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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Ngalaba Cardiology, Poliambulanza Foundation Hospital, Brescia, 2 Ngalaba Cardiology, Mahadum Katọlik nke Obi Nsọ nke Rome, Italy Nkọwa: Ọgwụ na-ewepụ ihe ndị na-eme ka mmadụ ghara inwe ike ime ihe ndị na-eme ka mmadụ ghara inwe ike ime ihe ndị na-eme ka mmadụ ghara inwe ike ime ihe ndị na-eme ka mmadụ ghara inwe ike ime ihe ndị na-eme ka mmadụ ghara inwe ike ime ihe ndị na-adịghị mma. Agbanyeghị, ọ bụ ezie na mmalite nke DES nke ọgbọ nke abụọ yiri ka ọ na-edozi ihe a ma e jiri ya tụnyere ọgbọ nke mbụ nke DES, nchegbu dị ukwuu ka dị maka nsogbu ndị nwere ike ime n'oge na-adịghị anya nke itinye stent, dị ka stent thrombosis (ST) na mwepụ stent. Stenosis (ISR).ST bụ ihe nwere ike ịkpata ọdachi nke ebelatala nke ukwuu site na stenting emelitere, atụmatụ stent ọhụrụ, na ọgwụgwọ antiplatelet abụọ. A na-enyocha usoro kpọmkwem nke na-akọwa ihe merenụ, n'ezie, ọtụtụ ihe kpatara ya. A na-ewere ISR na BMS dị ka ọnọdụ kwụsiri ike na mmalite nke hyperplasia intimal (na ọnwa 6) wee soro oge nlọghachi nke ihe karịrị otu afọ. N'ụzọ dị iche, ma ọmụmụ ahụike na histological nke DESs gosipụtara ihe akaebe nke uto neointimal na-aga n'ihu n'oge nleba anya ogologo oge, ihe a maara dị ka ihe "ejide n'oge". Echiche na ISR bụ ọnọdụ ahụike dị nro ka ihe akaebe na-egosi na ndị ọrịa nwere ISR nwere ike ịmalite ọrịa coronary syndromes dị egwu. Foto intracoronary bụ usoro mwakpo nke nwere ike ịchọpụta plaques atherosclerotic stented na njirimara nke ọgwụgwọ arịa ọbara mgbe stent gasịrị; A na-ejikarị ya eme ihe iji mezue nchọpụta ọrịa akwara obi na usoro ọgwụgwọ. A na-ewere tomography njikọ anya dị ka usoro onyonyo kachasị elu ugbu a. Ma e jiri ya tụnyere ultrasound intravascular, ọ na-enye mkpebi ka mma (ma ọ dịkarịa ala ugboro 10), na-enye ohere ịkọwapụta nkọwa zuru ezu nke nhazi elu nke mgbidi arịa ọbara. "Ọmụmụ onyonyo In vivo" nke kwekọrọ na nchọpụta histological na-egosi na mbufụt na-adịghị ala ala na/ma ọ bụ nsogbu endothelial nwere ike ibute neo-atherosclerosis n'oge ikpeazụ n'ime BMS na DES. Ya mere, neo-atherosclerosis abụrụla ihe a na-enyo enyo na ọ bụ isi na pathogenesis nke ọdịda stent late.Isiokwu: coronary stent, stent thrombosis, restenosis, neoatherosclerosis
Ọgwụgwọ akwara obi nke Percutaneous (PCI) site na itinye stent bụ usoro a na-ejikarị eme ihe maka ọgwụgwọ nke ọrịa akwara obi nke na-egosi ihe mgbaàmà, usoro a na-agakwa n'ihu na-agbanwe agbanwe.1 Ọ bụ ezie na stents ọgwụ na-ewepụ (DES) na-ebelata oke nke stents bare-metal (BMSs), nsogbu ndị dị ka stent thrombosis (ST) na in-stent restenosis (ISR) nwere ike ime na stent implantation. , nchegbu ndị dị oke njọ ka dị.2-5
Ọ bụrụ na ST bụ ihe nwere ike ịkpata ọdachi, amata na ISR bụ ọrịa na-adịghị mma n'oge na-adịbeghị anya abụrụla ihe akaebe nke ọrịa akwara obi (ACS) na ndị ọrịa ISR.4
Taa, a na-ewere usoro onyonyo intracoronary optical coherence tomography (OCT) 6-9 dị ka usoro onyonyo kachasị ọhụrụ ugbu a, na-enye mkpebi ka mma karịa ultrasound intravascular (IVUS) "In vivo" ọmụmụ onyonyo, 10-12 kwekọrọ na nchọpụta histological, na-egosi usoro "ọhụrụ" nke nzaghachi vaskụla mgbe etinyere stent, yana de novo "neoatherosclerosis" n'ime BMS na DES.
