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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Ishami ry’indwara z’umutima, Ibitaro bya Poliambulanza Foundation, Brescia, 2 Ishami ry’indwara z’umutima, Kaminuza Gatolika y’Umutima Mutagatifu w’i Roma, mu Butaliyani Incamake: Indwara zo Gukoresha Imiti (DES) zigabanya imbogamizi za stent z’icyuma (BMS) nyuma yo kwibasirwa n’imitsi yo mu mutima. Nyamara, nubwo gutangiza DES yo mu gisekuru cya kabiri bisa nkaho byagabanyije iki kibazo ugereranije na DES yo mu gisekuru cya mbere, impungenge zikomeye ziracyari ku bibazo bishobora guterwa no kwibasirwa n’imitsi yo mu mutima nyuma yo gucibwamo stent (ST) no gucibwamo stent. Stenose (ISR).ST ni ikintu gishobora kuba icyorezo cyagabanutse cyane bitewe no gukoresha stent neza, imiterere mishya ya stent, no kuvura indwara ebyiri zirwanya platelet. Uburyo nyabwo busobanura igaragara ryayo burimo gukorwaho iperereza, kandi koko, hari ibintu byinshi bibitera. ISR muri BMS mbere yafatwaga nk'imimerere ihamye ifite urwego rwo hejuru rw'ingufu zikomoka ku maraso (ku mezi 6) hagakurikiraho igihe cyo gusubira inyuma cy'umwaka urenga. Mu buryo bunyuranye, inyigo z'ubuvuzi n'iz'amateka kuri DESS zagaragaje ibimenyetso by'ikura ry'ingufu zikomoka ku maraso mu gihe kirekire cyo gukurikirana, ikintu kizwi nka "catch-up event". Imyumvire y'uko ISR ari indwara idakira yavuguruwe vuba aha n'ibimenyetso bigaragaza ko abarwayi ba ISR bashobora kugira indwara z'umutima zikabije. Ishusho ya Intracoronary ni uburyo bwo kwibasira bushobora kumenya plaque za atherosclerotic plaques hamwe n'ibimenyetso by'ubuvuzi bwo mu mitsi nyuma ya stent; Akenshi ikoreshwa mu kurangiza angiography y'umutima no gutuma habaho uburyo bwo gupima. Intracoronary optical coherence tomography ubu ifatwa nk'uburyo bugezweho bwo gufata amashusho. Ugereranyije na ultrasound yo mu mitsi, itanga igisubizo cyiza (nibura inshuro zigera kuri 10), bigatuma hagaragazwa neza imiterere y'urukuta rw'imitsi. "Inyigo zo mu mubiri zijyanye n'ibyavuye mu bushakashatsi bw'amateka zigaragaza ko kubyimba gukabije cyangwa/cyangwa kudakora neza kw'imitsi bishobora gutera neo-atherosclerosis mu cyiciro cya nyuma muri BMS na DES. Kubwibyo, neo-atherosclerosis yabaye ikibazo cy'ingenzi mu gutera kwa stent ya nyuma. Amagambo y'ingenzi: stent ya coronary, stent thrombosis, restenosis, neoatherosclerosis
Uburyo bwo gutera umutima bukoresha stent (PCI) hakoreshejwe uburyo bwo gutera umutima bukoresha stent ni bwo bukoreshwa cyane mu kuvura indwara z’imitsi y’umutima zigaragaza ibimenyetso, kandi ubu buryo bukomeje gutera imbere.1 Nubwo stent zo mu bwoko bwa drug-eluting (DES) zigabanya imbogamizi za stent z’icyuma (BMSs), ingorane zitinda nka stent thrombosis (ST) na in-stent restenosis (ISR) zishobora kubaho iyo stent ikoreshejwe. , impungenge zikomeye ziracyahari.2-5
Niba ST ishobora kuba icyorezo gikomeye, kwemera ko ISR ari indwara idapfa kwibasirwa byagaragaye ko hari ibimenyetso by’indwara y’umutima ikabije (ACS) ku barwayi ba ISR.4
Muri iki gihe, ikoranabuhanga rya intracoronary optical coherence tomography (OCT)6-9 rifatwa nk'uburyo bugezweho bwo gufata amashusho, ritanga ubushobozi bwo gukora neza kurusha ultrasound yo mu mitsi (IVUS).”Inyigo zo gufata amashusho mu mubiri,10-12 zijyanye n'ibyavuye mu bushakashatsi bwa histological, zigaragaza uburyo “bushya” bwo gusubiza imitsi nyuma yo gutera stent, hamwe na “neoatherosclerosis” nshya muri BMS na DES.
