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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Tari Cardiology, Poliambulanza Foundation Hospital, Brescia, 2 Tari Cardiology, Catholic University of the Sacred Heart of Rome, Italy Whakarāpopototanga: Ka whakaitihia e ngā Stents Drug-Eluting (DES) ngā herenga o ngā stents konganuku tahanga (BMS) i muri i te wawaotanga coronary percutaneous. Heoi, ahakoa te ahua nei kua whakaōritehia tēnei āhuatanga e te whakaurunga o te DES o te reanga tuarua ki te DES o te reanga tuatahi, kei te mau tonu ngā āwangawanga nui mō ngā raruraru pea o muri mai o te whakaurunga stent, pērā i te stent thrombosis (ST) me te tango stent. Ko te Stenosis (ISR). He āhuatanga kino pea te ST, ā, kua tino whakaitihia mā te whakamahi i te stenting kua arotauhia, ngā hoahoa stent hou, me te rongoā antiplatelet takirua. Kei te tirotirohia te tikanga tika e whakamārama ana i tōna putanga mai, ā, he pono, he maha ngā āhuatanga e whai kawenga ana. I mua, i whakaarohia te ISR i roto i te BMS he āhua pumau me te tihi wawe o te intimal hyperplasia (i te 6 marama) ā, ka whai ake ko te wā whakahekenga neke atu i te 1 tau. He rerekē, i whakaatuhia e ngā rangahau haumanu me ngā rangahau histological o ngā DES he taunakitanga mō te tipu neointimal tonu i te wā o te aroturukitanga roa, he āhuatanga e mōhiotia ana ko te āhuatanga "late catch-up". Ko te whakaaro he āhua haumanu pai te ISR kua werohia tata nei e ngā taunakitanga ka pāngia pea ngā tūroro me te ISR e ngā mate coronary acute. Ko te whakaahua intracoronary he tikanga whakaeke e taea ai te tautuhi i ngā papa atherosclerotic stent me ngā āhuatanga o te whakaora oko toto i muri i te stent; He maha ngā wā ka whakamahia hei whakaoti i te angiography coronary diagnostic me te akiaki i ngā tikanga wawaotanga. Ko te tomography coherence optical intracoronary e kiia ana ko te tikanga whakaahua tino matatau. Ki te whakatauritea ki te ultrasound intravascular, he pai ake te whakataunga (neke atu i te 10 ngā wā), e āhei ai te whakaahua taipitopito o te hanganga mata o te pakitara o te oko toto. Ko ngā rangahau whakaahua "In vivo" e rite ana ki ngā kitenga histological e kī ana ko te mumura mau tonu me/ranei te ngoikore o te endothelial ka puta te neo-atherosclerosis i te wā mutunga i roto i te BMS me te DES. Nō reira, kua noho te neo-atherosclerosis hei whakapae matua mō te pathogenesis o te rahunga o te stent mutunga. Ngā Kupumatua: stent coronary, stent thrombosis, restenosis, neoatherosclerosis
Ko te wawaotanga o te ngakau ā-kiri (PCI) me te whakaurunga stent te tikanga e whakamahia whānuitia ana mō te rongoā i ngā tohumate o te mate uaua ngakau, ā, kei te whanake tonu te tikanga.1 Ahakoa ka whakaitihia e ngā stent eluting drug (DES) ngā herenga o ngā stent bare-metal (BMS), tera pea ka puta ngā raruraru tōmuri pērā i te stent thrombosis (ST) me te in-stent restenosis (ISR) me te whakaurunga stent. , kei te mau tonu ngā āwangawanga nui.2-5
Mena he aituā kino pea te ST, kua whakahēngia te mōhiotanga he mate ngāwari te ISR e ngā taunakitanga o te mate pūkahukahu acute (ACS) i roto i ngā tūroro ISR.4
I ēnei rā, ko te intracoronary optical coherence tomography (OCT)6-9 e kiia ana ko te tikanga whakaahua hou rawa atu, e tuku ana i te taumira pai ake i te intravascular ultrasound (IVUS). "Ko ngā rangahau whakaahua in vivo",10-12 e rite ana ki ngā kitenga histological, e whakaatu ana i tētahi tikanga "hou" o te urupare vascular i muri i te whakaurunga stent, me te "neoatherosclerosis" de novo i roto i te BMS me te DES.
