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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, Hōhipera Poliambulanza Foundation, Brescia, 2 Tari Cardiology, Whare Wānanga Katorika o te Ngākau Tapu o Rōma, Itari Whakarāpopototanga: Ka whakaitihia e ngā Stents Rongoā kua pania (DES) ngā herenga o te whakamahi i ngā stents whakarewa tahanga (BMS) i muri i te wawaotanga coronary percutaneous. Heoi, ahakoa te ahua nei kua whakaitihia tēnei āhuatanga e te whakaurunga o te DES o te reanga tuarua ki te whakataurite ki te DES o te reanga tuatahi, kei te mau tonu ngā āwangawanga nui mō ngā raruraru pea o te whakaurunga stent pēnei i te thrombosis stent (ST) me te tango stent, stenosis (SSI). He huihuinga kino pea te ST kua tino whakaitihia e te whakaurunga stent kua pai ake, ngā hoahoa stent hou, me te rongoā antiplatelet takirua. Kei te tirotirohia te tikanga tika e whakamārama ana i tōna putanga mai, ā, 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 muri ko te wā whakahekenga neke atu i te 1 tau. He rerekē, kua whakaatuhia e ngā rangahau haumanu me ngā rangahau histological o te DES he taunakitanga mō te tipu neointimal pumau i roto i te wā roa o te whai muri, he āhuatanga e mōhiotia ana ko te āhuatanga "late catch-up". Ko te whakaaro he āhua haumanu pai te ISR kua whakahēngia tata nei e ngā taunakitanga ka pāngia pea ngā tūroro whai ISR ​​e ngā mate coronary acute. Ko te whakaahua intracoronary he tikanga whakaeke hei tautuhi i ngā papa atherosclerotic stent me ngā tohu o te whakaora toto i muri i te stenting, ā, he maha ngā wā e whakamahia ana hei whakaoti i te angiography coronary diagnostic me te mahi i ngā tikanga wawao. Ko te tomography coherence optical intracoronary e kiia ana ko te momo whakaahua tino matatau i tēnei wā. Ki te whakaritea ki te ultrasound intravascular, he pai ake te taumira (neke atu i te 10 ngā wā), ā, ka taea te whakaahua taipitopito i te hanganga o waho o te pakitara o te toto. Ki te whakaritea ki te ultrasound intravascular, he pai ake te taumira (neke atu i te 10 ngā wā), ā, ka taea te whakaahua taipitopito i te hanganga o waho o te pakitara o te toto. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, >10 раз), что потздво охарактеризовать поверхностную структуру стенки сосуда. Ki te whakaritea ki te ultrasound ā-roto, he pai ake te taumira (neke atu i te 10 ngā wā), e taea ai te whakaahua taipitopito i te hanganga mata o te pakitara o te toto.与血管内超声相比，它提供了更好的分辨率（至少> 10 倍），允许详细表征好的管表征合面管。与血管内超声相比，它提供了更好的分辨率（至少> 10），允许详细表征血管管安。Ki te whakatauritea ki te ultrasound ā-roto o te toto, he pai ake te taumira (neke atu i te 10 ngā wā), e taea ai te whakaahua taipitopito i te hanganga mata o te pakitara o te toto.E whakaatu ana ngā rangahau whakaahua in vivo e rite ana ki ngā kitenga histological, ko te mumura mau tonu me/ranei te ngoikore o te endothelial ka puta pea te neoatherosclerosis matatau i roto i te HMS me te DES. Nō reira, kua noho te neoatherosclerosis hei whakapae matua mō te pathogenesis o te rahunga o te stent mutunga. Ngā kupu matua: stent coronary, stent thrombosis, restenosis, neoatherosclerosis.
Ko te wawaotanga o te ngakau kua werohia ki te kiri (PCI) te tikanga e whakamahia whānuitia ana mō te rongoā i ngā mate uaua ngakau kua kitea ngā tohu, ā, kei te whanake tonu te tikanga. 1 Ahakoa ka whakaitihia e ngā stent eluting drug (DES) ngā herenga o ngā stent kāore i pania (UES), ka puta pea ngā raruraru tōmuri pēnei i te stent thrombosis (ST) me te stent restenosis (ISR) me te whakaurunga stent, ā, kei te mau tonu ngā āwangawanga nui. 2-5
Mena he aituā kino pea te ST, kua whakahēngia te whakaae ko te ISR he mate ngawari noa iho e ngā taunakitanga mō te mate pūkahukahu acute (ACS) i roto i ngā tūroro e pāngia ana e te ISR.