Mu 1964, Charles Theodore Dotter na Melvin P Judkins basobanuye uburyo bwa mbere bwo gupima indwara ya angioplasty. Mu 1978, Andreas Gruntzig yakoze angioplasty ya mbere ya ballon (angioplasty ishaje ya ballon); yari uburyo bwo kuvura bushya ariko bwari bufite ingorane zo gufunga imitsi ikaze no kugarura ububabare.13 Ibi byatumye havumburwa stent ya coronary: Puel na Sigwart bashyize stent ya mbere ya coronary mu 1986, batanga stent yo gukumira gufunga imitsi ikaze no gukuraho systolic nyuma.14 Nubwo izi stent za mbere zabujije gufunga umutsi mu buryo butunguranye, zateje kwangirika gukomeye kwa endothelial no kubyimba. Nyuma, igerageza ribiri ry’ingenzi, igerageza rya Belgian-Dutch Stent Trial 15 na Stent Restenosis Study 16, byashyigikiye umutekano wa stent hakoreshejwe uburyo bubiri bwo kurwanya platelet therapy (DAPT) cyangwa tekiniki zikwiye zo gushyiramo.17,18 Nyuma y’izi gerageza, habayeho ukwiyongera gukomeye mu mubare wa PCI zakozwe.
Ariko, ikibazo cya iatrogenic in-stent neointimal hyperplasia nyuma yo gushyirwa muri BMS cyagaragaye vuba, bituma ISR igaragara kuri 20%–30% by'ibisebe byavuwe. Mu 2001, DES yashyizweho19 kugira ngo igabanye gukenera restenosis no kongera gutera. DES zongereye icyizere ku baganga b'indwara z'umutima, bituma umubare munini w'ibisebe bigoye kuvurwa byatekerezwaga ko byakemuwe no gushyira mu mitsi y'umutima. Mu 2005, 80%–90% by'ibice byose bya PCI byaherekejwe na DES.
Ibintu byose bifite ingorane zabyo, kandi kuva mu 2005, impungenge ku mutekano wa DES "zo mu gisekuru cya mbere" zariyongereye, kandi stent nshya nka 20,21 zarateguwe kandi zishyirwa ahagaragara.22 Kuva icyo gihe, imbaraga zo kunoza imikorere ya stent zariyongereye cyane, kandi ikoranabuhanga rishya ritangaje ryakomeje kuvumburwa no kugezwa ku isoko vuba.
BMS ni umuyoboro w'insinga woroshye. Nyuma yo gukoresha "Urukuta" rwometseho, Gianturco-Roubin yometseho na Palmaz-Schatz, ubu hari BMS nyinshi zitandukanye.
Imiterere itatu itandukanye irashoboka: coil, tubular mesh n'umuyoboro upfundikiye. Imiterere ya coil ifite insinga z'icyuma cyangwa imirongo ikoze mu ishusho y'uruziga; imiterere ya tubular mesh ifite insinga zipfunyitse hamwe mu muyoboro kugira ngo ikore umuyoboro; imiterere ya tubular mesh ipfundikiwe igizwe n'imiyoboro y'icyuma ikozwe muri laser. Ibi bikoresho bitandukanye mu miterere (icyuma kidafunze, nichrome, cobalt chrome), imiterere y'inyubako (imiterere n'ubugari butandukanye, diameter n'uburebure, imbaraga za radial, radiation pacity) na sisitemu zo gutanga (kwiyagura cyangwa kwiyongerera balloon).
Muri rusange, BMS nshya igizwe na aloyi ya cobalt-chromium, ituma habaho imigozi mito kandi irushaho kuba myiza mu gutwara ibintu, bigatuma ikomeza gukomera.
Zigizwe n'icyuma gikoresha stent (ubusanzwe icyuma kidashonga) kandi zisizweho polymer idakoresha imiti irwanya ikwirakwira ry'imitsi cyangwa ubushyuhe.
Sirolimus (izwi kandi nka rapamycin) yabanje gukorwa nk'umuti urwanya icyorezo. Uburyo ikora buturuka ku kubuza uruhererekane rw'uturemangingo mu kubuza ihinduka kuva kuri G1 kugeza kuri S no kubuza iremwa rya neointima. Mu 2001, ubunararibonye bwa "mbere mu bantu" kuri SES bwagaragaje umusaruro mwiza, bituma stent ya Cypher itera imbere.23 Igerageza rinini ryagaragaje ko rigira akamaro mu gukumira ISR.24
Paclitaxel yari yemewe mbere kuvura kanseri y'intanga ngore, ariko imiterere yayo ikomeye ya cytostatic - uyu muti utuma microtubules zihagarara mu gihe cya mitosis, ugatuma uturemangingo tw'uturemangingo duhagarara kandi ukabuza neointimmal kwirema - bituma iba imvange ya Taxus Express PES. Igerageza rya TAXUS V na VI ryagaragaje akamaro k'igihe kirekire ka PES mu ndwara z'imitsi y'umutima zishobora gutera ibyago byinshi kandi zikomeye.25,26 Nyuma ya TAXUS Liberté yari ifite urubuga rw'icyuma kitagira umugese kugira ngo byorohereze gutanga.
