Javascript tam sim no raug kaw hauv koj lub browser.Qee yam ntawm lub vev xaib no yuav tsis ua haujlwm thaum javascript raug kaw.
Sau npe nrog koj cov ntsiab lus tshwj xeeb thiab cov tshuaj tshwj xeeb ntawm kev txaus siab thiab peb yuav phim cov ntaub ntawv koj muab nrog cov ntawv hauv peb cov ntaub ntawv dav dav thiab xa email rau koj sai li sai tau rau daim ntawv PDF.
Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Department of Cardiology, Poliambulanza Foundation Tsev Kho Mob, Brescia, 2 Department of Cardiology, Catholic University of the Sacred Heart of Rome, Italy Abstractions (Dr. Bare hlau stents (BMS) tom qab percutaneous coronary intervention.Txawm li cas los xij, txawm li cas los xij, txawm hais tias kev qhia txog DES tiam thib ob zoo li muaj kev cuam tshuam qhov tshwm sim no piv rau thawj tiam DES, kev txhawj xeeb loj tseem nyob ntawm qhov teeb meem lig ntawm stent implantation, xws li stent thrombosis (ST) thiab stent resection. Stenosis (ISR).ST yog qhov tshwm sim muaj kev puas tsuaj loj uas tau txo qis los ntawm kev ua kom zoo stenting, tshiab stent designs, thiab dual antiplatelet therapy.Qhov tseeb mechanism piav qhia nws qhov tshwm sim yog nyob rau hauv kev tshawb nrhiav, thiab qhov tseeb, ntau yam yog lub luag haujlwm.ISR hauv BMS yav dhau los suav tias yog lub xeev khov kho nrog lub sijhawm ntxov ntawm intimal replasia (6 lub hlis dhau los) Nyob rau hauv sib piv, ob qho tib si soj ntsuam thiab histological kev tshawb fawb ntawm DESs qhia tau hais tias cov pov thawj ntawm tsis tu ncua neointimal kev loj hlob nyob rau hauv lub sij hawm ntev kev soj ntsuam, ib tug tshwm sim hu ua "late catch-up" phenomenon.Qhov kev xaav tias ISR yog ib tug kuj benign kho mob tej yam kev mob tsis ntev los no tau sib tw los ntawm cov pov thawj tias cov neeg mob nrog ISR tej zaum yuav tshwm sim acute coronary txheej txheem. tuaj yeem txheeb xyuas cov kab mob atherosclerotic plaques thiab cov yam ntxwv ntawm kev kho cov hlab ntsha tom qab stent; Nws feem ntau yog siv los ua kom tiav kev kuaj mob coronary angiography thiab tsav cov txheej txheem cuam tshuam.Intracoronary optical coherence tomography tam sim no suav tias yog cov txheej txheem kuaj pom zoo tshaj plaws.Piv rau intravascular ultrasound, nws muab kev daws teeb meem zoo dua (tsawg kawg> 10 zaug), tso cai rau cov ncauj lus kom ntxaws ntawm cov qauv ntawm phab ntsa ntawm phab ntsa. Tej zaum yuav induce late-stage neo-atherosclerosis nyob rau hauv BMS thiab DES.Yog li ntawd, neo-atherosclerosis tau dhau los ua tus thawj neeg raug liam nyob rau hauv lub pathogenesis ntawm lig stent tsis ua hauj lwm.Keywords: coronary stent, stent thrombosis, restenosis, neoatherosclerosis
Percutaneous coronary intervention (PCI) nrog stent implantation yog cov txheej txheem siv dav tshaj plaws rau kev kho cov kab mob coronary artery, thiab cov txheej txheem txuas ntxiv mus ntxiv.1 Txawm hais tias cov tshuaj eluting stents (DES) txo qis cov kev txwv ntawm bare-metal stents (BMSs), cov teeb meem lig STenosis (xws li stentosis). (ISR) yuav tshwm sim nrog stent implantation. , kev txhawj xeeb tseem ceeb.2-5
Yog tias ST yog qhov tshwm sim muaj kev puas tsuaj loj, kev lees paub tias ISR yog ib tus kab mob benign tsis ntev los no tau raug cuam tshuam los ntawm cov pov thawj ntawm tus mob coronary syndrome (ACS) hauv cov neeg mob ISR.4
Niaj hnub no, intracoronary optical coherence tomography (OCT) 6-9 yog suav tias yog tam sim no lub xeev-of-the-art imaging txheej txheem, muab kev daws teeb meem zoo dua li intravascular ultrasound (IVUS).