I ēnei rā, e kiia ana ko te intracoronary optical coherence tomography (OCT)6-9 he momo whakaahua hou e tuku ana i te taumira pai ake i te intravascular ultrasound (IVUS). Ko ngā rangahau whakaahua in vivo10-12 e rite ana ki ngā kitenga histological e whakaatu ana i tētahi tikanga urupare vascular "hou" 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 Grunzig te angioplasty poihau tuatahi (te angioplasty poihau tawhito); he maimoatanga hou, engari he ngoikoretanga anō hoki o te katinga tere o ngā oko toto me te restenosis. 13 Nā tēnei i kitea ai ngā stent coronary: I tāutahia e Puel rāua ko Sigwart te stent coronary tuatahi i te tau 1986, e whakarato ana 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. Nō nā tata nei, e rua ngā rangahau nui, ko te Belgian-Dutch Stent Study 15 me te Stent Restenosis Study 16, kua tautoko i te haumaru o te stenting rongoā antiplatelet takirua (DAPT) me/ranei ngā tikanga whakatinanatanga tika. 17,18 Whai muri i ēnei whakamātautau, i tino piki ake te maha o ngā PCI i mahia.
Heoi, i tere te tautuhi i te raruraru o te iatrogenic in-stent neointima hyperplasia i muri i te whakatakotoranga BMS, ā, i hua ake ai te ISR i roto i te 20–30% o ngā whara i rongoatia. I whakaurua te DES19 i te tau 2001 hei whakaiti i te hiahia mō te restenosis me te mahi anō. Kua whakapiki ake te DES i te whakapono o ngā tākuta ngakau mā te tuku i te maimoatanga o te maha o ngā whara uaua i whakaarohia i mua he mea ka taea te rongoa 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", 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 a ngā stent, ā, kei te haere tonu te kitea me te tere o te kawe mai i ngā hangarau hou whakahihiri ki te mākete.
He ngongo waea angiangi te BMS. Whai muri i te wheako tuatahi ki te whakairi pakitara, te whakairi Gianturco-Roubin me te whakairi Palmaz-Schatz, he maha ngā momo BMS e wātea ana inaianei.
E toru ngā momo hoahoa e wātea ana: he serpentine, he mata ngongo me te ngongo kōhao. Ko ngā hoahoa koiri he waea whakarewa, he rīpene rānei e hanga ana i te āhua koiri porowhita; i roto i ngā hoahoa mata ngongo, ka hurihia te waea hei mata ka hanga he ngongo; ko ngā hoahoa kōhao he ngongo whakarewa ka tapahia ki te laser. He rerekē te hanganga o ēnei taputapu (he kowiri tira, he nichrome, he cobalt chrome), te hoahoa (ngā āhua me ngā whānui o ngā mokowā, 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, ka angiangi ake ngā pou, ka pai ake te mahi taraiwa, ā, ka mau tonu te kaha ā-ringa.
He papa stent whakarewa ēnei (he kowiri tira te nuinga) ā, he mea pani ki te polymer e tuku ana i ngā rongoā ārai-tipu me/ranei ārai-mumura.
I whakawhanakehia tuatahitia a Sirolimus (e mōhiotia ana ko te rapamycin) hei rongoā harore. Ko tōna tikanga mahi e pā ana ki 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 "tangata tuatahi" ki te SES he hua pai, i arahina ki te whanaketanga o te Cypher stent. 23 Kua whakaatuhia e ngā whakamātautau nui tōna whai huatanga ki te aukati i te IR. 24
I whakaaetia tuatahitia a Paclitaxel mō te rongoā i te mate pukupuku ovarian, engari ko ōna āhuatanga cytostatic kaha—ka whakaū te rongoā i ngā microtubules i te wā mitosis, ka aukati i te huringa pūtau, ka 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 ngakau uaua nui. 25,26 Ko te TAXUS Liberté i muri mai i whakaatu i tētahi papa maitai kore waikura mō te ngāwari o te tuku.