Ibimenyetso by'ingenzi bivuye mu isuzuma ribiri ryakozwe ku buryo busanzwe n'isesengura rya meta bigaragaza ko SES ifite inyungu kurusha PES bitewe n'uko igipimo cya ISR n'ishyirwa mu bikorwa ry'imitsi yo mu bwonko (TVR) biri hasi, ndetse n'icyerekezo cyo kwiyongera kwa infarction y'umutima (AMI) mu itsinda rya PES. 27,28
Ibikoresho byo mu gisekuru cya kabiri byagabanyije ubugari bwa strut, byongereye ubushobozi bwo koroshya/gutanga, byazamuye ubushobozi bwo guhuza polymer na polymer/imiti, ndetse n'uburyo bwiza bwo kongera gukora re-endothelialization. Mu mikorere ya none, ni byo bishushanyo bya DES bigezweho cyane ndetse n'amasende akomeye ya coronary ashyirwa ku isi yose.
Taxus Elements ni intambwe ikomeye ifite polymeri yihariye yagenewe kongera kurekurwa hakiri kare hamwe na sisitemu nshya ya platine-chromium strut itanga struts ntoya kandi irushaho kuba nziza. Igerageza rya PERSEUS 29 ryagaragaje ibisubizo bisa hagati ya Element na Taxus Express mu gihe cy'amezi agera kuri 12. Ariko, igerageza ryo kugereranya imiterere ya yew n'izindi DES zo mu gisekuru cya kabiri ntiriraboneka.
Endeavor ya zotarolimus-eluting stent (ZES) ishingiye ku buryo bukomeye bwa cobalt-chromium stent ifite ubushobozi bwo koroha cyane kandi ifite ingano nto ya stent. Zotarolimus ni analogue ya sirolimus ifite ingaruka zisa zo gukumira ubudahangarwa bw'umubiri ariko yongera ubushobozi bwo gukamura amaraso kugira ngo yongere ubushobozi bwo gushyira mu mwanya urukuta rw'imitsi.ZES ikoresha polimeri nshya ya phosphorylcholine igenewe kongera ubushobozi bwo guhuza umubiri no kugabanya ububyimbirwe. Imiti myinshi iracika mu gihe cy'imvune ya mbere, hagakurikiraho gusana imitsi. Nyuma y'igerageza rya mbere rya ENDEAVOR, igerageza ryakurikiyeho rya ENDEAVOR III ryagereranije ZES na SES, ryagaragaje ko habayeho gutakaza lumen nyinshi nyuma y'igihe gito na ISR ariko habayeho ingaruka mbi nke z'umutima n'imitsi (MACE) kurusha SES .30 Igerageza rya ENDEAVOR IV, ryagereranije ZES na PES, ryongeye kugaragaza ko habayeho ISR nyinshi, ariko habayeho AMI nke, bigaragara ko iterwa na ST ikomeye cyane mu itsinda rya ZES.31 Ariko, igerageza rya PROTECT ntiryagaragaje itandukaniro mu gipimo cya ST hagati ya stents za Endeavor na Cypher.32
Endeavor Resolute ni verisiyo nziza ya stent ya Endeavor ifite polymer nshya y’ibice bitatu. Resolute Integrity nshya (rimwe na rimwe yitwa DES y’igisekuru cya gatatu) ishingiye ku rubuga rushya rufite ubushobozi bwo gutanga (platform ya Integrity BMS), kandi polymer nshya, ifite ibice bitatu ihuza neza n’ibinyabuzima, ishobora guhagarika igisubizo cy’ibanze cy’ububyimbirwe no gukuraho umuti mwinshi mu minsi 60 iri imbere. Igerageza ryagereranije Resolute na Xience V (stent ya everolimus-eluting [EES]) ryagaragaje ko sisitemu ya Resolute idakomeye mu bijyanye n’urupfu n’ingaruka z’ibisebe.33,34
Everolimus, ikomoka kuri sirolimus, ni na yo igabanya uruhererekane rw'uturemangingo ikoreshwa mu guteza imbere Xience (Multi-link Vision BMS platform) / Promus (Platinum Chromium platform) EES. Igerageza rya SPIRIT 35-37 ryagaragaje ko imikorere yayo yarushijeho kuba myiza kandi rigabanya MACE hamwe na Xience V ugereranije na PES, mu gihe igerageza rya EXCELLENT ryagaragaje ko EES itari hasi ya SES mu gukumira igihombo cyatinze mu mezi 9 n'ingaruka z'ubuvuzi mu mezi 12.38 Amaherezo, stent ya Xience yagaragaje ibyiza kurusha BMS mu gihe habayeho ST-segment elevation myocardial infarction (MI).39
EPC ni itsinda ry’uturemangingo tuzenguruka mu mitsi tugira uruhare mu gusana imitsi no gusana imitsi. Kongera EPCs aho imitsi yakomeretse bizafasha kongera kugaragara mu mitsi hakiri kare, bishobora kugabanya ibyago byo kugerageza kwa mbere kwa ST.EPC mu bijyanye no gushushanya stent ni stent ya Geneous ifite antibody ya CD34, ishobora gufata EPCs zizenguruka binyuze mu bimenyetso byayo byo mu maraso kugira ngo yongere kongera kugaragara mu mitsi. Nubwo ubushakashatsi bwa mbere bwari bushimishije, ibimenyetso biherutse gutangwa bigaragaza ko TVR.40 ari yo iri hejuru.
