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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, Tsev Kawm Ntawv Qib Siab Catholic ntawm Lub Plawv Dawb Huv ntawm Rome, Ltalis Cov Lus Qhia Tseem Ceeb: Cov Tshuaj Stents coated (DES) txo cov kev txwv ntawm kev siv cov hlau bare metal stents (BMS) tom qab percutaneous coronary intervention. Txawm li cas los xij, thaum kev qhia txog tiam thib ob DES zoo li tau txo qhov xwm txheej no piv rau tiam thawj DES, tseem muaj kev txhawj xeeb tseem ceeb txog qhov ua tau lig ntawm stent implantation xws li stent thrombosis (ST) thiab stent resection, stenosis (SSI). ST yog qhov xwm txheej loj heev uas tau raug txo qis los ntawm kev ua kom zoo tshaj plaws stent implantation, cov qauv tsim stent tshiab, thiab kev kho mob dual antiplatelet. Lub tshuab tseeb uas piav qhia txog nws qhov tshwm sim yog nyob rau hauv kev tshawb nrhiav, thiab tseeb ntau yam yog lub luag haujlwm. ISR hauv BMS yav dhau los tau suav hais tias yog lub xeev ruaj khov nrog qhov siab tshaj plaws ntawm intimal hyperplasia (thaum 6 lub hlis) ua raws li lub sijhawm regression ntau dua 1 xyoos. Qhov sib txawv, ob qho kev tshawb fawb hauv tsev kho mob thiab histological ntawm DES tau ua pov thawj ntawm kev loj hlob ntawm neointimal tas mus li dhau lub sijhawm ntev, ib qho xwm txheej hu ua "late catch-up phenomenon". Lub tswv yim tias ISR yog ib qho mob tsis zoo hauv tsev kho mob tau raug tsis lees paub tsis ntev los no los ntawm cov pov thawj tias cov neeg mob uas muaj ISR yuav tsim cov kab mob plawv mob hnyav. Intracoronary imaging yog ib txoj hauv kev nkag mus rau hauv lub cev los txheeb xyuas cov stented atherosclerotic plaques thiab cov cim ntawm kev kho cov hlab ntsha tom qab stenting, thiab feem ntau yog siv los ua kom tiav kev kuaj mob coronary angiography thiab ua cov txheej txheem interventional. Intracoronary optical coherence tomography tam sim no suav hais tias yog qhov kev ntsuas duab siab tshaj plaws. nws muab, piv rau kev siv ultrasound hauv cov hlab ntsha, qhov kev daws teeb meem zoo dua (tsawg kawg >10 zaug), uas tso cai rau kev piav qhia ntxaws ntxaws ntawm cov qauv sab nraud ntawm phab ntsa hlab ntsha. nws muab, piv rau kev siv ultrasound hauv cov hlab ntsha, qhov kev daws teeb meem zoo dua (tsawg kawg >10 zaug), uas tso cai rau kev piav qhia ntxaws ntxaws ntawm cov qauv sab nraud ntawm phab ntsa hlab ntsha. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, > 10 чте зат), детально охарактеризовать поверхностную структуру стенки сосуда. nws muab, piv rau kev siv ultrasound hauv cov hlab ntsha, qhov kev daws teeb meem zoo dua (tsawg kawg >10 zaug), uas tso cai rau kev piav qhia ntxaws ntxaws ntawm cov qauv ntawm phab ntsa hlab ntsha.与血管 的更多内容与血管内超声相比，它提供了更好的分辨率（至少> 10），允许详细表征血管壁的表滓。Piv rau kev siv ultrasound hauv cov hlab ntsha, nws muab qhov kev daws teeb meem zoo dua (tsawg kawg 10 zaug), uas tso cai rau kev piav qhia ntxaws ntxaws ntawm cov qauv ntawm phab ntsa hlab ntsha.Cov kev tshawb fawb hauv vivo imaging uas sib xws nrog cov kev tshawb pom histological qhia tias kev mob ntev thiab / lossis endothelial dysfunction yuav ua rau muaj kev mob neoatherosclerosis hauv HMS thiab DES. Yog li, neoatherosclerosis tau dhau los ua qhov kev xav tseem ceeb hauv pathogenesis ntawm kev ua tsis tiav ntawm stent lig. Cov lus tseem ceeb: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
Kev kho mob plawv los ntawm kev siv stented percutaneous coronary intervention (PCI) 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 tshuaj eluting stents (DES) txo qhov kev txwv ntawm cov uncoated stents (UES), cov teeb meem lig xws li hauv stent thrombosis (ST) thiab hauv stent restenosis (ISR) tuaj yeem tshwm sim nrog stent implantation, thiab kev txhawj xeeb loj tseem nyob. 2-5
Yog tias ST yog ib qho xwm txheej loj heev, kev lees txais tias ISR yog ib yam kab mob tsis muaj teeb meem tau raug tawm tsam los ntawm cov pov thawj rau mob plawv mob hnyav (ACS) hauv cov neeg mob uas muaj ISR. plaub