E whakaatu ana ngā taunakitanga pakari 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 IVR me te whakahounga o ngā oko toto ūnga (TVA), 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 te pou o ngā taputapu o te whakatipuranga tuarua, kua pai ake te ngāwari/te tuku, kua pai ake te hototahitanga koiora o te polymer/te whakakorenga rongoā, ā, he pai ake te kaha o te reendothelialization. I roto i ngā mahi o nāianei, koinei ngā hoahoa DES tino matatau me ngā stent coronary nui kua whakauruhia puta noa i te ao.
Ka neke ake tēnei mahi a Taxus Elements mā te whakamahi i tētahi pūhui ahurei i hangaia mō te tukunga wawe rawa atu, me tētahi pūnaha whakawehe platinum-chromium hou e whakarato ana i ngā whakawehe angiangi me te whakanui ake i te radiopacity. I kitea e te rangahau PERSEUS 29 ngā hua ōrite i waenga i a Element me Taxus Express mō te 12 marama. Heoi, kāore i te nui ngā whakamātautau e whakataurite ana i ngā huānga yew me ētahi atu DES o te whakatupuranga tuarua.
Ko te Stent Panihia o Endeavor Zotarolimus (ZES) he mea hanga mai i tētahi papa stent cobalt-chromium kaha ake, he nui ake te ngāwari me te iti ake o te turanga stent. Ko te Zotarolimus he rite ki te sirolimus me ngā pānga ārai mate rite tonu, engari he nui ake te lipophilicity hei whakapai ake i te wāhi i roto i te pakitara o te 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 horoia atu i te wāhanga 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 te ZES ki te SES, i whakaatu i te ngaronga lumen mutunga teitei ake me te HR engari he iti ake ngā mate kino o te ngakau (MACEs) i te SES. 30 I kitea anō e te rangahau ENDEAVOR IV e whakarite ana i te ZES ki te PES he nui ake te auau o te SIS engari he iti ake te auau o te MI, e ai ki te ST tino noa i roto i te rōpū ZES. 31 Heoi, i rahua te rangahau PROTECT ki te whakaatu i te rerekētanga o te auau ST i waenga i ngā stent Endeavor me Cypher. 32
Ko te Endeavor Resolute he putanga whakapai ake o te stent Endeavor me tētahi polymer papa-toru hou. Ko te Resolute Integrity hou ake (e kiia ana ko te DES tuatoru o ngā whakatupuranga) e hangai ana ki tētahi tūāpapa hou me ngā āheinga tuku teitei ake (te tūāpapa Integrity BMS) me tētahi polymer papa-toru hou, e hototahi ana ki te koiora, ka taea te pehi i te urupare mumura tuatahi me te tango atu i te nui o te rongoā i roto i ngā rā 60 e whai ake nei. I whakaatuhia i roto i tētahi whakamātautau e whakataurite ana i a Resolute ki a Xience V (everolimus eluting stent [EES]) he rite tonu te whai huatanga o te pūnaha Resolute i runga i te mate me te korenga o te whara ūnga. 33.34
Ko Everolimus, he mea hanga mai i te sirolimus, he aukati huringa pūtau anō hoki e whakamahia ana i roto i te whanaketanga o te EES Xience (pūhara Multi-link Vision BMS)/Promus (pūhara Platinum Chromium). I whakaatuhia e te whakamātautau SPIRIT 35-37 he pai ake ngā putanga 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 he rite te pai o te EES ki te SES ki te pehi i te ngaronga o te ngākau i te 9 marama me ngā huihuinga haumanu i te 12 marama. 38 Hei whakamutunga, kua whakaatuhia te pai ake o te stent Xience i te BMS i roto i te horopaki o te ST elevation myocardial infarction (MI). 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 whakanui ake i te 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 urunga tuatahi a EPC Biology ki te hoahoa stent ko te Genous stent, kua pania ki ngā paturopi anti-CD34, ka taea te here i ngā EPC e rere ana i roto i ngā toto mā 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 TVR teitei. 40
I runga i ngā pānga kino pea o te whakaora whakaroa i puta mai i te polymer e pā ana ki te mōrearea ST, ka tukuna e ngā polymer bioresorbable ngā painga o te DES mā te karo i ngā āwangawanga roa mō te pumau o te polymer. Tae noa ki tēnei wā, kua whakaaetia ngā pūnaha bioresorbable maha (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 ā-tikanga o te whakarato tautoko ā-ringa i te tīmatanga ina whakaarohia te hokinga whakamuri ngāwari 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 pūhui waikawa lactic (poly-l-lactic acid [PLLA]), engari he maha ngā pūnaha stent kei te whanakehia, ahakoa he wero tonu te kimi i te taurite pai i waenga i te whakaputanga rongoā me te nekehanga pirau. I whakaatuhia e te rangahau ABSORB te haumaru me te whai huatanga o ngā stent PLLA pania everolimus. 43 He pai ake te whakahoutanga o te stent Absorb o te whakatupuranga tuarua i te mea o mua me te whai muri i te 2 tau pai. 44 Ko te rangahau ABSORB II o nāianei, te whakamātautau matapōkere tuatahi e whakataurite ana i te stent Absorb me te stent Xience Prime, me whakarato i ētahi atu raraunga, ā, he mea whakamīharo ngā hua tuatahi e wātea ana. 45 Heoi, me whakamārama ngā āhuatanga pai, te tikanga whakauru pai, me te kōtaha haumaru i roto i te mate uaua coronary.