Ukurikije ingaruka mbi zishobora guterwa no gutinda gukira bitewe na polymer, bifitanye isano n'ibyago bya ST, polymer zishobora kunyagirwa zitanga inyungu za DES, birinda impungenge zimaze igihe kirekire ku bijyanye no kuguma kwa polymer. Kugeza ubu, sisitemu zitandukanye zishobora kunyagirwa ziremewe (urugero: Nobori na Biomatrix, stent ya biolimus eluting, Synergy, EES, Ultimaster, SES), ariko inyandiko zishyigikira umusaruro wazo w'igihe kirekire ni nke.41
Ibikoresho bishobora kwinjiza ibinyabuzima bifite akarusho mu buryo bw’imitekerereze kuko byabanje gutanga inkunga ya mekanike iyo harebwe uburyo bwo gusubira inyuma kw’imitsi no kugabanya ibyago by’igihe kirekire bifitanye isano n’ibyuma bisanzwe. Ikoranabuhanga rishya ryatumye habaho iterambere rya polymer zishingiye kuri aside lactic (aside poly-l-lactic [PLLA]), ariko sisitemu nyinshi za stent zirimo gukorwa, nubwo kugena uburinganire bwiza hagati yo gukuraho imiti no kwangirika kw’imitsi biracyari ikibazo. Igerageza rya ABSORB ryagaragaje umutekano n’ubushobozi bwa stent za PLLA zikora neza.43 Ivugurura rya Absorb stent ryo mu gisekuru cya kabiri ryari iterambere ugereranyije n’iryabanje hamwe n’ikurikiranwa ryiza ry’imyaka 2.44 Igerageza rya ABSORB II ririmo gukorwa, igerageza rya mbere ryakozwe ku buryo butunguranye rigereranya stent ya Absorb na stent ya Xience Prime, rigomba gutanga amakuru menshi, kandi ibisubizo bya mbere biboneka biratanga icyizere.45 Ariko, imiterere myiza, uburyo bwiza bwo gutera, n’imiterere y’umutekano w’ibisebe by’umutima bigomba gusobanurwa neza.
Kurwara indwara ya Thrombosis haba muri BMS na DES bigira ingaruka mbi ku buvuzi. Mu isuzuma ry’abarwayi bashyizwe mu cyiciro cya DES, 47% by’abarwayi ba ST byateje urupfu, 60% bivuye ku ndwara ya MI idahitana, na 7% bivuye ku ndwara ya angina idakira. PCI mu gihe cy’ubutabazi ST ikunze kuba mbi cyane, aho igaruka muri 12% by’abarwayi.48
ST yo mu rwego rwo hejuru ishobora kugira ingaruka mbi ku buvuzi. Mu bushakashatsi bwa BASKET-LATE, nyuma y'amezi 6 kugeza kuri 18 nyuma yo gushyirwaho stent, igipimo cy'impfu z'umutima n'indwara zitari iz'urupfu za MI cyari hejuru mu itsinda rya DES ugereranyije n'itsinda rya BMS (4.9% na 1.3%, uko bikurikirana).20 Isesengura rya meta-igerageza ry'ibizamini icyenda, aho abarwayi 5.261 bakorewe SES, PES, cyangwa BMS ku buryo butaziguye, ryagaragaje ko mu myaka 4 yo gukurikirana, SES (0.6% ugereranije na 0%, p = 0.025) na PES (0.7%) byongereye umubare w'abarwaye ST batinze cyane ugereranije na BMS ku kigero cya 0.2%, p = 0.028).49 Mu buryo bunyuranye, mu isesengura rya meta-isesengura ryarimo abarwayi 5.108, 21 hagaragaye ukwiyongera kwa 60% mu rupfu cyangwa MI kuri SES ugereranije na BMS (p = 0.03), mu gihe PES yari ifite ukwiyongera kwa 15% kutari gukomeye (Ikurikirana kuva ku mezi 9 kugeza kuri 3). imyaka).