Xyoo 1964, Charles Theodore Dotter thiab Melvin P Judkins tau piav txog thawj qhov angioplasty.In 1978, Andreas Gruntzig tau ua thawj lub zais pa angioplasty (plain qub balloon angioplasty); Nws yog kev kho dua tshiab tab sis muaj qhov tsis zoo ntawm cov hlab ntsha kaw thiab rov ua kom rov zoo.13 Qhov no ua rau kev tshawb pom ntawm coronary stents: Puel thiab Sigwart tau siv thawj coronary stent hauv xyoo 1986, muab lub stent los tiv thaiv cov hlab ntsha kaw thiab lig systolic retraction.14 lawv tiv thaiv cov hlab ntsha loj heev. endothelial puas thiab o.Tom qab, ob qhov kev sim ua pov thawj, 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/los yog tsim nyog xa tawm cov tswv yim.17,18 Tom qab cov kev sim no, muaj cov PCI ua tau zoo ntau ntxiv hauv PCI.
Txawm li cas los xij, qhov teeb meem ntawm iatrogenic in-stent neointimal hyperplasia tom qab BMS qhov kev tso kawm tau pom sai sai, ua rau ISR hauv 20% -30% ntawm cov kab mob kho.In 2001, DES tau qhia txog 19 kom txo qis qhov xav tau rau restenosis thiab reintervention.DESs tau nce cov kev ntseeg siab ntawm cov kws kho plawv ntawm cov kev xav tau nce ntxiv rau kev kho mob ua ntej. Los ntawm coronary artery bypass grafting.In 2005, 80%–90% ntawm tag nrho cov 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, thiab cov tiam tshiab stents xws li 20,21 tau tsim thiab qhia.22 Txij thaum ntawd los, kev siv zog los txhim kho stent kev ua tau zoo tau loj hlob sai, thiab tshiab, xav tsis thoob technologies tau txuas ntxiv mus nrhiav tau sai thiab coj mus rau kev lag luam.
BMS yog ib lub mesh nyias hlau raj.Tom qab thawj qhov kev paub nrog "Pall" mount, Gianturco-Roubin mount thiab Palmaz-Schatz mount, muaj ntau yam BMSs tam sim no muaj.
Peb qhov sib txawv tsim tau: coil, tubular mesh thiab slotted tube.Coil designs feature hlau xov hlau los yog strips tsim rau hauv ib lub voj voog; tubular mesh tsim muaj cov xov hlau qhwv ua ke hauv ib lub mesh los ua ib lub raj; slotted tube designs muaj cov hlau raj uas yog laser txiav ua.Cov khoom siv no sib txawv hauv cov khoom sib txawv (stainless steel, nichrome, cobalt chrome), cov qauv tsim (cov qauv sib txawv thiab qhov dav, txoj kab uas hla thiab qhov ntev, lub zog radial, radiopacity) thiab cov khoom xa tuaj (tus kheej nthuav dav lossis balloon-expandable).
Feem ntau, BMS tshiab muaj cov cobalt-chromium alloy, uas ua rau cov struts thinner nrog kev txhim kho navigability, tswj lub zog txhua yam.
Lawv muaj cov hlau stent platform (feem ntau stainless hlau) thiab coated nrog ib tug polymer uas elutes anti-proliferative thiab / los yog anti-inflammatory kev kho mob.
Sirolimus (tseem hu ua rapamycin) yog Ameslikas tsim los ua cov tshuaj tiv thaiv kab mob.Nws cov txheej txheem ntawm kev ua haujlwm stems los ntawm kev thaiv lub voj voog ntawm tes los ntawm kev thaiv qhov kev hloov ntawm G1 theem mus rau S theem thiab inhibiting neointima tsim.In 2001, "thawj-hauv-tib neeg" kev paub nrog SES pom qhov kev loj hlob ntawm 2 st. ua kom pom nws qhov ua tau zoo hauv kev tiv thaiv ISR.twenty plaub
Paclitaxel yog Ameslikas pom zoo rau kev mob qog noj ntshav ntawm zes qe menyuam, tab sis nws cov khoom muaj zog cytostatic - cov tshuaj stabilizes microtubules thaum lub sij hawm mitosis, ua rau cell voj voog ntes thiab inhibits neointimal tsim - ua rau nws cov compound rau Taxus Express PES.The TAXUS V thiab VI trials pom tau hais tias lub sij hawm ntev efficacy ntawm kab mob-2, PES nyob rau hauv high school cov kab mob. Tom qab TAXUS Liberté tau nthuav tawm lub platform stainless hlau rau kev xa khoom yooj yim dua.
