Javascript pakadali pano yatsekedwa mu msakatuli wanu. Zina mwa zinthu zomwe zili patsamba lino sizigwira ntchito ngati javascript yatsekedwa.
Lembetsani ndi tsatanetsatane wanu ndi mankhwala enaake omwe mukufuna ndipo tidzagwirizanitsa zomwe mumapereka ndi nkhani zomwe zili mu database yathu yayikulu ndikukutumizirani imelo nthawi yomweyo.
Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Dipatimenti ya Cardiology, Poliambulanza Foundation Hospital, Brescia, 2 Dipatimenti ya Cardiology, Catholic University of the Sacred Heart of Rome, Italy Chidule: Mankhwala Oletsa Mankhwala Oletsa Mankhwala (DES) amachepetsa zoletsa za stents zachitsulo zopanda kanthu (BMS) pambuyo pa percutaneous coronary intervention. Komabe, ngakhale kuti kuyambitsa DES ya m'badwo wachiwiri kukuwoneka kuti kwachepetsa vutoli poyerekeza ndi DES ya m'badwo woyamba, nkhawa zazikulu zikupitirirabe za zovuta zomwe zingachitike pambuyo pake za kuyika stent, monga stent thrombosis (ST) ndi stent resection. Stenosis (ISR).ST ndi chochitika choopsa chomwe chachepetsedwa kwambiri chifukwa cha kupukutira bwino kwa stent, mapangidwe atsopano a stent, ndi mankhwala awiri oletsa ma platelet. Njira yeniyeni yomwe ikufotokozera kufalikira kwake ikufufuzidwa, ndipo ndithudi, pali zinthu zingapo zomwe zimayambitsa. ISR mu BMS kale inkaonedwa kuti ndi mkhalidwe wokhazikika wokhala ndi pachimake choyambirira cha intimal hyperplasia (pa miyezi 6) kutsatiridwa ndi nthawi yochepera chaka chimodzi. Mosiyana ndi zimenezi, maphunziro azachipatala komanso a histological a DESSs adawonetsa umboni wa kukula kosalekeza kwa neointimal panthawi yotsatiridwa kwa nthawi yayitali, chochitika chodziwika kuti "mochedwa catch-up". Kuwona kuti ISR ​​ndi matenda osachiritsika kwatsutsidwa posachedwapa ndi umboni wakuti odwala omwe ali ndi ISR ​​amatha kukhala ndi matenda a mtima oopsa. Kujambula m'mimba ndi njira yolowerera yomwe imatha kuzindikira ma plaque a atherosclerotic omwe ali ndi stent ndi mawonekedwe a kuchira kwa mitsempha yamagazi pambuyo pa stent; Kawirikawiri imagwiritsidwa ntchito pomaliza matenda a coronary angiography ndikuyendetsa njira zochiritsira. Intracoronary optical coherence tomography pakadali pano imaonedwa kuti ndi njira yapamwamba kwambiri yojambulira zithunzi. Poyerekeza ndi ultrasound yamkati mwa mitsempha, imapereka chidziwitso chabwino (osachepera nthawi 10), zomwe zimathandiza kufotokoza mwatsatanetsatane kapangidwe ka pamwamba pa khoma la mitsempha. "Mafukufuku ojambula mu vivo omwe akugwirizana ndi zomwe zapezeka mu histological akuwonetsa kuti kutupa kosatha ndi/kapena kusagwira bwino ntchito kwa endothelial kungayambitse neo-atherosclerosis yomaliza mu BMS ndi DES. Chifukwa chake, neo-atherosclerosis yakhala chikayikiro chachikulu pakupanga kwa kulephera kwa stent komaliza. Mawu ofunikira: coronary stent, stent thrombosis, restenosis, neoatherosclerosis
Kulowetsa mitsempha ya mtima (PCI) pogwiritsa ntchito stent implantation ndiyo njira yomwe imagwiritsidwa ntchito kwambiri pochiza matenda a mitsempha ya mtima, ndipo njirayi ikupitilirabe kusintha.1 Ngakhale kuti stent yogwiritsa ntchito mankhwala (DES) imachepetsa zofooka za stent yachitsulo (BMSs), mavuto obwera chifukwa cha stent thrombosis (ST) ndi in-stent restenosis (ISR) amatha kuchitika ndi stent implantation. , nkhawa zazikulu zikupitirirabe.2-5
Ngati ST ndi vuto lalikulu lomwe lingakhale loopsa, kuzindikira kuti ISR ​​ndi matenda abwinobwino kwatsutsidwa posachedwapa ndi umboni wa matenda a mtima (ACS) mwa odwala a ISR.4
Masiku ano, intracoronary optical coherence tomography (OCT)6-9 imaonedwa kuti ndi njira yamakono yojambulira zithunzi, yomwe imapereka chidziwitso chabwino kuposa intravascular ultrasound (IVUS).”Mafukufuku ojambula zithunzi mu vivo,10-12 ogwirizana ndi zomwe zapezeka mu histology, akuwonetsa njira “yatsopano” yoyankhira mitsempha yamagazi pambuyo poika stent, yokhala ndi “neoatherosclerosis” yatsopano mkati mwa BMS ndi DES.
