 2005, kev txhawj xeeb txog kev nyab xeeb ntawm "thawj tiam" DES tau nce siab, thiab cov stents tshiab xws li 20,21 tau tsim thiab qhia.22 Txij thaum ntawd los, kev siv zog los txhim kho kev ua haujlwm ntawm stent tau loj hlob sai, thiab cov thev naus laus zis tshiab, xav tsis thoob tau txuas ntxiv mus nrhiav pom thiab coj mus rau kev ua lag luam sai.
BMS yog ib lub raj hlau nyias nyias. Tom qab thawj zaug kev paub nrog "Wall" mount, Gianturco-Roubin mount thiab Palmaz-Schatz mount, ntau yam BMSs sib txawv tam sim no muaj.
Muaj peb hom kev tsim sib txawv: coil, tubular mesh thiab slotted tube. Cov qauv coil muaj cov hlau xaim lossis cov strips ua rau hauv lub voj voog coil; cov qauv tubular mesh muaj cov hlau xaim qhwv ua ke hauv lub mesh los ua ib lub raj; cov qauv slotted tube muaj cov hlau xaim uas yog laser txiav ua. Cov khoom siv no sib txawv hauv kev sib xyaw (steel stainless hlau, nichrome, cobalt chrome), kev tsim qauv (cov qauv strut thiab dav sib txawv, diameters thiab ntev, radial strength, radiopacity) thiab cov txheej txheem xa khoom (tus kheej-expanding lossis balloon-expandable).
Feem ntau, BMS tshiab muaj cov hlau cobalt-chromium, uas ua rau cov struts nyias dua nrog kev txhim kho kev tsav tsheb, tswj hwm lub zog kho tshuab.
Lawv muaj ib lub platform hlau stent (feem ntau yog stainless hlau) thiab coated nrog ib tug polymer uas elutes anti-proliferative thiab/lossis anti-inflammatory therapeutics.
Sirolimus (tseem hu ua rapamycin) yog thawj tsim los ua ib yam tshuaj tua kab mob fungal. Nws txoj kev ua haujlwm yog los ntawm kev thaiv kev loj hlob ntawm lub voj voog ntawm cov hlwb los ntawm kev thaiv kev hloov pauv ntawm theem G1 mus rau theem S thiab tiv thaiv kev tsim neointima. Xyoo 2001, "thawj zaug hauv tib neeg" kev paub nrog SES tau qhia txog cov txiaj ntsig zoo, ua rau muaj kev tsim Cypher stent.23 Kev sim loj tau qhia txog nws qhov ua tau zoo hauv kev tiv thaiv ISR.nees nkaum plaub
Paclitaxel tau pom zoo thawj zaug rau mob qog nqaij hlav zes qe menyuam, tab sis nws cov khoom muaj zog cytostatic - cov tshuaj no ua kom cov microtubules ruaj khov thaum lub sijhawm mitosis, ua rau lub voj voog ntawm lub hlwb nres thiab tiv thaiv kev tsim neointimal - ua rau nws yog cov tshuaj rau Taxus Express PES. Cov kev sim TAXUS V thiab VI tau ua pov thawj tias PES ua haujlwm tau zoo mus sij hawm ntev hauv cov kab mob coronary artery uas muaj kev pheej hmoo siab thiab nyuaj.25,26 Tom qab ntawd TAXUS Liberté tau nthuav tawm lub platform hlau tsis xeb rau kev xa khoom yooj yim dua.
Cov pov thawj xaus lus los ntawm ob qhov kev tshuaj xyuas tsis tu ncua thiab kev tshuaj xyuas meta qhia tias SES muaj qhov zoo dua li PES vim yog tus nqi qis dua ntawm ISR thiab kev kho dua tshiab ntawm cov hlab ntsha (TVR), nrog rau qhov sib txawv ntawm kev nce ntxiv ntawm myocardial infarction (AMI) hauv PES cohort. 27,28
Cov khoom siv tiam thib ob tau txo qhov tuab ntawm strut, txhim kho kev ywj pheej / kev xa khoom, txhim kho cov polymer biocompatibility / tshuaj elution profiles, thiab zoo heev re-endothelialization kinetics. Hauv kev xyaum niaj hnub no, lawv yog cov qauv DES siab tshaj plaws thiab cov stents loj hauv lub plawv cog rau thoob ntiaj teb.