Na 1964, Charles Theodore Dotter na Melvin P Judkins kọwara angioplasty mbụ ahụ. Na 1978, Andreas Gruntzig mere angioplasty mbụ nke balloon (angioplasty ochie nke balloon); ọ bụ ọgwụgwọ mgbanwe mana o nwere nsogbu nke mmechi akwara na restenosis.13 Nke a mere ka a chọpụta stents akwara obi: Puel na Sigwart tinyere stents akwara obi mbụ na 1986, na-enye stent iji gbochie mmechi akwara obi na mwepụta systolic n'oge.14 Ọ bụ ezie na stents mbụ ndị a gbochiri mmechi nke arịa ahụ ozugbo, ha kpatara nnukwu mmebi endothelial na mbufụt. Mgbe e mesịrị, nnwale abụọ dị mkpa, Belgium-Dutch Stent Trial 15 na Stent Restenosis Study 16, kwadoro nchekwa nke stenting na ọgwụgwọ antiplatelet abụọ (DAPT) na/ma ọ bụ usoro ntinye kwesịrị ekwesị.17,18 Mgbe nnwale ndị a gasịrị, enwere mmụba dị ukwuu na ọnụọgụ PCI emere.
Agbanyeghị, a chọpụtara nsogbu nke hyperplasia neointimal in-stent mgbe etinyere BMS ngwa ngwa, nke butere ISR na 20%–30% nke ọnya ndị a gwọrọ. Na 2001, ewebatara DES19 iji belata mkpa maka restenosis na reintervention. DESs emeela ka ndị dọkịta obi nwekwuo obi ike, na-ekwe ka a gwọọ ọtụtụ ọnya ndị dị mgbagwoju anya nke e chere na mbụ na a ga-edozi site na grafting akwara obi. Na 2005, 80%–90% nke PCI niile so DES.
Ihe niile nwere nsogbu ya, kemgbe afọ 2005, nchegbu gbasara nchekwa nke "ọgbọ mbụ" DES amụbaala, emepụtala ma webata stents ọgbọ ọhụrụ dịka 20,21.22 Kemgbe ahụ, mgbalị iji melite arụmọrụ stent etolitela ngwa ngwa, a ka na-achọpụta ma na-eweta teknụzụ ọhụrụ na-eju anya n'ahịa ngwa ngwa.
BMS bụ ọkpọkọ waya dị gịrịgịrị. Mgbe ha nwesịrị ahụmịhe mbụ na mkpọ "Mgbidi", mkpọ Gianturco-Roubin na mkpọ Palmaz-Schatz, ọtụtụ BMS dị iche iche dị ugbu a.
Enwere ike imepụta ihe atọ dị iche iche: eriri kọlụm, eriri tubular na tube nwere oghere. Nhazi eriri kọlụm nwere waya ígwè ma ọ bụ mpempe ígwè e ji aka kee n'ụdị eriri kọlụm gburugburu; nhazi eriri tubular nwere waya e ji aka kee n'ime eriri iji mepụta tube; nhazi tube nwere oghere nwere tube ígwè e ji laser bee. Ngwaọrụ ndị a dị iche na nhazi (ígwè anaghị agba nchara, nichrome, cobalt chrome), nhazi nhazi (ụdị na obosara dị iche iche, dayameta na ogologo, ike radial, rediopacity) na sistemụ nnyefe (nke na-agbasa onwe ya ma ọ bụ nke a na-agbasa site na balloon).
N'ozuzu, BMS ọhụrụ ahụ nwere cobalt-chromium alloy, nke na-eme ka struts dị gịrịgịrị ma na-eme ka ọ na-agagharị nke ọma, na-eme ka ike igwe sie ike.
Ha nwere ikpo okwu stent ígwè (nke na-abụkarị ígwè anaghị agba nchara) ma kpuchie ya na polima nke na-enye ọgwụgwọ mgbochi mmụba na/ma ọ bụ mgbochi mbufụt.
E bu ụzọ mee Sirolimus (nke a makwaara dị ka rapamycin) dị ka ihe na-egbochi nje. Usoro ọrụ ya sitere na igbochi ọganihu okirikiri sel site na igbochi mgbanwe site na usoro G1 gaa na usoro S na igbochi nhazi neointima. Na 2001, ahụmịhe "onye mbụ n'ime mmadụ" na SES gosipụtara nsonaazụ dị mma, nke butere mmepe nke stent Cypher.23 Nnukwu nnwale gosipụtara irè ya n'igbochi ISR.24 iri abụọ na anọ
A nabatara Paclitaxel na mbụ maka ọrịa kansa ovarian, mana ikike cytostatic ya dị ike - ọgwụ ahụ na-eme ka microtubules kwụsie ike n'oge mitosis, na-eduga na njide okirikiri sel ma na-egbochi mmepụta neointimal - na-eme ka ọ bụrụ ihe mejupụtara Taxus Express PES. Nnwale TAXUS V na VI gosipụtara irè ogologo oge nke PES na ọrịa akwara obi dị oke egwu, nke dị mgbagwoju anya.25,26 TAXUS Liberté sochirinụ gosipụtara ikpo okwu ígwè anaghị agba nchara maka nnyefe dị mfe.