Mu 1964, Charles Theodore Dotter ndi Melvin P Judkins anafotokoza za angioplasty yoyamba. Mu 1978, Andreas Gruntzig anachita angioplasty yoyamba ya baluni (angioplasty yakale ya baluni); chinali chithandizo chosintha koma chinali ndi zovuta za kutseka kwa mitsempha yamagazi ndi restenosis.13 Izi zinayambitsa kupezeka kwa ma stents a coronary: Puel ndi Sigwart adagwiritsa ntchito stent yoyamba ya coronary mu 1986, kupereka stent yoletsa kutsekedwa kwa mitsempha yamagazi ndi kubweza kwa systolic mochedwa.14 Ngakhale ma stents oyambawa adaletsa kutsekedwa kwadzidzidzi kwa mitsempha yamagazi, adayambitsa kuwonongeka kwakukulu kwa endothelial ndi kutupa. Pambuyo pake, mayeso awiri ofunikira, Belgian-Dutch Stent Trial 15 ndi Stent Restenosis Study 16, adalimbikitsa chitetezo cha stenting ndi dual antiplatelet therapy (DAPT) ndi/kapena njira zoyenera zoperekera.17,18 Pambuyo pa mayesowa, panali kuwonjezeka kwakukulu kwa chiwerengero cha ma PCI omwe adachitidwa.
Komabe, vuto la iatrogenic in-stent neointimal hyperplasia pambuyo pa kuikidwa kwa BMS linazindikirika mwachangu, zomwe zinapangitsa kuti ISR ​​ichitike mu 20%–30% ya zilonda zomwe zinachiritsidwa. Mu 2001, DES idayambitsidwa19 kuti ichepetse kufunikira kwa restenosis ndi reintervention. Ma DES awonjezera chidaliro cha akatswiri a mtima, zomwe zalola kuti zilonda zovuta zambiri zichiritsidwe zomwe poyamba zinkaganiziridwa kuti zathetsedwa ndi coronary artery bypass grafting. Mu 2005, 80%–90% ya ma PCI onse anali limodzi ndi DES.
Chilichonse chili ndi zovuta zake, ndipo kuyambira mu 2005, nkhawa zokhudza chitetezo cha DES ya "m'badwo woyamba" yakwera, ndipo ma stenti atsopano monga 20,21 apangidwa ndikuyambitsidwa.22 Kuyambira pamenepo, khama lowongolera magwiridwe antchito a stent lakula mofulumira, ndipo ukadaulo watsopano, wodabwitsa wapitiliza kupezeka ndikubweretsedwa pamsika mwachangu.
BMS ndi chubu cha waya woonda kwambiri. Pambuyo poyesa koyamba kugwiritsa ntchito chomangira cha "Wall", chomangira cha Gianturco-Roubin ndi chomangira cha Palmaz-Schatz, ma BMS ambiri osiyanasiyana tsopano akupezeka.
Mapangidwe atatu osiyanasiyana ndi otheka: coil, tubular mesh ndi slotted chubu. Mapangidwe a coil ali ndi mawaya achitsulo kapena timizere topangidwa kukhala mawonekedwe ozungulira a coil; mapangidwe a tubular mesh ali ndi mawaya okulungidwa pamodzi mu mesh kuti apange chubu; mapangidwe a machubu odulidwa amakhala ndi machubu achitsulo omwe amadulidwa ndi laser. Zipangizozi zimasiyana mu kapangidwe kake (chitsulo chosapanga dzimbiri, nichrome, cobalt chrome), kapangidwe ka kapangidwe kake (mawonekedwe osiyanasiyana a strut ndi m'lifupi, mainchesi ndi kutalika, mphamvu ya radial, radiopacity) ndi machitidwe operekera (odzikulitsa okha kapena owonjezera baluni).
Kawirikawiri, BMS yatsopanoyi imakhala ndi cobalt-chromium alloy, zomwe zimapangitsa kuti zikhale ndi zingwe zopyapyala zomwe zimathandiza kuti makina aziyenda bwino, zomwe zimapangitsa kuti makina azigwira ntchito bwino.
Zimakhala ndi nsanja yachitsulo ya stent (nthawi zambiri chitsulo chosapanga dzimbiri) ndipo yokutidwa ndi polima yomwe siili ndi mankhwala oletsa kufalikira kwa maselo ndi/kapena kutupa.
Sirolimus (yomwe imadziwikanso kuti rapamycin) poyamba idapangidwa ngati mankhwala opha ma fungus. Kagwiridwe kake ka ntchito kamachokera pakuletsa kupita patsogolo kwa maselo mwa kuletsa kusintha kuchokera ku gawo la G1 kupita ku gawo la S ndikuletsa kupangika kwa neointima. Mu 2001, zomwe zidachitika "mwa munthu woyamba" ndi SES zidawonetsa zotsatira zabwino, zomwe zidapangitsa kuti stent ya Cypher ipangidwe.23 Mayeso akuluakulu adawonetsa kuti imagwira ntchito bwino poletsa ISR.24
Paclitaxel poyamba idavomerezedwa kuti igwiritsidwe ntchito pa khansa ya m'chiberekero, koma mphamvu zake zamphamvu zoteteza thupi - mankhwalawa amalimbitsa ma microtubules panthawi ya mitosis, amachititsa kuti maselo asamayende bwino komanso amaletsa mapangidwe a neointimal - zimapangitsa kuti ikhale mankhwala a Taxus Express PES. Mayeso a TAXUS V ndi VI adawonetsa kugwira ntchito kwa PES kwa nthawi yayitali mu matenda oopsa komanso ovuta a mitsempha ya mtima.25,26 TAXUS Liberté yotsatira inali ndi nsanja yachitsulo chosapanga dzimbiri kuti iperekedwe mosavuta.