He kino ngā hua haumanu o te thrombosis i roto i te BMS me te DES. I roto i tētahi rēhita o ngā tūroro i whakatōkia ki te DES,47 24% o ngā take ST i mate, 60% i roto i te MI kore-mate, me te 7% i roto i te angina kore pumau. Ko te PCI mō 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 whānui. I roto i te rangahau BASKET-LATE, 6–18 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 SMP (4.9% me te 1.3%, ia). 20 I whakaatuhia e te tātaritanga-maha o ngā rangahau e iwa i reira i whakaritea ai ngā tūroro 5261 ki te SES, PES, BMS rānei, i muri i ngā tau 4 o te aroturukitanga, i whakanuia e te SES (0.6% versus 0%, p = 0.025) me te PES (0.7%) ) te auau o te ST tino mutunga ki te BMS mā te 0.2%, p = 0.028). 49 He rerekē, i roto i tētahi tātaritanga whānui i uru atu ki te 5108 tūroro, 21 i pūrongohia he pikinga whanaunga 60% o te mate, te MI rānei me te SES ki te whakataurite ki te BMS (p = 0.03), i te mea ko te PES i honoa ki tētahi pikinga koretake o te 15% (tirohia – tae atu ki te 9 marama ki te 3 tau).
He maha ngā rēhita, ngā whakamātautau matapōkere, me ngā tātaritanga-maha kua tirotiro 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 6906 i rongoatia ki te BMS, DES rānei, kāore he rerekētanga o ngā putanga haumanu, o ngā reiti ST rānei i te 1 tau o te aroturuki. 48 I roto i tētahi atu rēhita o ngā tūroro 8146, i kitea te mōrearea o te taikaha ST tonu he 0.6% ia tau ki te whakataurite ki te BMS. 49 I whakaatuhia e tētahi tātaritanga-maha o ngā rangahau e whakataurite ana i te SES, i te PES rānei ki ngā SMP he nui ake te mōrearea o te mate me te MI me te DES o te whakatupuranga tuatahi ki te whakataurite ki ngā SMP, 21 me tētahi atu tātaritanga-maha o ngā tūroro 4545 i matapōkeretia ki te SES, ki te ST rānei i waenga i te PES me te BMS i te 4 tau o te aroturuki. 50 Kua whakaatuhia e ētahi atu rangahau o te ao tūturu he nui ake te mōrearea o te ST me te MI haere whakamua i roto i ngā tūroro i rongoatia ki te DES o te whakatupuranga tuatahi i muri i te whakamutua o te DAPT. 51
I runga i ngā raraunga taupatupatu, he maha ngā tātaritanga me ngā meta-tātaritanga i whakatau ngātahi kāore i tino rerekē te mōrearea o te mate, te MI rānei i waenga i te DES me te SGM o te whakatipuranga tuatahi, engari he nui ake te mōrearea o te ST tino noa i waenga i te SGM me te SGM. 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 whakatipuranga tuatahi e ai ki te tohu, ā, he iti te mōrearea o te ST tino matatau, engari kāore i te nui. , He pikinga nui. Nō reira, e taunaki ana te FDA me te rōpū kia whakaroahia te wā DAPT ki te 1 tau, ahakoa he iti noa ngā taunakitanga 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 kua whakapaitia. Ko CoCr-EES te mea i whai i te rangahau haumanu tino whānui. I roto i te tātaritanga-maha a Baber et al.54 o ngā tūroro 17,101, i whakaitihia e CoCr-EES te ST me te MI tino/tūpono ki te PES, SES, me te ZES i te 21 marama. Hei whakamutunga, i whakaatu a Palmerini et al i roto i te tātaritanga-maha o ngā tūroro 16,775 he iti ake te ST wawe, mutunga, 1- me te 2-tau kua tautuhia e CoCr-EES ki te whakataurite ki ētahi atu DES kua whakakotahihia. 55 Kua whakaatuhia e ngā rangahau tūturu he whakaiti i te mōrearea o te ST me 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 rangahau RESOLUTE-AC me TWENTE. 33,57 Kāore he rerekētanga nui i roto i te mate, te mate ngakau, te wāhanga ST rānei kua tautuhia i waenga i ngā stent e rua.