Niaj hnub no, kev siv tshuab intracoronary optical coherence tomography (OCT)6-9 yog suav hais tias yog ib qho kev siv tshuab thaij duab zoo tshaj plaws uas muab kev daws teeb meem zoo dua li kev siv tshuab ultrasound hauv lub plawv (IVUS). Kev tshawb fawb txog kev thaij duab hauv lub cev10-12 raws li cov kev tshawb pom histological qhia txog "tshiab" vascular response mechanism tom qab stent implantation nrog 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 Grunzig tau ua thawj qhov kev phais balloon angioplasty (qhov kev phais balloon angioplasty qub); nws yog ib qho kev kho mob tshiab, tab sis nws kuj muaj qhov tsis zoo ntawm kev kaw cov hlab ntsha sai thiab rov qab stenosis. 13 Qhov no ua rau muaj kev tshawb pom ntawm coronary stents: Puel thiab Sigwart tau teeb tsa thawj lub coronary stent hauv xyoo 1986, muab lub stent los tiv thaiv kev kaw cov hlab ntsha sai thiab kev rov qab systolic lig. 14 Txawm hais tias cov stents thawj zaug no tiv thaiv kev kaw ntawm cov hlab ntsha sai, lawv ua rau muaj kev puas tsuaj loj heev thiab o. Tsis ntev los no, ob txoj kev tshawb fawb tseem ceeb, Belgian-Dutch Stent Study 15 thiab Stent Restenosis Study 16, tau tawm tswv yim txog kev nyab xeeb ntawm kev kho mob antiplatelet ob zaug (DAPT) stenting thiab / lossis cov txheej txheem xa tawm tsim nyog. 17,18 Tom qab cov kev sim no, tus lej ntawm PCIs tau ua nce ntxiv ntau heev.
Txawm li cas los xij, qhov teeb meem ntawm iatrogenic in-stent neointima hyperplasia tom qab BMS tso tau pom sai sai, ua rau muaj ISR hauv 20-30% ntawm cov qhov txhab kho. DES19 tau qhia rau xyoo 2001 los txo qhov xav tau restenosis thiab rov ua dua. DES tau ua rau cov kws kho mob plawv ntseeg siab ntxiv los ntawm kev tso cai rau kev kho mob ntawm cov qhov txhab nyuaj uas yav dhau los suav tias kho tau nrog 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 ntxiv, cov stents tshiab xws li 20,21 tau tsim thiab qhia. 22 Txij thaum ntawd los, kev siv zog los txhim kho kev ua tau zoo ntawm stents tau loj hlob sai, thiab cov thev naus laus zis tshiab zoo siab tau txuas ntxiv mus nrhiav pom thiab coj mus rau kev ua lag luam sai sai.
BMS yog ib lub raj hlau mesh zoo. Tom qab thawj zaug kev paub nrog Wall mount, Gianturco-Roubin mount thiab Palmaz-Schatz mount, ntau yam BMS sib txawv tam sim no muaj.
Muaj peb hom qauv sib txawv: serpentine, tubular mesh thiab slotted tube. Cov qauv coil muaj cov hlau xaim lossis strips ua ib lub voj voog coil; hauv cov qauv tubular mesh, hlau dov ua ke rau hauv lub mesh ua ib lub raj; cov qauv slotted muaj cov hlau xaim uas yog laser txiav. Cov khoom siv no sib txawv hauv kev sib xyaw (steel stainless hlau, nichrome, cobalt chrome), kev tsim (ntau yam spacer duab thiab dav, diameters thiab ntev, radial zog, radiopacity), thiab cov txheej txheem xa khoom (tus kheej-expanding lossis balloon-expandable).
Feem ntau, BMS tshiab muaj cov hlau cobalt-chromium, ua rau cov struts nyias dua, kev tsav tsheb zoo dua thiab khaws cia lub zog kho tshuab.
Lawv muaj ib lub platform hlau stent (feem ntau yog stainless hlau) thiab tau coated nrog ib tug polymer uas tso tawm anti-proliferative thiab/lossis anti-inflammatory therapeutic agents.
Sirolimus (tseem hu ua rapamycin) tau tsim thawj zaug ua ib yam tshuaj tua kab mob fungal. Nws txoj kev ua haujlwm yog txuam nrog kev thaiv kev nce qib ntawm lub voj voog ntawm tes los ntawm kev thaiv kev hloov pauv ntawm theem G1 mus rau theem S thiab tiv thaiv kev tsim neointima. Xyoo 2001, "thawj tus neeg" kev paub nrog SES tau qhia txog cov txiaj ntsig zoo, ua rau kev tsim Cypher stent. 23 Kev sim loj tau ua pov thawj nws qhov ua tau zoo hauv kev tiv thaiv IR. 24
Paclitaxel tau pom zoo thawj zaug rau kev kho mob qog nqaij hlav zes qe menyuam, tab sis nws cov khoom muaj zog cytostatic - cov tshuaj no ua rau 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 ib qho tshuaj rau Taxus Express PES. Cov kev sim TAXUS V thiab VI tau ua pov thawj txog kev ua haujlwm ntev ntawm PES hauv kev mob plawv coronary uas muaj kev pheej hmoo siab. 25,26 Tom qab ntawd TAXUS Liberté tau nthuav tawm lub platform hlau tsis xeb rau kev yooj yim ntawm kev xa khoom.
