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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’Ubumenyi bw’Indwara z’Imitima, Ibitaro bya Poliambulanza Foundation, Brescia, 2 Ishami ry’Ubumenyi bw’Indwara z’Imitima, Kaminuza Gatolika y’Umutima Mutagatifu w’i Roma, mu Butaliyani Incamake: Imiti ya Stents ipfutse (DES) igabanya imbogamizi zo gukoresha stents z’icyuma (BMS) nyuma yo gutera umutima mu nda. Ariko, 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 gutera stent nyuma yo gucika stent (ST) no gucibwa stent, stenosis (SSI). ST ni ikintu gishobora kuba icyorezo cyagabanutse cyane bitewe no gutera 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'aho ihoraho ifite ubwiyongere bw'agahenge k'inyuma (ku mezi 6) hagakurikiraho igihe cyo gusubira inyuma cy'umwaka urenga 1. Ibinyuranye n'ibyo, inyigo zo mu buvuzi n'iz'impinduka za DES zagaragaje ibimenyetso by'uko intanga zikura mu gihe kirekire mu gihe kirekire cyo gukurikirana, ikintu kizwi nka "catch-up phenomenon". Igitekerezo cy'uko ISR ari indwara idakira cyane giherutse kwemezwa n'ibimenyetso by'uko abarwayi ba ISR bashobora kugira indwara z'umutima zikabije. Ishusho ya Intracoronary ni uburyo bwo kumenya plaque za atherosclerotic zifite stent n'ibimenyetso by'uko imitsi ikira nyuma yo gushyuha, kandi akenshi ikoreshwa mu kurangiza angiography y'umutima no gukora ibikorwa byo kwifashisha. Intracoronary optical coherence tomography ubu ifatwa nk'uburyo bugezweho bwo gufata amashusho. Bitanga, ugereranije na ultrasound yo mu mitsi, ubushobozi bwo kureba neza (nibura inshuro > 10), bigatuma hagaragazwa neza imiterere y’urukuta rw’imitsi. Bitanga, ugereranije na ultrasound yo mu mitsi, ubushobozi bwo kureba neza (nibura inshuro > 10), bigatuma hagaragazwa neza imiterere y’urukuta rw’imitsi. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере,> 10 раз), что позволяет чинно ох чизизовать поверхностную кюки скида. Bitanga, ugereranije na ultrasound yo mu mitsi, ubushobozi bwo kureba neza (nibura inshuro > 10), ibyo bikaba bituma habaho imiterere irambuye y'ubuso bw'urukuta rw'imitsi.与血管内超声相比，它提供了更好的分辨率（至少> 10 倍），允许详细表征血管壁的表面结构。与血管内超声相比，它提供了更好的分辨率（至少> 10 ），允许详细表征血管壁的表面结构。Ugereranyije na ultrasound yo mu mitsi, itanga ubushobozi bwo kureba neza (nibura inshuro 10), ibyo bigatuma hagaragazwa neza imiterere y'ubuso bw'urukuta rw'imitsi.Inyigo zo gupima mu mubiri zijyanye n'ibyavuye mu bushakashatsi bw'imitsi zigaragaza ko kubyimba gukabije cyangwa kudakora neza kw'imitsi yo mu nda bishobora gutera indwara ya neo-atherosclerosis ikabije muri HMS na DES. Bityo, neo-atherosclerosis yabaye ikibazo gikomeye mu gutera kwangirika kwa stent nyuma yo gucika intege. Amagambo y'ingenzi: stent y'umutima, stent thrombosis, restenosis, neo-atherosclerosis.
Uburyo bwo kuvura indwara y’imitsi ifata imitsi (PCI) bukoreshwa cyane mu kuvura indwara z’imitsi ifata imitsi y’umutima, kandi ubu buryo bukomeje gutera imbere. 1 Nubwo imiti igabanya stent (DES) igabanya imbogamizi za stent zidafite irangi (UES), ingorane zitinda nko mu ndwara ya stent thrombosis (ST) no muri stent restenosis (ISR) zishobora kubaho iyo stent ishyizwe mu mubiri, kandi haracyari impungenge zikomeye. 2-5
Niba ST ishobora kuba icyorezo gikomeye, kwemera ko ISR ari indwara idapfa kwibasirwa byaherutse kwangwa n'ibimenyetso by'indwara y'umutima ikabije (ACS) ku barwayi bafite ISR.