Taxus Elements yog ib qho kev nce qib ntxiv nrog cov polymer tshwj xeeb uas tsim los kom tso tawm ntxov tshaj plaws thiab lub platinum-chromium strut system tshiab uas muab cov struts nyias dua thiab ua kom muaj radiopacity zoo dua. Qhov kev sim PERSEUS 29 tau sau tseg cov txiaj ntsig zoo sib xws ntawm Element thiab Taxus Express txog li 12 lub hlis. Txawm li cas los xij, kev sim sib piv cov ntsiab lus yew nrog lwm tiam thib ob DES tsis muaj.
Lub zotarolimus-eluting stent (ZES) Endeavor yog ua los ntawm lub platform cobalt-chromium stent uas muaj zog dua nrog kev ywj pheej ntau dua thiab qhov loj me ntawm stent strut. Zotarolimus yog ib qho analog sirolimus nrog cov teebmeem zoo sib xws ntawm kev tiv thaiv kab mob tab sis txhim kho lipophilicity los txhim kho qhov chaw ntawm phab ntsa hlab ntsha. ZES siv cov txheej txheem tshiab phosphorylcholine polymer tsim los ua kom muaj kev sib raug zoo tshaj plaws thiab txo qhov o. Feem ntau cov tshuaj raug eluted thaum lub sijhawm raug mob thawj zaug, ua raws li kev kho cov hlab ntsha. Tom qab thawj qhov kev sim ENDEAVOR, qhov kev sim ENDEAVOR III tom qab ntawd piv rau ZES nrog SES, uas qhia tau tias muaj kev poob ntawm lumen lig thiab ISR ntau dua tab sis muaj tsawg dua qhov xwm txheej loj ntawm cov hlab ntsha (MACE) dua li SES.30 Qhov kev sim ENDEAVOR IV, uas piv rau ZES nrog PES, pom dua qhov tshwm sim ntawm ISR ntau dua, tab sis qhov tshwm sim qis dua ntawm AMI, pom tseeb los ntawm ST siab heev hauv pawg ZES.31 Txawm li cas los xij, qhov kev sim PROTECT tsis tau qhia txog qhov sib txawv ntawm ST nqi ntawm Endeavor thiab Cypher stents.32
Endeavor Resolute yog ib qho version zoo dua ntawm Endeavor stent nrog ib txheej polymer tshiab peb txheej. Lub Resolute Integrity tshiab (qee zaum hu ua tiam thib peb DES) yog raws li lub platform tshiab nrog kev xa khoom siab dua (lub platform Integrity BMS), thiab ib qho tshiab, biocompatible peb txheej polymer, tuaj yeem tiv thaiv kev mob thawj zaug thiab elute feem ntau ntawm cov tshuaj hauv 60 hnub tom ntej. Ib qho kev sim sib piv Resolute nrog Xience V (everolimus-eluting stent [EES]) tau qhia txog qhov tsis qis dua ntawm Resolute system hauv kev tuag thiab kev ua tsis tiav ntawm lub hom phiaj lesion.33,34
Everolimus, ib qho derivative ntawm sirolimus, kuj yog ib qho cell cycle inhibitor siv rau hauv kev tsim Xience (Multi-link Vision BMS platform) / Promus (Platinum Chromium platform) EES. Qhov kev sim SPIRIT 35-37 tau qhia txog kev ua tau zoo dua thiab txo MACE nrog Xience V piv rau PES, thaum qhov kev sim EXCELLENT tau qhia tias EES tsis qis dua SES hauv kev tswj hwm kev poob lig ntawm 9 lub hlis thiab cov xwm txheej hauv kev kho mob ntawm 12 lub hlis.38 Thaum kawg, Xience stent tau qhia txog qhov zoo dua BMS hauv qhov chaw ntawm ST-segment elevation myocardial infarction (MI).39
Cov EPCs yog ib pawg ntawm cov hlwb uas koom nrog kev kho cov hlab ntsha thiab kev kho cov hlab ntsha endothelial. Kev txhim kho cov EPCs ntawm qhov chaw raug mob ntawm cov hlab ntsha yuav txhawb nqa kev rov ua dua tshiab thaum ntxov, tej zaum yuav txo qhov kev pheej hmoo ntawm ST. EPC biology thawj zaug sim hauv kev tsim stent yog CD34 antibody-coated Genous stent, uas muaj peev xwm khi cov EPCs uas ncig los ntawm nws cov cim hematopoietic kom txhim kho kev rov ua dua tshiab. Txawm hais tias cov kev tshawb fawb thawj zaug tau txhawb nqa, cov pov thawj tsis ntev los no qhia txog cov nqi siab ntawm TVR.40