Cov pov thawj muaj zog 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 tias qis dua ntawm IVR thiab kev kho dua tshiab ntawm cov hlab ntsha (TVA), nrog rau qhov sib txawv ntawm kev nce ntxiv ntawm kev mob plawv nres (AMI) hauv PES cohort. 27.28
Cov khoom siv tiam thib ob tau txo qhov tuab ntawm tus ncej, txhim kho kev ywj pheej / kev xa khoom, txhim kho cov qauv polymer biocompatibility / kev tshem tawm tshuaj, thiab cov kinetics reendothelialization zoo dua. Hauv kev xyaum tam sim no, cov no yog cov qauv DES siab tshaj plaws thiab cov stent loj loj uas tau cog rau hauv lub plawv thoob ntiaj teb.
Taxus Elements coj qhov no mus ib kauj ruam ntxiv nrog cov polymer tshwj xeeb tsim los rau kev tso tawm ntxov tshaj plaws thiab lub kaw lus tshiab platinum-chromium spacer uas muab cov spacers nyias dua thiab ua rau muaj radiopacity ntau dua. Kev tshawb fawb 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, tsis muaj kev sim txaus los piv cov ntsiab lus yew nrog lwm tiam neeg thib ob DESs.
Lub Endeavor Zotarolimus Coated Stent (ZES) yog ua raws li lub platform cobalt-chromium stent muaj zog dua nrog kev ywj pheej ntau dua thiab lub stent strut me dua. Zotarolimus yog ib qho analogue sirolimus nrog cov teebmeem zoo sib xws immunosuppressive, tab sis nrog kev nce lipophilicity los txhim kho qhov chaw hauv phab ntsa ntawm cov 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 ntxuav tawm hauv theem pib ntawm kev raug mob, 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 lumen lig thiab HR ntau dua tab sis muaj tsawg dua qhov xwm txheej tsis zoo ntawm lub plawv (MACEs) dua li SES. 30 Kev tshawb fawb ENDEAVOR IV piv rau ZES nrog PES dua pom muaj qhov tshwm sim ntau dua ntawm SIS tab sis qhov tshwm sim qis dua ntawm MI, tej zaum vim yog ST feem ntau hauv pawg ZES. 31 Txawm li cas los xij, kev tshawb fawb PROTECT tsis tau qhia txog qhov sib txawv ntawm ST zaus ntawm Endeavor thiab Cypher stents. 32
Lub Endeavor Resolute yog ib qho version zoo dua ntawm Endeavor stent nrog ib txheej polymer tshiab peb txheej. Lub Resolute Integrity tshiab dua (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 txheej polymer tshiab, biocompatible peb txheej uas tuaj yeem tiv thaiv kev mob thawj zaug thiab elute ntau dua ntawm cov tshuaj hauv 60 hnub tom ntej. Ib qho kev sim sib piv Resolute nrog Xience V (everolimus eluting stent [EES]) tau qhia tias lub Resolute system muaj txiaj ntsig zoo ib yam li kev tuag thiab kev ua tsis tiav ntawm lub hom phiaj. 33.34
Everolimus, ib qho tshuaj sirolimus derivative, kuj yog ib qho tshuaj cell cycle inhibitor siv rau hauv kev tsim EES Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform). Kev sim SPIRIT 35-37 tau qhia txog cov txiaj ntsig zoo dua thiab txo MACE nrog Xience V piv rau PES, thaum kev sim EXCELLENT tau qhia tias EES zoo li SES hauv kev tswj 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 pom tias zoo dua BMS hauv qhov chaw ntawm ST elevation myocardial infarction (MI). 39
EPCs yog ib pawg ntawm cov hlwb uas ncig mus los uas koom nrog kev kho cov hlab ntsha thiab kev kho cov hlab ntsha endothelial. Kev nce EPC ntawm qhov chaw raug mob ntawm cov hlab ntsha yuav txhawb kev rov ua dua tshiab thaum ntxov, tej zaum yuav txo qhov kev pheej hmoo ntawm ST. EPC Biology thawj zaug nkag mus rau hauv kev tsim stent yog Genous stent, coated nrog antibodies anti-CD34, uas muaj peev xwm khi cov EPCs ncig mus los ntawm nws cov cim hematopoietic los txhim kho kev rov ua dua tshiab. Txawm hais tias kev tshawb fawb thawj zaug tau txhawb nqa, cov pov thawj tsis ntev los no qhia txog tus nqi TVR siab. 40
Vim muaj tej yam tsis zoo uas ua rau cov polymer kho qeeb uas cuam tshuam nrog ST, cov bioresorbable polymers muab cov txiaj ntsig ntawm DES los ntawm kev zam kev txhawj xeeb txog kev ruaj khov ntawm polymer. Txog niaj hnub no, ntau yam bioresorbable systems 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 tsawg. 41
Cov ntaub ntawv Bioabsorbable muaj qhov zoo ntawm kev muab kev txhawb nqa thaum pib thaum elastic recoil raug coj mus rau hauv tus account 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 lactic acid polymers (poly-l-lactic acid [PLLA]), tab sis ntau lub tshuab stent tab tom tsim kho, txawm hais tias nrhiav qhov sib npaug zoo tagnrho ntawm cov tshuaj elution thiab degradation kinetics tseem yog qhov nyuaj. Kev tshawb fawb ABSORB tau qhia txog kev nyab xeeb thiab kev ua tau zoo ntawm everolimus-coated PLLA stents. 43 Kev kho dua tshiab ntawm tiam thib ob Absorb stent zoo dua li yav dhau los nrog kev ua raws li 2-xyoo zoo. 44 Kev tshawb fawb ABSORB II tam sim no, thawj qhov kev sim randomized piv rau Absorb stent nrog Xience Prime stent, yuav tsum muab cov ntaub ntawv ntxiv, thiab thawj qhov tshwm sim muaj kev cia siab. 45 Txawm li cas los xij, cov xwm txheej zoo tagnrho, cov txheej txheem cog zoo tshaj plaws, thiab cov ntaub ntawv kev nyab xeeb hauv kab mob coronary artery yuav tsum tau piav qhia meej.