Muri iki gihe, uburyo bwo gupima imiterere y’imitsi mu maraso (OCT)6-9 bufatwa nk'uburyo bugezweho bwo gupima butanga ubushobozi bwo kureba neza kurusha uburyo bwo gupima imiterere y’imitsi mu maraso (IVUS). Ubushakashatsi bwo gupima mu maraso10-12 bujyanye n'ibyavuye mu bushakashatsi bw'imitsi bugaragaza uburyo "bushya" bwo gusubiza imitsi nyuma yo gushyirwamo stent hamwe n'uburyo bushya bwo "neoatherosclerosis" 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 Grunzig yakoze angioplasty ya mbere ya ballon (angioplasty isanzwe ya ballon); yari uburyo bushya bwo kuvura, ariko yari ifite n’ingaruka mbi zo gufunga imitsi no kuruhuka. 13 Ibi byatumye havumburwa stents za coronary: Puel na Sigwart bashyizeho stent ya mbere ya coronary mu 1986, itanga stent yo gukumira gufunga imitsi no gutinda kwa systolic. 14 Nubwo izi stents za mbere zabujije gufunga imitsi mu buryo butunguranye, zateje kwangirika gukomeye kwa endothelium no kubyimba. Vuba aha, ubushakashatsi bubiri bw’ingenzi, Inyigo ya Belgian-Dutch Stent 15 na Stent Restenosis Study 16, byashyigikiye umutekano wa stent ebyiri zo kurwanya platelet (DAPT) cyangwa uburyo bukwiye bwo kuyishyira mu bikorwa. 17,18 Nyuma y’ibi bigeragezo, umubare wa PCIs wakozwe wariyongereye cyane.
Ariko, ikibazo cya iatrogenic in-stent neointima hyperplasia nyuma yo gushyirwa muri BMS cyagaragaye vuba, bituma ISR igaragara kuri 20-30% by'ibisebe byavuwe. DES19 yatangijwe mu 2001 kugira ngo igabanye gukenera restenosis no kongera kubagwa. DES yongereye icyizere ku baganga b'indwara z'umutima binyuze mu kwemerera kuvura ibisebe byinshi bigoye byafatwaga nk'ibishobora kuvurwa hakoreshejwe uburyo bwo gutera imiti 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, stent nshya nka 20,21 zarateguwe kandi zishyirwa ahagaragara. 22 Kuva icyo gihe, imbaraga zo kunoza imikorere ya stent zariyongereye cyane, kandi ikoranabuhanga rishya rishimishije ryakomeje kuvumburwa no kugezwa ku isoko vuba.
BMS ni umuyoboro mwiza w'insinga. Nyuma yo gukoresha Wall mount, Gianturco-Roubin mount na Palmaz-Schatz mount bwa mbere, ubu hari BMS nyinshi zitandukanye.
Hari imiterere itatu itandukanye: serpentine, tubular mesh n'umuyoboro ufunze. Imiterere ya coil igizwe n'insinga z'icyuma cyangwa uduce tugize ishusho y'uruziga; mu miterere ya coil, insinga zivanze hamwe mu miyoboro zigize tubular mesh zikora tubular; imiterere ya coil igizwe n'imiyoboro y'icyuma icibwa na laser. Ibi bikoresho bitandukanye mu miterere (icyuma kidafunze, nichrome, cobalt chrome), imiterere (imiterere itandukanye y'ubugari n'ubugari, uburebure n'umurambararo, imbaraga za radial, radiation pacity), na sisitemu zo gutanga (zikura ubwazo cyangwa zishobora kwaguka mu ibara ry'umuhondo).
Nk’uko bisanzwe, BMS nshya igizwe na aloyi ya cobalt-chromium, bigatuma habaho imigozi mito, kunoza imikorere yo gutwara no kugumana imbaraga za mekanike.
Zigizwe n'icyuma gikoresha stent (ubusanzwe icyuma kidashonga) kandi zisizweho polymer isohora imiti irwanya ikwirakwira ry'imitsi cyangwa ubushyuhe.