Xav txog qhov teeb meem uas yuav tshwm sim los ntawm kev kho qeeb ntawm cov polymer, uas cuam tshuam nrog kev pheej hmoo ntawm ST, cov bioabsorbable polymers muab cov txiaj ntsig ntawm DES, zam kev txhawj xeeb ntev txog kev ruaj khov ntawm cov polymer. Txog niaj hnub no, ntau lub tshuab bioabsorbable tau pom zoo (piv txwv li Nobori thiab Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), tab sis cov ntaub ntawv txhawb nqa lawv cov txiaj ntsig mus sij hawm ntev yog txwv.41
Cov ntaub ntawv Bioabsorbable muaj qhov zoo dua theoretical ntawm kev pib muab kev txhawb nqa thaum xav txog elastic recoil thiab txo cov kev pheej hmoo mus sij hawm ntev uas cuam tshuam nrog cov hlau struts uas twb muaj lawm. Cov thev naus laus zis tshiab tau ua rau kev tsim cov polymers lactic acid (poly-l-lactic acid [PLLA]), tab sis ntau lub tshuab stent tab tom tsim kho, txawm hais tias kev txiav txim siab qhov sib npaug zoo tagnrho ntawm cov tshuaj elution thiab degradation kinetics tseem yog qhov nyuaj. Kev sim ABSORB tau qhia txog kev nyab xeeb thiab kev ua tau zoo ntawm everolimus-eluting PLLA stents.43 Kev kho dua tshiab ntawm Absorb stent tiam thib ob yog kev txhim kho dua li yav dhau los nrog kev ua raws li 2-xyoo zoo.44 Kev sim ABSORB II uas tab tom ua, thawj qhov kev sim randomized piv rau Absorb stent rau Xience Prime stent, yuav tsum muab cov ntaub ntawv ntxiv, thiab thawj qhov tshwm sim muaj yog cog lus.45 Txawm li cas los xij, qhov chaw zoo tagnrho, cov txheej txheem cog zoo tshaj plaws, thiab cov ntaub ntawv kev nyab xeeb rau cov kab mob coronary yuav tsum tau piav qhia zoo dua.
Kev mob ntshav txhaws hauv BMS thiab DES muaj cov txiaj ntsig kho mob tsis zoo. Hauv cov npe ntawm cov neeg mob uas tau txais DES implantation,47 24% ntawm cov neeg mob ST ua rau tuag, 60% los ntawm MI tsis ua rau tuag taus, thiab 7% los ntawm angina tsis ruaj khov. PCI hauv ST thaum muaj xwm txheej ceev feem ntau tsis zoo, nrog rau kev rov tshwm sim hauv 12% ntawm cov neeg mob.48
ST theem siab muaj tej yam tshwm sim tsis zoo rau kev kho mob. Hauv kev tshawb fawb BASKET-LATE, 6 txog 18 lub hlis tom qab muab stent tso rau, tus nqi ntawm kev tuag ntawm lub plawv thiab MI uas tsis ua rau tuag tau siab dua hauv pawg DES dua li hauv pawg BMS (4.9% thiab 1.3%, feem).20 Kev tshuaj xyuas meta-analysis ntawm cuaj qhov kev sim, uas 5,261 tus neeg mob tau raug xaiv los ua SES, PES, lossis BMS, tau tshaj tawm tias thaum 4 xyoos ntawm kev saib xyuas, SES (0.6% vs 0%, p = 0.025) thiab PES (0.7%)) tau nce qhov tshwm sim ntawm ST lig heev piv rau BMS los ntawm 0.2%, p = 0.028).49 Qhov sib piv, hauv kev tshuaj xyuas meta-analysis suav nrog 5,108 tus neeg mob, 21 qhov kev nce ntxiv 60% ntawm kev tuag lossis MI tau tshaj tawm nrog SES piv rau BMS (p = 0.03), thaum PES tau cuam tshuam nrog 15% kev nce ntxiv tsis tseem ceeb (Kev saib xyuas 9 lub hlis txog 3 xyoos).
