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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Department of Cardiology, Poliambulanza Foundation Hospital, Brescia, 2 Department of Cardiology, Catholic University of the Sacred Heart of Rome, Italy Abstract: Drug-Eluting metal stemitions (BMS) pambuyo pa percutaneous coronary intervention.Komabe, ngakhale kuti kuyambitsidwa kwa DES ya m'badwo wachiwiri kumawoneka kuti kunawongolera zochitikazi poyerekeza ndi DES ya m'badwo woyamba, nkhawa zazikulu zimakhalabe zokhudzana ndi zovuta zomwe zingatheke mochedwa za kuikidwa kwa stent, monga stent thrombosis (ST) ndi stent resection. Stenosis (ISR) .ST ndizochitika zoopsa zomwe zachepetsedwa kwambiri chifukwa cha kukhathamiritsa kwabwino, mapangidwe atsopano a stent, ndi mankhwala a antiplatelet apawiri.Njira yeniyeni yofotokozera zochitika zake ikufufuzidwa, ndipo ndithudi, zifukwa zambiri zimakhala ndi udindo.ISR mu BMS poyamba inkaganiziridwa kukhala yokhazikika yokhala ndi nsonga yoyambirira ya intimal hyperplasia (kupitirira kwa miyezi 6). Mosiyana ndi zimenezi, maphunziro a zachipatala ndi a histological a DESs adawonetsa umboni wa kukula kosalekeza kwa neointimal panthawi yotsatiridwa kwa nthawi yayitali, chinthu chodziwika bwino chotchedwa "kuchedwa catch-up". zolembera ndi mawonekedwe a machiritso a pambuyo stent; Nthawi zambiri amagwiritsidwa ntchito pomaliza matenda a coronary angiography ndi kuyendetsa njira zothandizira.Intracoronary optical coherence tomography panopa imatengedwa kuti ndi njira yapamwamba kwambiri yojambula zithunzi.Poyerekeza ndi intravascular ultrasound, imapereka chigamulo chabwino (nthawi zosachepera> 10), kulola kufotokozera mwatsatanetsatane mawonekedwe a pamwamba pa khoma la chombo." Mochedwa neo-atherosclerosis mkati mwa BMS ndi DES.Chotero, neo-atherosulinosis yakhala yokayikira kwambiri pathogenesis ya kulephera kwamtima mochedwa.
Percutaneous coronary intervention (PCI) yokhala ndi stent implantation ndiyo njira yomwe imagwiritsidwa ntchito kwambiri pochiza zizindikiro za matenda a mitsempha ya mitsempha, ndipo njirayi ikupitirizabe kusintha.1 Ngakhale kuti mankhwala opangira mankhwala (DES) amachepetsa malire a bare-metal stents (BMSs), mavuto ochedwa monga stent thrombosis (SRST) ndi stent thrombosis stent implantation. , nkhawa zidakalipobe.2-5
Ngati ST ndizochitika zoopsa kwambiri, kuzindikira kuti ISR ​​ndi matenda osadziwika bwino posachedwapa akutsutsidwa ndi umboni wa acute coronary syndrome (ACS) mu odwala ISR.4.
Masiku ano, intracoronary optical coherence tomography (OCT) 6-9 imatengedwa kuti ndi njira yamakono yojambula zithunzi, yomwe imapereka njira yabwinoko kuposa intravascular ultrasound (IVUS)." Maphunziro a kujambula mu vivo, 10-12 yogwirizana ndi zotsatira za histological, amasonyeza "zatsopano" njira ya mitsempha ya MS pambuyo pa kuikidwa kwa stent mkati mwa "Bnevoloscope" ndi DES novos.
Mu 1964, Charles Theodore Dotter ndi Melvin P Judkins anafotokoza angioplasty yoyamba. Icho chinali chithandizo chosinthika koma chinali ndi zovuta za kutsekedwa kwa chotengera choopsa ndi restenosis.13 Izi zinayambitsa kutulukira kwa mitsempha ya mitsempha: Puel ndi Sigwart adatumiza stent yoyamba ya coronary mu 1986, kupereka stent kuti ateteze kutsekedwa kwa chotengera chachikulu komanso mochedwa systolic retraction. mayesero awiri odziwika bwino, Belgian-Dutch Stent Trial 15 ndi Stent Restenosis Study 16, adalimbikitsa chitetezo cha stenting ndi awiri antiplatelet therapy (DAPT) ndi / kapena njira zoyenera zotumizira.17,18 Pambuyo pa mayeserowa, panali kuwonjezeka kwakukulu kwa ma PCI omwe anachitidwa.