Sirolimus (izwi kandi nka rapamycin) yabanje gukorwa nk'umuti urwanya icyorezo. Uburyo ikora bufitanye isano no kubuza uruhererekane rw'uturemangingo mu kubuza ihinduka kuva kuri G1 kugeza kuri S no kubuza iremwa rya neointima. Mu 2001, ubunararibonye bwa "muntu wa mbere" kuri SES bwagaragaje umusaruro mwiza, bituma stent ya Cypher itera imbere. 23 Igerageza rinini ryagaragaje ko rikora neza mu gukumira IR. 24
Paclitaxel yari yemewe mbere mu kuvura kanseri y'intanga ngore, ariko imiterere yayo ikomeye ya cytostatic - uyu muti utuma microtubules zihagarara mu gihe cya mitosis, ugatera guhagarara k'uturemangingo, 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'umutima zikomeye. 25,26 Nyuma ya TAXUS Liberté yari ifite urubuga rw'icyuma kitagira umugese kugira ngo byorohereze gutanga.
Ibimenyetso bikomeye bivuye mu isuzuma rikurikiranye hamwe n'isesengura rya meta bigaragaza ko SES ifite inyungu kurusha PES bitewe n'umuvuduko muto wa IVR na target vessel revascularization (TVA), ndetse n'icyerekezo cyo kwiyongera kwa acute myocardial infarction (AMI) mu itsinda rya PES. 27.28
Ibikoresho byo mu gisekuru cya kabiri byagabanije ubugari bw'umugozi, byongereye ubushobozi bwo koroshya/gutanga, byarushijeho kuba byiza mu bijyanye no guhuza imiti n'ibinyabutabire, ndetse binatuma imiti ikomeza gukora neza. Muri iki gihe, ibi ni byo bipimo bya DES bigezweho cyane ndetse n'ibice by'ingenzi bya coronary stents byashyizwe ku isi yose.
Taxus Elements itera iyi ntambwe irengaho hamwe na polymeri idasanzwe yagenewe kurekurwa hakiri kare cyane hamwe na sisitemu nshya ya platinum-chromium spacer itanga spacers ntoya kandi ikongera ubushobozi bwo gukoresha imirasire y'izuba. Inyigo ya PERSEUS 29 yagaragaje ibisubizo bisa hagati ya Element na Taxus Express mu gihe cy'amezi agera kuri 12. Ariko, nta geragezwa rihagije ryakozwe kugereranya ibintu bya yew n'ibindi bisekuruza bya kabiri bya DES.
Endeavor Zotarolimus Coated Stent (ZES) ishingiye ku buryo bukomeye bwa cobalt-chromium stent ifite ubushobozi bwo koroha cyane hamwe n'umuvuduko muto wa stent. Zotarolimus ni sirolimus analogue ifite ingaruka nk'izo zo gukumira ubudahangarwa bw'umubiri, ariko hamwe n'ubwiyongere bw'ubushyuhe kugira ngo yongere ubushobozi bwo gushyira mu mwanya wayo mu rukuta rw'imitsi. ZES ikoresha polimeri nshya ya phosphorylcholine igenewe kongera ubushobozi bwo guhuza umubiri no kugabanya ububyimbirwe. Imiti myinshi irasukurwa mu cyiciro cya mbere cy'imvune, 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 HR ariko hakagira ingaruka mbi nke z'umutima n'imitsi (MACEs) kurusha SES. 30 Inyigo ya ENDEAVOR IV yagereranyaga ZES na PES yongeye kugaragaza ko habayeho SIS nyinshi ariko MI nke, bishoboka ko biterwa na ST isanzwe mu itsinda rya ZES. 31 Ariko, inyigo ya PROTECT ntiyashoboye kugaragaza itandukaniro mu mikorere ya ST hagati ya stenti 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 yo mu gisekuru cya gatatu) ishingiye ku rubuga rushya rufite ubushobozi bwo gutanga (platform ya Integrity BMS) na polymer nshya, ihuza neza n’ibinyabuzima, ishobora guhagarika igisubizo cy’ububyimbirwe bwa mbere no gukuraho umuti mwinshi mu minsi 60 iri imbere. Igerageza ryagereranije Resolute na Xience V (everolimus eluting stent [EES]) ryagaragaje ko sisitemu ya Resolute yari ifite akamaro kangana mu bijyanye n’impfu no kunanirwa kw’ibisebe. 33.34