I roto i tētahi tātaritanga whatunga o ngā tūroro 50,844, tae atu ki te 49 RCT, 58 ngā CoCr-EES i honoa ki tētahi auau iti iho o te ST kua tautuhia i te BMS, he kitenga kāore i kitea me ētahi atu DES; kāore i te "tino wawe" anake te hekenga me muri i ngā rā 30 (58). ōwehenga tūpono [OR] 0.21, 95% wā whakawhirinaki [CI] 0.11-0.42) me te 1 tau (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 auau ST iti iho i te 1 tau.
He maha ngā āhuatanga e pā ana ki te tīmatanga o te ST. Ko te āhua o te papaki me te taumaha o te thrombus te āhua nei he pānga ki te putanga i muri i te PCI;59 ko te urunga hohonu ake o ngā pou e te necrotic core (NC) prolapse, te roa o te haehae waenga i roto i te stent, te stenting kāore i te tino pai me ngā tapahi taha toenga, te stenosis taha nui rānei, te apposition kāore i oti, me te whānui kāore i oti o te stent kua whakatōkia ka piki ake te mōrearea o te ST.60 Ko te tikanga rongoā o ngā rongoā antiplatelet kāore e tino pā ki te auau o te ST wawe: i roto i tētahi whakamātautau matapōkere e whakarite ana i ngā BMS me ngā DES, he rite tonu ngā reiti o te ST whakapeka me te ST iti i te wā o te DAPT (<1%).61 Nō reira, ko te ST wawe te āhua nei e pā ana ki ngā whara kua rongoatia me ngā āhuatanga tukanga. Ko te āhua o te papaki me te taumaha o te thrombus te āhua nei he pānga ki te putanga i muri i te PCI;59 ko te urunga hohonu ake o ngā pou e te necrotic core (NC) prolapse, te roa o te haehae waenga i roto i te stent, te stenting kāore i te tino pai me ngā tapahi taha toenga, te stenosis taha nui rānei, te apposition kāore i oti, me te whānui kāore i oti o te stent kua whakatōkia ka piki ake te mōrearea o te ST.60 Ko te tikanga rongoā o ngā rongoā antiplatelet kāore e tino pā ki te auau o te ST wawe: i roto i tētahi whakamātautau matapōkere e whakarite ana i ngā BMS me ngā DES, he rite tonu ngā reiti o te ST whakapeka me te ST iti i te wā o te DAPT (<1%) .61 Nō reira, ko te ST wawe te āhua nei e pā ana ki ngā whara kua rongoatia me ngā āhuatanga tukanga. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВ;59 болека трация из-за пролапса некротического ядра (NC), длинного медиального разрыва внутри стента, субоптимального стентирования стентирования стентирования расслоениями или значительным краевым стенозом, неполной аппозицией и неполным расширением имплантированного стента может увеличить рискетичет Т.60 Т антитромбоцитарных препаратов не оказывает существенного влияния на частоту раннего ST: в рандомизированном исслед исслед DES, частота острого и подострого ST во время DAPT была одинаковой (<1%) .61 Таким образом, ранняя ST, по-видимому, в первую очередь связана с лежансипноми в лежансироми поражениями и процедурными факторами. Ko te āhua o te papa me te thrombosis te āhua nei he pānga ki te putanga i muri i te PCI;59 ko te urunga hohonu ake o te strut nā te prolapse o te nucleus necrotic (NC), te roa o te haehae waenga i roto i te stent, te stenting kāore i te tino pai me ngā wehenga taha toenga, te stenosis taha nui rānei, te whakapiringa kāore i oti me te whānui kāore i oti o te stent kua whakatōkia ka piki ake te mōrearea o te ST.60 Ko te tikanga rongoā o ngā rongoā antiplatelet kāore e tino pā ki te auau o te ST wawe: i roto i tētahi whakamātautau matapōkere e whakarite ana i te BMS me te DES, ko te auau o te ST whakapeka me te ST iti i te wā o te DAPT he rite tonu (<1%) .61 Nō reira, ko te ST wawe te āhua nei e pā ana ki ngā whara kua rongoatia me ngā āhuatanga tukanga.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 的随与顺他们，有一一一一一一期间急性和亚急性ST 的发生率相似（<1%） .61 因此，早期ST似乎主要与潜在的治疗病变和手术因素有关。