Komabe, vuto la iatrogenic in-stent neointimal hyperplasia pambuyo pa kuyika kwa BMS linadziwika mwamsanga, zomwe zinachititsa ISR mu 20% -30% ya zilonda zochiritsidwa. Mu 2005, 80% -90% ya ma PCI onse adatsagana ndi DES.
Chilichonse chili ndi zovuta zake, ndipo kuyambira 2005, nkhawa zokhudzana ndi chitetezo cha "m'badwo woyamba" wa DES zawuka, ndipo ma stents amtundu watsopano monga 20,21 apangidwa ndi kuyambitsidwa.22 Kuyambira nthawi imeneyo, zoyesayesa zowonjezera ntchito za stent zakula mofulumira, ndipo matekinoloje atsopano, odabwitsa apitirizabe kupezeka ndikubweretsedwa ku msika mofulumira.
BMS ndi ma mesh woonda waya chubu.Atakumana koyamba ndi "Wall" phiri, Gianturco-Roubin phiri ndi Palmaz-Schatz phiri, ambiri BMSs osiyanasiyana tsopano.
Mapangidwe atatu osiyanasiyana ndi otheka: koyilo, mauna a tubular ndi chubu chopindika.Mapangidwe a makola amakhala ndi mawaya achitsulo kapena mizere yopangidwa kukhala yozungulira yozungulira; mapangidwe a mauna a tubular amakhala ndi mawaya okulungidwa pamodzi mu mesh kuti apange chubu; machubu otsekedwa amapangidwa ndi machubu achitsulo omwe amadulidwa ndi laser made.Zidazi zimasiyana mosiyanasiyana (zitsulo zosapanga dzimbiri, nichrome, cobalt chrome), mapangidwe apangidwe (mitundu yosiyanasiyana ya strut ndi m'lifupi, ma diameter ndi kutalika, mphamvu ya radial, radiopacity) ndi machitidwe operekera (kudzikulitsa kapena baluni-expandable) .
Nthawi zambiri, BMS yatsopano imakhala ndi aloyi ya cobalt-chromium, yomwe imapangitsa kuti ma struts ang'onoang'ono aziyenda bwino, kukhalabe ndi mphamvu zamakina.
Amakhala ndi nsanja yachitsulo yachitsulo (nthawi zambiri chitsulo chosapanga dzimbiri) komanso yokutidwa ndi polima yomwe imachotsa mankhwala oletsa kufalikira komanso / kapena oletsa kutupa.
Sirolimus (omwe amadziwikanso kuti rapamycin) adapangidwa kuti akhale antifungal agent. Njira yake yochitira zinthu imachokera ku kutsekereza kufalikira kwa maselo poletsa kusintha kwa gawo la G1 kupita ku gawo la S ndikuletsa mapangidwe a neointima. mphamvu popewa ISR.makumi awiri ndi zinayi
Paclitaxel idavomerezedwa koyambirira kwa khansa ya ovarian, koma mphamvu zake za cytostatic - mankhwalawa amakhazikika ma microtubules panthawi ya mitosis, amatsogolera kumangidwa kwa cell cycle ndikuletsa mapangidwe a neointimal - kupanga kukhala gulu la Taxus Express PES. Liberté anali ndi nsanja yachitsulo chosapanga dzimbiri kuti azitumiza mosavuta.
Umboni wotsimikizirika kuchokera ku ndemanga ziwiri zowonongeka ndi kusanthula kwa meta zimasonyeza kuti SES ili ndi mwayi kuposa PES chifukwa cha kuchepa kwa ISR ndi cholinga cha revascularization chombo (TVR), komanso chizolowezi chowonjezeka cha acute myocardial infarction (AMI) mu gulu la PES. 27, 28
Zida za m'badwo wachiwiri zachepetsa makulidwe a strut, kusinthasintha / kutulutsidwa, kupititsa patsogolo mbiri ya polymer biocompatibility/mankhwala alution, komanso re-endothelialization kinetics.Muzochita zamakono, ndi mapangidwe apamwamba kwambiri a DES ndi ma stents akuluakulu obzalidwa padziko lonse lapansi.