Umboni womaliza wochokera ku ndemanga ziwiri zokonzedwa bwino komanso kusanthula kwa meta kukuwonetsa kuti SES ili ndi mwayi kuposa PES chifukwa cha kuchepa kwa ISR ndi target vessel revascularization (TVR), komanso chizolowezi chowonjezeka cha acute myocardial infarction (AMI) mu gulu la PES. 27,28
Zipangizo za m'badwo wachiwiri zili ndi makulidwe ochepa a strut, kusinthasintha/kutumiza bwino, ma polymer biocompatibility/drug elution profiles abwino kwambiri, komanso njira zabwino kwambiri zobwezeretsanso endothelialization. Masiku ano, ndi mapangidwe apamwamba kwambiri a DES ndi ma coronary stents akuluakulu omwe amaikidwa padziko lonse lapansi.
Taxus Elements ndi kupita patsogolo kwina ndi polima yapadera yopangidwa kuti iwonjezere kutulutsidwa koyambirira komanso dongosolo latsopano la platinum-chromium strut lomwe limapereka struts zoonda komanso mphamvu yowonjezera ya radiopacity. Mayeso a PERSEUS 29 adawona zotsatira zofanana pakati pa Element ndi Taxus Express kwa miyezi 12. Komabe, mayeso oyerekeza zinthu za yew ndi zina za DES za m'badwo wachiwiri akusowa.
Endeavor ya zotarolimus-eluting stent (ZES) imachokera pa nsanja yamphamvu ya cobalt-chromium stent yokhala ndi kusinthasintha kwakukulu komanso kukula kochepa kwa stent. Zotarolimus ndi analog ya sirolimus yokhala ndi zotsatira zofanana zoletsa chitetezo chamthupi koma yowonjezera lipophilicity kuti iwonjezere malo a khoma la mitsempha yamagazi.ZES imagwiritsa ntchito utoto watsopano wa phosphorylcholine polymer wopangidwa kuti ukhale wogwirizana kwambiri ndi thupi ndikuchepetsa kutupa. Mankhwala ambiri amachotsedwa panthawi yoyamba yovulala, kutsatiridwa ndi kukonzanso kwa mitsempha yamagazi. Pambuyo pa kuyesa koyamba kwa ENDEAVOR, kuyesa kotsatira kwa ENDEAVOR III kunayerekeza ZES ndi SES, komwe kunawonetsa kutayika kwakukulu kwa lumen ndi ISR ​​koma zochitika zochepa zoyipa zamtima (MACE) kuposa SES .30 Kuyesa kwa ENDEAVOR IV, komwe kunayerekeza ZES ndi PES, kunapezanso kuchuluka kwa ISR, koma kuchuluka kochepa kwa AMI, komwe kumadziwika kuti ndi ST yapamwamba kwambiri m'gulu la ZES.31 Komabe, kuyesa kwa PROTECT kunalephera kuwonetsa kusiyana kwa kuchuluka kwa ST pakati pa stents za Endeavor ndi Cypher.32
Endeavor Resolute ndi mtundu wabwino wa stent ya Endeavor yokhala ndi polima yatsopano ya magawo atatu. Resolute Integrity yatsopano (nthawi zina imatchedwa DES ya m'badwo wachitatu) imachokera pa nsanja yatsopano yokhala ndi mphamvu zoperekera zambiri (pulatifomu ya Integrity BMS), ndipo polima yatsopano, yogwirizana kwambiri ndi zinthu zitatu, imatha kuletsa kuyankhidwa koyamba kwa kutupa ndikuchotsa mankhwala ambiri m'masiku 60 otsatira. Kuyesa koyerekeza Resolute ndi Xience V (stent ya everolimus-eluting [EES]) kunawonetsa kusatsika kwa dongosolo la Resolute pankhani ya imfa ndi kulephera kwa zilonda zomwe zatsala.33,34
Everolimus, yomwe imachokera ku sirolimus, ndi chinthu choletsa maselo omwe amagwiritsidwa ntchito popanga Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform) EES. Kuyesa kwa SPIRIT 35-37 kunawonetsa magwiridwe antchito abwino komanso kuchepa kwa MACE ndi Xience V poyerekeza ndi PES, pomwe kuyesa kwa EXCELLENT kunawonetsa kuti EES sinali yotsika kuposa SES pakuletsa kutayika mochedwa pa miyezi 9 ndi zochitika zachipatala pa miyezi 12.38 Pomaliza, stent ya Xience inawonetsa zabwino kuposa BMS pakukhazikitsa ST-segment elevation myocardial infarction (MI).39
Ma EPC ndi gulu la maselo ozungulira omwe amagwira ntchito mu homeostasis ya mitsempha yamagazi ndi kukonzanso endothelial. Kupititsa patsogolo ma EPC pamalo omwe mitsempha yamagazi yavulala kudzalimbikitsa kubwezeretsanso endothelialization msanga, zomwe zingachepetse chiopsezo cha kuyesa koyamba kwa ST.EPC biology pakupanga stent ndi stent ya CD34 antibody-coated Genous, yomwe imatha kumangirira ma EPC ozungulira kudzera mu zizindikiro zake za hematopoietic kuti iwonjezere kubwezeretsanso endothelialization. Ngakhale kuti maphunziro oyamba anali olimbikitsa, umboni waposachedwa ukusonyeza kuti TVR.40 ndi yokwera kwambiri.