Muaj ntau daim ntawv sau npe, kev sim tshuaj ntsuam xyuas, thiab kev tshuaj xyuas meta-analyses tau tshawb xyuas qhov kev pheej hmoo ntawm ST tom qab BMS thiab DES implantation thiab tau tshaj tawm cov txiaj ntsig tsis sib xws. Hauv kev sau npe ntawm 6,906 tus neeg mob tau txais BMS lossis DES, tsis muaj qhov sib txawv ntawm cov txiaj ntsig kho mob lossis ST tus nqi thaum lub sijhawm 1-xyoo kev saib xyuas.48 Hauv lwm daim ntawv sau npe ntawm 8,146 tus neeg mob, qhov kev pheej hmoo ntawm ST ntau dhau tau pom tias yog 0.6% / xyoo piv nrog BMS.49 Ib qho kev tshuaj xyuas meta-analysis ntawm kev sim sib piv SES lossis PES nrog BMS tau qhia txog kev pheej hmoo ntawm kev tuag thiab MI nrog thawj tiam DES piv nrog BMS, 21 thiab lwm qhov kev tshuaj xyuas meta-analysis ntawm 4,545 tus neeg mob randomized rau SES lossis Tsis muaj qhov sib txawv ntawm qhov tshwm sim ntawm ST ntawm PES thiab BMS ntawm 4 xyoos ntawm kev saib xyuas.50 Lwm cov kev tshawb fawb hauv ntiaj teb tiag tiag tau qhia txog kev pheej hmoo ntawm ST thiab MI nce siab hauv cov neeg mob tau txais thawj tiam DES tom qab tsis siv DAPT.51
Muab cov pov thawj tsis sib haum, ntau qhov kev tshuaj xyuas thiab kev tshuaj xyuas ua ke tau txiav txim siab tias thawj tiam DES thiab BMS tsis sib txawv ntawm qhov kev pheej hmoo ntawm kev tuag lossis MI, tab sis SES thiab PES muaj kev pheej hmoo ntawm ST siab heev piv rau BMS. Txhawm rau tshuaj xyuas cov pov thawj muaj, US Food and Drug Administration (FDA) tau tsa ib pawg kws tshaj lij53 uas tau tshaj tawm ib daim ntawv lees paub tias thawj tiam DES tau ua haujlwm zoo rau cov cim qhia ntawm daim ntawv lo thiab tias qhov kev pheej hmoo ntawm ST siab heev yog me me tab sis me me. Kev nce ntxiv tseem ceeb. Yog li ntawd, FDA thiab lub koom haum pom zoo kom ncua lub sijhawm DAPT mus rau 1 xyoos, txawm hais tias muaj cov ntaub ntawv me me los txhawb qhov kev thov no.
Raws li tau hais ua ntej, tiam ob DES nrog cov qauv tsim siab heev tau tsim. CoCr-EESs tau dhau los ntawm kev tshawb fawb kho mob dav tshaj plaws. Hauv kev tshuaj xyuas meta los ntawm Baber et al,54 suav nrog 17,101 tus neeg mob, CoCr-EES txo qis qhov tseeb / tej zaum ST thiab MI piv nrog PES, SES, thiab ZES tom qab 21 lub hlis. Thaum kawg, Palmerini et al tau qhia hauv kev tshuaj xyuas meta ntawm 16,775 tus neeg mob tias CoCr-EES muaj qis dua thaum ntxov, lig, 1- thiab 2-xyoo qhov tseeb ST piv nrog lwm cov DES sib sau ua ke.55 Cov kev tshawb fawb tiag tiag tau qhia txog kev txo qis hauv ST kev pheej hmoo nrog CoCr-EES piv rau thawj tiam DES.56
Re-ZES tau muab piv rau CoCr-EES hauv RESOLUTE-AC thiab TWENTE kev sim.33,57 Tsis muaj qhov sib txawv tseem ceeb hauv qhov tshwm sim ntawm kev tuag, myocardial infarction, lossis ST tseeb ntawm ob lub stents.
Hauv kev tshuaj xyuas network ntawm 50,844 tus neeg mob suav nrog 49 RCTs, 58CoCr-EES tau cuam tshuam nrog qhov tshwm sim qis dua ntawm ST dua li BMS, qhov tshwm sim tsis tau pom hauv lwm DES; qhov kev txo qis tsis yog tsuas yog tseem ceeb thaum ntxov thiab ntawm 30 hnub (qhov sib piv [OR] 0.21, 95% kev ntseeg siab [CI] 0.11-0.42) thiab tseem ntawm 1 xyoos (OR 0.27, 95% CI 0.08-0.74) thiab 2 xyoos (OR 0.35, 95% CI 0.17–0.69). Piv nrog PES, SES, thiab ZES, CoCr-EES tau cuam tshuam nrog qhov tshwm sim qis dua ntawm ST ntawm 1 xyoos.