Ibiro byinshi byo kwandikamo, ibizamini byakozwe ku buryo butaziguye, n'isesengura ryakozwe ku buryo butaziguye byakoze ubushakashatsi ku ngaruka za ST nyuma yo gushyirwa mu kigero cya BMS na DES kandi byagaragaje ibisubizo bivuguruzanya. Mu isuzuma ry'abarwayi 6.906 bahabwaga BMS cyangwa DES, nta tandukaniro ryagaragaye mu bisubizo by'ubuvuzi cyangwa igipimo cya ST mu gihe cy'umwaka umwe wo gukurikirana.48 Mu rindi suzuma ry'abarwayi 8.146, ibyago byo gukomeza gutakaza ST byagaragaye ko ari 0.6% / umwaka ugereranije na BMS.49 Isesengura ryakozwe ku igerageza rigereranya SES cyangwa PES na BMS ryagaragaje ko hari ibyago byinshi byo gupfa no kubura MI hamwe na DES yo mu gisekuru cya mbere ugereranije na BMS, 21 n'irindi sesengura ryakozwe ku barwayi 4.545 bakorewe ku buryo butaziguye cyangwa Nta tandukaniro ryagaragaye mu kugaragara kwa ST hagati ya PES na BMS mu myaka 4 yo gukurikirana.50 Ubundi bushakashatsi bwakozwe ku isi bwagaragaje ko hari ibyago byinshi byo kuba ST na MI iteye imbere mu barwayi bahabwa DES yo mu gisekuru cya mbere nyuma yo guhagarika DAPT.51
Bitewe n'ibimenyetso bivuguruzanya, isesengura ryakozwe hamwe n'isesengura rya meta-analyses byagaragaje ko DES na BMS byo mu gisekuru cya mbere ntaho bitandukaniye cyane mu byago byo gupfa cyangwa MI, ariko SES na PES byagize ibyago byinshi byo kurwara ST iteye imbere cyane ugereranije na BMS. Kugira ngo harebwe ibimenyetso biboneka, Ikigo gishinzwe ibiribwa n'imiti muri Amerika (FDA) cyashyizeho itsinda ry'impuguke53 ryasohoye itangazo ryemeza ko DES zo mu gisekuru cya mbere zigira akamaro ku bimenyetso byagaragajwe kandi ko ibyago byo kurwara ST iteye imbere cyane ari bike ariko ari bike. Ubwiyongere bugaragara. Kubera iyo mpamvu, FDA n'ishyirahamwe basaba ko igihe cya DAPT cyongerwa kikagera ku mwaka umwe, nubwo hari amakuru make ashyigikira iki kirego.
Nkuko byavuzwe mbere, DES zo mu gisekuru cya kabiri zifite imiterere ihanitse zarakozwe. CoCr-EES zakorewe ubushakashatsi bwagutse cyane mu buvuzi. Mu isesengura ryakozwe na Baber et al,54 harimo abarwayi 17.101, CoCr-EES yagabanyije cyane ST na MI ifatika/ishoboka ugereranije na PES, SES, na ZES nyuma y'amezi 21. Amaherezo, Palmerini et al bagaragaje mu isesengura ryakozwe ku barwayi 16.775 ko CoCr-EES yari ifite ST ifatika nke cyane mbere, nyuma, umwaka umwe n'imyaka ibiri ifatika ugereranije n'izindi DES zari zihuriweho.55 Ubushakashatsi bwakozwe mu buryo bw'ukuri bwagaragaje ko ibyago byo kugabanuka kwa ST ugereranije na DES yo mu gisekuru cya mbere.56
Re-ZES yagereranyijwe na CoCr-EES mu igeragezwa rya RESOLUTE-AC na TWENTE.33,57 Nta tandukaniro rigaragara mu bwiyongere bw'impfu, indwara ya myocardial infarction, cyangwa ST ihamye hagati ya stent ebyiri.
Mu isesengura ryakozwe ku barwayi 50.844 harimo na RCT 49,58CoCr-EES yagaragaye ko ifite ST nke cyane kurusha BMS, umusaruro utaragaragaye mu zindi DES; kugabanuka kwabyo ntibyagaragaye gusa mu gihe cy'iminsi 30 (igipimo cy'amahirwe [OR] 0.21, 95% interval y'icyizere [CI] 0.11-0.42) ndetse no mu mwaka 1 (OR 0.27, 95% CI 0.08-0.74) n'imyaka 2 (OR 0.35, 95% CI 0.17–0.69). Ugereranyije na PES, SES, na ZES, CoCr-EES yagaragaye ko ifite ST nke mu mwaka 1.
ST yo mu ntangiriro ifitanye isano n'ibintu bitandukanye. Imiterere y'imitsi yo mu mutwe n'umutwaro wa thrombus bisa nkaho bigira ingaruka ku musaruro nyuma ya PCI; 59 Kwinjira mu buryo bwimbitse kw'imitsi bitewe no kugabanuka k'umutsi wo mu mutwe (NC), gucika kw'imitsi mu burebure bwa stent, gucibwamo kabiri hamwe n'imirongo isigaye, cyangwa kugabanya cyane imirongo. Gufata stent neza, kugabanya imisemburo, no kwaguka ku buryo budahagije.60 Uburyo bwo kuvura hakoreshejwe imiti igabanya platelet ntabwo bugira ingaruka zikomeye ku kugabanuka kwa ST yo mu ntangiriro: kugaragara kwa ST yo mu mutwe n'iyo mu gice cya kabiri cya DAPT mu igerageza ryakozwe ku buryo butunguranye rigereranya BMS na DES Igipimo cyari kimwe (<1%).61 Bityo, ST yo mu ntangiriro isa nkaho ifitanye isano ahanini n'ibisebe by'ubuvuzi n'ibintu byo kubaga.