I te tau 1964, i whakaahuahia e Charles Theodore Dotter rāua ko Melvin P Judkins te angioplasty tuatahi. I te tau 1978, i whakahaerehia e Andreas Gruntzig te angioplasty poihau tuatahi (te angioplasty poihau tawhito noa); he maimoatanga hou engari he ngoikoretanga o te katinga tere o ngā oko toto me te restenosis.13 Nā tēnei i ārahi te kitenga o ngā stent coronary: I whakatinanahia e Puel rāua ko Sigwart te stent coronary tuatahi i te tau 1986, me te whakarato i te stent hei ārai i te katinga tere o ngā oko toto me te whakahokinga systolic tōmuri.14 Ahakoa i āraihia e ēnei stent tuatahi te katinga ohorere o te oko toto, i puta he kino nui ki te endothelial me te mumura. I muri mai, e rua ngā whakamātautau nui, ko te Belgian-Dutch Stent Trial 15 me te Stent Restenosis Study 16, i tautoko i te haumaru o te stenting me te rongoā antiplatelet takirua (DAPT) me/ranei ngā tikanga whakatinanatanga tika.17,18 I muri i ēnei whakamātautau, i piki ake te maha o ngā PCI i mahia.
Heoi, i tere te tautuhi i te raruraru o te iatrogenic in-stent neointimal hyperplasia whai muri i te whakatakotoranga BMS, ka hua ake te ISR i roto i te 20%–30% o ngā whara i rongoatia. I te tau 2001, i whakaurua mai te DES19 hei whakaiti i te hiahia mō te restenosis me te wawaotanga anō. Kua whakanui ake te DES i te whakapono o ngā tākuta ngakau, ā, ka taea te whakanui ake i te maha o ngā whara uaua kia rongoatia i whakaarohia i mua ka whakatauhia mā te coronary artery bypass grafting. I te tau 2005, 80%–90% o ngā PCI katoa i haere tahi me te DES.
He ngoikoretanga tō te katoa, ā, mai i te tau 2005, kua piki ake ngā āwangawanga mō te haumaru o ngā DES "whakatipuranga tuatahi", ā, kua whakawhanakehia, kua whakaurua mai hoki ngā stent o te whakatupuranga hou pērā i te 20,21.22 Mai i taua wā, kua tere te tipu o ngā mahi hei whakapai ake i te mahi stent, ā, kua tere tonu te kitea me te kawe mai i ngā hangarau hou, miharo ki te mākete.
He ngongo waea angiangi te BMS. Whai muri i te wheako tuatahi ki te maunga "Wall", te maunga Gianturco-Roubin me te maunga Palmaz-Schatz, he maha ngā momo BMS e wātea ana inaianei.
E toru ngā momo hoahoa e taea ana: te koiri, te mata ngongo me te ngongo kōhao. Ko ngā hoahoa koiri he waea whakarewa, he rīpene rānei kua hangaia kia rite ki te āhua koiri porowhita; ko ngā hoahoa mata ngongo he waea kua takai tahitia ki roto i te mata hei hanga ngongo; ko ngā hoahoa ngongo kōhao he ngongo whakarewa kua tapahia ki te laser. He rerekē te hanganga o ēnei taputapu (he kowiri tira, he nichrome, he cobalt chrome), he hoahoa hanganga (he rerekē ngā tauira me ngā whānui o te pou, ngā diameter me ngā roa, te kaha radial, te radiopacity) me ngā pūnaha tuku (ka taea te whakawhanui i a ia anō, te whakawhanui rānei i te poihau).
Ko te tikanga, he koranu cobalt-chromium te mea hanga o te BMS hou, ā, ko te hua he angiangi ake ngā pou me te pai ake o te whakatere, kia mau tonu ai te kaha ā-ringa.
He papa stent whakarewa ēnei (he kowiri tira te nuinga) ā, he mea pani ki te polymer e ārai ana i ngā rongoā ārai-whakatipu me/ranei ārai-mumura.
I hangaia tuatahitia a Sirolimus (e mōhiotia ana ko te rapamycin) hei rongoā harore. Ko tana tikanga mahi e ahu mai ana i te aukati i te ahunga whakamua o te huringa pūtau mā te aukati i te whakawhiti mai i te wāhanga G1 ki te wāhanga S me te aukati i te hanganga neointima. I te tau 2001, i whakaatuhia e te wheako "tuatahi-i-te-tangata" me te SES he hua pai, i arahina ki te whanaketanga o te stent Cypher.23 I whakaatuhia e ngā whakamātautau nui tōna whai huatanga ki te aukati i te ISR. E rua tekau mā whā
I whakaaetia tuatahitia a Paclitaxel mō te mate pukupuku ovarian, engari ko ōna āhuatanga cytostatic kaha - ka whakaū te rongoā i ngā microtubules i te wā mitosis, ka arahi ki te aukati i te huringa pūtau me te aukati i te hanganga neo-intimal - ka waiho hei matū mō te Taxus Express PES. I whakaatuhia e ngā whakamātautau TAXUS V me VI te whai huatanga roa o te PES i roto i ngā mate uaua coronary tino mōrearea, uaua.25,26 Ko te TAXUS Liberté i muri mai i whakaatu i tētahi papa maitai kore waikura mō te tuku ngāwari ake.