潜在 的 斑块 形态 和 血栓 似乎 影响 影响 pci 后 结果 ； ； ； ； ； 坏 死 坏 死核心 核心 核心 脱垂 导致 的 深 的 支柱 穿透 、 内长 的 内侧 、 具有 残余 残余边缘 狭窄 次 次 次 次 的 的 的 的 的 的 的 的 的 的 的 的 的 的 的 的 的 的 。抗血 小板 药物 的 治疗 方案 不 显着 影响 影响 早期 的： 在 项 比较 比与 des bms ， dapt bms期间 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 发生 发生 发生 发生 发生 发生率相似（<1%） .61Ko te āhua o te papa me te thrombosis 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 prolapse o te nucleus necrotic (NC), ngā pakaru o te roa o te stent i waenganui, 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 Kāore he pānga nui o te tikanga antiplatelet ki te putanga wawe o te ST: ko te putanga 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. e pā ana ki ngā whara rongoā me ngā āhuatanga pokanga.
I ēnei rā, ko te arotahi ko te ST tōmuri/tino tōmuri. Ahakoa te āhua nei he wāhi nui ngā āhuatanga tukanga me ngā āhuatanga hangarau ki te whanaketanga o te ST whakapeka me te ST iti iho i te whakapeka, te āhua nei he uaua ake te tikanga o ngā huihuinga toto toto whakaroa. Kua whakaarohia ko ētahi āhuatanga o te tūroro he take mōrearea pea mō te ST ahu whakamua 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 maha-toto, te whakapūmau, te aukati katoa, ngā stent roa te āhua nei e hono ana ki te mōrearea o te ST ahu whakamua. 62,63 Ko te urupare ngoikore ki te rongoā antiplatelet he take mōrearea nui mō te thrombosis DES ahu whakamua 51. Tērā pea nā te korenga o te manawanui ki te whakarongo, te iti o te horopeta, ngā taunekeneke rongoā, ngā mate tāpiri e pā ana ki te urupare rongoā, te polymorphism ira taumata-kaiwhakawhiwhi (ina koa te ātete clopidogrel), me te whakahohenga o ētahi atu ara mō te whakahohenga pereti. E kiia ana ko te neoatherosclerosis o te stent he tikanga nui mō te korenga o te stent i te mutunga, tae atu ki te ST64 i te mutunga (wāhanga "Stent Neoatherosclerosis"). Ko te endothelium kore e pakaru ana ka wehe i te pakitara oko toto me ngā pou stent mai i te toto, ka huna i ngā matū antithrombotic me te vasodilatory. Ka whakaatuhia e te DES te pakitara oko toto ki ngā rongoā anti-proliferative me te tūāpapa tuku rongoā, me ngā pānga rerekē ki te whakaora me te mahi endothelial, me te mōrearea o te thrombosis i te mutunga. 65 Kua whakaatuhia e ngā rangahau pathological ka taea e ngā polymer DES o te whakatupuranga tuatahi te whai wāhi ki te mumura mau tonu, te whakatakotoranga fibrin mau tonu, te whakaora endothelial ngoikore, ā, nō reira ka piki ake te mōrearea o te thrombosis. 3 Ko te hypersensitivity i te mutunga ki te DES te ahua nei ko tētahi atu tikanga e arahi ana ki te ST. I kōrero a Virmani et al. [66] i ngā kitenga postmortem i muri i te ST e whakaatu ana i te whānui o te aneurysm i roto i te wāhanga stent me ngā tauhohenga hypersensitivity ā-rohe e tito ana i ngā T-lymphocytes me ngā eosinophils; ka whakaata pea ēnei kitenga i te awe o ngā polymer kore e taea te whakangaro. 67 Tērā pea nā te korenga o te whānui o te stent i te pai, ka puta rānei i ētahi marama i muri i te PCI te korenga o te taunga o te stent. Ahakoa he take mōrearea te tūnga hē o te stent mō te ST whakapeka me te ST 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 pumau 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 whakatauritea ki te CoCr-EES, ko ngā tūāpapa stent cobalt-chromium angiangi (81 µm), ngā fluoropolymers antithrombotic, te iti o te ihirangi polymer, me te uta rongoā ka whai wāhi pea ki te whakaheke i ngā reiti ST. Kua whakaatuhia e ngā rangahau whakamātautau he iti ake te thrombosis me te whakatakotoranga pereti i roto i ngā stent kua pania ki te fluoropolymer i ngā stent kāore i pania. 