Cov pov thawj tseeb los ntawm ob qhov kev tshuaj xyuas thiab kev tshuaj ntsuam xyuas meta qhia tias SES muaj qhov zoo dua PES vim qhov qis dua ntawm ISR thiab lub hom phiaj ntawm lub hlab ntsha revascularization (TVR), nrog rau cov qauv mus rau qhov mob myocardial infarction (AMI) hauv PES cohort. 27,28 ib
Cov khoom siv thib ob tau txo cov tuab tuab, txhim kho kev yooj yim / xa tawm, txhim kho polymer biocompatibility / yeeb tshuaj elution profiles, thiab zoo heev re-endothelialization kinetics.Nyob rau hauv kev xyaum, lawv yog cov tshaj plaws DES tsim thiab loj coronary stents implanted thoob ntiaj teb.
Taxus Elements yog ib qho kev nce qib ntxiv nrog ib qho tshwj xeeb polymer tsim los ua kom ntev tshaj plaws kev tso tawm thiab ib qho tshiab platinum-chromium strut system uas muab thinner struts thiab txhim kho radiopacity.The PERSEUS sim 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 yew cov ntsiab lus tsis muaj lwm yam thib ob.
Lub zotarolimus-eluting stent (ZES) Endeavor yog raws li lub zog cobalt-chromium stent platform nrog kev yooj yim dua thiab me me stent strut loj.Zotarolimus yog sirolimus analog nrog cov tshuaj tiv thaiv zoo sib xws tab sis txhim kho lipophilicity los txhim kho cov hlab ntsha hauv zos. Cov tshuaj feem ntau yog eluted thaum pib raug mob, ua raws li kev kho cov hlab ntsha.Tom qab thawj qhov kev sim ENDEAVOR, qhov kev sim tom qab ENDEAVOR III piv rau ZES nrog SES, uas pom ntau dua lumen poob thiab ISR tab sis tsawg dua cov teeb meem mob plawv loj (MACE) dua li SES .30 Kev sim dua ZES, qhov kev sim pom dua, Qhov xwm txheej ntawm ISR, tab sis qhov tshwm sim qis dua ntawm AMI, ostensibly los ntawm cov qib siab heev ST hauv pawg ZES.31 Txawm li cas los xij, qhov kev sim PROTECT ua tsis tau zoo los ua kom pom qhov sib txawv ntawm ST tus nqi ntawm Endeavor thiab Cypher stents.32
Endeavor Resolute yog ib qho kev txhim kho ntawm Endeavor stent nrog peb txheej polymer tshiab.Qhov tshiab Resolut Integrity (qee zaum hu ua peb tiam DES) yog raws li lub platform tshiab nrog lub peev xwm xa khoom siab dua (Kev Ncaj Ncees BMS platform), thiab ib qho tshiab, ntau biocompatible peb-txheej polymer, tuaj yeem cuam tshuam cov tshuaj tiv thaiv ntau tshaj 6 hnub tom ntej. Muab piv Resolute nrog Xience V (everolimus-eluting stent [EES]) pom tias tsis muaj kev cuam tshuam ntawm Resolute system hais txog kev tuag thiab lub hom phiaj lesion tsis ua haujlwm.33,34
Everolimus, ib tug derivative ntawm sirolimus, kuj yog ib tug cell voj voog inhibitor siv nyob rau hauv txoj kev loj hlob ntawm Xience (Multi-link Vision BMS platform) / Promus (Platinum Chromium platform) EES.The SPIRIT trial 35-37 qhia tau hais tias kev txhim kho kev ua tau zoo thiab txo MACE nrog Xience V piv rau PES, thaum lub sij hawm lub SPIRIT trial 35-37 qhia kev txhim kho kev ua tau zoo thiab txo MACE nrog Xience V piv rau PES, thaum lub sij hawm lub EXCELLES trial tsis tau. suppressing lig poob ntawm 9 lub hlis thiab cov xwm txheej kho mob ntawm 12 lub hlis.38 Thaum kawg, Xience stent tau pom qhov zoo ntawm BMS hauv kev teeb tsa ntawm ST-segment elevation myocardial infarction (MI).39