E whakaatu ana ngā taunakitanga whakamutunga mai i ngā arotake pūnaha e rua me ngā tātaritanga-meta he painga tō te SES i te PES nā te iti o ngā reiti ISR ​​me te whakahounga o ngā oko toto ūnga (TVR), me te ia o te pikinga o te infarction myocardial acute (AMI) i roto i te rōpū PES. 27,28
Kua whakaitihia te matotoru o ngā taputapu o te whakatipuranga tuarua, kua pai ake te ngāwari/te tuku, kua whakarei ake i te hototahitanga koiora o te polymer/ngā kōtaha whakaputanga rongoā, ā, he pai rawa atu te kaha o te whakahounga-endothelialization. I roto i ngā mahi o nāianei, koinei ngā hoahoa DES tino matatau me ngā stent coronary nui kua whakatōkia puta noa i te ao.
Ko Taxus Elements tētahi atu whanaketanga me tētahi pūhui ahurei i hangaia hei whakanui ake i te tukunga wawe me tētahi pūnaha tautoko konukawata-kromium hou e whakarato ana i ngā tautoko angiangi me te whakanui ake i te kaha o te irahiko. I kitea i roto i te whakamātautau PERSEUS 29 ngā hua ōrite i waenga i a Element me Taxus Express tae atu ki te 12 marama. Heoi, kāore i te rawaka ngā whakamātautau e whakataurite ana i ngā huānga yew me ētahi atu DES o te whakatupuranga tuarua.
Ko te zotarolimus-eluting stent (ZES) Endeavor e hangai ana ki tētahi papa stent cobalt-chromium kaha ake, he nui ake te ngāwari me te iti ake o te rahi o te stent. Ko te Zotarolimus he rite ki te sirolimus me ngā pānga ārai mate rite engari he nui ake te lipophilicity hei whakarei ake i te rohe o te pakitara oko toto. Ka whakamahia e te ZES tētahi paninga polymer phosphorylcholine hou i hangaia hei whakanui ake i te biocompatibility me te whakaiti i te mumura. Ko te nuinga o ngā rongoā ka tukuna i te wā tuatahi o te whara, ā, ka whai ake ko te whakatikatika uaua. Whai muri i te whakamātautau ENDEAVOR tuatahi, i whakaritea e te whakamātautau ENDEAVOR III i muri mai a ZES ki te SES, i whakaatu i te ngaronga lumen mutunga nui me te ISR engari he iti ake ngā kaupapa kino nui o te cardiovascular (MACE) i te SES.30 I kitea anō e te whakamātautau ENDEAVOR IV, i whakaritea a ZES ki te PES, he nui ake te auau o te ISR, engari he iti ake te auau o te AMI, mai i te ST tino matatau i roto i te rōpū ZES.31 Heoi, i rahua te whakamātautau PROTECT ki te whakaatu i te rerekētanga o ngā reiti ST i waenga i ngā stents Endeavor me Cypher.32
Ko te Endeavor Resolute he putanga whakapai ake o te stent Endeavor me te polymer papa-toru hou. Ko te Resolute Integrity hou (e kiia ana ko te DES tuatoru o ngā whakatupuranga) e ahu mai ana i tētahi tūāpapa hou me ngā āheinga tuku teitei ake (te tūāpapa Integrity BMS), ā, ka taea e tētahi polymer papa-toru hou, he pai ake te biocompatible, te pehi i te urupare mumura tuatahi me te whakakore i te nuinga o te rongoā i roto i ngā rā 60 e whai ake nei. I whakaatuhia e tētahi whakamātautau e whakataurite ana i a Resolute ki a Xience V (everolimus-eluting stent [EES]) te kore ngoikore o te pūnaha Resolute i runga i te mate me te korenga o te whara ūnga.33,34
Ko Everolimus, he mea i ahu mai i te sirolimus, he aukati huringa pūtau anō hoki e whakamahia ana i roto i te whanaketanga o te Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform) EES. I whakaatuhia e te whakamātautau SPIRIT 35-37 te pai ake o te mahi me te whakaiti i te MACE me te Xience V ki te whakataurite ki te PES, i te mea i whakaatuhia e te whakamātautau EXCELLENT kāore te EES i te iti iho i te SES i te pehi i te ngaronga mutunga i te 9 marama me ngā huihuinga haumanu i te 12 marama.38 Hei whakamutunga, i whakaatuhia e te stent Xience ngā painga ki te BMS i roto i te horopaki o te infarction myocardial (MI) e whakanui ana i te wāhanga ST.39