Kev mob thrombosis hauv ob qho tib si BMS thiab DES muaj cov txiaj ntsig tsis zoo. Hauv kev sau npe ntawm cov neeg mob uas tau cog nrog DES,47 24% ntawm cov neeg mob ST ua rau tuag, 60% hauv MI tsis tuag taus, thiab 7% hauv angina tsis ruaj khov. PCI rau ST ceev ceev feem ntau tsis zoo, nrog rov tshwm sim hauv 12% ntawm cov neeg mob. 48
ST txuas ntxiv muaj cov txiaj ntsig tsis zoo rau kev kho mob. Hauv kev tshawb fawb BASKET-LATE, 6-18 lub hlis tom qab muab stent tso rau, cov nqi ntawm kev tuag ntawm lub plawv thiab MI uas tsis ua rau tuag tau siab dua hauv pawg DES dua li hauv pawg SMP (4.9% thiab 1.3%, feem). 20 Kev tshuaj xyuas meta-analysis ntawm cuaj txoj kev tshawb fawb uas 5261 tus neeg mob tau raug xaiv los rau SES, PES, lossis BMS qhia tau tias tom qab 4 xyoos ntawm kev saib xyuas, SES (0.6% piv rau 0%, p = 0.025) thiab PES (0.7%)) ua rau muaj 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 5108 tus neeg mob, 21 qhov kev nce ntxiv ntawm 60% ntawm kev tuag lossis MI tau tshaj tawm nrog SES piv nrog BMS (p = 0.03), thaum PES cuam tshuam nrog kev nce ntxiv tsis tseem ceeb ntawm 15% (saib - txog li 9 lub hlis txog 3 xyoos).
Muaj ntau lub npe sau npe, kev sim tshuaj ntsuam xyuas, thiab kev tshuaj xyuas meta-analyses tau tshuaj 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 6906 tus neeg mob kho nrog BMS lossis DES, tsis muaj qhov sib txawv ntawm cov txiaj ntsig kho mob lossis ST tus nqi ntawm 1 xyoos ntawm kev saib xyuas. 48 Hauv lwm lub npe sau npe ntawm 8146 tus neeg mob, qhov kev pheej hmoo ntawm ST ntau dhau tau pom tias yog 0.6% ib xyoos piv nrog BMS. 49 Ib qho kev tshuaj xyuas meta-analysis ntawm kev tshawb fawb sib piv SES lossis PES nrog SMPs tau qhia txog kev pheej hmoo ntawm kev tuag thiab MI nrog thawj tiam DES piv nrog SMPs, 21 thiab lwm qhov kev tshuaj xyuas meta-analysis ntawm 4545 tus neeg mob randomized rau SES lossis 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 ntxiv hauv cov neeg mob kho nrog thawj tiam DES tom qab tsis siv DAPT. 51
Vim muaj cov ntaub ntawv tsis sib haum, ntau qhov kev tshuaj xyuas thiab kev tshuaj xyuas meta tau ua ke tau txiav txim siab tias DES thiab thawj tiam SGM tsis sib txawv ntau hauv kev pheej hmoo ntawm kev tuag lossis MI, tab sis SES thiab PES muaj kev pheej hmoo ntawm ST ntau heev piv rau SGM. 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 muaj txiaj ntsig zoo raws li tau sau tseg thiab tias qhov kev pheej hmoo ntawm cov theem siab heev ST yog me me, tab sis tsis loj. , 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 pov thawj me ntsis los txhawb qhov kev thov no.