ST thaum ntxov muaj feem cuam tshuam nrog ntau yam sib txawv. Cov qauv plaque thiab thrombus zoo li cuam tshuam rau cov txiaj ntsig tom qab PCI; 59 Kev nkag mus tob dua vim yog necrotic core (NC) prolapse, medial tear hauv stent ntev, secondary dissection nrog cov npoo seem, lossis cov npoo nqaim tseem ceeb Kev zoo tshaj plaws stenting, tsis tiav apposition, thiab tsis tiav expansion60 Kev kho mob nrog cov tshuaj antiplatelet tsis cuam tshuam rau qhov tshwm sim ntawm ST thaum ntxov: qhov tshwm sim ntawm mob hnyav thiab subacute ST thaum lub sijhawm DAPT hauv kev sim randomized piv BMS nrog DES Cov nqi zoo sib xws (<1%).61 Yog li, ST thaum ntxov zoo li feem ntau cuam tshuam nrog cov qhov txhab kho mob hauv qab thiab cov yam ntxwv phais.
Niaj hnub no, muaj ib qho kev tsom mus rau ST lig/lig heev. Yog tias cov txheej txheem thiab cov yam ntxwv kev ua haujlwm zoo li ua lub luag haujlwm tseem ceeb hauv kev loj hlob ntawm ST mob hnyav thiab mob me, cov txheej txheem ntawm cov xwm txheej thrombotic qeeb zoo li nyuaj dua. Nws tau hais tias qee tus yam ntxwv ntawm tus neeg mob yuav yog cov yam ntxwv pheej hmoo rau ST mob hnyav thiab mob hnyav heev: ntshav qab zib mellitus, ACS thaum phais thawj zaug, lub raum tsis ua haujlwm, hnub nyoog laus, txo qis ejection fraction, cov teeb meem loj ntawm lub plawv hauv 30 hnub ntawm kev phais thawj zaug. Rau BMS thiab DES, cov yam ntxwv txheej txheem, xws li cov hlab ntsha me me, bifurcations, kab mob polyvascular, calcification, tag nrho occlusion, stents ntev, zoo li cuam tshuam nrog kev pheej hmoo ntawm ST mob hnyav.62,63 Kev teb tsis txaus rau antiplatelet therapy yog ib qho tseem ceeb pheej hmoo rau DES thrombosis mob hnyav 51. Cov lus teb no yuav yog vim tus neeg mob tsis ua raws li, kev noj tshuaj tsis txaus, kev sib cuam tshuam tshuaj, cov kab mob sib koom ua ke uas cuam tshuam rau kev teb tshuaj, kev hloov pauv caj ces ntawm qib receptor (tshwj xeeb tshaj yog clopidogrel tsis kam), thiab kev nce ntxiv ntawm lwm txoj hauv kev ua kom cov ntshav platelet. Hauv-stent Kab mob neoatherosclerosis yog suav hais tias yog ib qho tseem ceeb ntawm kev ua tsis tiav ntawm stent lig, suav nrog ST64 lig (ntu "In-stent neoatherosclerosis"). Lub endothelium uas tsis hloov pauv cais cov phab ntsa hlab ntsha uas raug thrombosed thiab stent struts ntawm cov ntshav ntws thiab tso tawm cov tshuaj antithrombotic thiab vasodilatory. DES ua rau cov phab ntsa hlab ntsha raug rau cov tshuaj antiproliferative thiab lub platform tshuaj-eluting nrog cov teebmeem sib txawv ntawm kev kho endothelial thiab kev ua haujlwm, nrog rau kev pheej hmoo ntawm kev mob thrombosis lig.65 Cov kev tshawb fawb pathological qhia tias cov polymers ruaj khov ntawm thawj tiam DES yuav ua rau mob ntev, mob fibrin deposition ntev, kev kho endothelial tsis zoo, thiab ua rau muaj kev pheej hmoo ntawm thrombosis.3 Kev mob hnyav lig rau DES zoo li yog lwm txoj hauv kev ua rau ST.Virmani et al66 tau tshaj tawm cov kev tshawb pom tom qab tuag tom qab ST qhia