Taxus Elements ndikupita patsogolo kokhala ndi polima yapadera yopangidwa kuti ipititse patsogolo kumasulidwa koyambirira komanso kachitidwe katsopano ka platinamu-chromium strut system yomwe imapereka ma struts ocheperako komanso ma radiopacity owonjezera.
Zotarolimus-eluting stent (ZES) Endeavor imachokera pa nsanja yamphamvu ya cobalt-chromium stent yokhala ndi kusinthasintha kwakukulu komanso kukula kwa stent stent. biocompatibility ndi kuchepetsa kutupa. Mankhwala ambiri amachotsedwa panthawi yovulazidwa koyambirira, ndikutsatiridwa ndi kukonzanso kwa mitsempha.Pambuyo pa mayesero oyambirira a ENDEAVOUR, mayesero a ENDEAVOUR III adayerekeza ZES ndi SES, zomwe zinawonetsa kutayika kwakukulu kwa lumen ndi ISR ​​koma zochepa zazikulu zowononga zochitika za mtima (MACE) kuposa SES .30 The ENDEAVOUR, yomwe inapezanso mayesero a ZIV, omwe anayerekezera ndi ZIV ndi PESSR. chiwerengero chochepa cha AMI, chodziwika bwino kuchokera ku ST yapamwamba kwambiri mu gulu la ZES.31 Komabe, kuyesa kwa PROTECT kunalephera kusonyeza kusiyana kwa ST rates pakati pa Endeavor ndi Cypher stents.32
Endeavor Resolute ndi mtundu wowongoka wa Endeavor stent wokhala ndi polima watsopano wosanjikiza zitatu. Watsopano Resolute Integrity (omwe nthawi zina amatchedwa DES wa m'badwo wachitatu) amachokera pa nsanja yatsopano yokhala ndi kuthekera kwapamwamba kopereka (platform ya Integrity BMS), ndi buku, biocompatible yochulukirapo yamitundu itatu imatha kuyankha polima polima. Masiku a 60. Mlandu woyerekeza Resolute ndi Xience V (everolimus-eluting stent [EES]) unawonetsa kusakhala pansi kwa dongosolo la Resolute ponena za imfa ndi kulephera kwa zilonda zam'tsogolo.33,34
Everolimus, yochokera ku sirolimus, imakhalanso cell cycle inhibitor yomwe imagwiritsidwa ntchito popanga Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform) EES. The SPIRIT trial 35-37 inasonyeza ntchito yabwino ndikuchepetsa MACE ndi Xience V poyerekeza ndi PES, pamene EXfenin's supremes inali yoyesedwa mu EES. kutayika mochedwa pa miyezi 9 ndi zochitika zachipatala pa miyezi 12.38 Pomaliza, Xience stent inasonyeza ubwino pa BMS poika ST-segment elevation myocardial infarction (MI) 39.
EPCs ndi kagawo kakang'ono ka maselo ozungulira omwe amakhudzidwa ndi vascular homeostasis ndi endothelial kukonza.Kupititsa patsogolo kwa EPCs pamalo ovulala kwa mitsempha kudzalimbikitsa kukonzanso koyambirira, zomwe zingathe kuchepetsa chiopsezo cha ST.EPC biology kuyesa koyamba pakupanga stent ndi CD34 antibody-yokutidwa ndi anti-yokutidwa ndi Genous stent kudzera mu stent yake ya Genous bipostent, yomwe imatha kuchepetsa chiopsezo cha ST.EPC biology. onjezerani re-endothelialization.Ngakhale kuti maphunziro oyambirira anali olimbikitsa, umboni waposachedwapa umasonyeza kuti TVR.40 ikukwera kwambiri.