Muri iki gihe, hibandwa cyane kuri ST itinze/itinze cyane. Niba ibintu by’imikorere n’ikoranabuhanga bisa nkaho bigira uruhare runini mu iterambere rya ST ikaze n’ifite ubukana, uburyo bwo gutinda kw’imitsi mu maraso busa n’aho bugoye cyane. Byavuzwe ko imiterere imwe n’imwe y’umurwayi ishobora kuba impamvu z’ibyago byo kurwara ST iteye imbere kandi ikomeye cyane: diyabete, ACS mu gihe cyo kubagwa bwa mbere, kunanirwa kw’impyiko, gusaza, kugabanuka k’igice cyo gusohora amaraso, ingaruka mbi zikomeye z’umutima mu minsi 30 uhereye igihe babazwe bwa mbere. Kuri BMS na DES, ibintu by’imikorere, nk’ingano y’imitsi mito, kubyimba kw’imitsi, indwara ya polyvascular, calcification, kuziba kw’imitsi yose, stent ndende, bisa nkaho bifitanye isano n’ibyago byo kurwara ST.62,63 Kudakira neza imiti igabanya ubukana ni ikintu gikomeye gishobora gutera thrombosis iteye imbere y’umurwayi 51. Iki gisubizo gishobora guterwa no kutita ku murwayi, kudatanga imiti bihagije, imikoranire y’imiti, ibindi bintu bigira ingaruka ku muvuduko w’imiti, polymorphisms za genetiki ku rwego rwa receptor (cyane cyane clopidogrel resistance), no kwiyongera kw’izindi nzira zo gukora platelet. Indwara ya neo-atherosclerosis ifatwa nk'uburyo bw'ingenzi bwo kuvura nyuma yo kubagwa. Kunanirwa kw'umutsi, harimo na ST64 ya nyuma (igice cya “In-stent neoatherosclerosis”). Endothelium idahinduka itandukanya urukuta rw'imitsi rwangiritse n'imitsi ya stent mu maraso kandi igasohora ibintu birwanya imitsi n'imitsi igabanya ubukana bw'amaraso. DES ishyira urukuta rw'imitsi ku miti igabanya ubukana bw'imitsi n'ahantu ho gufunga imiti, hamwe n'uburyo bwo kuvura imitsi mu buryo butandukanye, hamwe n'ingaruka zitandukanye ku gukira no gukora kw'imitsi mu buryo bw'imitsi, hamwe n'ibyago byo kurwara imitsi mu buryo bwihuse.65 Ubushakashatsi bw'indwara bugaragaza ko polymeri ziramba za DES zo mu gisekuru cya mbere zishobora kugira uruhare mu kubyimba guhoraho, kwishyiramo fibrin mu buryo buhoraho, gukira nabi kw'imitsi mu buryo bwihuse, ndetse n'ibyago byo kurwara imitsi mu buryo bwihuse.3 Kurwara imitsi mu buryo bwihuse kuri DES bisa nkaho ari ubundi buryo butuma ST.Virmani et al66 batangaje ibyavuye mu bushakashatsi nyuma ya ST nyuma y'urupfu bigaragaza ko hari ikwirakwira ry'imitsi mu gice cya stent hamwe n'ingaruka zo kwangirika kw'imitsi mu gace kayo zigizwe na T lymphocytes na eosinophils; Ibi byavumbuwe bishobora kugaragaza ingaruka za polymeri zitarogotwa.67 Kutagira stent neza bishobora guterwa no kwaguka kwa stent mu buryo butari bwiza cyangwa bikabaho amezi menshi nyuma ya PCI. Nubwo kudakora neza kw'imikorere ari ikintu gishobora gutera ST ikaze kandi ingana na subacute, akamaro k'ubuvuzi k'ukutagira stent neza gushobora guterwa no kuvugurura imitsi cyane cyangwa gukira gutinze bitewe n'imiti, ariko akamaro kayo mu buvuzi karavugwaho rumwe.68
Ingaruka zo kurinda za DES zo mu gisekuru cya kabiri zishobora kuba zirimo kwihuta cyane kandi zidahinduka mu mikorere y’uturemangingo, ndetse n’itandukaniro mu miterere n’imiterere ya stent, ubunini bwa strut, imiterere ya polymer, n’ubwoko bw’imiti irwanya ikwirakwira ry’uturemangingo, urugero, n’uburyo kinetics zitera.
Ugereranyije na CoCr-EES, stent struts nto (81 µm) za cobalt-chromium, fluoropolymers zirwanya thrombosis, polymer nke, n'umubyigano w'imiti bishobora gutuma ST igabanuka. Ubushakashatsi bwagaragaje ko thrombosis na platelet deposition ya stents za fluoropolymer-coated ari bike cyane ugereranyije n'iza stents za bare-metal.69 Niba izindi DES zo mu gisekuru cya kabiri zifite imiterere nk'iyo bikwiye kwigwaho cyane.