Everolimus, ikomoka kuri sirolimus, ni na yo igabanya uruhererekane rw'uturemangingo ikoreshwa mu guteza imbere EES Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform). Igerageza rya SPIRIT 35-37 ryagaragaje umusaruro mwiza kandi rigabanya MACE hamwe na Xience V ugereranije na PES, mu gihe igerageza rya EXCELLENT ryagaragaje ko EES yari nziza nka SES mu gukumira igihombo cyatinze mu mezi 9 n'ingaruka z'ubuvuzi mu mezi 12. 38 Amaherezo, stent ya Xience yagaragaye ko iruta BMS mu gihe cy'indwara ya ST elevation myocardial infarction (MI). 39
EPC ni itsinda ry’uturemangingo tuzenguruka mu mitsi tugira uruhare mu gusana imitsi no gusana imitsi. Kwiyongera kwa EPC aho imitsi yakomerekeye bizafasha kongera gutera imitsi mu mitsi hakiri kare, bishobora kugabanya ibyago byo kurwara ST. Uburyo bwa mbere EPC Biology yateye mu gushushanya stent ni stent ya Genous, itwikiriwe n’uturemangingo turwanya CD34, ishobora gufata EPC zizenguruka binyuze mu bimenyetso byayo byo mu maraso kugira ngo yongere uburyo bwo gutera imitsi mu mitsi. Nubwo ubushakashatsi bwa mbere bwateye inkunga, ibimenyetso biherutse kugaragaza ko hari igipimo cyo hejuru cya TVR. 40
Bitewe n’ingaruka mbi zishobora guterwa no gutinda gukira bitewe na polymer zifitanye isano n’ibyago bya ST, polymer zishobora guhindurwamo biosorbable zitanga inyungu za DES mu kwirinda impungenge zimaze igihe kirekire ku bijyanye no kugumana polymer. Kugeza ubu, sisitemu zitandukanye zishobora guhindurwamo biosorbable zemejwe (urugero: Nobori na Biomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), ariko inyandiko zishyigikira umusaruro wazo w’igihe kirekire ni nke. 41
Ibikoresho bishobora kwinjizamo ibinyabuzima bifite inyungu mu buryo bw’imitekerereze yo gutanga inkunga ya mekanike mu ntangiriro iyo hatekerejwe ku gusubira inyuma kwa elastic no kugabanya ibyago by’igihe kirekire bifitanye isano n’imitsi isanzweho y’icyuma. Ikoranabuhanga rishya ryatumye habaho iterambere rya polymer za aside lactic (aside poly-l-lactic [PLLA]), ariko sisitemu nyinshi za stent zirimo gukorwa, nubwo kubona uburinganire bwiza hagati yo gukuraho imiti no kwangirika kw’imitsi biracyari ikibazo. Inyigo ya ABSORB yagaragaje umutekano n’ubushobozi bwa stent za PLLA za everolimus. 43 Ivugurura rya stent ya Absorb yo mu gisekuru cya kabiri ryari ryiza kurusha iryabanje hamwe n’ikurikiranwa ryiza ry’imyaka 2. 44 Inyigo ya ABSORB II iriho ubu, igerageza rya mbere ryakozwe ku buryo butunguranye rigereranya stent ya Absorb na stent ya Xience Prime, rigomba gutanga amakuru y’inyongera, kandi ibisubizo bya mbere biboneka biratanga icyizere. 45 Ariko, imiterere myiza, uburyo bwiza bwo gutera, n’imiterere y’umutekano mu ndwara z’imitsi y’umutima bigomba gusobanurwa neza.