Ihe akaebe zuru ezu sitere na nyocha usoro abụọ na meta-analyses na-egosi na SES nwere uru karịa PES n'ihi obere ọnụego nke ISR na revascularization arịa ebumnuche (TVR), yana usoro nke mmụba nke nnukwu myocardial infarction (AMI) na otu PES. 27,28
Ngwaọrụ ọgbọ nke abụọ ebelatala ọkpụrụkpụ strut, meziwanye mgbanwe/nnyefe, mmelite biocompatibility/ọgwụ elution nke polymer, yana ezigbo kinetics re-endothelialization. N'oge a, ha bụ atụmatụ DES kachasị elu na nnukwu stents coronary etinyere n'ụwa niile.
Taxus Elements bụ ọganihu ọzọ nwere polima pụrụ iche e mere iji mee ka mwepụta ngwa ngwa dịkwuo elu yana sistemụ platinum-chromium strut ọhụrụ nke na-enye struts dị gịrịgịrị na rediopacity emelitere. Nnwale PERSEUS 29 kwuru ihe yiri nke ahụ n'etiti Element na Taxus Express ruo ọnwa 12. Agbanyeghị, nnwale ndị na-atụnyere yew elements na ọgbọ nke abụọ DES adịghị.
E ji usoro stent zotarolimus-eluting (ZES) Endeavor mee ihe dabere na ikpo okwu stent cobalt-chromium siri ike nke nwere mgbanwe dị elu na obere nha stent strut. Zotarolimus bụ sirolimus analog nwere mmetụta mgbochi ahụ ike yiri nke ahụ mana lipophilicity emelitere iji mee ka ebe mgbidi arịa dịkwuo mma. ZES na-eji mkpuchi phosphorylcholine polymer ọhụrụ nke e mere iji mee ka biocompatibility dịkwuo elu ma belata mbufụt. A na-ewepụ ọtụtụ ọgwụ n'oge mmerụ ahụ mbụ, wee rụzie akwara. Mgbe nnwale ENDEAVOR mbụ gasịrị, nnwale ENDEAVOR III sochirinụ tụnyere ZES na SES, nke gosipụtara nnukwu mfu lumen late na ISR mana obere ihe omume obi ọjọọ (MACE) karịa SES.30 Nnwale ENDEAVOR IV, nke tụnyere ZES na PES, chọtara ọzọ mmụba nke ISR, mana obere mmụba nke AMI, nke a na-ahụkarị site na ST dị elu na otu ZES.31 Agbanyeghị, nnwale PRECTE egosighi ọdịiche na ọnụego ST n'etiti Endeavor na Cypher stents.32
Endeavor Resolute bụ ụdị Endeavor stent ka mma nke nwere polymer ọhụrụ nwere akwa atọ. Resolute Integrity ọhụrụ (nke a na-akpọ DES ọgbọ nke atọ) dabere na ikpo okwu ọhụrụ nwere ikike nnyefe dị elu (ikpo okwu Integrity BMS), yana polymer ọhụrụ, nke dabara adaba karịa nke nwere akwa atọ, nwere ike igbochi nzaghachi mkpali mbụ ma wepụ ọtụtụ ọgwụ ahụ n'ime ụbọchị 60 sochirinụ. Nnwale tụnyere Resolute na Xience V (everolimus-eluting stent [EES]) gosipụtara na sistemụ Resolute adịghị ala ma e jiri ya tụnyere ọnwụ na ọdịda mmerụ ahụ.33,34
Everolimus, ihe sitere na sirolimus, bụkwa ihe na-egbochi okirikiri sel nke ejiri mee ihe na mmepe nke Xience (Multi-link Vision BMS platform)/Promus (platinum Chromium platform) EES. Nnwale SPIRIT 35-37 gosipụtara arụmọrụ ka mma ma belata MACE na Xience V ma e jiri ya tụnyere PES, ebe nnwale EXCELLENT gosiri na EES adịghị ala karịa SES n'igbochi mfu oge na ọnwa 9 na ihe omume ahụike na ọnwa 12.38 N'ikpeazụ, Xience stent gosipụtara uru karịa BMS na ntọala nke ST-segment elevation myocardial infarction (MI).39