Raws li tau hais ua ntej, tiam thib ob DES tau tsim nrog cov qauv tsim zoo dua. CoCr-EES tau dhau los ntawm kev tshawb fawb kho mob dav tshaj plaws. Hauv kev tshuaj xyuas meta-tsom xam los ntawm Baber et al.54 ntawm 17,101 tus neeg mob, CoCr-EES txo qis qhov tseeb / tej zaum ST thiab MI piv nrog PES, SES, thiab ZES ntawm 21 lub hlis. Thaum kawg, Palmerini et al tau qhia hauv kev tshuaj xyuas meta-tsom xam ntawm 16,775 tus neeg mob tias CoCr-EES muaj qis dua thaum ntxov, lig, 1- thiab 2-xyoo txhais ST piv rau lwm cov DES sib sau ua ke. 55 Cov kev tshawb fawb tiag tiag tau ua pov thawj tias muaj kev txo qis ntawm kev pheej hmoo ntawm ST nrog CoCr-EES piv nrog thawj tiam DES. 56
Re-ZES tau muab piv rau CoCr-EES hauv RESOLUTE-AC thiab TWENTE kev tshawb fawb. 33,57 Tsis muaj qhov sib txawv tseem ceeb hauv kev tuag, myocardial infarction, lossis ST segment txhais ntawm ob lub stents.
Hauv kev tshuaj xyuas network ntawm 50,844 tus neeg mob, suav nrog 49 RCTs, 58 CoCr-EES tau cuam tshuam nrog qhov tshwm sim qis dua ntawm ST txhais tau tias dua li BMS, qhov kev tshawb pom tsis tau pom nrog lwm DES; qhov kev poob qis tsis yog tsuas yog "thaum ntxov heev" thiab tom qab 30 hnub (58). qhov sib piv [OR] 0.21, 95% kev ntseeg siab [CI] 0.11-0.42) thiab 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 rau PES, SES, thiab ZES, CoCr-EES tau cuam tshuam nrog tus nqi ST qis dua ntawm 1 xyoos.
ST thaum ntxov muaj feem cuam tshuam nrog ntau yam. Cov qauv ntawm cov plaque hauv qab thiab cov thrombus zoo li cuam tshuam rau qhov tshwm sim tom qab PCI;59 cov struts tob dua los ntawm necrotic core (NC) prolapse, ntev medial tear hauv stent, suboptimal stenting nrog cov seem ntug dissections lossis tseem ceeb ntug stenosis, tsis tiav apposition, thiab tsis tiav nthuav dav ntawm implanted stent yuav ua rau muaj kev pheej hmoo ntawm ST.60 Kev kho mob ntawm cov tshuaj antiplatelet tsis cuam tshuam rau qhov tshwm sim ntawm ST thaum ntxov: hauv kev sim randomized piv BMSs nrog DESs, cov nqi ntawm mob hnyav thiab subacute ST thaum lub sijhawm DAPT 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 rau cov txheej txheem txheej txheem. Cov qauv ntawm cov plaque hauv qab thiab cov thrombus zoo li cuam tshuam rau qhov tshwm sim tom qab PCI;59 cov struts tob dua los ntawm necrotic core (NC) prolapse, ntev medial tear hauv stent, suboptimal stenting nrog cov seem ntug dissections lossis tseem ceeb ntug stenosis, tsis tiav apposition, thiab tsis tiav nthuav dav ntawm implanted stent yuav ua rau muaj kev pheej hmoo ntawm ST.60 Kev kho mob ntawm cov tshuaj antiplatelet tsis cuam tshuam rau qhov tshwm sim ntawm ST thaum ntxov: hauv kev sim randomized piv BMSs nrog DESs, cov nqi ntawm mob hnyav thiab subacute ST thaum lub sijhawm DAPT 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 rau cov txheej txheem txheej txheem. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВ;59 болека труете глует распорок из-за пролапса некротического ядра (NC), длинного медиального разрыва внутри стеонта, субьлопата с остаточными краевыми расслоениями или значительным краевым стенозом, неполной аппозицией и неполным расширением имплантированного стента может увеличить риск ST.60 Терапкевтичес антитромбоцитарных препаратов не оказывает существенного влияния на частоту раннего ST: в роновомизир ованнего сравнивающем BMS и DES, частота острого и подострого ST во время DAPT была одинаковой (<1%) .61 Таким образом образом ранняя ST, по-видимому, в первую очередь связана с лежащими в основе пролеченными поражениякми и пролеченными поражениякми и пролеченными Cov qauv ntawm cov plaque thiab thrombosis hauv qab zoo li cuam tshuam rau qhov tshwm sim tom qab PCI;59 qhov nkag mus tob dua vim yog necrotic nucleus (NC) prolapse, ntev medial tear hauv lub stent, suboptimal stenting nrog cov seem marginal delaminations lossis tseem ceeb marginal stenosis, tsis tiav apposition thiab tsis tiav expansion ntawm ib qho implanted stent yuav ua rau muaj kev pheej hmoo ntawm ST.60 Kev kho mob ntawm cov tshuaj antiplatelet tsis cuam tshuam rau qhov tshwm sim ntawm ST thaum ntxov: hauv kev sim randomized piv BMS thiab DES, qhov tshwm sim ntawm acute thiab subacute ST thaum lub sijhawm DAPT yog tib yam (<1%).61 Yog li, ST thaum ntxov zoo li feem ntau cuam tshuam nrog cov qhov txhab kho hauv qab thiab cov txheej txheem txheej txheem.