Poganizira zomwe zingawononge machiritso ochedwa chifukwa cha polima, zomwe zimagwirizanitsidwa ndi chiopsezo cha ST, ma polima opangidwa ndi bioabsorbable amapereka ubwino wa DES, kupewa nkhawa za nthawi yaitali za kulimbikira kwa polima. zotsatira za nthawi yayitali ndizochepa.41
Zipangizo za bioabsorbable zili ndi mwayi wofotokozera poyamba kupereka chithandizo chamakina pamene zotanuka zotanuka zimaganiziridwa ndi kuchepetsa kuopsa kwa nthawi yaitali kugwirizana ndi zitsulo zomwe zilipo kale.Tekinoloje zatsopano zachititsa kuti pakhale ma polima a lactic acid (poly-l-lactic acid [PLLA]), koma machitidwe ambiri a stent ali pachitukuko, ngakhale kuti kuthetsa vuto la mankhwala osokoneza bongo la BOR ndi lovuta kwambiri. kuyesedwa kunawonetsa chitetezo ndi mphamvu ya everolimus-eluting PLLA stents.43 Mbadwo wachiwiri wa Absorb stent revision unali kusintha kuposa wapitawo ndi kutsata kwabwino kwa zaka 2.44 Kuyesa kosalekeza kwa ABSORB II, kuyesa koyamba kosasinthika kuyerekeza ndi Absorb stent ndi Xience Prime stent, kuyenera kupereka zotsatira zabwino zowonjezera, komabe, zoyamba zopezeka ndi promisi5. njira yopangira implantation, komanso mbiri yachitetezo cha zotupa zam'mitsempha ziyenera kufotokozedwa bwino.
Thrombosis mu BMS ndi DES ili ndi zotsatira zoipa zachipatala.Mu kaundula wa odwala omwe amalandira DES implantation, 47 24% ya STS inachititsa imfa, 60% kuchokera ku MI yosapha, ndi 7% kuchokera ku angina yosakhazikika.PCI muzochitika zadzidzidzi ST nthawi zambiri zimakhala zochepa, ndikuyambiranso mu 12% ya milandu.48
Mu phunziro la BASKET-LATE, 6 kwa miyezi 18 pambuyo pa kuyika kwa stent, chiwerengero cha imfa ya mtima ndi MI yosapha inali yapamwamba mu gulu la DES kusiyana ndi gulu la BMS (4.9% ndi 1.3%, motero) 20 Meta-analysis ya odwala 5, PES2, odwala asanu ndi anayi, mayesero asanu ndi anayi, PES2, kapena mayesero asanu ndi anai. BMS, inanena kuti pazaka 4 zotsatiridwa, SES (0.6% vs 0%, p = 0.025) ndi PES (0.7%) ) inachulukitsa zochitika za ST mochedwa kwambiri poyerekeza ndi BMS ndi 0.2%, p = 0.028) .49 Mosiyana ndi zimenezi, mu meta-analysis kuphatikizapo 5,108 odwala, 0% ES MMS inafotokozedwa ndi imfa ya 21% poyerekeza ndi imfa ya 21% (p=0.03), pomwe PES idalumikizidwa ndi 15% yocheperako (Kutsatira miyezi 9 mpaka zaka 3).