EPCs bụ otu n'ime mkpụrụ ndụ na-agagharị agagharị nke na-etinye aka na homeostasis vascular na ndozi endothelial. Mmelite nke EPCs n'ebe mmerụ ahụ vascular ga-akwalite nlọghachi azụ n'oge, nke nwere ike ibelata ihe egwu nke mbọ mbụ nke ST.EPC biology n'ọhịa nke imepụta stent bụ stent Genous nke CD34 na-ekpuchi antibody, nke nwere ike ijikọ EPCs na-agagharị site na akara hematopoietic ya iji melite re-endothelialization. Ọ bụ ezie na ọmụmụ ihe mbụ ahụ na-agba ume, ihe akaebe na-adịbeghị anya na-egosi na ọnụego TVR dị elu.40
N'ịtụle mmetụta ọjọọ nke ọgwụgwọ oge polima kpatara, nke jikọtara ya na ihe egwu nke ST, polima ndị a na-anabata nke ọma na-enye uru nke DES, na-ezere nchegbu ogologo oge gbasara ntachi obi polima. Ruo taa, a kwadola usoro dị iche iche nke bioabsorbable (dịka ọmụmaatụ Nobori na Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), mana akwụkwọ ndị na-akwado nsonaazụ ogologo oge ha pere mpe.41
Ihe ndị a na-amịkọrọ ihe ndị nwere ike ime ka mmadụ ghara ịmịkọrọ ihe nwere uru dị na mbụ inye nkwado igwe mgbe a tụlere mgbanwe elastic ma belata ihe egwu ogologo oge metụtara struts metal dị adị. Teknụzụ ọhụrụ edugala na mmepe nke polymers dabere na lactic acid (poly-l-lactic acid [PLLA]), mana ọtụtụ sistemụ stent ka na-etolite, ọ bụ ezie na ịchọpụta nguzozi zuru oke n'etiti mwepụ ọgwụ na mmebi ka bụ ihe ịma aka. Nnwale ABSORB gosipụtara nchekwa na irè nke everolimus-eluting PLLA stents.43 Ndozigharị stent nke ọgbọ nke abụọ nke Absorb bụ mmụba karịa nke gara aga yana ezigbo nleba anya afọ 2.44 Nnwale ABSORB II na-aga n'ihu, nnwale mbụ enweghị usoro atụnyere ntụnyere Absorb stent na Xience Prime stent, kwesịrị inye data ndị ọzọ, nsonaazụ mbụ dịnụ na-ekwe nkwa.45 Agbanyeghị, ọ dị mkpa ka edozi ntọala zuru oke, usoro ntinye kacha mma, na profaịlụ nchekwa maka mmerụ ahụ akwara obi nke ọma.
Thrombosis na BMS na DES anaghị arụpụta ihe dị mma n'ụlọ ọgwụ. N'akwụkwọ ndekọ nke ndị ọrịa natara DES, 47% nke ndị ọrịa ST butere ọnwụ, 60% site na MI na-anaghị egbu egbu, na 7% site na angina na-adịghị akwụsi ike. PCI n'oge mberede ST anaghị adịkarị mma, yana nlọghachi na 12% nke ndị ọrịa.48
ST Advanced nwere ike ibute nsogbu ahụike. N'ọmụmụ BASKET-LATE, ọnwa 6 ruo 18 mgbe etinyechara stent, ọnụọgụ ọnwụ obi na MI na-anaghị egbu egbu dị elu na otu DES karịa na otu BMS (4.9% na 1.3%, n'otu n'otu).20 Nyocha meta nke nnwale itoolu, ebe e tinyere ndị ọrịa 5,261 na SES, PES, ma ọ bụ BMS n'usoro, kọrọ na na afọ 4 nke nleba anya, SES (0.6% vs 0%, p=0.025) na PES (0.7%) mụbara ọnụọgụgụ nke ST n'oge na-adịghị anya ma e jiri ya tụnyere BMS site na 0.2%, p=0.028).49 N'ụzọ dị iche, na nyocha meta gụnyere ndị ọrịa 5,108, 21 a kọrọ mmụba 60% na ọnwụ ma ọ bụ MI na SES ma e jiri ya tụnyere BMS (p=0.03), ebe ejikọtara PES na mmụba 15% na-abụghị nke dị mkpa (Nleba anya ọnwa 9 ruo afọ 3).