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 tuku iho (PTCA), he uauatanga ā-tinana (te aukati toto, te tapahi, me ētahi atu) me te nui o ngā restenoses (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 BGM. 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BMSHeoi, ahakoa ngā whanaketanga o te hangarau, ngā tikanga, me ngā maimoatanga, ko te mōrearea o te restenosis i muri i te whakaurunga BMS he tata ki te 20%, me ngā reiti neke atu i te 40% i roto i ētahi rōpū iti.71 I te nuinga o te wā, kua whakaatuhia e ngā rangahau haumanu ko te restenosis i muri i te whakaurunga BMS, he rite ki te mea i kitea me te PTCA tikanga, ka eke ki te taumata teitei i roto i te 3–6 marama ka mutu i roto i te 1 tau.72
Ka whakaitihia anō e te DES ngā reiti ISR,73 ahakoa he mea whakawhirinaki tēnei whakahekenga ki te angiographic me te haumanu. Ka tukuna e te paninga polymer DES ngā kaihoko anti-inflammatory me te anti-proliferative, ka aukati i te hanganga neointima, ā, ka whakaroa i te whakatikatika o ngā oko toto mō ngā marama, mō ngā tau rānei.74 I roto i ngā rangahau haumanu me ngā rangahau histological, kua kitea te tipu tonu o te neointima i roto i te wā roa whai muri i te whakaurunga o te DES, he āhuatanga e mōhiotia ana ko te "late catch-up" 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 hua ake te endothelialization me te hipoki neo-intimal. E ai ki ngā kitenga histopathological, ko te hyperplasia neo-intimal (HMS me DES) i muri i te whakaurunga stent ko te nuinga o ngā pūtau uaua maeneene e tipu haere ana i roto i te matrix extracellular whai proteoglycan. 70
Nō reira, ko te hyperplasia neointimal he tukanga whakatikatika e uru ana ki ngā āhuatanga toto totoka me te mumura, tae atu ki 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 whakatakotoria ngā pereti me te fibrin ki te pakitara o te oko toto ka kukume i ngā leukocyte mā roto i te raupapa o ngā ngota piri pūtau. Ka piri ngā leukocyte hurihuri ki ngā pereti piri mā te taunekeneke i waenga i te integrin leukocyte Mac-1 (CD11b/CD18) me te glycoprotein pereti Ibα 53, te fibrinogen rānei e hono ana ki te glycoprotein pereti IIb/IIIa. 76.77
E ai ki ngā raraunga hou, kei roto ngā pūtau tupuna o te hinu wheua i ngā tauhohenga toto me ngā tukanga whakatikatika. Ko te nekenekehanga o te EPC mai i te hinu wheua ki 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 hei taupori pumau o ngā EPC, kua whakaatuhia e ngā rangahau anō ko te antigen mata CD34 e mōhio ana ki ngā pūtau take hinu wheua kāore i rerekē me te kaha ki te rerekē ki ngā EPC me ngā PBMC. Ko te whakawhiti i ngā pūtau CD34-pai ki roto i te whakapapa EPC, SMPC rānei e whakawhirinaki ana ki te taiao o te rohe; ka puta te rerekētanga ki te momo EPC nā ngā āhuatanga ischemic, e whakatairanga ana i te reendothelialization, ko ngā āhuatanga mumura ka puta te rerekētanga ki te momo SMPC, e whakatairanga ana 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, ā, ko te tere teitei ake o te restenosis i roto i te hunga 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, tae atu ki te pūnaha (hei tauira, te rerekētanga o te urupare mumura) me te anatomical (hei tauira, ngā oko toto iti ake, ngā whara roa ake, te mate horapa, me ētahi atu), e whakanui motuhake ana i te mōrearea o te ISR. 70
I rerekē te pānga o te whānui o te oko toto me te roa o te whara ki ngā reiti ISR, ā, ko ngā whara iti ake te whānui/roa ake ka nui ake te pikinga o ngā restenosis ki te whakatauritea ki ngā whara nui ake te whānui/poto ake. 71
He matotoru ake ngā pou stent o te whakatupuranga tuatahi me ngā ISR teitei ake i ērā o te whakatupuranga tuarua me ngā pou angiangi ake.