Ma registries ambiri, mayesero osasinthika, ndi kusanthula kwa meta afufuza za chiopsezo chochepa cha ST pambuyo pa BMS ndi DES implantation ndipo afotokoza zotsatira zotsutsana.Mu registry ya odwala 6,906 omwe amalandila BMS kapena DES, panalibe kusiyana kwa zotsatira zachipatala kapena ST rates panthawi ya 1-year-up.48 Mu registry ina ya ST146 odwala opitirira 8 anapeza chiopsezo cha ST. 0.6% / chaka poyerekeza ndi BMS.49 Meta-analysis of trials poyerekeza SES kapena PES ndi BMS inasonyeza chiopsezo chowonjezereka cha imfa ndi MI ndi DES ya m'badwo woyamba poyerekeza ndi BMS, 21 ndi meta-analysis ina ya odwala 4,545 osankhidwa mwachisawawa ku SES kapena Panalibe kusiyana pakati pa zochitika za ST pakati pa zaka za 450 ndi BMS zotsatizana zawonjezeka pazaka za 450 zomwe zakhala zikuwonjezeka. chiopsezo cha ST ndi MI yapamwamba kwa odwala omwe amalandira DES ya m'badwo woyamba atasiya DAPT.51
Chifukwa cha umboni wotsutsana, kusanthula kambiri kophatikizidwa ndi kusanthula kwa meta pamodzi kunatsimikizira kuti DES ndi BMS ya m'badwo woyamba sizinasiyane kwambiri pa chiopsezo cha imfa kapena MI, koma SES ndi PES zinali ndi chiopsezo chowonjezereka cha ST yapamwamba kwambiri poyerekeza ndi BMS. Kuti tiwunikenso Umboni womwe ulipo, bungwe la US Food and Drug Administration (FDA) linasankha gulu la akatswiri53 lomwe linapereka mawu ovomereza kuti DES ya m'badwo woyamba inali yothandiza pa zizindikiro zolembera komanso kuti chiopsezo cha ST yapamwamba kwambiri chinali chaching'ono koma chaching'ono. Kuwonjezeka kwakukulu.Chotsatira chake, a FDA ndi bungwe amalimbikitsa kuwonjezera nthawi ya DAPT kwa chaka cha 1, ngakhale kuti pali deta yochepa yochirikiza izi.
Monga tanenera kale, DES yachiwiri yokhala ndi mapangidwe apamwamba apangidwa.CoCr-EESs adachita maphunziro ochuluka kwambiri a zachipatala.Mu meta-analysis ndi Baber et al, 54 kuphatikizapo odwala 17,101, CoCr-EES yachepetsedwa kwambiri yotsimikizika / zotheka ST ndi MI poyerekeza ndi PES, SES, ndi ZES pambuyo pa miyezi ya 21 metanat-anali ya Palmerini, Palmerini-analysis mu Palmerini-EES. Odwala a 16,775 omwe CoCr-EES anali ndi otsika kwambiri oyambirira, mochedwa, 1- ndi 2-chaka chotsimikizika ST poyerekeza ndi maphunziro ena a DES.55 Real-world awonetsa kuchepetsa chiopsezo cha ST ndi CoCr-EES poyerekeza ndi DES.56 ya m'badwo woyamba.
Re-ZES inayerekezedwa ndi CoCr-EES mu mayesero a RESOLUTE-AC ndi TWENTE.33,57 Panalibe kusiyana kwakukulu pazochitika za imfa, myocardial infarction, kapena ST yotsimikizika pakati pa ma stents awiri.
Mu meta-analysis ya intaneti ya odwala 50,844 kuphatikizapo 49 RCTs, 58CoCr-EES inagwirizanitsidwa ndi zochitika zotsika kwambiri za ST kuposa BMS, zotsatira zomwe sizinawonedwe mu DES zina; kuchepetsa sikunali kokha Kufunika koyambirira komanso pamasiku a 30 (zosamveka chiŵerengero [OR] 0.21, 95% nthawi yodalirika [CI] 0.11-0.42) komanso pa 1 chaka (OR 0.27, 95% CI 0.08-0.74) ndi zaka 2 (OR 0.35% 0.9 0.CI 0.6, red). PES, SES, ndi ZES, CoCr-EES idalumikizidwa ndi kuchepa kwa ST pa 1 chaka.
Early ST ikugwirizana ndi zinthu zosiyanasiyana.Pansi pa plaque morphology ndi katundu wa thrombus amawoneka kuti amakhudza zotsatira pambuyo pa PCI; 59 Kulowera kozama chifukwa cha necrotic core (NC) prolapse, misozi yapakati pamtunda wautali, kugawanika kwachiwiri ndi malire otsalira, kapena kuchepa kwakukulu kwa malire Kukwanira bwino, kuyika kosakwanira, ndi kufalikira kosakwanira60 Chithandizo cha mankhwala ndi antiplatelet sichimakhudza kwambiri kupha kwa ST pa nthawi ya mankhwala: DAPT muyeso yowonongeka poyerekeza ndi BMS ndi DES Mitengo inali yofanana (<1%).61 Choncho, ST yoyambirira ikuwoneka kuti ikugwirizana kwambiri ndi zilonda zam'mimba zochiritsira komanso zopangira opaleshoni.