Ọtụtụ ndebanye aha, nnwale ndị a na-eme n'usoro, na nyocha meta-analyses enyochaala ihe egwu dị na ST mgbe etinyere BMS na DES ma kọọ nsonaazụ na-emegiderịta onwe ha. N'ime ndekọ nke ndị ọrịa 6,906 na-anata BMS ma ọ bụ DES, enweghị ọdịiche na nsonaazụ ahụike ma ọ bụ ọnụego ST n'oge nleba anya afọ 1.48 N'ime ndekọ ọzọ nke ndị ọrịa 8,146, a chọpụtara na ihe egwu nke ST na-aga n'ihu dị 0.6%/afọ ma e jiri ya tụnyere BMS.49 Nyocha meta nke nnwale ndị na-atụnyere SES ma ọ bụ PES na BMS gosiri mmụba nke ihe egwu nke ọnwụ na MI na ọgbọ mbụ DES ma e jiri ya tụnyere BMS, 21 na nyocha meta-analyses ọzọ nke ndị ọrịa 4,545 nke a na-eme n'usoro na SES ma ọ bụ Enweghị ọdịiche na ọnọdụ nke ST n'etiti PES na BMS na afọ 4 nke nleba anya.50 Ọmụmụ ihe ndị ọzọ n'ụwa egosila mmụba nke ihe egwu nke ST na MI dị elu na ndị ọrịa na-anata DES ọgbọ mbụ mgbe akwụsịsịrị DAPT.51
N'ihi ihe akaebe ndị na-emegiderịta onwe ha, ọtụtụ nyocha na meta-analyses jikọtara ọnụ kpebiri na ọgbọ mbụ DES na BMS adịghị iche nke ukwuu n'ihe ize ndụ nke ọnwụ ma ọ bụ MI, mana SES na PES nwere nnukwu ihe ize ndụ nke ST dị elu ma e jiri ya tụnyere BMS. Iji nyochaa ihe akaebe dị, US Food and Drug Administration (FDA) họpụtara otu ndị ọkachamara53 nke wepụtara nkwupụta na-ekweta na ọgbọ mbụ DES dị irè maka ihe ngosi dị na akara ahụ nakwa na ihe ize ndụ nke ST dị elu dị obere mana obere. Mmụba dị ukwuu. N'ihi ya, FDA na otu ahụ na-akwado ịgbatị oge DAPT ruo otu afọ, ọ bụ ezie na enweghị data dị nta iji kwado nkwupụta a.
Dịka ekwuru na mbụ, e mepụtala DES nke ọgbọ nke abụọ nwere atụmatụ imewe dị elu. CoCr-EESs emeela ọmụmụ ihe gbasara ahụike kachasị ukwuu. Na nyocha meta nke Baber et al.54 gụnyere ndị ọrịa 17,101, CoCr-EES belatara nke ukwuu ST na MI doro anya/nwere ike ịbụ ma e jiri ya tụnyere PES, SES, na ZES mgbe ọnwa 21 gachara. N'ikpeazụ, Palmerini et al. gosiri na nyocha meta nke ndị ọrịa 16,775 na CoCr-EES nwere obere ST mbụ, mbubreyo, na afọ 2 nke doro anya ma e jiri ya tụnyere DES ndị ọzọ a gbakọtara ọnụ.55 Ọmụmụ ihe Real-world egosila mbelata na ihe egwu ST na CoCr-EES ma e jiri ya tụnyere ọgbọ mbụ DES.56
A tụnyere Re-ZES na CoCr-EES na nnwale RESOLUTE-AC na TWENTE. 33,57 Enweghị nnukwu ọdịiche dị na ọnụọgụ ọnwụ, nkụchi obi, ma ọ bụ ST doro anya n'etiti stents abụọ ahụ.
N'ime nyocha nke ndị ọrịa 50,844 gụnyere RCT 49, 58CoCr-EES jikọtara ya na obere mmụba nke ST doro anya karịa BMS, nsonaazụ a na-ahụbeghị na DES ndị ọzọ; mbelata ahụ abụghị naanị na mmalite dị mkpa na ụbọchị 30 (nha nhata [OR] 0.21, oge ntụkwasị obi 95% [CI] 0.11-0.42) nakwa na otu afọ (OR 0.27, 95% CI 0.08-0.74) na afọ 2 (OR 0.35, 95% CI 0.17–0.69). Ma e jiri ya tụnyere PES, SES, na ZES, ejikọtara CoCr-EES na obere mmụba nke ST na otu afọ.
ST mbụ metụtara ihe dị iche iche. Ọdịdị plaque na ibu thrombus yiri ka ọ na-emetụta ihe ndị a ga-esi na ya pụta mgbe PCI gasịrị; 59 Mbido miri emi nke strut n'ihi necrotic core (NC) prolapse, medial waves in the long stent, nkewa nke abụọ na oke fọdụrụ, ma ọ bụ mbelata oke dị mkpa stenting kacha mma, ntinye zuru oke, na mgbasawanye ezughị ezu60 Usoro ọgwụgwọ na ọgwụ antiplatelet anaghị emetụta oke nke ST mbụ: ihe omume nke nnukwu ST na subacute n'oge DAPT na nnwale enweghị usoro atụnyere BMS na DES Ọnụego yiri nke ahụ (<1%).61 Ya mere, ST mbụ yiri ka ọ bụ ihe metụtara mmerụ ahụ ọgwụgwọ na ihe ndị a na-awa ahụ.