Ko ngā EPC he huinga iti o ngā pūtau e rere ana i roto i te toto e uru ana ki te homeostasis vascular me te whakatikatika endothelial. Mā te whakarei ake i ngā EPC i te wāhi i whara ai te toto ka whakatairanga i te re-endothelialization wawe, ka whakaiti pea i te mōrearea o te ST. Ko te ngana tuatahi a te koiora EPC i roto i te mara o te hoahoa stent ko te stent Genous kua pania ki te antibody CD34, ka taea te here i ngā EPC e rere ana i roto i ōna tohu hematopoietic hei whakarei ake i te re-endothelialization. Ahakoa he whakatenatena ngā rangahau tuatahi, e tohu ana ngā taunakitanga hou ki ngā reiti teitei o te TVR.40
I runga i ngā pānga kino pea o te whakaora whakaroa i puta mai i te polymer, e pā ana ki te mōrearea o te ST, ka tukuna e ngā polymer bioabsorbable ngā painga o te DES, ka karohia ngā āwangawanga roa mō te pumau o te polymer. Tae noa ki tēnei wā, kua whakaaetia ngā pūnaha bioabsorbable rerekē (hei tauira, Nobori me Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), engari he iti noa ngā tuhinga e tautoko ana i ō rātou hua mō te wā roa.41
Ko ngā rauemi mimiti koiora he painga ariā o te whakarato i te tautoko ā-ringa i te tīmatanga ina whakaarohia te hokinga whakamuri tere me te whakaiti i ngā mōrearea roa e pā ana ki ngā pou whakarewa o nāianei. Kua arahina e ngā hangarau hou te whanaketanga o ngā polymer e hangai ana ki te waikawa lactic (poly-l-lactic acid [PLLA]), engari he maha ngā pūnaha stent kei te whanakehia, ahakoa he wero tonu te whakatau i te taurite pai i waenga i te whakaputanga rongoā me te nekehanga whakahekenga. I whakaatuhia e te whakamātautau ABSORB te haumaru me te whai huatanga o ngā stent PLLA e whakamahi ana i te everolimus.43 Ko te whakahoutanga o te stent Absorb o te whakatupuranga tuarua he whakapainga ake i te mea o mua me te whai muri i te 2 tau pai.44 Ko te whakamātautau ABSORB II e haere tonu ana, te whakamātautau matapōkere tuatahi e whakataurite ana i te stent Absorb ki te stent Xience Prime, me whakarato i ētahi atu raraunga, ā, he mea whakamīharo ngā hua tuatahi e wātea ana.45 Heoi, me mārama ake te tautuhinga pai, te tikanga whakauru pai, me te kōtaha haumaru mō ngā whara o te ngakau.
He kino ngā putanga haumanu o te thrombosis i roto i te BMS me te DES. I roto i tētahi rēhita o ngā tūroro e whiwhi ana i te whakaurunga DES,47 24% o ngā take ST i mate, 60% mai i te MI kore-mate, me te 7% mai i te angina kore pumau. Ko te PCI i roto i te ST ohorere he iti iho i te pai, me te hokinga mai i roto i te 12% o ngā take.48
He kino pea ngā hua haumanu o te ST matatau. I roto i te rangahau BASKET-LATE, 6 ki te 18 marama i muri i te whakatakotoranga o te stent, he teitei ake ngā reiti mate ngakau me te MI kore-mate i roto i te rōpū DES i te rōpū BMS (4.9% me te 1.3%, ia).20 I roto i tētahi tātaritanga-maha o ngā whakamātautau e iwa, i reira 5,261 ngā tūroro i whakaritea matapōkeretia ki te SES, PES, BMS rānei, i kōrero i te 4 tau o te aroturukitanga, ko te SES (0.6% vs 0%, p=0.025) me te PES (0.7%) ) i whakapiki ake i te auau o te ST tino mutunga ki te BMS mā te 0.2%, p=0.028).49 I tētahi rerekētanga, i roto i tētahi tātaritanga-maha tae atu ki te 5,108 ngā tūroro, 21 i kōrerohia he pikinga whanaunga 60% o te mate, te MI rānei me te SES ki te BMS (p=0.03), engari ko te PES i honoa ki te pikinga kore-tino 15% (Aroturukitanga 9 marama ki te 3 tau).