Masiku ano, chidwi chapadera chimakhala chakumapeto / mochedwa kwambiri ST.Ngati zinthu za ndondomeko ndi zamakono zimawoneka kuti zikuthandizira kwambiri pa chitukuko cha ST, njira yochedwa thrombotic zochitika zikuwoneka kuti ndizovuta kwambiri.Zanenedwa kuti zizindikiro zina za odwala zikhoza kukhala zoopsa za ST: matenda a shuga, ACS panthawi ya opaleshoni yoyamba, kulephera kwaimpso, kukalamba, kutsika kwa 30 masiku oyambirira a edverse cardiction. Opaleshoni.Kwa BMS ndi DES, zosinthika zamachitidwe, monga kukula kwa chotengera chaching'ono, bifurcations, polyvascular disease, calcification, occlusion kwathunthu, stents yaitali, zikuwoneka kuti zikugwirizana ndi chiopsezo cha ST.62,63 Kuyankha kosakwanira kwa antiplatelet therapy ndi chiopsezo chachikulu cha DES thrombosis 51. kuyankha, ma genetic polymorphisms pamlingo wa cholandilira (makamaka clopidogrel resistance), komanso kuwongolera njira zina zoyambitsa mapulateleti. In-stent neoatherosclerosis imawonedwa ngati njira yofunika kwambiri yakulephera kwa stent mochedwa, kuphatikiza mochedwa ST64 (gawo la "In-stent neoatherosclerosis"). vasodilatory substances.DES imasonyeza khoma la chotengera ku mankhwala oletsa tizilombo toyambitsa matenda komanso malo opangira mankhwala osokoneza bongo omwe ali ndi zotsatira zosiyana pa machiritso a endothelial ndi ntchito, ndi chiopsezo chakumapeto kwa thrombosis.65 Maphunziro a pathological amasonyeza kuti ma polima olimba a DES a m'badwo woyamba angapangitse kutupa kosatha, kuwonongeka kwa fibrin kosalekeza, kuwonongeka kwa endothelial consensibility ya DES, komanso kuwonjezeka kwa chiwopsezo cha DES . kukhala njira ina yomwe imatsogolera ku ST.Virmani et al66 inanena za post-mortem post-ST zomwe zikuwonetsa kuwonjezeka kwa aneurysm pa gawo la stent ndi machitidwe a hypersensitivity amderalo omwe amapangidwa ndi T lymphocytes ndi eosinophils; Zotsatirazi zikhoza kusonyeza mphamvu ya ma polima osasinthika.67 Stent malapposition ikhoza kukhala chifukwa cha kuwonjezeka kwa stent kapena kumachitika miyezi ingapo pambuyo pa PCI. zotsutsana.68
Zotsatira zoteteza za m'badwo wachiwiri wa DES zingaphatikizepo endothelialization yofulumira komanso yosasunthika, komanso kusiyana kwa stent alloy ndi mapangidwe, makulidwe a strut, katundu wa polima, ndi mtundu wa mankhwala osokoneza bongo, mlingo, ndi kinetics.
Mogwirizana ndi CoCr-EES, zowonda (81 µm) za cobalt-chromium stent stent, antithrombotic fluoropolymers, polima yochepa, ndi kulongedza kwa mankhwala kungathandize kuchepetsa chiwerengero cha ST. Kafukufuku wasonyeza kuti thrombosis ndi kuikidwa kwa mapulateleti kwa fluoropolymer-coated stents ndi otsika kwambiri a stether6 otsika kwambiri. DES ya m'badwo wachiwiri ili ndi katundu wofanana ndi woyenera kuphunzira.