Taa, a na-elekwasị anya kpọmkwem na ST n'oge/n'oge dị anya. Ọ bụrụ na ihe ndị dị na usoro na teknụzụ yiri ka ha na-arụ ọrụ dị mkpa na mmepe nke ST dị oke njọ na nke dị ala, usoro nke ihe ndị na-eme ka thrombotic ghara ịdị irè yiri ka ọ dị mgbagwoju anya karịa. A na-atụ aro na ụfọdụ njirimara ndị ọrịa nwere ike ịbụ ihe egwu maka ST dị elu na nke dị elu: ọrịa shuga mellitus, ACS n'oge ịwa ahụ mbụ, ọdịda akụrụ, afọ ndụ, mbelata nke ejection fraction, nnukwu ihe omume obi ọjọọ n'ime ụbọchị 30 nke ịwa ahụ mbụ. Maka BMS na DES, mgbanwe usoro, dị ka obere nha arịa ọbara, bifurcations, ọrịa polyvascular, calcification, mkpokọta mkpọchi, stents ogologo, yiri ka ejikọtara ya na ihe egwu nke ST dị elu.62,63 Enweghị nzaghachi zuru oke na ọgwụgwọ antiplatelet bụ nnukwu ihe egwu maka thrombosis dị elu DES 51. Nzaghachi a nwere ike ịbụ n'ihi enweghị nrapara nke onye ọrịa, oke dose, mmekọrịta ọgwụ, ihe ndị na-akpata mmeghachi omume ọgwụ, polymorphisms mkpụrụ ndụ ihe nketa na ọkwa nnabata (karịsịa iguzogide clopidogrel), na mmụba nke ụzọ mkpali platelet ndị ọzọ. A na-ewere neoatherosclerosis dị ka ihe dị mkpa usoro nke ọdịda stent n'oge, gụnyere ST64 nke ikpeazụ (ngalaba "In-stent neoatherosclerosis"). Endothelium ahụ na-adịghị agwụ agwụ na-ekewapụ mgbidi arịa thrombosis na stent struts site na ọbara ma na-ewepụta ihe ndị na-egbochi thrombosis na vasodilatory. DES na-ekpughe mgbidi arịa ahụ nye ọgwụ mgbochi mmụba na ikpo okwu ọgwụ na-ewepụ ihe dị iche iche na ọgwụgwọ na ọrụ endothelial, yana ihe egwu nke thrombosis n'oge ikpeazụ.65 Ọmụmụ ihe gbasara ọrịa na-atụ aro na polymers siri ike nke ọgbọ mbụ DES nwere ike itinye aka na mbufụt na-adịghị ala ala, nkwụnye fibrin na-adịghị ala ala, ọgwụgwọ endothelial na-adịghị mma, na nnukwu ihe egwu nke thrombosis.3 Mmetụta mberede na DES yiri ka ọ bụ usoro ọzọ na-eduga na ST.Virmani et al66 kọrọ nchọpụta mgbe nwụchara nwụchara na-egosi mmụba aneurysm na ngalaba stent yana mmeghachi omume hypersensitivity mpaghara nke mejupụtara T lymphocytes na eosinophils; Nchọpụta ndị a nwere ike igosipụta mmetụta nke polima ndị na-adịghị agbaze agbaze.67 Nsogbu stent nwere ike ịbụ n'ihi mmụba stent na-adịghị mma ma ọ bụ mee ọnwa ole na ole ka PCI gasịrị. Ọ bụ ezie na nsogbu usoro bụ ihe egwu maka ST dị oke njọ na nke dị ala, mkpa ahụike nke nsogbu stent enwetara nwere ike ịdabere na mgbanwe akwara siri ike ma ọ bụ ọgwụgwọ egbu oge nke ọgwụ kpatara, mana mkpa ahụike ya na-arụ ụka.68
Mmetụta nchebe nke DES nke ọgbọ nke abụọ nwere ike ịgụnye endothelialization ngwa ngwa na nke na-adịghị agbanwe agbanwe, yana ọdịiche dị na stent alloy na nhazi, ọkpụrụkpụ strut, njirimara polymer, na ụdị ọgwụ mgbochi proliferative, dose, na kinetics.
Ma e jiri ya tụnyere CoCr-EES, obere stent struts cobalt-chromium (81 µm), antithrombotic fluoropolymers, obere polymer, na ibu ọgwụ nwere ike itinye aka na obere ọnụọgụ nke ST. Ọmụmụ ihe nnwale egosila na thrombosis na platelet nke stents a kpuchiri fluoropolymer dị obere nke ukwuu karịa nke stents ígwè efu.69 Ma DES ọgbọ nke abụọ ndị ọzọ nwere ihe ndị yiri ya kwesịrị ịmụkwu ihe.