Poganizira zotsatira zomwe zingawononge kuchira kochedwa chifukwa cha polima, komwe kumakhudzana ndi chiopsezo cha ST, ma polima otha kuyamwa amapereka ubwino wa DES, kupewa nkhawa zomwe zakhalapo kwa nthawi yayitali zokhudza kupirira kwa polima. Mpaka pano, machitidwe osiyanasiyana otha kuyamwa avomerezedwa (monga Nobori ndi Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), koma mabuku omwe akuthandizira zotsatira zawo za nthawi yayitali ndi ochepa.41
Zipangizo zomwe zimatha kuyamwa zinthu zomwe zimapezeka m'thupi zimakhala ndi ubwino wongoganizira poyamba popereka chithandizo chamakina pamene elastic recoil ikuganiziridwa ndikuchepetsa zoopsa zomwe zingachitike nthawi yayitali zokhudzana ndi zitsulo zomwe zilipo. Ukadaulo watsopano watsogolera kukukula kwa ma polima okhala ndi lactic acid (poly-l-lactic acid [PLLA]), koma machitidwe ambiri a stent akupangidwa, ngakhale kuti kupeza bwino pakati pa mankhwala ochotsera ndi kuwonongeka kwa kinetics kukupitirirabe kukhala vuto. Kuyesa kwa ABSORB kunawonetsa chitetezo ndi mphamvu ya stent za PLLA zotchedwa everolimus-eluting.43 Kusinthidwa kwa Absorb stent ya m'badwo wachiwiri kunali kusintha kuposa komwe kunachitika kale ndi zotsatira zabwino za zaka ziwiri.44 Kuyesa kwa ABSORB II komwe kukupitilira, kuyesa koyamba kosankhidwa mwachisawawa koyerekeza Absorb stent ndi Xience Prime stent, kuyenera kupereka zambiri zina, ndipo zotsatira zoyambirira zomwe zikupezeka zikulonjeza.45 Komabe, malo abwino, njira yabwino kwambiri yoyikiramo, ndi mbiri yachitetezo cha zilonda zamtima ziyenera kufotokozedwa bwino.
Matenda a Thrombosis mu BMS ndi DES ali ndi zotsatira zoyipa zachipatala. Mu kaundula wa odwala omwe amalandira DES implantation, 47% ya milandu ya ST inachititsa imfa, 60% chifukwa cha MI yosapha, ndi 7% chifukwa cha angina yosakhazikika. PCI mu ST yadzidzidzi nthawi zambiri imakhala yosakwanira, ndipo kubwereranso kwa 12% ya milandu.48
ST yapamwamba ili ndi zotsatira zoyipa zachipatala. Mu kafukufuku wa BASKET-LATE, miyezi 6 mpaka 18 atayikidwa stent, kuchuluka kwa imfa za mtima ndi MI zosapha kunali kwakukulu mu gulu la DES kuposa gulu la BMS (4.9% ndi 1.3%, motsatana).20 Kusanthula kwa meta-mayeso asanu ndi anayi, momwe odwala 5,261 adasankhidwa mwachisawawa ku SES, PES, kapena BMS, kunanena kuti pazaka 4 zotsatiridwa, SES (0.6% vs 0%, p=0.025) ndi PES (0.7%) zidawonjezera kuchuluka kwa ST mochedwa kwambiri poyerekeza ndi BMS ndi 0.2%, p=0.028).49 Mosiyana ndi zimenezi, mu kusanthula kwa meta kuphatikiza odwala 5,108, 21 kuwonjezeka kwa 60% kwa imfa kapena MI kunanenedwa ndi SES poyerekeza ndi BMS (p=0.03), pomwe PES idalumikizidwa ndi kuwonjezeka kwa 15% kosafunikira (Kutsatira miyezi 9 mpaka 3). zaka).