Ma coronary stents amathandizira kuti maopaleshoni apambane akuyenda bwino poyerekeza ndi chikhalidwe cha percutaneous transluminal coronary angioplasty (PTCA), chomwe chimakhala ndi zovuta zamakina (vascular occlusion, dissection, etc.) komanso kuchuluka kwa restenosis (mpaka 40% -50% ya milandu). Pofika kumapeto kwa zaka za m'ma 1990, pafupifupi 70% ya ma PCI anachitidwa ndi BMS implantation.70
Komabe, ngakhale kupita patsogolo kwa teknoloji, njira, ndi chithandizo chamankhwala, chiopsezo cha restenosis pambuyo pa kuikidwa kwa BMS ndi pafupifupi 20%, ndi> 40% m'magulu enaake.71 Ponseponse, maphunziro a zachipatala asonyeza kuti restenosis pambuyo pa kuikidwa kwa BMS, zofanana ndi zomwe zimawonedwa ndi PTCA wamba, zimafika pa 3-6 miyezi ndipo zimathetsa pambuyo pa 1 chaka.72.
DES imachepetsanso chiwerengero cha ISR,73 ngakhale kuti kuchepa kumeneku kumadalira angiography ndi chikhalidwe chachipatala.Kuvala kwa polima pa DES kumatulutsa anti-inflammatory and anti-proliferative agents, kulepheretsa mapangidwe a neointima, ndi kuchedwetsa kukonzanso kwa mitsempha ya mitsempha kwa miyezi mpaka zaka.74 Kukula kosalekeza kwa neointimal panthawi yotsatiridwa kwa nthawi yayitali pambuyo pa "DES" yodziwika bwino, yomwe imadziwika kuti "phenoimplantation" yomwe imadziwika kuti "phenomenome" yodziwika bwino pambuyo pa "DES" yodziwika bwino. maphunziro a histological. 75
Kuvulala kwa mitsempha pa PCI kumapanga njira yovuta yotupa ndi kukonzanso mu nthawi yochepa (masabata mpaka miyezi), zomwe zimatsogolera ku endothelialization ndi neointimal coverage. Malingana ndi kuwonetsetsa kwa histopathological, neointimal hyperplasia (BMS ndi DES) pambuyo pa kukhazikitsidwa kosasunthika kunali makamaka kumapangidwa ndi proliferative proliferative smooth matrix 7 cell cell.
Choncho, neointimal hyperplasia imayimira njira yokonzanso yomwe imaphatikizapo coagulation ndi zinthu zotupa komanso maselo omwe amachititsa kuti maselo osalala a minofu apangidwe komanso mapangidwe a extracellular matrix.Atangotha ​​​​PCI, mapulateleti ndi fibrin deposit pa khoma la chombo ndikulemba leukocyte kupyolera mu mndandanda wa ma cell adhesion molecule. (CD11b/CD18) ndi mapulateleti glycoprotein Ibα 53 kapena fibrinogen womangidwa ku platelet glycoprotein IIb/IIIa.76,77
Malingana ndi deta yomwe ikubwera, maselo amtundu wa mafupa omwe amachokera ku mafupa amakhudzidwa ndi mayankho a mitsempha ndi kukonzanso njira.Kusonkhanitsa kwa EPCs kuchokera m'mafupa kupita ku magazi amtundu wamagazi kumalimbikitsa kusinthika kwa endothelial ndi postnatal neovascularization.Zikuoneka kuti mafupa osalala a mitsempha ya progenitor cell (SMPC) amasamukira ku malo a kuvulala kwa mitsempha, zomwe zimatsogolera ku maselo a CD4, omwe amatsogolera ku neointi8. kukhala anthu okhazikika a EPC; kafukufuku wina wasonyeza kuti CD34 pamwamba antigen kwenikweni amazindikira osadziwika fupa tsinde maselo ndi luso kusiyanitsa EPCs ndi SMPCs.Transdifferentiation wa CD34-positive maselo ku EPC kapena SMPC mzere kumadalira malo am'deralo; Mikhalidwe ya ischemic imapangitsa kusiyana kwa EPC phenotype kulimbikitsa kubwezeretsanso endothelialization, pamene kutupa kumapangitsa kusiyana kwa phenotype ya SMPC kulimbikitsa kufalikira kwa neointimal.79
Matenda a shuga amawonjezera chiopsezo cha ISR ndi 30% -50% pambuyo pa kuikidwa kwa BMS, 80 komanso kuchuluka kwa restenosis kwa odwala omwe ali ndi matenda a shuga poyerekeza ndi odwala omwe alibe matenda a shuga kunapitirirabe mu nthawi ya DES. matenda, etc.) zinthu zomwe zimawonjezera paokha Zowopsa za ISR.70
Kutalika kwa chotengera ndi kutalika kwa zilonda zinakhudza zochitika za ISR, ndi zilonda zazing'ono zapakati / zazitali zomwe zimachulukitsa kwambiri restenosis poyerekeza ndi zilonda zazikulu / zazifupi.71
Mapulatifomu a m'badwo woyamba adawonetsa ma stent stent ndi ma ISR apamwamba kwambiri poyerekeza ndi nsanja zam'badwo wachiwiri zokhala ndi zingwe zoonda.