Imisemburo yo mu mitsi yo mu mutima yongera igipimo cyo kubaga cy’intwaro z’umutima ugereranije na angioplasty isanzwe ya percutaneous transluminal coronary angioplasty (PTCA), ifite ibibazo bya tekiniki (kuziba imitsi, gucibwamo, nibindi) hamwe n’igipimo cyo kuruhuka cyane (kugeza kuri 40%–50% by’abarwaye). Mu mpera z’imyaka ya 1990, hafi 70% bya PCIs byakozwe hakoreshejwe BMS implantation.70
Ariko, nubwo hari iterambere mu ikoranabuhanga, ubuhanga, n'ubuvuzi, ibyago byo kurwara restenosis nyuma yo gutera BMS ni hafi 20%, aho >40% mu matsinda mato yihariye.71 Muri rusange, ubushakashatsi bwagaragaje ko restenosis nyuma yo gutera BMS, nk'uko byagaragaye kuri PTCA isanzwe, igera ku rwego rwo hejuru mu mezi 3-6 kandi igashira nyuma y'umwaka 1.72
DES igabanya cyane ikwirakwira rya ISR,73 nubwo uku kugabanuka guterwa na angiography n'aho ubuvuzi buherereye. Irangi rya polymer kuri DES risohora imiti irwanya ububyimbirwe n'irwanya ikwirakwira ry'imitsi, ribuza ishingwa rya neontima, kandi rigatinza inzira yo gusana imitsi mu mezi cyangwa imyaka.74 Gukura kw'imitsi mu gihe kirekire nyuma yo gutera DES, ikintu kizwi nka "gufata nyuma y'igihe gito", cyagaragaye mu bushakashatsi bw'ubuvuzi n'ubw'amateka.75
Gukomereka kw'imitsi mu gihe cya PCI bitera inzira igoye yo kubyimba no gusana mu gihe gito cyane (ibyumweru kugeza ku mezi), biganisha ku kuzura kw'imitsi no gukwirakwira kw'imitsi mito. Dukurikije ibyavumbuwe n'abahanga mu by'amateka, indwara ya neointimal hyperplasia (BMS na DES) nyuma yo gushyirwamo stent yari igizwe ahanini n'uturemangingo tw'imitsi yoroshye twinshi muri matrix ya excremental iri ku bwinshi bwa proteoglycan.70
Bityo, hyperplasia ya neointimal igaragaza inzira yo gusana irimo gufungana no gutera ububyimbirwe ndetse n'uturemangingo dutuma imitsi ikura neza no gukora matrix yo hanze y'umubiri. Nyuma ya PCI, platelets na fibrin bishyirwa ku rukuta rw'imitsi maze bigakurura leukocytes binyuze mu ruhererekane rw'uturemangingo dufatana. Leukocytes zizunguruka zifatana na platelets zifatana binyuze mu mikoranire iri hagati ya leukocyte integrin Mac-1 (CD11b/CD18) na platelets glycoprotein Ibα 53 cyangwa fibrinogen ifatanye na platelets glycoprotein IIb/IIIa.76,77
Dukurikije amakuru agaragara, uturemangingo tw’umusemburo dukomoka ku musemburo tugira uruhare mu gusubiza imitsi no gusana. Gukurura EPCs kuva mu musemburo w’amagufwa zijya mu maraso yo ku nkengero bitera kuvugurura imitsi no gutera amaraso nyuma yo kubyara. Bigaragara ko uturemangingo tw’umusemburo w’amagufwa (SMPC) twimukira aho imitsi yakomeretse, bigatuma habaho kwiyongera kw’imitsi.78 Mbere, uturemangingo tw’umusemburo wa CD34 twafatwaga nk’ubwoko buhoraho bwa EPCs; ubundi bushakashatsi bwagaragaje ko antigen ya CD34 ku buso koko imenya uturemangingo tw’umusemburo w’amagufwa tudatandukanye dufite ubushobozi bwo gutandukana muri EPCs na SMPCs. Guhindura uturemangingo tw’umusemburo wa CD34 kugera kuri EPC cyangwa SMPC biterwa n’ibidukikije; indwara zo mu mutwe zitera gutandukana ku buryo bwa EPC kugira ngo zitere imbere ku kongera gutera amaraso, mu gihe indwara zo mu mutwe zitera gutandukana ku buryo bwa SMPC kugira ngo zitere imbere ku kwiyongera kw’imitsi.79
Diyabete yongera ibyago byo kurwara ISR ho 30%–50% nyuma yo gushyirwa mu kibuno cya BMS,80 kandi umubare munini w’abarwayi ba diyabete ugereranije n’abarwayi batari diyabete na wo wakomeje kubaho mu gihe cya DES. Uburyo bw’iyi ngingo bushobora kuba butandukanye, burimo ibintu byinshi (urugero: guhindagurika mu mikorere y’ububyimbirwe) n’ibintu bigize umubiri (urugero: imiyoboro mito y’amaraso, ibisebe birebire, indwara zikwirakwira, nibindi) byongera ibyago byo kurwara ISR ku giti cyabo.70
Ubugari bw'ubwato n'uburebure bw'ibisebe byagize ingaruka ku bwiyongere bwa ISR, aho uburebure buke/uburebure bw'ibisebe byongera cyane igipimo cyo kuruhuka ugereranije n'uburebure bunini/ubugufi.71
Imbuga za stent zo mu gisekuru cya mbere zagaragaje stent struts nini kandi zifite igipimo cya ISR kiri hejuru ugereranije n’iz’igisekuru cya kabiri zifite struts nto.