Ma registry ambiri, mayeso osankhidwa mwachisawawa, ndi meta-analyses afufuza za chiopsezo cha ST pambuyo pa BMS ndi DES implantation ndipo apereka zotsatira zotsutsana. Mu registry ya odwala 6,906 omwe amalandira BMS kapena DES, panalibe kusiyana pa zotsatira zachipatala kapena kuchuluka kwa ST panthawi yotsatiridwa kwa chaka chimodzi.48 Mu registry ina ya odwala 8,146, chiopsezo cha ST yochulukirapo nthawi zonse chinapezeka kuti chinali 0.6%/chaka poyerekeza ndi BMS.49 Kusanthula kwa meta-mayesero poyerekeza SES kapena PES ndi BMS kunawonetsa chiopsezo chowonjezeka cha imfa ndi MI ndi DES ya m'badwo woyamba poyerekeza ndi BMS, 21 ndi meta-mayesero ena a odwala 4,545 omwe adasankhidwa mwachisawawa ku SES kapena Panalibe kusiyana pa kuchuluka kwa ST pakati pa PES ndi BMS pazaka 4 zotsatiridwa.50 Kafukufuku wina weniweni wasonyeza chiopsezo chowonjezeka cha ST ndi MI yapamwamba mwa odwala omwe amalandira DES ya m'badwo woyamba atasiya kugwiritsa ntchito DAPT.51
Popeza umboni wotsutsanawu unalipo, kusanthula kosiyanasiyana ndi kusanthula kwa meta pamodzi kunatsimikiza kuti DES ndi BMS za m'badwo woyamba sizinasiyane kwambiri pa chiopsezo cha imfa kapena MI, koma SES ndi PES zinali ndi chiopsezo chowonjezeka cha ST yapamwamba kwambiri poyerekeza ndi BMS. Kuti ziwunikenso umboni womwe ulipo, US Food and Drug Administration (FDA) idasankha gulu la akatswiri53 lomwe lidapereka chikalata chovomereza kuti DES ya m'badwo woyamba inali yothandiza pazizindikiro zomwe zili pa chizindikirocho ndipo chiopsezo cha ST yapamwamba kwambiri chinali chochepa koma chochepa. Kuwonjezeka kwakukulu. Zotsatira zake, FDA ndi bungweli amalimbikitsa kuwonjezera nthawi ya DAPT mpaka chaka chimodzi, ngakhale kuti pali deta yochepa yotsimikizira izi.
Monga tanenera kale, ma DES a m'badwo wachiwiri okhala ndi mawonekedwe apamwamba apangidwa. Ma CoCr-EES achita kafukufuku wochuluka kwambiri wazachipatala. Mu kusanthula kwa meta kwa Baber et al, 54 kuphatikiza odwala 17,101, CoCr-EES yachepetsa kwambiri ST ndi MI yotsimikizika/yotheka poyerekeza ndi PES, SES, ndi ZES patatha miyezi 21. Pomaliza, Palmerini et al adawonetsa mu kusanthula kwa meta kwa odwala 16,775 kuti CoCr-EES inali ndi ST yotsimikizika yotsika kwambiri koyambirira, mochedwa, chaka chimodzi ndi ziwiri poyerekeza ndi ma DES ena ophatikizidwa.55 Kafukufuku weniweni wasonyeza kuchepa kwa chiopsezo cha ST ndi CoCr-EES poyerekeza ndi DES ya m'badwo woyamba.56
Re-ZES inayerekezeredwa ndi CoCr-EES mu mayeso a RESOLUTE-AC ndi TWENTE.33,57 Panalibe kusiyana kwakukulu pa kuchuluka kwa imfa, matenda a mtima, kapena ST yeniyeni pakati pa ma stents awiriwa.
Mu kafukufuku wa netiweki wa odwala 50,844 kuphatikiza ma RCT 49, 58CoCr-EES idalumikizidwa ndi kuchuluka kochepa kwa ST yeniyeni kuposa BMS, zotsatira zake sizinawonekere mu ma DES ena; kuchepa sikunali kokha mu Kuzindikira koyambirira komanso pa masiku 30 (chiŵerengero cha mwayi [OR] 0.21, 95% nthawi yodzidalira [CI] 0.11-0.42) komanso pa chaka chimodzi (OR 0.27, 95% CI 0.08-0.74) ndi zaka ziwiri (OR 0.35, 95% CI 0.17–0.69). Poyerekeza ndi PES, SES, ndi ZES, CoCr-EES idalumikizidwa ndi kuchuluka kochepa kwa ST pa chaka chimodzi.
ST yoyambirira imakhudzana ndi zinthu zosiyanasiyana. Kapangidwe ka plaque pansi pake ndi kuchuluka kwa thrombus zikuwoneka kuti zimakhudza zotsatira pambuyo pa PCI; 59 Kulowa mozama kwa strut chifukwa cha necrotic core (NC) prolapse, kung'ambika kwa medial mu stent lengths, secondary dissection with residual margins, kapena significant margin stenting. Optimal stenting, incomplete apposition, and incomplete expansion60. Chithandizo cha mankhwala ndi mankhwala oletsa ma platelet sichimakhudza kwambiri kuchuluka kwa ST yoyambirira: kuchuluka kwa ST yoopsa komanso ya subacute panthawi ya DAPT mu mayeso osankhidwa mwachisawawa poyerekeza BMS ndi DES Rates zinali zofanana (<1%).61 Chifukwa chake, ST yoyambirira ikuwoneka kuti ikugwirizana kwambiri ndi zilonda zochiritsira komanso zinthu zochitidwa opaleshoni.