Kuonjezera apo, chiwopsezo cha restenosis chinali chokhudzana ndi kutalika kwa stent, ndi kutalika kwa stent> 35 mm pafupifupi kawiri kuposa <20 mm. Chomaliza chochepa cha lumen m'mimba mwake chinathandizanso kwambiri: gawo laling'ono lomaliza la lumen linanena kuti chiopsezo chowonjezeka cha restenosis.81,82
Mwachizoloŵezi, intimal hyperplasia yotsatira BMS implantation imaonedwa kuti ndi yokhazikika, ndi nsonga yoyambirira pakati pa miyezi 6 ndi 1 chaka, ndikutsatiridwa ndi nthawi yochedwa. neointimal regression .83 Komabe, maphunziro omwe amatsatira nthawi yayitali awonetsa kuyankha katatu pambuyo pa kuyika kwa BMS, ndi kupuma koyambirira, kutsika kwapakati, ndi kuchedwa kwa lumen restenosis.84
Mu nthawi ya DES, kukula kwa neointimal mochedwa kunasonyezedwa potsatira SES kapena PES implantation mu zitsanzo za nyama.85 Kafukufuku wambiri wa IVUS wasonyeza kuchepetsedwa koyambirira kwa kukula kwapamtima komwe kumatsatiridwa ndi kugwidwa mochedwa pakapita nthawi pambuyo pa SES kapena PES implantation, mwinamwake chifukwa cha kutupa kosalekeza.86
Ngakhale kuti "kukhazikika" komwe kumatchedwa ISR, pafupifupi gawo limodzi mwa magawo atatu a odwala BMS ISR amapanga ACS.4
Pali umboni wowonjezereka wosonyeza kuti kutupa kosatha ndi / kapena endothelial insufficiency imapangitsa kuti neatherosclerosis ipite patsogolo mkati mwa BMS ndi DES (makamaka DES ya m'badwo woyamba), yomwe ingakhale njira yofunikira ya ISR yapamwamba kapena ST.Inoue et al. 87 inanena kuti zotsatira za histological kuchokera ku zitsanzo za autopsy pambuyo pa kuikidwa kwa Palmaz-Schatz coronary stents, kutanthauza kuti kutupa kwapang'onopang'ono kungapangitse kusintha kwatsopano kwa atherosclerotic mkati mwa stent. Zitsanzo zochokera ku milandu ya ACS zimasonyeza zowonongeka zowonongeka m'mitsempha yamtundu wa coronary Histological morphology ya chipika chokhala ndi foamy macrophages ndi makristasi a kolesteroloni. Kuphatikiza apo, poyerekeza BMS ndi DES, kusiyana kwakukulu pa nthawi ya chitukuko cha atherosclerosis yatsopano kunadziwika. Zilonda za BMS zinachitika zaka 2 pambuyo pake ndipo zinakhalabe zosawerengeka mpaka zaka 4. Komanso, DES stenting chifukwa cha zilonda zosakhazikika monga thin-cap fibroatherosclerosis (TCFA) kapena kuphulika kwa intimal kumakhala ndi nthawi yaifupi ya chitukuko poyerekeza ndi BMS.
Zotsatira za DES ya m'badwo wachiwiri kapena DES mu chitukuko zikuyenera kuphunziridwa; ngakhale zowona zomwe zilipo za m'badwo wachiwiri wa DESs88 zikuwonetsa kutupa kocheperako, zochitika za neoatherosclerosis ndizofanana ndi za m'badwo woyamba, koma kafukufuku wowonjezera akufunikabe.