txog kev nthuav dav aneurysm ntawm qhov stent nrog cov tshuaj tiv thaiv hauv zos uas muaj T lymphocytes thiab eosinophils; cov kev tshawb pom no tej zaum yuav qhia txog kev cuam tshuam ntawm cov polymers uas tsis yooj yim rhuav.67 Qhov tsis zoo ntawm Stent tej zaum yuav yog vim qhov kev nthuav dav ntawm stent tsis zoo lossis tshwm sim ntau lub hlis tom qab PCI. Txawm hais tias qhov tsis zoo ntawm cov txheej txheem yog qhov ua rau muaj kev pheej hmoo rau ST mob hnyav thiab mob me, qhov tseem ceeb ntawm kev kho mob ntawm qhov tsis zoo ntawm stent uas tau txais yuav nyob ntawm kev kho cov hlab ntsha hnyav lossis kev kho qeeb vim tshuaj, tab sis nws qhov tseem ceeb ntawm kev kho mob yog qhov tsis sib haum xeeb.68
Cov teebmeem tiv thaiv ntawm DES tiam thib ob yuav suav nrog kev ua kom cov hlab ntsha sai dua thiab zoo, nrog rau qhov sib txawv ntawm cov hlau nplaum thiab cov qauv, strut thickness, cov khoom polymer, thiab cov tshuaj antiproliferative hom, koob tshuaj, thiab kinetics.
Piv rau CoCr-EES, cov hlau cobalt-chromium stent struts nyias (81 µm), cov tshuaj fluoropolymers tiv thaiv kev ntshav txhaws, cov polymer qis, thiab kev thauj tshuaj yuav ua rau muaj kev pheej hmoo tsawg dua ntawm ST. Kev tshawb fawb sim tau qhia tias qhov thrombosis thiab platelet deposition ntawm fluoropolymer-coated stents qis dua li cov ntawm bare-metal stents.69 Seb lwm tiam thib ob DES puas muaj cov khoom zoo sib xws tsim nyog tau kawm ntxiv.
Cov stents ntawm lub plawv (coronary stents) ua rau qhov kev phais mob zoo dua qub piv rau cov kev phais mob percutaneous transluminal coronary angioplasty (PTCA) ib txwm muaj, uas muaj teeb meem ntawm lub cev (vascular occlusion, dissection, thiab lwm yam) thiab muaj feem ntau ntawm kev rov ua stenosis (txog li 40%–50% ntawm cov neeg mob). Thaum kawg ntawm xyoo 1990, yuav luag 70% ntawm PCIs tau ua tiav nrog BMS implantation.70
Txawm li cas los xij, txawm tias muaj kev nce qib hauv thev naus laus zis, cov txheej txheem, thiab kev kho mob, qhov kev pheej hmoo ntawm kev rov qab stenosis tom qab BMS implantation yog kwv yees li 20%, nrog rau >40% hauv cov pab pawg tshwj xeeb.71 Zuag qhia tag nrho, cov kev tshawb fawb hauv tsev kho mob tau qhia tias kev rov qab stenosis tom qab BMS implantation, zoo ib yam li qhov pom nrog cov PTCA ib txwm muaj, nce siab tshaj plaws ntawm 3-6 lub hlis thiab daws tau tom qab 1 xyoos.72
DES txo qhov tshwm sim ntawm ISR,73 txawm hais tias qhov kev txo qis no nyob ntawm angiography thiab chaw kho mob. Lub polymer txheej ntawm DES tso tawm cov tshuaj tiv thaiv kev o thiab tiv thaiv kev loj hlob, tiv thaiv kev tsim neointima, thiab ncua cov txheej txheem kho cov hlab ntsha rau ntau lub hlis mus rau ntau xyoo.74 Kev loj hlob ntawm neointimal tas mus li thaum lub sijhawm ntev tom qab DES implantation, ib qho tshwm sim hu ua "late catch-up", tau pom nyob rau hauv kev tshawb fawb kho mob thiab histological.75