He maha ngā rēhita, ngā whakamātautau matapōkere, me ngā tātaritanga-meta kua rangahau i te mōrearea whanaunga o te ST i muri i te whakaurunga BMS me te DES, ā, kua pūrongohia ngā hua taupatupatu. I roto i tētahi rēhita o ngā tūroro 6,906 e whiwhi ana i te BMS, i te DES rānei, kāore he rerekētanga o ngā putanga haumanu, o ngā reiti ST rānei i te wā o te aroturukitanga 1-tau.48 I roto i tētahi atu rēhita o ngā tūroro 8,146, i kitea te mōrearea o te ST nui rawa atu he 0.6%/tau ki te whakataurite ki te BMS.49 I whakaatuhia e tētahi tātaritanga-meta o ngā whakamātautau e whakataurite ana i te SES, i te PES rānei ki te BMS he nui ake te mōrearea o te mate me te MI me te DES o te whakatupuranga tuatahi ki te whakataurite ki te BMS, 21 me tētahi atu tātaritanga-meta o ngā tūroro 4,545 i matapōkeretia ki te SES, ki te BMS rānei. Kāore he rerekētanga o te auau o te ST i waenga i te PES me te BMS i te 4 tau o te aroturukitanga.50 Kua whakaatuhia e ētahi atu rangahau o te ao tūturu he nui ake te mōrearea o te ST me te MI matatau i roto i ngā tūroro e whiwhi ana i te DES o te whakatupuranga tuatahi i muri i te whakamutua o te DAPT.51
I runga i ngā taunakitanga taupatupatu, he maha ngā tātaritanga me ngā meta-tātaritanga i whakatau ko te DES me te BMS o te whakatupuranga tuatahi kāore i tino rerekē te mōrearea o te mate, o te MI rānei, engari he nui ake te mōrearea o te SES me te PES ki te ST tino matatau ki te BMS. Hei arotake i ngā taunakitanga e wātea ana, i whakatūria e te US Food and Drug Administration (FDA) tētahi rōpū tohunga53 i whakaputa i tētahi kōrero e whakaae ana he whai hua te DES o te whakatupuranga tuatahi mō ngā tohu kei runga i te tapanga, ā, he iti noa te mōrearea o te ST tino matatau. He pikinga nui. Nō reira, e taunaki ana te FDA me te whakahaere kia whakaroahia te wā DAPT ki te 1 tau, ahakoa he iti noa ngā raraunga hei tautoko i tēnei kereme.
E ai ki te kōrero i mua ake nei, kua whakawhanakehia ngā DES o te reanga tuarua me ngā āhuatanga hoahoa matatau. Ko ngā CoCr-EES te hunga i whai i ngā rangahau haumanu tino whānui. I roto i tētahi tātaritanga-maha nā Baber et al,54 tae atu ki te 17,101 tūroro, i whakaitihia e te CoCr-EES te ST me te MI tino/tūpono ki te PES, SES, me te ZES i muri i te 21 marama. Hei whakamutunga, i whakaatu a Palmerini et al i roto i tētahi tātaritanga-maha o te 16,775 tūroro he iti ake te ST tino wawe, te mutunga, te 1- me te 2-tau o CoCr-EES ki te whakataurite ki ētahi atu DES kua whakakotahihia.55 Kua whakaatuhia e ngā rangahau o te ao tūturu he whakaiti i te mōrearea ST me te CoCr-EES ki te whakataurite ki te DES o te reanga tuatahi.56
I whakaritea a Re-ZES ki a CoCr-EES i roto i ngā whakamātautau RESOLUTE-AC me TWENTE.33,57 Kāore he rerekētanga nui i roto i te auau o te mate, te mate ngakau, te ST tino tika rānei i waenga i ngā stent e rua.
I roto i tētahi tātaritanga whatunga o ngā tūroro 50,844 tae atu ki te 49 RCT, i honoa te 58CoCr-EES ki tētahi putanga iti iho o te ST tino tika i te BMS, he hua kāore i kitea i roto i ētahi atu DES; kāore i kitea te whakahekenga i roto i te Hiranga wawe me te 30 rā anake (ōwehenga ōwehenga [OR] 0.21, 95% wā whakawhirinaki [CI] 0.11-0.42) me te 1 tau hoki (OR 0.27, 95% CI 0.08-0.74) me te 2 tau (OR 0.35, 95% CI 0.17–0.69). Ki te whakatauritea ki te PES, SES, me te ZES, i honoa te CoCr-EES ki tētahi putanga iti iho o te ST i te 1 tau.
He rerekē ngā āhuatanga o te ST wawe. Ko te āhua o te papa me te taumaha o te thrombus te āhua nei he pānga ki ngā putanga i muri i te PCI; 59 Te hohonu ake o te urunga o te strut nā te necrotic core (NC) prolapse, ngā haehae o roto i te roa o te stent, te wehenga tuarua me ngā taha toenga, te whaiti nui rānei o te taha Ko te stenting tino pai, te apposition kāore i oti, me te whānui kāore i oti60 Ko te tikanga maimoatanga me ngā rongoā antiplatelet kāore e tino pā ki te auau o te ST wawe: ko te auau o te ST whakapeka me te subacute i te wā o te DAPT i roto i tētahi whakamātautau matapōkere e whakarite ana i te BMS me te DES He rite tonu ngā reiti (<1%).61 Nō reira, ko te ST wawe te āhua nei he pānga matua ki ngā whara rongoā me ngā āhuatanga pokanga.