EPCs yog ib feem ntawm cov hlwb circulating koom nrog hauv vascular homeostasis thiab endothelial kho.Enhancement ntawm EPCs ntawm qhov chaw ntawm vascular raug mob yuav txhawb thaum ntxov re-endothelialization, uas yuav txo tau qhov kev pheej hmoo ntawm ST.EPC biology thawj zaug sim nyob rau hauv lub teb ntawm stent tsim yog CD34 antibody-coated Genous stent, muaj peev xwm ntawm PC circulating binding. re-endothelialization.Txawm hais tias cov kev tshawb fawb thawj zaug tau txhawb nqa, cov pov thawj tsis ntev los no taw qhia rau cov nqi siab ntawm TVR.40
Xav txog qhov muaj feem cuam tshuam ntawm polymer-induced qeeb kho, uas cuam tshuam nrog kev pheej hmoo ntawm ST, bioabsorbable polymers muab cov txiaj ntsig ntawm DES, tsis txhob muaj kev txhawj xeeb ntev txog polymer persistence.Tam sim no, cov tshuab bioabsorbable sib txawv tau pom zoo (xws li Nobori thiab Biomatrix, biolimus eluting stent, Emaster, ES, Synertic stent. kev txhawb nqa lawv cov txiaj ntsig mus ntev yog txwv.41
Bioabsorbable cov ntaub ntawv muaj qhov zoo tshaj plaws ntawm kev pib muab kev txhawb nqa txhua yam thaum elastic recoil raug txiav txim siab thiab txo cov kev pheej hmoo mus sij hawm ntev uas cuam tshuam nrog cov hlau struts.New technologies tau coj mus rau kev txhim kho ntawm lactic acid-based polymers (poly-l-lactic acid [PLLA]), tab sis ntau stent systems nyob rau hauv txoj kev loj hlob, txawm hais tias txiav txim siab qhov zoo tshaj plaws kev sib tw ntawm cov tshuaj . ABSORB kev sim ua kom pom kev nyab xeeb thiab kev ua tau zoo ntawm everolimus-eluting PLLA stents.43 Qhov thib ob-tiam Absorb stent hloov kho yog ib qho kev txhim kho dua yav dhau los nrog kev soj ntsuam zoo 2 xyoos.44 Kev sim ABSORB II tsis tu ncua, thawj qhov kev sim randomized piv rau cov ntaub ntawv Absorb stent yog thawj zaug, thiab cov ntaub ntawv tseem ceeb yuav tsum tau muab rau Xi. promising.45 Txawm li cas los xij, qhov chaw zoo tshaj plaws, cov txheej txheem implantation zoo tshaj plaws, thiab kev ruaj ntseg profile rau cov kab mob coronary yuav tsum tau ua kom pom tseeb dua.
Thrombosis nyob rau hauv ob qho tib si BMS thiab DES muaj cov txiaj ntsig kev kho mob tsis zoo.Hauv kev sau npe ntawm cov neeg mob tau txais DES implantation, 47 24% ntawm cov neeg mob ST ua rau tuag, 60% los ntawm cov neeg tsis tuag MI, thiab 7% los ntawm qhov tsis ruaj tsis khov angina.PCI thaum muaj xwm txheej ceev ST feem ntau yog qhov zoo tshaj plaws, nrog rov tshwm sim ntawm 48%.
Advanced ST muaj peev xwm ua rau muaj qhov tshwm sim tsis zoo.Nyob rau hauv txoj kev tshawb fawb BASKET-LATE, 6 mus rau 18 lub hlis tom qab tso stent, cov neeg mob plawv thiab tsis tuag MI tau siab dua hauv pawg DES ntau dua li hauv BMS pawg (4.9% thiab 1.3%, feem). SES, PES, los yog BMS, tau tshaj tawm tias ntawm 4 xyoo ntawm kev soj ntsuam, SES (0.6% vs 0%, p = 0.025) thiab PES (0.7%)) nce qhov tshwm sim ntawm ST lig heev piv nrog BMS los ntawm 0.2%, p = 0.028).49 Hauv qhov sib piv, hauv kev txheeb xyuas meta-10 cov neeg mob nce 5 , 1 , 2% . tshaj tawm nrog SES piv nrog BMS (p = 0.03), qhov PES tau txuam nrog 15% tsis tseem ceeb nce (Tom qab 9 lub hlis mus rau 3 xyoos).