Ngwụcha afọ 1990, a na-eji usoro ọgwụgwọ akwara obi eme ka ọ dịkwuo mma ma e jiri ya tụnyere usoro ọgwụgwọ akwara obi (PTCA) nke nwere nsogbu dị iche iche (mkpuchi akwara ọbara, mwepụ akwara, wdg) yana oke mbelata ọbara (ruo 40%–50% nke ikpe). Ka ọ na-erule ngwụcha afọ 1990, e jiri usoro ọgwụgwọ BMS mee ihe fọrọ nke nta ka ọ bụrụ 70% nke PCI.70
Agbanyeghị, n'agbanyeghị ọganihu na teknụzụ, usoro, na ọgwụgwọ ahụike, ihe egwu nke restenosis mgbe etinyere BMS dị ihe dị ka 20%, yana ihe karịrị 40% na obere ndị otu.71 N'ozuzu, ọmụmụ ihe ahụike egosila na restenosis mgbe etinyere BMS, dịka nke a hụrụ na PTCA nkịtị, na-arị elu mgbe ọnwa 3-6 gachara ma na-akwụsị mgbe otu afọ gasịrị.72
DES na-ebelatakwa ohere nke ISR,73, ọ bụ ezie na mbelata a dabere na angiography na ọnọdụ ahụike. Mkpuchi polymer dị na DES na-ewepụta ihe ndị na-egbochi mbufụt na mgbochi mmụba, na-egbochi mmepe nke neointima, ma na-egbu oge usoro ndozi akwara ruo ọnwa ruo afọ.74 A hụrụ uto neointimal na-adịgide adịgide n'oge nleba anya ogologo oge mgbe etinyere DES, ihe a maara dị ka "ịnyachi azụ n'oge", na ọmụmụ ihe ahụike na histological. 75
Mmerụ ahụ akwara n'oge PCI na-emepụta usoro dị mgbagwoju anya nke mbufụt na ndozi n'ime obere oge (izu ruo ọnwa), na-eduga na endothelialization na mkpuchi neointimal. Dịka nchọpụta histopathological si kwuo, neointimal hyperplasia (BMS na DES) mgbe etinyere stent bụ ihe mejupụtara mkpụrụ ndụ akwara dị nro na-agbasa na matrix extracellular nke bara ọgaranya na proteoglycan.70
Ya mere, hyperplasia neointimal na-anọchite anya usoro ndozi nke gụnyere coagulation na ihe mkpali yana mkpụrụ ndụ ndị na-akpali mmụba nke mkpụrụ ndụ akwara dị nro na nhazi matrix extracellular. Ozugbo PCI gasịrị, platelets na fibrin na-etinye na mgbidi arịa ahụ ma na-anakọta leukocytes site na usoro nke mkpụrụ ndụ njikọta sel. Leukocytes na-agagharị na-ejikọ na platelets na-arapara site na mmekọrịta dị n'etiti leukocyte integrin Mac-1 (CD11b/CD18) na platelet glycoprotein Ibα 53 ma ọ bụ fibrinogen nke ejikọtara na platelet glycoprotein IIb/IIIa.76,77
Dịka data na-apụta si kwuo, mkpụrụ ndụ progenitor sitere na ụmị ọkpụkpụ na-etinye aka na nzaghachi akwara na usoro ndozi. Ịkwalite EPC site na ụmị ọkpụkpụ gaa na ọbara dị n'akụkụ na-akwalite mmụgharị endothelial na neovascularization mgbe amuchara nwa. O yiri ka mkpụrụ ndụ progenitor akwara dị nro (SMPC) na-akwaga ebe mmerụ ahụ akwara dị, na-eduga na mmụba neointimal.78 Na mbụ, a na-ewere mkpụrụ ndụ CD34 dị ka ndị nwere EPC; ọmụmụ ihe ndị ọzọ egosila na antigen elu CD34 na-amata mkpụrụ ndụ stem nke ọkpụkpụ dị iche iche nwere ike ịmata ọdịiche dị na EPC na SMPC. Mgbanwe nke mkpụrụ ndụ CD34 dị mma na usoro EPC ma ọ bụ SMPC dabere na gburugburu ebe obibi; ọnọdụ ischemic na-akpali ọdịiche gaa na phenotype EPC iji kwalite re-endothelialization, ebe ọnọdụ mkpali na-akpali ọdịiche gaa na phenotype SMPC iji kwalite mmụba neointimal.79
Ọrịa shuga na-eme ka ohere nke ISR dịkwuo elu site na 30%–50% mgbe etinyere BMS, 80 na mmụba nke restenosis n'ime ndị ọrịa shuga ma e jiri ya tụnyere ndị ọrịa na-abụghị ndị ọrịa shuga ka nọgidere n'oge DES. Usoro ndị dị n'okpuru ihe a nwere ike ịbụ ọtụtụ ihe, gụnyere sistemụ (dịka ọmụmaatụ, mgbanwe na nzaghachi mkpali) na anatomical (dịka ọmụmaatụ, obere arịa dị n'obosara, ọnya ndị dị ogologo, ọrịa na-agbasa, wdg) ihe ndị na-eme ka ọ dịkwuo elu n'adabereghị onwe ya Ihe egwu nke ISR.70
Dayameta akwara na ogologo mmerụ ahụ metụtara ọnọdụ ISR n'adabereghị onwe ya, ebe obere dayameta/obere mmerụ ahụ na-abawanye ọnụego restenosis nke ukwuu ma e jiri ya tụnyere nnukwu dayameta/obere mmerụ ahụ.71
Ngwugwu stent nke ọgbọ mbụ gosipụtara stent struts dị arọ na ọnụego ISR dị elu ma e jiri ya tụnyere ngwugwu stent nke ọgbọ nke abụọ nwere stut dị gịrịgịrị.