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 的发生率：在一项比较BMS 与DES 的鸚霺薇。期间急性和亚急性ST 的发生率相似（<1%） .61 因此，早期ST 似乎主要潜的治疳咅友。潜在的斑块形态和 血栓 似乎 影响 影响 pci 后 结果 ； ； ； ＠ 坏 帿僿核心 核心 脱垂 寪致 的 深的 支柱 穿透 、 内长 的 内侧 、 具有 残余 狄羭 繼次 次 次的优支架、不 完全 并置和 不 扩张扩张扩张扩张扩张小板药物的治疗方案不显着影响影响早期的：在项比较比较 bms 与 des ，急性 亚急性的 发生 发生 发生 发生 发生 发生 发生 发生 发生 发生 发生 发生发生 发生 发生 发生 发生 发生率相似 (<1%) .61Qhov morphology ntawm cov plaque thiab thrombosis hauv qab no zoo li cuam tshuam rau cov txiaj ntsig tom qab PCI; 59 Kev nkag mus tob dua ntawm strut vim yog necrotic nucleus (NC) prolapse, medial ruptures hauv stent ntev, secondary dissection nrog cov npoo seem, lossis qhov nqaim ntawm ntug. Qhov zoo tshaj plaws stenting, tsis tiav apposition, thiab tsis tiav expansion60 Antiplatelet regimen tsis muaj qhov cuam tshuam loj rau ST thaum ntxov: qhov tshwm sim ntawm acute thiab subacute ST thaum lub sijhawm DAPT hauv kev sim randomized piv rau BMS thiab DES. feem ntau yog cuam tshuam nrog cov kab mob kho mob hauv qab thiab cov yam ntxwv phais.
Niaj hnub no, qhov kev tsom mus rau ST lig/lig heev. Txawm hais 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 kev mob hnyav thiab mob hnyav heev: ntshav qab zib mellitus, ACS thaum lub sijhawm phais thawj zaug, kev ua haujlwm ntawm lub raum, hnub nyoog laus, txo qis ejection fraction, cov xwm txheej loj ntawm lub plawv tsis zoo 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 ntau lub hlab ntsha, calcification, tag nrho occlusion, stents ntev zoo li cuam tshuam nrog kev pheej hmoo ntawm kev mob hnyav. 62,63 Kev teb tsis zoo rau kev kho mob antiplatelet yog qhov pheej hmoo loj rau kev mob hnyav DES thrombosis 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 tus neeg txais (tshwj xeeb tshaj yog clopidogrel tsis kam), thiab kev ua haujlwm ntawm lwm txoj hauv kev rau kev ua haujlwm ntawm platelet. Stent neoatherosclerosis yog suav hais tias yog ib qho tseem ceeb rau kev ua tsis tiav ntawm stent lig, suav nrog ST64 lig (ntu "Stent Neoatherosclerosis"). Lub endothelium uas tsis hloov pauv cais cov phab ntsa hlab ntsha thiab cov stent posts ntawm cov ntshav thiab tso tawm cov tshuaj antithrombotic thiab vasodilatory. DES ua rau cov phab ntsa hlab ntsha raug tshuaj tiv thaiv kev loj hlob thiab lub platform tso tshuaj, nrog rau ntau yam teebmeem ntawm kev kho thiab kev ua haujlwm endothelial, nrog rau kev pheej hmoo ntawm kev mob thrombosis lig. 65 Cov kev tshawb fawb pathological tau qhia tias cov polymers DES thawj tiam muaj zog tuaj yeem ua rau mob o, mob fibrin deposition ntev, kev kho endothelial tsis zoo, thiab yog li ntawd 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 al. [66] tau tshaj tawm cov kev tshawb pom tom qab tuag tom qab ST qhia txog kev nthuav dav aneurysm hauv qhov stent nrog cov tshuaj tiv thaiv hauv zos uas muaj T-lymphocytes thiab eosinophils; cov kev tshawb pom no yuav cuam tshuam txog kev cuam tshuam ntawm cov polymers uas tsis tuaj yeem rhuav tshem tau. 67 Qhov tsis haum ntawm lub stent tej zaum yuav yog vim lub stent nthuav dav tsis zoo lossis tshwm sim ob peb lub hlis tom qab PCI. Txawm hais tias kev ua 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 tau txais stent malapposition 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 txiaj ntsig tiv thaiv ntawm DES tiam thib ob yuav suav nrog kev ua kom cov hlab ntsha sai dua thiab zoo dua, 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 scaffolds nyias (81 µm), cov tshuaj fluoropolymers tiv thaiv kev ntshav txhaws, cov polymer tsawg, thiab kev thauj tshuaj yuav ua rau cov nqi ST qis dua. Cov kev tshawb fawb sim tau qhia tias thrombosis thiab platelet deposition qis dua hauv cov fluoropolymer-coated stents dua li hauv cov stents tsis coated. 69 Seb lwm cov DESs tiam thib ob puas muaj cov khoom zoo sib xws tsim nyog tau kawm ntxiv.