Ntau qhov kev sau npe, kev sim randomized, thiab kev tshuaj ntsuam 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 haum. 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 soj ntsuam, 48 ntawm lwm cov neeg mob. Kev pheej hmoo siab tshaj ST tau pom tias yog 0.6% / xyoo piv nrog BMS.49 Ib qho kev tshuaj ntsuam xyuas meta-kev sim piv rau SES lossis PES nrog BMS pom tias muaj kev pheej hmoo ntawm kev tuag thiab MI nrog thawj tiam DES piv nrog BMS, 21 thiab lwm qhov kev tshuaj ntsuam meta ntawm 4,545 cov neeg mob randomized rau SES hauv 4 xyoo thiab tsis muaj qhov sib txawv ntawm BMS. ntawm kev taug qab.50 Lwm cov kev tshawb fawb hauv ntiaj teb no tau pom tias muaj kev pheej hmoo ntau ntxiv ntawm ST thiab MI hauv cov neeg mob tau txais thawj tiam DES tom qab txiav tawm ntawm DAPT.51
Muab cov pov thawj tsis sib haum xeeb, ntau qhov kev soj ntsuam sib koom ua ke thiab kev tshuaj ntsuam xyuas meta ua ke tau txiav txim siab tias thawj tiam DES thiab BMS tsis txawv ntawm qhov kev pheej hmoo ntawm kev tuag lossis MI, tab sis SES thiab PES muaj kev pheej hmoo siab heev ntawm ST piv nrog BMS. Txhawm rau tshuaj xyuas cov ntaub ntawv pov thawj muaj, US Food and Drug Administration (FDA) tau xaiv ib tus kws tshaj lij panel53 uas tau tshaj tawm tsab ntawv lees paub tias thawj tiam DES tau ua haujlwm zoo rau cov lus qhia ntawm daim ntawv lo thiab tias qhov kev pheej hmoo ntawm ST siab heev yog me me tab sis me me. Ib qho kev nce ntxiv.Yog li ntawd, FDA thiab lub koom haum pom zoo kom ncua lub sijhawm DAPT mus rau 1 xyoo, txawm tias muaj cov ntaub ntawv me me los txhawb qhov kev thov no.
Raws li tau hais ua ntej lawm, tiam thib ob DES nrog cov qauv tsim tau zoo tau tsim.CoCr-EESs tau dhau los ua cov kev tshawb fawb soj ntsuam ntau tshaj plaws.In a meta-analysis los ntawm Baber et al,54 suav nrog 17,101 tus neeg mob, CoCr-EES txo qis qhov tseeb / qhov tshwm sim ST thiab MI piv nrog PES, SES, thiab ZESmerally tom qab 2 lub hlis. meta-kev soj ntsuam ntawm 16,775 tus neeg mob uas CoCr-EES tau qis qis thaum ntxov, lig, 1- thiab 2-xyoo tus kheej ST piv nrog lwm cov kev tshawb fawb DES.55 tiag tiag hauv ntiaj teb tau pom tias txo qis hauv ST kev pheej hmoo nrog CoCr-EES piv rau thawj tiam DES.56.
Re-ZES tau muab piv nrog CoCr-EES hauv RESOLUTE-AC thiab TWENTE kev sim.
Hauv kev txheeb xyuas network ntawm 50,844 tus neeg mob suav nrog 49 RCTs, 58CoCr-EES tau cuam tshuam nrog qhov tshwm sim qis dua ntawm qhov tseeb ST dua BMS, qhov tshwm sim tsis tau pom hauv lwm DES; Qhov kev txo qis tsis yog tsuas yog qhov tseem ceeb thaum ntxov thiab ntawm 30 hnub (qhov sib txawv ntawm qhov sib txawv [OR] 0.21, 95% kev ntseeg siab lub sijhawm [CI] 0.11-0.42) thiab kuj ntawm 1 xyoo (LOSSIS 0.27, 95% CI 0.08-0.74) thiab 2 xyoo (OR 0.35% CI). PES, SES, thiab ZES, CoCr-EES tau cuam tshuam nrog qis qis ntawm ST ntawm 1 xyoo.
Thaum Ntxov ST muaj feem cuam tshuam rau ntau yam.Cov quav hniav hauv qab ntawm cov quav hniav thiab lub nra thrombus tshwm sim los cuam tshuam cov txiaj ntsig tom qab PCI; 59 Kev sib sib zog nqus strut vim yog necrotic core (NC) prolapse, cov kua muag nruab nrab hauv qhov ntev stent, kev phais thib ob nrog cov npoo seem, lossis cov npoo tseem ceeb nqaim Qhov zoo tshaj plaws stenting, tsis tiav, thiab tsis tiav expansion60 Kev kho mob nrog cov tshuaj antiplatelet tsis cuam tshuam rau qhov tshwm sim ntawm ST thaum ntxov: DAPT nyob rau hauv ib qho kev sim randomized sib piv BMS nrog DES Cov Nqis tau zoo sib xws (<1%).61 Yog li, ST thaum ntxov zoo li feem ntau cuam tshuam nrog cov kab mob hauv qab thiab kev phais mob.