Kurwara indwara ya Thrombosis haba muri BMS na DES bigira ingaruka mbi ku buvuzi. Mu isuzuma ry’abarwayi batewe DES, 47% by’abarwayi ba ST byateje urupfu, 60% muri MI idahitana, na 7% muri angina idahamye. PCI kuri ST yihutirwa akenshi iba itari nziza, aho igaruka muri 12% by’abarwayi. 48
ST ya Extended ishobora kugira ingaruka mbi ku buvuzi. Mu bushakashatsi bwa BASKET-LATE, nyuma y'amezi 6-18 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 SMP (4.9% na 1.3%, uko bikurikirana). 20 Isesengura rya meta ry'ubushakashatsi icyenda aho abarwayi 5261 bakorewe SES, PES, cyangwa BMS ku buryo butaziguye ryagaragaje ko nyuma y'imyaka 4 yo gukurikirana, SES (0.6% ugereranyije na 0%, p = 0.025) na PES (0.7%) biyongereyeho indwara ya ST yatinze cyane ugereranije na BMS ku kigero cya 0.2%, p = 0.028). 49 Mu buryo bunyuranye, mu isesengura ryakozwe harimo abarwayi 5108, 21 hagaragaye ukwiyongera kwa 60% by'impfu cyangwa MI kuri SES ugereranije na BMS (p = 0.03), mu gihe PES yahujwe n'ubwiyongere butari bunini bwa 15% (reba - kugeza ku mezi 9 kugeza ku myaka 3).
Ibiro byinshi byo kwandikamo, ibizamini byakozwe ku buryo butaziguye, n'isesengura rya meta byasuzumye ibyago byo kurwara ST nyuma yo gutera BMS na DES kandi byagaragaje ibisubizo bivuguruzanya. Mu isesengura ry'abarwayi 6906 bavuwe na BMS cyangwa DES, nta tandukaniro ryagaragaye mu bisubizo by'ubuvuzi cyangwa igipimo cya ST mu mwaka umwe wo gukurikirana. 48 Mu rindi sesengura ry'abarwayi 8146, ibyago byo kurwara ST idakira byagaragaye ko ari 0.6% ku mwaka ugereranije na BMS. 49 Isesengura rya meta ryakozwe ku gereranya SES cyangwa PES na SMPs ryagaragaje ko ibyago byo gupfa byiyongera ndetse na MI hamwe na DES yo mu gisekuru cya mbere ugereranije na SMPs, 21 n'irindi sesengura rya meta rya abarwayi 4545 bakorewe SES cyangwa ST hagati ya PES na BMS mu myaka 4 yo gukurikirana. 50 Ubundi bushakashatsi bufatika bwagaragaje ko ibyago byo kurwara ST na MI byiyongera mu barwayi bavuwe na DES yo mu gisekuru cya mbere nyuma yo guhagarika DAPT. 51
Bitewe n'amakuru avuguruzanya, isesengura ryinshi ryakusanyijwe hamwe n'isesengura rya meta ryagaragaje ko DES na SGM yo mu gisekuru cya mbere ntaho bihuriye cyane n'ibyago byo gupfa cyangwa MI, ariko SES na PES byari bifite ibyago byinshi byo kurwara ST ugereranije na SGM. Kugira ngo harebwe ibimenyetso bihari, Ikigo gishinzwe ibiribwa n'imiti muri Amerika (FDA) cyashyizeho itsinda ry'impuguke53 ryasohoye itangazo ryemeza ko DES yo mu gisekuru cya mbere ifite akamaro nk'uko byanditse kandi ko ibyago byo kurwara ST mu cyiciro cya mbere ari bike, ariko atari byinshi. , Ubwiyongere bugaragara. Kubera iyo mpamvu, FDA n'ishyirahamwe basaba ko igihe cya DAPT cyongerwa kikagera ku mwaka 1, nubwo nta bimenyetso bifatika bihari bishyigikira iki kirego.
Nkuko byavuzwe mbere, DES zo mu gisekuru cya kabiri zakozwe zifite imiterere myiza. CoCr-EES yakoze ubushakashatsi bwagutse cyane mu buvuzi. Mu isesengura ryakozwe na Baber et al.54 ku barwayi 17.101, CoCr-EES yagabanyije cyane ST na MI ifatika/ishoboka ugereranije na PES, SES, na ZES mu mezi 21. Amaherezo, Palmerini et al bagaragaje mu isesengura ryakozwe ku barwayi 16.775 ko CoCr-EES ifite ST iri hasi cyane mu ntangiriro, mu gihe gito, mu mwaka 1 na 2 ugereranije n'izindi DES zashyizwe hamwe. 55 Ubushakashatsi bwakozwe mu buzima busanzwe bwagaragaje ko ibyago byo kurwara ST hamwe na CoCr-EES bigabanuka ugereranije na DES zo mu gisekuru cya mbere. 56
Re-ZES yagereranyijwe na CoCr-EES mu bushakashatsi bwa RESOLUTE-AC na TWENTE. 33,57 Nta tandukaniro rigaragara mu rupfu, indwara y’umutima ifata imitsi, cyangwa igice cya ST cyagenwe hagati ya stent ebyiri.