Cov hlab ntsha hauv lub plawv (coronary stents) ua kom kev phais mob zoo dua piv rau cov hlab ntsha hauv lub plawv (PTCA) ib txwm muaj, uas muaj teeb meem ntawm cov khoom siv (vascular occlusion, dissection, thiab lwm yam) thiab muaj cov restenoses ntau (txog li 40–50% ntawm cov neeg mob). Thaum kawg ntawm xyoo 1990, yuav luag 70% ntawm PCIs tau ua tiav nrog BGM implantation. 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BMSTxawm 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 ua dua tom qab kev cog BMS yog kwv yees li 20%, nrog rau cov nqi ntau dua 40% hauv qee pawg me. 71 Feem ntau, cov kev tshawb fawb hauv tsev kho mob tau qhia tias kev rov ua dua tom qab kev cog BMS, zoo ib yam li qhov pom nrog PTCA ib txwm muaj, nce siab tshaj plaws ntawm 3-6 lub hlis thiab daws tau ntawm 1 xyoos. 72
DES txo cov nqi ISR ​​ntxiv,73 txawm hais tias qhov kev txo qis no yog angiographically thiab clinically nyob ntawm. Lub DES polymer txheej tso tawm cov tshuaj tiv thaiv kev o thiab tiv thaiv kev loj hlob, tiv thaiv kev tsim neointima, thiab qeeb kev kho cov hlab ntsha los ntawm lub hlis lossis xyoo.74 Hauv kev tshawb fawb hauv tsev kho mob thiab histological, kev loj hlob ntawm neointima tau pom nyob rau lub sijhawm ntev tom qab DES implantation, ib qho xwm txheej hu ua "late catch-up" 75.
Kev raug mob ntawm cov hlab ntsha thaum lub sijhawm PCI ua rau muaj kev o thiab kho mob nyuaj heev rau lub sijhawm luv luv (lub lis piam mus rau lub hlis), ua rau endothelialization thiab neointimal kev them. Raws li kev soj ntsuam histopathological, neointimal hyperplasia (HMS thiab DES) tom qab stent implantation feem ntau muaj cov hlwb proliferative smooth muscle hauv cov proteoglycan-nplua nuj extracellular matrix. 70
Yog li, neointimal hyperplasia yog ib qho txheej txheem kho uas muaj cov coagulation thiab o, nrog rau cov hlwb uas ua rau cov leeg nqaij du thiab cov extracellular matrix tsim. Tam sim ntawd tom qab PCI, platelets thiab fibrin raug tso rau ntawm phab ntsa hlab ntsha thiab nyiam cov leukocytes los ntawm ntau cov cell adhesion molecules. Dov leukocytes txuas rau cov platelets txuas los ntawm kev sib cuam tshuam ntawm leukocyte integrin Mac-1 (CD11b/CD18) thiab platelet glycoprotein Ibα 53 lossis fibrinogen cuam tshuam nrog platelet glycoprotein IIb/IIIa. 76.77
Raws li cov ntaub ntawv tshiab, cov hlwb pob txha progenitor koom nrog cov tshuaj tiv thaiv vascular thiab cov txheej txheem kho. Kev txav mus los ntawm EPC los ntawm cov hlwb pob txha mus rau cov ntshav peripheral txhawb kev rov ua dua tshiab endothelial thiab kev tsim cov hlab ntsha tshiab tom qab yug me nyuam. Nws zoo li tias cov hlwb pob txha du cov leeg nqaij progenitor hlwb (SMPCs) tsiv mus rau qhov chaw raug mob vascular, ua rau muaj kev loj hlob neointimal. 78 Yav dhau los, CD34-positive hlwb tau suav hais tias yog cov pej xeem ruaj khov ntawm EPCs, kev tshawb fawb ntxiv tau qhia tias CD34 nto antigen yeej paub txog cov hlwb pob txha tsis sib txawv nrog lub peev xwm los sib txawv mus rau hauv EPCs thiab PBMCs. Kev hloov pauv ntawm CD34-positive hlwb mus rau hauv EPC lossis SMPC kab yog nyob ntawm qhov chaw ib puag ncig hauv zos; cov xwm txheej ischemic ua rau muaj kev sib txawv ntawm EPC phenotype, uas txhawb nqa reendothelialization, thaum cov xwm txheej inflammatory ua rau muaj kev sib txawv ntawm SMPC phenotype, uas txhawb nqa neointimal proliferation. 79
Kab mob ntshav qab zib ua rau muaj kev pheej hmoo ntawm ISR los ntawm 30-50% tom qab kev cog BMS, thiab tus nqi siab dua ntawm kev rov ua dua 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 zoo li muaj ntau yam, suav nrog kev ua haujlwm 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 ywj pheej ua rau muaj kev pheej hmoo ntawm ISR. 70
Txoj kab uas hla ntawm cov hlab ntsha thiab qhov ntev ntawm qhov mob tau cuam tshuam rau tus nqi 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 tias cov stent struts tuab dua thiab ISRs siab dua piv rau cov platform stent tiam thib ob nrog cov struts nyias dua.