Niaj hnub no, ib qho kev tsom xam yog nyob rau lig / lig heev ST.Yog cov txheej txheem thiab cov txheej txheem kev tshwm sim los ua lub luag haujlwm tseem ceeb hauv kev txhim kho cov mob hnyav thiab subacute ST, cov txheej txheem ntawm cov txheej txheem qeeb thrombotic zoo li nyuaj dua. 30 hnub ntawm kev phais thawj zaug.Rau BMS thiab DES, cov txheej txheem sib txawv, xws li cov hlab ntsha me me, bifurcations, polyvascular kab mob, calcification, tag nrho occlusion, ntev stents, zoo li cuam tshuam nrog kev pheej hmoo ntawm ST.62,63 Cov lus teb tsis txaus rau kev kho antiplatelet yog ib qho kev pheej hmoo loj rau cov neeg mob uas tsis yog DES thrombosis 51. underdosing, kev sib cuam tshuam ntawm cov tshuaj, comorbidities cuam tshuam rau cov tshuaj teb, genetic polymorphisms ntawm qib receptor (tshwj xeeb yog clopidogrel tsis kam), thiab upregulation ntawm lwm cov platelet activation pathways.In-stent neoatherosclerosis yog suav hais tias yog ib qho tseem ceeb mechanism ntawm lig stent tsis ua hauj lwm, suav nrog lig ST64 (section "In-stacterosis). thrombosed hlab ntsha phab ntsa thiab stent struts los ntawm cov ntshav khiav thiab secretes antithrombotic thiab vasodilatory tshuaj.DES exposes lub hlab ntsha phab ntsa rau antiproliferative tshuaj thiab ib tug tshuaj-eluting platform nrog sib txawv los ntawm endothelial kho thiab muaj nuj nqi, nrog rau cov kev pheej hmoo ntawm lig thrombosis.65 Pathological kev tshawb fawb qhia hais tias lub check polymers ntawm lub inflammatory txheej txheem yuav ua rau thawj-fibronic deposition. Kev kho mob tsis zoo endothelial, thiab qhov ua rau muaj kev pheej hmoo ntawm thrombosis.3 Late hypersensitivity rau DES zoo nkaus li yog lwm txoj hauv kev ua rau ST.Virmani thiab al66 tau tshaj tawm cov kev tshawb pom tom qab kev tuag tom qab ST qhia txog kev nthuav dav ntawm ntu stent nrog cov tshuaj tiv thaiv hauv zos uas muaj cov T lymphocytes thiab; Cov kev tshawb pom no tuaj yeem cuam tshuam qhov cuam tshuam ntawm nonnerodible polymers.67 Stent malapposition tej zaum yuav yog vim qhov kev nthuav dav stent tsis zoo lossis tshwm sim ntau lub hlis tom qab PCI.Txawm hais tias cov txheej txheem malapposition yog ib qho kev pheej hmoo rau mob hnyav thiab subacute ST, qhov tseem ceeb ntawm kev tshawb nrhiav stent malapposition tuaj yeem yog nyob ntawm cov tshuaj tiv thaiv kab mob hemorrhagic, tab sis kev kho mob ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha thiab cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha ntawm cov hlab ntsha thiab cov hlab ntsha ntawm cov hlab ntsha tuaj yeem tshwm sim. qhov tseem ceeb yog controversial.68
Qhov kev tiv thaiv ntawm DES tiam thib ob yuav suav nrog kev ua kom sai thiab tsis zoo ntawm cov endothelialization, nrog rau qhov sib txawv ntawm cov stent alloy thiab cov qauv, strut thickness, polymer zog, thiab antiproliferative tshuaj hom, koob tshuaj, thiab kinetics.
Cov txheeb ze rau CoCr-EES, nyias (81 µm) cobalt-chromium stent struts, antithrombotic fluoropolymers, tsis tshua muaj polymer, thiab cov tshuaj thauj khoom yuav ua rau muaj kev pheej hmoo tsawg ntawm ST.Cov kev tshawb fawb pom tau hais tias cov thrombosis thiab platelet deposition ntawm fluoropolymer-coated stents qis dua li ntawm 6 bar. DES tiam thib ob muaj cov khoom zoo sib xws tsim nyog tau txais kev kawm ntxiv.
Coronary stents txhim kho qhov kev ua tiav ntawm kev phais ntawm cov kev cuam tshuam ntawm coronary piv nrog cov tshuaj percutaneous transluminal coronary angioplasty (PTCA), uas muaj cov teeb meem kho tshuab (vascular occlusion, dissection, thiab lwm yam) thiab cov nqi siab (txog 40% -50% ntawm cov neeg mob). Los ntawm lig 1990s, ze li ntawm 70% ntawm PCIs tau ua nrog BMS implantation.70
Txawm li cas los xij, txawm tias muaj kev nce qib hauv cov cuab yeej technology, cov tswv yim, thiab kev kho mob, qhov kev pheej hmoo ntawm restenosis tom qab BMS implantation yog kwv yees li 20%, nrog > 40% nyob rau hauv tej subgroups.71 Zuag qhia tag nrho, cov kev tshawb fawb soj ntsuam tau pom tias restenosis tom qab BMS implantation, zoo ib yam li uas tau soj ntsuam nrog cov pa PTCA, peaks ntawm 3-6 lub hlis.72 tom qab ntawd.