Tinyere nke ahụ, ihe gbasara restenosis metụtara ogologo stent, ya na ogologo stent karịrị 35 mm ihe fọrọ nke nta ka ọ bụrụ okpukpu abụọ karịa ndị ahụ na-erughị 20 mm. Dayameta lumen kacha nta nke stent ikpeazụ rụkwara ọrụ dị mkpa: obere dayameta lumen kacha nta ikpeazụ buru amụma na ihe egwu restenosis ga-abawanye nke ukwuu.81,82
Dịka ọ dị na mbụ, a na-ewere hyperplasia intimal mgbe etinyere BMS n'ime ahụ ka ọ kwụsiri ike, yana oke mmalite n'etiti ọnwa isii na otu afọ, wee soro ya oge dị jụụ. A kọrọ na mbụ na uto intimal dị elu, wee soro ya na mmụba intimal na mmụba lumen ọtụtụ afọ mgbe etinyere stent; 71 ntozu okè nke mkpụrụ ndụ akwara dị nro na mgbanwe na matrix extracellular ka atụpụtara dị ka usoro enwere ike maka nlọghachi neointimal late .83 Agbanyeghị, ọmụmụ ihe nwere nleba anya ogologo oge egosila mmeghachi omume triphasic mgbe etinyechara BMS, yana restenosis mbụ, nlọghachi etiti, na restenosis late lumen.84
N'oge DES, e gosipụtara uto neointimal n'oge na mbụ mgbe etinyere SES ma ọ bụ PES n'ime ụdị anụmanụ.85 Ọtụtụ ọmụmụ IVUS egosila mbelata mmalite nke uto intimal na-esote oge mgbe etinyere SES ma ọ bụ PES, ikekwe n'ihi usoro mkpali na-aga n'ihu.86
N'agbanyeghị "nkwụsi ike" nke a na-ejikarị eme ihe na ISR, ihe dị ka otu ụzọ n'ụzọ atọ nke ndị ọrịa BMS ISR na-enweta ACS.4
E nwere ihe akaebe na-egosi na mbufụt na-adịghị ala ala na/ma ọ bụ enweghị ike zuru oke na endothelial na-akpata neoatherosclerosis dị elu n'ime BMS na DES (karịsịa DES nke ọgbọ mbụ), nke nwere ike ịbụ usoro dị mkpa maka ISR dị elu ma ọ bụ ST dị elu. 87 kọrọ nchọpụta histological site na ihe nlele nyocha ozu mgbe etinyere Palmaz-Schatz coronary stents, na-atụ aro na mbufụt peri-stent nwere ike ime ka mgbanwe atherosclerotic ọhụrụ na-adịghị mma dị ngwa ngwa n'ime stent. Ọmụmụ ihe ndị ọzọ 10 egosila na anụ ahụ restenotic dị n'ime BMS, ihe karịrị afọ 5, nwere atherosclerosis ọhụrụ na-apụta, yana mbufụt peri-stent ma ọ bụ na-enweghị ya; Ihe nlele sitere na ikpe ACS na-egosi ihe ndị na-adịghị ike na akwara obi. Ọdịdị histological nke ngọngọ ahụ nwere macrophages ụfụfụ na kristal cholesterol. Na mgbakwunye, mgbe a na-atụnyere BMS na DES, a hụrụ nnukwu ọdịiche na oge mmepe nke atherosclerosis ọhụrụ.11,12 Mgbanwe atherosclerotic mbụ na ntinye macrophage ụfụfụ malitere ọnwa anọ mgbe etinyere SES, ebe mgbanwe ndị ahụ na ọnya BMS mere afọ 2 ka e mesịrị ma nọgide na-abụ ihe a na-ahụkarị ruo afọ 4. Ọzọkwa, DES stenting maka ọnya ndị na-adịghị akwụsi ike dị ka fibroatherosclerosis dị gịrịgịrị (TCFA) ma ọ bụ mgbawa intimal nwere obere oge mmepe ma e jiri ya tụnyere BMS. Ya mere, neoatherosclerosis yiri ka ọ na-adịkarị ma na-eme na mbụ na DES nke ọgbọ mbụ karịa na BMS, ikekwe n'ihi ọrịa dị iche.
Mmetụta nke ọgbọ nke abụọ DES ma ọ bụ DES n'ime mmepe ka dị mkpa ịmụ; ọ bụ ezie na ụfọdụ ihe ndị e kwurula banyere ọgbọ nke abụọ DESs88 na-egosi obere mbufụt, ihe gbasara neoatherosclerosis yiri nke ọgbọ nke mbụ, mana a ka chọrọ nnyocha ọzọ.