I ēnei rā, he arotahi motuhake kei te ST mutunga/tino mutunga. Mena he mea nui te mahi a ngā āhuatanga tukanga me ngā āhuatanga hangarau ki te whanaketanga o te ST whakapeka me te ST iti, he uaua ake te tikanga o ngā huihuinga thrombotic whakaroa. Kua whakaarohia ko ētahi āhuatanga o te tūroro he mea mōrearea pea mō te ST matatau me te ST tino matatau: te mate huka mellitus, te ACS i te wā o te pokanga tuatahi, te ngoikore o te whatukuhu, te koroheketanga, te whakahekenga o te wāhanga ejection, ngā huihuinga ngakau kino nui i roto i ngā rā 30 o te pokanga tuatahi. Mō te BMS me te DES, ko ngā taurangi tukanga, pēnei i te rahi o te oko toto iti, ngā wehenga, te mate polyvascular, te calcification, te aukati katoa, ngā stents roa, te āhua nei e hono ana ki te mōrearea o te ST matatau.62,63 Ko te kore e ranea te urupare ki te rongoā antiplatelet he mea mōrearea nui mō te thrombosis DES matatau 51. Tērā pea nā te kore piri o te tūroro, te iti o te horopeta, ngā taunekeneke rongoā, ngā mate tāpiri e pā ana ki te urupare rongoā, ngā polymorphisms ira i te taumata kaiwhiwhi (ina koa te ātete clopidogrel), me te pikinga ake o ētahi atu ara whakahohenga pereti. Ko te neoatherosclerosis in-stent e kiia ana he tikanga nui o te wā whakamutunga. te korenga o te stent, tae atu ki te ST64 mutunga (wāhanga "In-stent neoatherosclerosis"). Mā te endothelium kore he toto e wehe te pakitara oko toto kua totohu me ngā pou stent mai i te rere o te toto, ā, ka huna e ia ngā matū antithrombotic me te vasodilatory. Ka whakaatuhia e te DES te pakitara oko toto ki ngā rongoā antiproliferative me te tūāpapa e whakaputa ana i te rongoā me ngā pānga rerekē ki te whakaora me te mahi endothelial, me te mōrearea o te thrombosis mutunga.65 E whakaatu ana ngā rangahau mate pukupuku ko ngā polymers pakari o te DES o te whakatupuranga tuatahi ka whai wāhi ki te mumura mau tonu, te whakatakotoranga fibrin mau tonu, te whakaora endothelial ngoikore, me te pikinga ake o te mōrearea o te thrombosis.3 Ko te hypersensitivity mutunga ki te DES te āhua nei ko tētahi atu tikanga e arahi ana ki te ST. I kōrero a Virmani et al66 i ngā kitenga post-mortem post-ST e whakaatu ana i te whānui o te aneurysm i te wāhanga stent me ngā tauhohenga hypersensitivity ā-rohe i titoa mai i ngā T lymphocytes me ngā eosinophils; Tērā pea ka whakaatahia e ēnei kitenga te awe o ngā pūmua kore-whakangaro.67 Tērā pea nā te korenga o te whānui o te stent i te tūnga hē o te stent, ka puta rānei i ngā marama i muri i te PCI te tūnga hē o te stent. Ahakoa he take mōrearea te tūnga hē o te tikanga mō te ST whakapeka me te iti iho i te whakapeka, ko te hiranga haumanu o te tūnga hē o te stent kua riro mai ka whakawhirinaki pea ki te whakahounga uaua kaha, ki te whakaora whakaroa rānei i puta mai i te rongoā, engari he tautohenga tōna hiranga haumanu.68
Ko ngā pānga tiaki o te DES o te reanga tuarua ko te tere me te kore he pakaru o te endothelialization, tae atu ki ngā rerekētanga o te koranu me te hanganga o te stent, te matotoru o te pou, ngā āhuatanga polymer, me te momo rongoā ārai-proliferative, te horopeta, me te nekehanga.
Ki te whakataurite ki te CoCr-EES, ko ngā pou stent cobalt-chromium angiangi (81 µm), ngā fluoropolymers antithrombotic, te iti o te polymer, me te utaina o te rongoā ka whai wāhi pea ki te iti ake o te auau o te ST. Kua whakaatuhia e ngā rangahau whakamātautau he iti ake te thrombosis me te whakatakotoranga pereti o ngā stent kua pania ki te fluoropolymer i ērā o ngā stent tahanga-konganuku.69 Me rangahau anō mēnā he rite ngā āhuatanga o ētahi atu DES o te whakatupuranga tuarua.