Kev raug mob ntawm cov hlab ntsha thaum lub sijhawm PCI ua rau muaj kev o thiab kho mob nyuaj hauv lub sijhawm luv luv (lub lis piam mus rau lub hlis), ua rau endothelialization thiab neointimal coverage.Raws li kev soj ntsuam histopathological, neointimal hyperplasia (BMS thiab DES) tom qab stent implantation feem ntau yog tsim los ntawm cov hlwb proliferative smooth muscle hauv cov proteoglycan-rich extracellular matrix.70
Yog li, neointimal hyperplasia sawv cev rau cov txheej txheem kho uas cuam tshuam nrog cov coagulation thiab cov yam ntxwv inflammatory nrog rau cov hlwb uas ua rau cov leeg nqaij du proliferation thiab extracellular matrix tsim. Tam sim ntawd tom qab PCI, platelets thiab fibrin tso rau ntawm phab ntsa hlab ntsha thiab nrhiav cov leukocytes los ntawm ntau cov cell adhesion molecules. Rolling leukocytes txuas rau adherent platelets los ntawm kev sib cuam tshuam ntawm leukocyte integrin Mac-1 (CD11b / CD18) thiab platelet glycoprotein Ibα 53 lossis fibrinogen khi rau platelet glycoprotein IIb / IIIa.76,77
Raws li cov ntaub ntawv tshiab, cov hlwb pob txha uas tau los ntawm cov pob txha muaj feem cuam tshuam rau cov hlab ntsha teb thiab cov txheej txheem kho. Kev txav cov EPCs los ntawm cov pob txha mus rau hauv cov ntshav peripheral txhawb kev rov ua dua tshiab ntawm endothelial thiab kev tsim cov hlab ntsha tshiab tom qab yug me nyuam. Zoo li cov hlwb pob txha cov leeg nqaij du (SMPC) tsiv mus rau qhov chaw raug mob ntawm cov hlab ntsha, ua rau muaj kev loj hlob tshiab.78 Yav dhau los, cov hlwb CD34-zoo tau suav hais tias yog cov pej xeem ruaj khov ntawm EPCs; kev tshawb fawb ntxiv tau qhia tias CD34 surface antigen yeej lees paub cov hlwb pob txha tsis sib txawv nrog lub peev xwm los sib txawv mus rau hauv EPCs thiab SMPCs. Kev hloov pauv ntawm cov hlwb CD34-zoo mus rau EPC lossis SMPC caj ces nyob ntawm qhov chaw ib puag ncig; cov mob ischemic ua rau muaj kev sib txawv ntawm EPC phenotype los txhawb kev rov ua dua tshiab, thaum cov mob o ua rau muaj kev sib txawv ntawm SMPC phenotype los txhawb kev loj hlob tshiab.79
Kab mob ntshav qab zib ua rau muaj kev pheej hmoo ntawm ISR los ntawm 30%–50% tom qab BMS implantation,80 thiab qhov muaj ntau dua ntawm kev rov ua dua tshiab hauv cov neeg mob ntshav qab zib piv rau cov neeg mob uas tsis muaj kab mob ntshav qab zib kuj tseem nyob hauv lub sijhawm DES. Cov txheej txheem hauv qab qhov kev soj ntsuam no yuav yog ntau yam, suav nrog kev sib kis thoob plaws (piv txwv li, kev hloov pauv ntawm kev teb rau kev o) thiab anatomical (piv txwv li, cov hlab ntsha me dua, cov qhov txhab ntev dua, kab mob sib kis, thiab lwm yam) uas nce ntxiv ywj pheej Kev Pheej Hmoo ntawm ISR.70
Txoj kab uas hla ntawm cov hlab ntsha thiab qhov ntev ntawm qhov mob tau cuam tshuam rau qhov tshwm sim ntawm ISR, nrog rau qhov me dua/qhov mob ntev dua ua rau muaj kev rov qab stenosis ntau dua piv rau qhov loj dua/qhov mob luv dua.71
Cov platform stent tiam thawj zaug tau qhia cov stent struts tuab dua thiab cov nqi ISR ​​siab dua piv rau cov platform stent tiam thib ob nrog cov struts nyias dua.