DES ntxiv txo qhov tshwm sim ntawm ISR, 73 txawm hais tias qhov kev txo qis no yog nyob ntawm angiography thiab chaw kho mob.Cov txheej txheem polymer ntawm DES tso tawm cov tshuaj tiv thaiv kab mob thiab tiv thaiv kev loj hlob, inhibits neointima tsim, thiab ncua cov txheej txheem kho vascular rau lub hlis mus rau xyoo.74 Kev loj hlob tsis tu ncua neointimal thaum lub sij hawm mus sij hawm ntev-tom qab kev cog qoob loo, paub tias yog "DES". tau pom nyob rau hauv kev tshawb fawb soj ntsuam thiab histological. 75
Vascular raug mob thaum PCI ua rau cov txheej txheem ntawm o thiab kho nyob rau hauv ib lub sij hawm luv luv (lub lis piam mus rau lub hlis), ua rau endothelialization thiab neointimal kev pab them nqi.Raws li histopathological soj ntsuam, lub neointimal hyperplasia (BMS thiab DES) tom qab stent implantation yog tsuas yog tsim los ntawm proliferative smooth leeg nqaij hlwb 7 ntxiv.
Yog li, neointimal hyperplasia sawv cev rau kev kho cov txheej txheem uas cuam tshuam nrog coagulation thiab inflammatory yam tseem ceeb nrog rau cov hlwb uas ua rau cov leeg nqaij pob txha loj hlob thiab tsim cov kab mob extracellular matrix.Tam sim tom qab PCI, platelets thiab fibrin tso rau ntawm phab ntsa ntawm cov hlab ntsha thiab nrhiav cov leukocytes los ntawm cov xov tooj ntawm tes adhesion molecules.Rolling adhering leukocytes ntawm platelet sib txuas los ntawm kev sib cuam tshuam ntawm cov platelets. Mac-1 (CD11b/CD18) thiab platelet glycoprotein Ibα 53 los yog fibrinogen khi rau platelet glycoprotein IIb/IIIa.76,77
Raws li cov ntaub ntawv tshwm sim, cov hlwb pob txha-derived progenitor hlwb tau koom nrog hauv vascular teb thiab kho cov txheej txheem.Mobilization ntawm EPCs los ntawm cov pob txha pob txha mus rau hauv cov ntshav peripheral txhawb endothelial regeneration thiab postnatal neovascularization.Nws zoo nkaus li tias cov pob txha pob txha du leeg progenitor cells (SMPC) migrate mus rau qhov chaw ntawm vascular raug mob 8, uas ua rau lub neej tsis zoo. raug suav hais tias yog cov pej xeem ruaj khov ntawm EPCs; Cov kev tshawb fawb ntxiv tau pom tias CD34 nto antigen tau lees paub qhov tsis sib xws ntawm cov pob txha pob txha qia hlwb nrog lub peev xwm sib txawv rau hauv EPCs thiab SMPCs.Transdifferentiation ntawm CD34-zoo hlwb mus rau EPC lossis SMPC kab mob nyob ntawm thaj chaw ib puag ncig; Cov kab mob ischemic ua rau muaj kev sib txawv ntawm EPC phenotype los txhawb kev rov qab endothelialization, thaum cov mob inflammatory ua rau muaj kev sib txawv ntawm SMPC phenotype los txhawb kev loj hlob neointimal.79
Ntshav qab zib mellitus ua rau muaj kev pheej hmoo ntawm ISR los ntawm 30% -50% tom qab BMS implantation, 80 thiab qhov tshwm sim ntau dua ntawm restenosis hauv cov neeg mob ntshav qab zib piv nrog cov neeg mob uas tsis muaj ntshav qab zib kuj tseem muaj nyob hauv DES era.Cov txheej txheem hauv qab kev soj ntsuam no yuav muaj ntau yam, cuam tshuam nrog cov kab ke (xws li, kev hloov pauv hauv cov kab mob me me, cov kab mob sib kis, thiab lwm yam) diffuse kab mob, thiab lwm yam.) yam uas nce nws tus kheej Risk ntawm ISR.70
Vessel txoj kab uas hla thiab qhov ntev ntawm qhov chaw ntawm nws tus kheej cuam tshuam qhov tshwm sim ntawm ISR, nrog rau txoj kab uas hla me me / ntev dua cov kab mob ua rau muaj kev cuam tshuam loj dua piv nrog cov kab loj dua / luv dua.71
Thawj-tiam stent platforms pom cov stent tuab thiab siab dua ISR tus nqi piv rau cov thib ob tiam stent platforms nrog thinner struts.