Ka whakapai ake ngā stent coronary i te angitu o ngā pokanga coronary ki te whakataurite ki te angioplasty coronary transluminal percutaneous tuku iho (PTCA), he uauatanga ā-tinana (te aukati toto, te tapahi, me ētahi atu) me te nui o ngā restenosis (tae atu ki te 40%–50% o ngā take). I te mutunga o te tekau tau atu i 1990, tata ki te 70% o ngā PCI i mahia me te whakaurunga BMS.70
Heoi, ahakoa ngā whanaketanga o te hangarau, ngā tikanga, me ngā maimoatanga hauora, ko te mōrearea o te restenosis i muri i te whakaurunga BMS he tata ki te 20%, me te >40% i roto i ngā rōpū iti motuhake.71 I te nuinga, kua whakaatuhia e ngā rangahau haumanu ko te restenosis i muri i te whakaurunga BMS, he rite ki tera i kitea me te PTCA tikanga, ka eke ki te taumata teitei i roto i te 3-6 marama ka mutu i muri i te 1 tau.72
Ka whakaitihia anō e te DES te auau o te ISR,73 ahakoa ko tēnei whakahekenga ka whakawhirinaki ki te angiography me te tautuhinga haumanu. Ka tukuna e te paninga polymer i runga i te DES ngā kaihoko ārai-mumura me te ārai-whakatipu, ka aukati i te hanganga neointima, ā, ka whakaroa i te tukanga whakatikatika toto mō ngā marama ki ngā tau.74 I kitea te tipu neointima tonu i te wā o te aroturukitanga roa i muri i te whakaurunga DES, he āhuatanga e mōhiotia ana ko te "late catch-up", i roto i ngā rangahau haumanu me te histological. 75
Ko te whara o ngā oko toto i te wā o te PCI ka puta he tukanga uaua o te mumura me te whakatikatika i roto i te wā poto noa (wiki ki ngā marama), ka arahi ki te endothelialization me te hipoki neointimal. E ai ki ngā kitenga histopathological, ko te hyperplasia neointimal (BMS me DES) i muri i te whakaurunga stent i titoa nuitia e ngā pūtau uaua maeneene tipu i roto i te matrix extracellular whai rawa i te proteoglycan.70
Nō reira, ko te hyperplasia neointimal he tukanga whakatikatika e uru ana ki te whakapūngao me ngā āhuatanga mumura me ngā pūtau e whakaoho ana i te tipu o ngā pūtau uaua maeneene me te hanganga o te matrix extracellular. I muri tonu i te PCI, ka whakatakotohia ngā pereti me ngā fibrin ki te pakitara o te oko toto ka kohikohi i ngā leukocytes mā roto i te raupapa o ngā ngota piri pūtau. Ka piri ngā leukocytes hurihuri ki ngā pereti piri mā te taunekeneke i waenga i te leukocyte integrin Mac-1 (CD11b/CD18) me te glycoprotein pereti Ibα 53, te fibrinogen rānei e herea ana ki te glycoprotein pereti IIb/IIIa.76,77
E ai ki ngā raraunga hou, kei roto i ngā urupare toto me ngā tukanga whakatika ngā pūtau tupuna i ahu mai i te hinu wheua. Ko te nekenekehanga o ngā EPC mai i te hinu wheua ki roto i te toto ā-taha e whakatairanga ana i te whakahoutanga endothelial me te neovascularization postnatal. Te āhua nei ka heke ngā pūtau tupuna uaua maeneene o te hinu wheua (SMPC) ki te wāhi i whara ai ngā toto, ka hua ake te tipu neointimal.78 I mua, i whakaarohia ngā pūtau CD34-pai he taupori pumau o ngā EPC; kua whakaatuhia e ētahi atu rangahau ko te CD34 surface antigen e mōhio ana ki ngā pūtau take hinu wheua kāore i rerekē me te kaha ki te rerekē ki ngā EPC me ngā SMPC. Ko te whakawhiti i ngā pūtau CD34-pai ki te whakapapa EPC, SMPC rānei, e whakawhirinaki ana ki te taiao o te rohe; ka puta te rerekētanga ki te momo EPC hei whakatairanga i te re-endothelialization, ko ngā āhuatanga mumura ka puta te rerekētanga ki te momo SMPC hei whakatairanga i te tipu neointimal.79
Ka piki ake te mōrearea o te ISR i te mate huka mā te 30%–50% i muri i te whakaurunga o te BMS,80 ā, ko te nui ake o te restenosis i roto i ngā tūroro mate huka ki te whakataurite ki ngā tūroro kāore i te mate huka i mau tonu i te wā o te DES. Ko ngā tikanga e whai ana i tēnei kitenga he maha ngā āhuatanga, e uru ana ki ngā āhuatanga pūnaha (hei tauira, te rerekētanga o te urupare mumura) me te anatomical (hei tauira, ngā oko toto iti ake te diameter, ngā whara roa ake, te mate horapa, me ētahi atu) e piki ake ana i runga i te tūponotanga o te ISR.70
I rerekē te pānga o te whānui o te oko toto me te roa o te whara ki te auau o te ISR, ā, ko te whānui iti/ngā whara roa ake ka nui ake te tere o te restenosis ki te whakatauritea ki ngā whānui nui ake/ngā whara poto ake.71
He matotoru ake ngā pou stent o ngā papa stent o te whakatipuranga tuatahi me ngā reiti ISR ​​teitei ake i ērā o ngā papa stent o te whakatipuranga tuarua me ngā pou angiangi ake.