Ntxiv mus, qhov tshwm sim ntawm kev rov qab stenosis muaj feem cuam tshuam nrog qhov ntev ntawm stent, nrog rau qhov ntev ntawm stent >35 mm yuav luag ob npaug ntev dua li cov <20 mm. Qhov kawg ntawm stent qhov tsawg kawg nkaus lumen txoj kab uas hla kuj ua lub luag haujlwm tseem ceeb: qhov kawg me dua qhov kawg qhov tsawg kawg nkaus lumen txoj kab uas hla kwv yees tias yuav muaj kev pheej hmoo ntawm kev rov qab stenosis ntau ntxiv.81,82
Ib txwm muaj, qhov mob intimal hyperplasia tom qab BMS implantation raug suav hais tias ruaj khov, nrog rau qhov siab tshaj plaws thaum ntxov ntawm 6 lub hlis thiab 1 xyoos, ua raws li lub sijhawm quiescent lig. Ib qho kev loj hlob ntawm intimal thaum ntxov tau tshaj tawm ua ntej, ua raws li intimal regression nrog lumen loj hlob ntau xyoo tom qab stent implantation;71 cov leeg nqaij du maturation thiab kev hloov pauv hauv extracellular matrix tau raug pom tias yog cov txheej txheem ua tau rau lig neointimal regression.83 Txawm li cas los xij, kev tshawb fawb nrog kev saib xyuas ntev dua tau qhia txog kev teb triphasic tom qab BMS tso, nrog rau thaum ntxov restenosis, intermediate regression, thiab lig lumen restenosis.84
Nyob rau hauv lub sijhawm DES, kev loj hlob lig neointimal tau pom thawj zaug tom qab SES lossis PES implantation hauv cov qauv tsiaj.85 Ntau txoj kev tshawb fawb IVUS tau qhia txog kev txo qis thaum ntxov ntawm kev loj hlob intimal ua raws li kev ntes lig dhau sijhawm tom qab SES lossis PES implantation, tej zaum vim yog cov txheej txheem o.86
Txawm hais tias "kev ruaj khov" feem ntau yog vim ISR, kwv yees li ib feem peb ntawm cov neeg mob BMS ISR tsim ACS.
Muaj ntau cov pov thawj ntxiv tias kev mob o thiab/lossis kev tsis txaus ntawm endothelial ua rau muaj kev mob neoatherosclerosis hauv BMS thiab DES (feem ntau yog thawj tiam DES), uas yuav yog ib qho tseem ceeb rau ISR lossis ST siab heev. Inoue et al. 87 tau tshaj tawm cov kev tshawb pom histological los ntawm cov qauv kuaj mob tom qab kev cog Palmaz-Schatz coronary stents, qhia tias kev mob peri-stent tuaj yeem ua rau muaj kev hloov pauv atherosclerotic tshiab hauv stent. Lwm cov kev tshawb fawb10 tau qhia tias cov ntaub so ntswg restenotic hauv BMS, ntau tshaj 5 xyoos, muaj cov atherosclerosis tshiab, nrog lossis tsis muaj kev mob peri-stent; Cov qauv los ntawm ACS cov rooj plaub qhia txog cov plaques uas tsis muaj zog hauv cov hlab ntsha hauv lub plawv. Histological morphology ntawm lub block nrog cov macrophages ua npuas ncauj thiab cov roj cholesterol crystals. Ntxiv mus, thaum piv BMS thiab DES, qhov sib txawv tseem ceeb hauv lub sijhawm rau kev loj hlob ntawm atherosclerosis tshiab tau sau tseg.11,12 Cov kev hloov pauv atherosclerotic thaum ntxov tshaj plaws hauv foamy macrophage infiltration pib 4 lub hlis tom qab SES implantation, thaum cov kev hloov pauv tib yam hauv BMS lesions tshwm sim 2 xyoos tom qab thiab tseem yog qhov tsis tshua muaj neeg pom txog 4 xyoos. Ntxiv mus, DES stenting rau cov lesions tsis ruaj khov xws li thin-cap fibroatherosclerosis (TCFA) lossis intimal rupture muaj lub sijhawm luv dua rau kev loj hlob piv rau BMS. Yog li, neoatherosclerosis zoo li yuav tshwm sim ntau dua thiab tshwm sim ntxov dua hauv thawj tiam DES dua li hauv BMS, tej zaum vim yog pathogenesis sib txawv.
Qhov cuam tshuam ntawm tiam thib ob DES lossis DES hauv kev txhim kho tseem yuav tsum tau kawm; txawm hais tias qee qhov kev soj ntsuam uas twb muaj lawm ntawm tiam thib ob DESs88 qhia tias muaj tsawg dua qhov mob, qhov tshwm sim ntawm neoatherosclerosis zoo ib yam li thawj tiam, tab sis tseem xav tau kev tshawb fawb ntxiv.