Heoi anō, ko te auau o te restenosis e pā ana ki te roa o te stent, tata rua te pikinga mō te roa o te stent >35 mm ki te whakaritea ki ērā <20 mm. Heoi anō, ko te auau o te restenosis e pā ana ki te roa o te stent, tata rua te pikinga mō te roa o te stent >35 mm ki te whakaritea ki ērā <20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента >35 мм по сравнению <с длиной 20 стента Hei tāpiri, ko te tere o te restenosis e pā ana ki te roa o te stent, tata rua te pikinga ina neke atu i te 35 mm te roa o te stent ki te 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 的两倍此外，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 больше, чем стента <20 мм. Hei tāpiritanga, ko te auau o te restenosis i whakawhirinaki ki te roa o te stent: ko te roa o te stent >35 mm e tata ana ki te rua te roa i te stent <20 mm.He mea nui anō hoki te whānui o te lumen whakamutunga o te stent: nā te iti o te whānui o te lumen whakamutunga i tohu he nui ake 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 moe roa. Kua pūrongohia i mua he tihi wawe o te tipu intimal, ā, muri iho ka heke te intimal me te whakanui i te lumen i roto i ētahi tau i muri i te whakaurunga stent; kua whakaarohia te pakeketanga o ngā pūtau uaua maeneene me ngā huringa i roto i te matrix extracellular hei tikanga pea mō te hekenga neointima mutunga. 83 Heoi, kua whakaatuhia e ngā rangahau whai muri mō te wā roa he urupare triplephasic i muri i te whakatakotoranga BMS me te restenosis wawe, te hekenga waenga, me te restenosis luminal 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 ngoikore wawe o te tipu intimal, ā, i muri mai ka hopukina wawetia i muri i te whakaurunga o te SES, te RPE rānei, nā te tukanga mumura tonu pea.86
Ahakoa te "pūmautanga" e kīia ana ko te ISR, tata ki te hautoru o ngā tūroro me te BMS ISR ka pāngia e te ACS. whā
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 ahu whakamua i roto i te HCM me te DES (ko te nuinga ko te DES o te whakatupuranga tuatahi), he tikanga nui pea tēnei mō te whanaketanga o te IR ahu whakamua, te ST ahu whakamua rānei. I kōrero a Inoue et al [87] mō ngā kitenga tātaritanga histological i muri i te whakaurunga o ngā stents coronary Palmaz-Schatz, e kī ana ko te mumura huri noa i te stent ka puta pea he huringa atherosclerotic hou i roto i te stent. Kua whakaatuhia e ētahi atu rangahau10 ko te kiko restenotic i roto i te CGM 5-tau he atherosclerosis hou kua tīmata me te mumura peritoneal, kāore rānei; ko ngā tauira mai i ngā take ACS e whakaatu ana i ngā papa ngoikore noa i roto i ngā uaua coronary taketake. Ko te āhua aukati histological 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, ko ngā huringa ōrite i roto i ngā whara CGM i puta i muri i te 2 tau, ā, he kitenga onge tonu tae noa ki te 4 tau. Hei tāpiritanga, he poto ake te wā whanaketanga o te DES stenting mō ngā whara kore pumau pērā i te thin tegmental fibroatherosclerosis (TCFA) te intimal rupture rānei, ki te whakaritea ki te BMS. Nō reira, te āhua nei he nui ake te kitea o te neoatherosclerosis, ā, ka puta wawe ake i roto i te DES o te whakatupuranga tuatahi i te BMS, nā te rerekētanga pea o te pathogenesis.
Me tūhura tonu te pānga o te DES o te whakatupuranga tuarua, te DES rānei ki te whanaketanga; ahakoa e kī ana ētahi kitenga o te DES88 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 tonu ētahi atu rangahau.