Tsis tas li ntawd, qhov tshwm sim ntawm restenosis muaj feem xyuam rau qhov ntev stent, nrog stent ntev> 35 hli yuav luag ob zaug ntev npaum li cov <20 mm.Qhov kawg stent yam tsawg kawg nkaus lumen txoj kab uas hla kuj tau ua lub luag haujlwm tseem ceeb: qhov me me kawg qhov kawg lumen txoj kab uas hla tau kwv yees qhov kev pheej hmoo ntawm restenosis.81,82.
Kev lig kev cai, intimal hyperplasia tom qab BMS implantation yog suav hais tias ruaj khov, nrog lub ncov thaum ntxov ntawm 6 lub hlis thiab 1 xyoo, ua raws li lub sij hawm quiescent lig.Thaum ntxov ntawm kev loj hlob intimal tau tshaj tawm, tom qab los ntawm intimal regression nrog lumen o ob peb xyoos tom qab stent implantation; 71 smooth nqaij cell maturation thiab alteration ntawm cellular ntxiv rau cov txheej txheem ntawm kev loj hlob. neointimal regression .83 Txawm li cas los xij, cov kev tshawb fawb nrog kev soj ntsuam ntev ntev tau pom cov lus teb triphasic tom qab BMS tso, nrog rau thaum ntxov restenosis, intermediate regression, thiab lig lumen restenosis.84
Nyob rau hauv DES era, lig neointimal kev loj hlob pib tshwm sim tom qab SES los yog PES implantation nyob rau hauv cov qauv tsiaj.85 Ob peb cov kev tshawb fawb IVUS tau pom ib tug thaum ntxov attenuation ntawm intimal loj hlob raws li los ntawm ib tug lig catch-up nyob rau hauv lub sij hawm tom qab SES los yog PES implantation, tejzaum nws yog vim ib tug tsis tu ncua inflammatory txheej txheem.86
Txawm hais tias "kev ruaj ntseg" ib txwm ua rau ISR, kwv yees li ib feem peb ntawm BMS ISR cov neeg mob tsim ACS.4
Muaj ntau cov pov thawj tias mob o thiab/los yog endothelial insufficiency induces advanced neoatherosclerosis nyob rau hauv BMS thiab DES (feem ntau yog thawj tiam DES), uas tej zaum yuav yog ib qho tseem ceeb mechanism rau advanced ISR los yog advanced ST.Inoue li al. 87 tau tshaj tawm cov kev tshawb pom histological los ntawm kev kuaj mob autopsy tom qab cog ntawm Palmaz-Schatz coronary stents, qhia tias peri-stent o tuaj yeem ua rau muaj kev hloov pauv atherosclerotic tshiab hauv stent.Lwm cov kev tshawb fawb 10 tau pom tias cov ntaub so ntswg restenotic nyob rau hauv BMS, tshaj 5 xyoo, muaj cov atherosclerosis tshiab los yog tsis muaj periost; Cov qauv los ntawm ACS cov ntaub ntawv qhia pom cov kab mob tsis zoo nyob hauv cov hlab ntsha hauv cov hlab ntsha hauv cov hlab ntsha Histological morphology ntawm lub block nrog foamy macrophages thiab cov roj cholesterol. Tsis tas li ntawd, thaum sib piv BMS thiab DES, qhov sib txawv tseem ceeb hauv lub sij hawm rau kev txhim kho atherosclerosis tshiab tau sau tseg.11,12 Qhov ntxov tshaj plaws atherosclerotic hloov pauv hauv lub hlis tom qab ES. implantation, whereas tib qhov kev hloov ntawm BMS qhov txhab tshwm sim 2 xyoo tom qab thiab tseem tsis tshua pom mus txog 4 xyoo. Tsis tas li ntawd, DES stenting rau cov kab mob tsis ruaj khov xws li nyias-cap fibroatherosclerosis (TCFA) los yog intimal rupture muaj lub sij hawm luv dua rau kev loj hlob piv rau BMS.Yog li ntawd, neoatherosclerosis tshwm sim thawj zaug thiab tshwm sim ntau dua li BMS. Tej zaum yog vim muaj qhov sib txawv pathogenesis.
Qhov cuam tshuam ntawm tiam thib ob DES lossis DES hauv kev txhim kho tseem yuav tau kawm; Txawm hais tias qee qhov kev soj ntsuam tam sim no ntawm DESs88 tiam thib ob qhia tias muaj mob tsawg dua, qhov tshwm sim ntawm neoatherosclerosis zoo ib yam li thawj tiam, tab sis tseem xav tau kev tshawb fawb ntxiv.