Byongeye kandi, umubare w’abantu barwaye restenosis waterwaga n’uburebure bwa stent, aho uburebure bwa stent bwari hejuru ya mm 35 hafi kabiri ugereranyije n’ubwo buri munsi ya mm 20. Umurambararo wa nyuma wa stent minimum lumen na wo wagize uruhare runini: umurambararo muto wa nyuma wa stent minimum lumen wagaragaje ko ibyago byo kurwara restenosis byiyongera cyane.81,82
Ubusanzwe, intimal hyperplasia nyuma yo gutera BMS ifatwa nk'ihamye, aho intimal hyperplasia iba hagati y'amezi 6 n'umwaka 1, igakurikirwa n'igihe cyo guceceka nyuma yo guceceka. Hari havuzwe ko intimal ikura mbere, hagakurikirwa no gusubira inyuma kw'intimal hamwe no kwiyongera kwa lumen imyaka myinshi nyuma yo gutera stent;71 gukura kw'uturemangingo tw'imitsi yoroshye n'impinduka muri matrix y'inyuma y'uturemangingo byavuzwe ko ari uburyo bushoboka bwo gusubira inyuma kwa neointimal nyuma yo guceceka.83 Ariko, ubushakashatsi bwakozwe igihe kirekire bwo gukurikirana bwagaragaje ko hari igisubizo cy'impande eshatu nyuma yo gutera BMS, hamwe no gusubira inyuma hakiri kare, gusubira inyuma hagati, na gusubira inyuma kwa lumen nyuma yo guceceka.84
Mu gihe cya DES, gukura kw'uturemangingo tw'intanga ngore mu gihe cya nyuma byagaragaye nyuma yo gutera SES cyangwa PES mu nyamaswa.85 Ubushakashatsi bwinshi bwa IVUS bwagaragaje ko gukura kw'intanga ngore mu gihe cya nyuma byakurikiwe no gutinda gukwirakwira nyuma y'igihe nyuma yo gutera SES cyangwa PES, bishoboka ko byatewe n'uburyo bukomeje bwo kubyimba.86
Nubwo "ubudahangarwa" busanzwe buterwa na ISR, hafi kimwe cya gatatu cy'abarwayi ba BMS ISR barwara ACS.4
Hari ibimenyetso byinshi bigaragaza ko ubushyuhe buhoraho n'ubudahagije bw'ingirabuzimafatizo bitera indwara ya neo-atherosclerosis iteye imbere muri BMS na DES (cyane cyane DES yo mu gisekuru cya mbere), ibi bishobora kuba uburyo bw'ingenzi bwo gutuma ISR cyangwa ST iteye imbere. Inoue et al. 87 batangaje ibyavuye mu bushakashatsi bwa histological bivuye mu bipimo byo gusuzuma umurambo nyuma yo gutera stenti za Palmaz-Schatz, bigaragaza ko ubushyuhe bwa peri-stent bushobora kwihutisha impinduka nshya za atherosclerotic muri stent. Ubundi bushakashatsi10 bwagaragaje ko ingirabuzimafatizo za restenotic muri BMS, mu myaka 5 ishize, zigizwe n'indwara nshya ya atherosclerosis, hamwe n'ubushyuhe bwa peri-stent cyangwa idafite; Ingero zavuye mu barwayi ba ACS zigaragaza ibimenyetso bisanzwe by’indwara mu mitsi y’umutima gakondo Histological morphology y’agace gafite foam macrophages na kristu za cholesterol. Byongeye kandi, mu kugereranya BMS na DES, itandukaniro rikomeye mu gihe cyo gutera indwara nshya ya atherosclerosis ryagaragaye.11,12 Impinduka za mbere za atherosclerotic mu kwinjira kwa macrophages bya foam zatangiye amezi 4 nyuma yo gushyirwa muri SES, mu gihe impinduka zimwe mu bisebe bya BMS zabayeho nyuma y’imyaka 2 kandi zakomeje kuba ikintu kidasanzwe kugeza ku myaka 4. Byongeye kandi, DES stenting ku bisebe bidahamye nka thin-cap fibroatherosclerosis (TCFA) cyangwa intimal rupture igira igihe gito cyo gutera imbere ugereranije na BMS. Bityo, neoatherosclerosis isa nkaho ikunze kugaragara cyane kandi ibaho mbere muri DES yo mu gisekuru cya mbere kurusha muri BMS, bishoboka ko biterwa n’uburyo butandukanye bwo gutera.
Ingaruka za DES cyangwa DES zo mu gisekuru cya kabiri mu iterambere ziracyari ngombwa kwigwaho; nubwo bimwe mu byagaragaye kuri DESs88 zo mu gisekuru cya kabiri bigaragaza ko ububyimbirwe buke, umubare w'abarwaye neo-atherosclerosis usa n'uw'abarwaye icyorezo cya mbere, ariko haracyakenewe ubundi bushakashatsi.