Masiku ano, cholinga chachikulu ndi ST mochedwa/mochedwa kwambiri. Ngati zinthu zaukadaulo ndi zaukadaulo zikuwoneka kuti zikugwira ntchito yayikulu pakukula kwa ST yoopsa komanso yocheperako, njira yochepetsera zochitika za thrombotic ikuwoneka kuti ndi yovuta kwambiri. Zanenedwa kuti makhalidwe ena a wodwala akhoza kukhala zinthu zomwe zimayambitsa ST yotsogola komanso yotsogola kwambiri: matenda a shuga, ACS panthawi ya opaleshoni yoyamba, kulephera kwa impso, ukalamba, kuchepa kwa gawo lotulutsa magazi, zochitika zazikulu zoyipa za mtima mkati mwa masiku 30 kuchokera pa opaleshoni yoyamba. Kwa BMS ndi DES, zinthu zosinthika, monga kukula kwa mitsempha yaying'ono, bifurcations, matenda a polyvascular, calcification, total occlusion, long stents, zikuwoneka kuti zikugwirizana ndi chiopsezo cha ST.62,63 Kuyankha kosakwanira ku mankhwala oletsa ma platelet ndi chinthu chachikulu chomwe chimayambitsa thrombosis yotsogola ya DES 51. Yankho ili likhoza kukhala chifukwa cha kusatsatira kwa wodwala, kuchepa kwa mlingo, kuyanjana ndi mankhwala, matenda ena omwe amakhudza kuyankha kwa mankhwala, ma genetic polymorphisms pamlingo wa receptor (makamaka clopidogrel resistance), komanso kukwera kwa njira zina zoyatsira ma platelet. In-stent neoatherosclerosis imaonedwa kuti ndi njira yofunika kwambiri yochedwa. Kulephera kwa stent, kuphatikizapo ST64 yomaliza (gawo lakuti “In-stent neoatherosclerosis”). Endothelium yosasinthika imalekanitsa khoma la mitsempha yamagazi ndi stent struts kuchokera ku magazi ndipo imatulutsa zinthu zotsutsana ndi thrombosis ndi vasodilatory.DES imawonetsa khoma la mitsempha yamagazi ku mankhwala oletsa kufalikira kwa magazi ndi nsanja yochotsa mankhwala yomwe ili ndi zotsatira zosiyana pa machiritso ndi ntchito ya endothelial, ndi chiopsezo cha thrombosis yomaliza.65 Kafukufuku wa matenda akuwonetsa kuti ma polima olimba a DES a m'badwo woyamba angathandize kutupa kosatha, kukhazikika kwa fibrin kosatha, kuchira koipa kwa endothelial, komanso chiopsezo chowonjezeka cha thrombosis.3 Kusamva bwino kwa DES mochedwa kumawoneka ngati njira ina yomwe imayambitsa ST.Virmani et al66 adanenanso za zomwe zapezeka pambuyo pa imfa ya ST zomwe zikuwonetsa kukula kwa aneurysm pa gawo la stent ndi zochitika za hypersensitivity zakomweko zopangidwa ndi ma T lymphocytes ndi eosinophils; Zomwe zapezekazi zitha kuwonetsa mphamvu ya ma polima osasinthika.67 Kusakhazikika kwa stent kungakhale chifukwa cha kukulira kwa stent kosakwanira kapena kumachitika miyezi ingapo PCI itatha. Ngakhale kusakhazikika kwa njira ndi chinthu chomwe chimayambitsa ST yoopsa komanso yocheperako, kufunika kwa stent yopezeka kungadalire kukonzanso kwamphamvu kwa mitsempha yamagazi kapena kuchira mochedwa chifukwa cha mankhwala, koma kufunika kwake kwachipatala ndi kotsutsana.68
Zotsatira zoteteza za DES ya m'badwo wachiwiri zitha kuphatikizapo endothelialization yofulumira komanso yosasintha, komanso kusiyana kwa stent alloy ndi kapangidwe kake, makulidwe a strut, mawonekedwe a polima, ndi mtundu wa mankhwala oletsa kufalikira, mlingo, ndi kinetics.
Poyerekeza ndi CoCr-EES, ma struts owonda (81 µm) a cobalt-chromium stent, ma fluoropolymers oletsa thrombosis, ma polymer ochepa, ndi kuchuluka kwa mankhwala kungathandize kuchepetsa kuchuluka kwa ST. Kafukufuku woyeserera wasonyeza kuti thrombosis ndi platelet deposition ya ma stents okhala ndi fluoropolymer ndi otsika kwambiri kuposa a ma stents opanda zitsulo.69 Ngati ma DES ena a m'badwo wachiwiri ali ndi makhalidwe ofanana ayenera kufufuzidwa kwambiri.