Ntxiv mus, qhov tshwm sim ntawm kev rov ua dua tshiab yog txuam nrog qhov ntev ntawm stent, yuav luag ob npaug rau qhov ntev ntawm stent > 35 mm piv rau cov <20 mm. Ntxiv mus, qhov tshwm sim ntawm kev rov ua dua yog txuam nrog qhov ntev ntawm stent, yuav luag ob npaug rau qhov ntev ntawm stent > 35 mm piv rau cov <20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента > 35 мрей по <20 мм. Ntxiv rau, tus nqi ntawm kev rov ua dua tshiab muaj feem cuam tshuam nrog qhov ntev ntawm stent, yuav luag ob npaug nrog qhov ntev ntawm stent > 35 mm piv rau qhov ntev ntawm stent <20 mm.此外，再狭窄的发生率与支架长度有关，支架长度>35 mm 的支架长度几乎是 <20 mm 的两個。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 <2тчета , Ntxiv rau, qhov zaus ntawm kev rov ua dua tshiab nyob ntawm qhov ntev ntawm lub stent: qhov ntev ntawm lub stent > 35 mm yog yuav luag ob npaug ntawm lub stent <20 mm.Qhov kawg tsawg kawg nkaus lumen txoj kab uas hla ntawm stent kuj ua lub luag haujlwm tseem ceeb: qhov kawg tsawg kawg nkaus lumen txoj kab uas hla me dua kwv yees tias yuav muaj kev pheej hmoo ntawm kev rov ua dua stenosis. 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 ntawm 6 lub hlis thiab 1 xyoos ua raws li lub sijhawm dormant lig. Lub sijhawm ntxov ntawm kev loj hlob intimal ua raws li intimal regression nrog lumen loj hlob ntau xyoo tom qab stent implantation tau tshaj tawm ua ntej; kev loj hlob ntawm cov leeg nqaij du thiab kev hloov pauv hauv cov extracellular matrix tau raug pom zoo ua cov txheej txheem ua tau rau kev rov qab neointima lig. 83 Txawm li cas los xij, kev tshawb fawb ntev dua tau qhia txog kev teb triphasic tom qab BMS tso nrog restenosis thaum ntxov, regression nruab nrab, thiab lig luminal restenosis. 84
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 RPE 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 uas muaj BMS ISR tau mob ACS. plaub
Muaj ntau cov pov thawj ntxiv tias kev mob o thiab/lossis endothelial tsis txaus ua rau muaj kev mob neoatherosclerosis hauv HCM thiab DES (feem ntau yog thawj tiam DES), uas yuav yog ib qho tseem ceeb rau kev txhim kho ntawm kev mob IR lossis kev mob ST. Inoue et al [87] tau tshaj tawm cov ntaub ntawv kuaj mob tom qab kev cog lus ntawm Palmaz-Schatz coronary stents, qhia tias kev mob o nyob ib puag ncig lub stent yuav ua rau muaj kev hloov pauv atherosclerotic tshiab hauv lub stent. Lwm cov kev tshawb fawb10 tau qhia tias cov ntaub so ntswg restenotic hauv 5-xyoo CGM muaj cov kab mob atherosclerosis tsis ntev los no nrog lossis tsis muaj kev mob peritoneal; cov qauv los ntawm ACS cov ntaub ntawv qhia txog cov plaques tsis muaj zog hauv cov hlab ntsha hauv lub cev Histological block morphology nrog cov macrophages ua npuas ncauj thiab cov roj cholesterol crystals. Tsis tas li ntawd, thaum piv BMS thiab DES, qhov sib txawv tseem ceeb hauv lub sijhawm rau kev txhim kho ntawm atherosclerosis tshiab tau sau tseg. 11,12 Cov kev hloov pauv atherosclerotic thaum ntxov tshaj plaws hauv cov foamy macrophage infiltration pib 4 lub hlis tom qab SES implantation, thaum cov kev hloov pauv tib yam hauv CGM lesions tshwm sim tom qab 2 xyoos thiab tseem yog qhov tsis tshua muaj neeg pom txog 4 xyoos. Tsis tas li ntawd, DES stenting rau cov lesions tsis ruaj khov xws li nyias tegmental 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 lwm yam pathogenesis.
Qhov cuam tshuam ntawm tiam thib ob DES lossis DES rau kev loj hlob tseem yuav tsum tau tshawb nrhiav; txawm hais tias qee qhov kev soj ntsuam uas twb muaj lawm ntawm tiam thib ob DES88 qhia tias muaj kev o tsawg dua, qhov tshwm sim ntawm neoatherosclerosis zoo sib xws piv rau tiam thawj, tab sis tseem xav tau kev tshawb fawb ntxiv.