Hei tāpiritanga, ko te auau o te restenosis i hono atu ki te roa o te stent, me te roa o te stent >35 mm tata ki te rua te roa atu i ērā <20 mm. He mea nui anō hoki te whānui o te lumen iti rawa o te stent whakamutunga: ko te iti o te whānui o te lumen iti rawa whakamutunga i tohu i te pikinga nui o te mōrearea o te restenosis.81,82
Ko te tikanga, ko te hyperplasia intimal i muri i te whakaurunga BMS e kiia ana he pumau, me te tihi wawe i waenga i te 6 marama me te 1 tau, ā, muri iho ka mutu te wā marino. I mua ake nei, i pūrongohia he tihi wawe o te tipu intimal, ā, muri iho ko te whakahekenga o te intimal me te whakanui ake i te lumen i ētahi tau i muri i te whakaurunga stent;71 kua whakaarohia te pakeketanga o ngā pūtau uaua maeneene me ngā whakarerekētanga i roto i te matrix extracellular hei tikanga pea mō te whakahekenga neointimal mutunga.83 Heoi, kua whakaatuhia e ngā rangahau me te aroturuki roa ake mō te wā roa he urupare triphasic i muri i te whakatakotoranga BMS, me te restenosis wawe, te whakahekenga waenga, me te restenosis lumen mutunga.84
I te wā o te DES, i whakaaturia tuatahitia te tipu neo-intimal i muri i te whakaurunga o te SES, te PES rānei ki ngā tauira kararehe.85 He maha ngā rangahau IVUS kua whakaatu i te whakahekenga wawe o te tipu intimal, ā, i muri mai ka hoki whakamuri i muri i te whakaurunga o te SES, te PES rānei, nā te tukanga mumura tonu pea.86
Ahakoa te "pūmautanga" e kīia ana ko te ISR, tata ki te kotahi hautoru o ngā tūroro BMS ISR ka pāngia e te ACS.4
Kei te piki haere ngā taunakitanga e whakaatu ana ko te mumura mau tonu me/ranei te ngoikore o te endothelial ka puta te neoatherosclerosis matatau i roto i te BMS me te DES (ko te nuinga ko te DES whakatupuranga tuatahi), he tikanga nui pea tēnei mō te ISR matatau, te ST matatau rānei. I kōrero a Inoue et al. 87 mō ngā kitenga histological mai i ngā tauira tātaritanga mate i muri i te whakaurunga o ngā stent coronary Palmaz-Schatz, e kī ana ka tere ake pea ngā huringa atherosclerotic hou i roto i te stent nā te mumura peri-stent. Kua whakaatuhia e ētahi atu rangahau10 ko te kiko restenotic i roto i te BMS, neke atu i te 5 tau, he atherosclerosis hou e puta mai ana, me te mumura peri-stent, kāore rānei; Ko ngā tauira mai i ngā kēhi ACS e whakaatu ana i ngā papaka ngoikore noa i roto i ngā uaua coronary taketake. Te āhua histological o te poraka me ngā macrophages huka me ngā tioata cholesterol. Hei tāpiri, i te whakataurite i te BMS me te DES, i kitea he rerekētanga nui i te wā ki te whanaketanga o te atherosclerosis hou.11,12 Ko ngā huringa atherosclerotic tuatahi i roto i te urunga macrophage huka i tīmata i te 4 marama i muri i te whakaurunga SES, engari ko ngā huringa ōrite i roto i ngā whara BMS i puta i te 2 tau i muri mai, ā, he kitenga onge tonu tae noa ki te 4 tau. Hei tāpiri, ko te stenting DES mō ngā whara kore pumau pēnei i te fibroatherosclerosis thin-cap (TCFA) te pakaru intimal rānei he poto ake te wā ki te whanaketanga ki te BMS. Nō reira, ko te neoatherosclerosis te ahua he nui ake te kitea, ā, ka puta wawe ake i roto i te DES whakatupuranga tuatahi i roto i te BMS, tera pea nā te pathogenesis rerekē.
Me rangahau tonu te pānga o te DES o te whakatupuranga tuarua, o te DES rānei ki te whanaketanga; ahakoa e kī ana ētahi kitenga o ngā DES o te whakatupuranga tuarua he iti ake te mumura, he rite tonu te auau o te neoatherosclerosis ki tērā o te whakatupuranga tuatahi, engari me whai rangahau tonu.