Ma stenti a mtima amathandiza kuti opaleshoni ya mtima ipambane poyerekeza ndi opaleshoni yachikhalidwe ya percutaneous transluminal coronary angioplasty (PTCA), yomwe ili ndi mavuto a makina (kutseka mitsempha yamagazi, kuduladula, ndi zina zotero) komanso kuchuluka kwa restenosis (mpaka 40%–50% ya milandu). Pofika kumapeto kwa zaka za m'ma 1990, pafupifupi 70% ya ma PCI anali atachitidwa opaleshoni pogwiritsa ntchito BMS implantation.70
Komabe, ngakhale kuti ukadaulo, njira, ndi chithandizo chamankhwala zapita patsogolo, chiopsezo cha restenosis pambuyo poika BMS m'thupi ndi pafupifupi 20%, ndi >40% m'magulu enaake.71 Ponseponse, maphunziro azachipatala asonyeza kuti restenosis pambuyo poika BMS m'thupi, mofanana ndi momwe zimachitikira ndi PTCA yachizolowezi, imafika pachimake pa miyezi 3-6 ndipo imatha patatha chaka chimodzi.72
DES imachepetsanso kuchuluka kwa ISR,73 ngakhale kuti kuchepa kumeneku kumadalira angiography ndi malo azachipatala. Chophimba cha polima pa DES chimatulutsa mankhwala oletsa kutupa ndi oletsa kufalikira, chimaletsa kupangika kwa neointima, ndikuchedwetsa njira yokonzanso mitsempha kwa miyezi mpaka zaka.74 Kukula kosalekeza kwa neointima panthawi yotsatiridwa kwa nthawi yayitali pambuyo pa kuikidwa kwa DES, chinthu chodziwika kuti "kugwidwa mochedwa", chinawonedwa mu maphunziro azachipatala ndi a histological.75
Kuvulala kwa mitsempha yamagazi panthawi ya PCI kumabweretsa njira yovuta yotupa ndi kukonzanso mkati mwa nthawi yochepa (masabata mpaka miyezi), zomwe zimapangitsa kuti endothelialization ndi neointimal coverage zipitirire. Malinga ndi zomwe zapezeka mu histopathological, neointimal hyperplasia (BMS ndi DES) pambuyo pa kuikidwa kwa stent inali makamaka yopangidwa ndi maselo osalala a minofu omwe ali mu proteoglycan-rich extracellular matrix.70
Motero, neukointimal hyperplasia ikuyimira njira yokonzanso yomwe imaphatikizapo kuuma ndi zinthu zotupa komanso maselo omwe amayambitsa kuchulukana kwa maselo a minofu yosalala komanso kupangika kwa matrix akunja kwa thupi. Nthawi yomweyo pambuyo pa PCI, ma platelet ndi fibrin zimayikidwa pakhoma la mitsempha yamagazi ndikusonkhanitsa ma leukocyte kudzera mu mamolekyulu angapo omatira a maselo. Ma leukocyte ozungulira amalumikizana ndi ma platelet omatira kudzera mu mgwirizano pakati pa leukocyte integrin Mac-1 (CD11b/CD18) ndi platelet glycoprotein Ibα 53 kapena fibrinogen yolumikizidwa ku platelet glycoprotein IIb/IIIa.76,77
Malinga ndi zomwe zapezeka, maselo obadwa kuchokera ku mafupa amatenga nawo mbali pa mayankho a mitsempha ndi njira zokonzanso. Kusuntha kwa ma EPC kuchokera ku mafupa kupita ku magazi ozungulira kumathandizira kukonzanso kwa endothelial ndi neovascularization pambuyo pa kubadwa. Zikuwoneka kuti maselo obadwa ndi minofu yosalala ya mafupa (SMPC) amasamukira kumalo komwe mitsempha yamagazi yavulala, zomwe zimapangitsa kuti neointimal ichuluke.78 Kale, maselo a CD34-positive ankaonedwa kuti ndi gulu lokhazikika la ma EPC; kafukufuku wina wasonyeza kuti CD34 surface antigen imazindikira maselo oyambira a mafupa osagawanika omwe amatha kusiyanitsa kukhala ma EPC ndi ma SMPC. Kusintha kwa maselo a CD34-positive kupita ku mzere wa EPC kapena SMPC kumadalira malo am'deralo; matenda a ischemic amachititsa kusiyanasiyana kupita ku phenotype ya EPC kuti alimbikitse kubwezeretsanso kwa endothelialization, pomwe matenda otupa amachititsa kusiyanasiyana kupita ku phenotype ya SMPC kuti alimbikitse kufalikira kwa neointimal.79
Matenda a shuga amawonjezera chiopsezo cha ISR ndi 30%–50% pambuyo poika BMS,80 ndipo kuchuluka kwa restenosis mwa odwala matenda a shuga poyerekeza ndi odwala omwe si odwala matenda a shuga kunapitirirabe mu nthawi ya DES. Njira zomwe zimayang'ana izi mwina ndi zinthu zambiri, kuphatikizapo zinthu zathupi (monga kusinthasintha kwa kutupa) ndi kapangidwe ka thupi (monga mitsempha yaying'ono ya m'mimba mwake, zilonda zazitali, matenda ofalikira, ndi zina zotero) zomwe zimawonjezera payekha Chiwopsezo cha ISR.70
Kutalika kwa mtsempha ndi chilonda kunakhudza kuchuluka kwa ISR payokha, ndipo zilonda zazing'ono/zazitali zinawonjezera kwambiri kuchuluka kwa restenosis poyerekeza ndi zilonda zazikulu/zazifupi.71
Mapulatifomu a stent a m'badwo woyamba adawonetsa ma strut okhuthala komanso kuchuluka kwa ISR poyerekeza ndi nsanja za stent za m'badwo wachiwiri zokhala ndi ma strut opyapyala.
Kuphatikiza apo, kuchuluka kwa restenosis kunali kogwirizana ndi kutalika kwa stent, ndipo kutalika kwa stent kunali kokwana 35 mm pafupifupi kawiri kuposa komwe kunali <20 mm. M'mimba mwake womaliza wa stent wocheperako wa lumen nawonso unachita gawo lofunika: m'mimba mwake wocheperako womaliza wa lumen unaneneratu kuti chiopsezo cha restenosis chiwonjezeka kwambiri.81,82
Mwachikhalidwe, intimal hyperplasia pambuyo pa kuikidwa kwa BMS imaonedwa kuti ndi yokhazikika, ndi pachimake koyambirira pakati pa miyezi 6 ndi chaka chimodzi, kutsatiridwa ndi nthawi yochedwa ya chete. Pachimake pakukula kwa intimal kunanenedwa kale, kutsatiridwa ndi intimal regression ndi kukula kwa lumen zaka zingapo pambuyo pa kuikidwa kwa stent;71 kukhwima kwa maselo osalala a minofu ndi kusintha kwa matrix yakunja kwawonetsedwa ngati njira zomwe zingatheke kuti neointimal regression ifike mochedwa.83 Komabe, maphunziro okhala ndi kutsatiridwa kwa nthawi yayitali kwawonetsa kuyankha kwa triphasic pambuyo pa kuikidwa kwa BMS, ndi early restenosis, intermediate regression, ndi late lumen restenosis.84
Mu nthawi ya DES, kukula kwa ma neointimal mochedwa kunayamba kuonekera pambuyo pa kuikidwa kwa SES kapena PES m'zitsanzo za nyama.85 Kafukufuku wambiri wa IVUS wasonyeza kuchepa msanga kwa kukula kwa intimal kutsatiridwa ndi kugwidwa mochedwa pakapita nthawi pambuyo pa kuikidwa kwa SES kapena PES, mwina chifukwa cha kutupa komwe kumachitika nthawi zonse.86
Ngakhale kuti nthawi zambiri zimaonedwa kuti ndi "kukhazikika" chifukwa cha ISR, pafupifupi gawo limodzi mwa magawo atatu a odwala a BMS ISR amakhala ndi ACS.4
Pali umboni wowonjezereka wakuti kutupa kosatha ndi/kapena kusakwanira kwa endothelial kumayambitsa matenda a neoatherosclerosis mkati mwa BMS ndi DES (makamaka DES ya m'badwo woyamba), zomwe zingakhale njira yofunika kwambiri ya ISR yapamwamba kapena ST. Inoue et al. 87 adanenanso za zomwe zapezeka mu histological kuchokera ku zitsanzo za autopsy pambuyo poyika stents ya Palmaz-Schatz coronary, zomwe zikusonyeza kuti kutupa kwa peri-stent kungafulumizitse kusintha kwatsopano kwa atherosclerotic mkati mwa stent. Kafukufuku wina10 wasonyeza kuti minofu ya restenotic mkati mwa BMS, pazaka 5, imakhala ndi atherosclerosis yatsopano, yokhala ndi kutupa kwa peri-stent kapena yopanda; Zitsanzo kuchokera ku milandu ya ACS zikuwonetsa ma plaque omwe ali pachiwopsezo m'mitsempha ya mtima ya m'deralo. Kapangidwe kake ka block ndi macrophages a thovu ndi makristalo a cholesterol. Kuphatikiza apo, poyerekeza BMS ndi DES, kusiyana kwakukulu pakati pa nthawi ndi chitukuko cha atherosclerosis yatsopano kunadziwika.11,12 Kusintha koyambirira kwa atherosclerotic mu kulowa kwa macrophage a thovu kunayamba miyezi 4 pambuyo pa kukhazikitsidwa kwa SES, pomwe kusintha komweko kwa zilonda za BMS kunachitika patatha zaka 2 ndipo kunakhalabe kosowa mpaka zaka 4. Kuphatikiza apo, DES stenting ya zilonda zosakhazikika monga thin-cap fibroatherosclerosis (TCFA) kapena intimal rupture ili ndi nthawi yochepa yokulira poyerekeza ndi BMS. Chifukwa chake, neoatherosclerosis ikuwoneka kuti ndi yofala kwambiri ndipo imachitika kale mu DES ya m'badwo woyamba kuposa mu BMS, mwina chifukwa cha matenda ena.
Zotsatira za DES kapena DES za m'badwo wachiwiri pakukula kwa matendawa zikadali kuphunziridwa; ngakhale kuti zomwe zapezeka kale za DESSs88 za m'badwo wachiwiri zikusonyeza kuti kutupa kochepa, kuchuluka kwa matenda a neoatherosclerosis n'kofanana ndi kwa m'badwo woyamba, koma kafukufuku wina akufunikabe.