Mu isesengura ryakozwe ku barwayi 50.844, harimo na RCT 49, 58 CoCr-EES yagaragaye ko ifite ST nke cyane kurusha BMS, ikintu kitagaragaye ku bandi ba DES; uku kugabanuka ntikwabaye gusa "hakiri kare cyane" na nyuma y'iminsi 30 (58). Igipimo cy'amahirwe [OR] 0.21, 95% interval y'icyizere [CI] 0.11-0.42) no ku mwaka 1 (OR 0.27, 95% CI 0.08-0.74) n'imyaka 2 (OR 0.35, 95% CI 0.17-0.69). Ugereranije na PES, SES, na ZES, CoCr-EES yagaragaye ko ifite ST rate iri hasi ku mwaka 1.
ST yo mu ntangiriro ifitanye isano n'ibintu bitandukanye. Imiterere y’imitsi yo mu gice cy’imbere n’umutwaro wa thrombus bisa nkaho bigira ingaruka ku musaruro nyuma ya PCI; 59 struts zimbitse zinjira mu gice cy’imbere cy’umutsi (NC) prolapse, kuranduka k’umurongo muremure muri stent, stent idafite ubushobozi bwo kuyikoresha hamwe n’ibice bisigaye by’umutsi cyangwa stenosis ikomeye y’umutsi, stent itarashyirwamo neza, no kwaguka kutuzuye kwa stent yashyizwemo bishobora kongera ibyago byo kurwara ST.60. Uburyo bwo kuvura imiti igabanya platelet ntabwo bugira ingaruka zikomeye ku kugaragara kwa ST yo hambere: mu igerageza ryakozwe ku buryo butunguranye rigereranya BMS na DESS, igipimo cya ST yo mu gihe cya DAPT cyari kimwe (<1%).61 Rero, ST yo hambere isa nkaho ifitanye isano ahanini n’ibisebe byavuwe ndetse n’ibintu biyitera. Imiterere y’imitsi yo mu gice cy’imbere n’umuvuduko w’amaraso asa n’aho agira ingaruka ku musaruro nyuma ya PCI; 59 struts zimbitse zinjira mu gice cy’imbere cy’umutsi (NC) prolapse, kuranduka k’umurongo muremure mu gice cy’umutsi, stent idafite ubushobozi bwo kuyikoresha hamwe n’ibice bisigaye by’umutsi cyangwa stenosis ikomeye y’umutsi, stent itarashyirwamo neza, no kwaguka kutuzuye kwa stent yashyizwemo bishobora kongera ibyago byo kurwara ST.60. Uburyo bwo kuvura imiti igabanya platelet ntabwo bugira ingaruka zikomeye ku kugaragara kwa ST yo hambere: mu igerageza ryakozwe ku buryo butunguranye rigereranya BMS na DESS, igipimo cya ST yo mu gihe cya DAPT cyari kimwe (<1%).61 Rero, ST yo hambere isa nkaho ifitanye isano ahanini n’ibisebe byavuwe ndetse n’ibintu biyitera. Морфология лежащей в основе матарики и тромбоз, по-видимому, влияют на исход после ЧКВ; стентирования с остаточными краевыми расслоениями или значительным краевым матозом, неполной аппозозей и неполным расширением данлантированного матта может увеличить риск ST.60 Тапапевтический мат антитромбоцитарных п пидов не оказывает сущственного влияния на частоту ранвег с в: сравнивающем BMS na DES, частота острого и подострого ST во время DAPT б б одинаковой (<1%) .61 Таким огом, ранняя ST, по-видимому, в первую акередь свяаза с лежащми в основе пролеченными пор мажениями и билгеными amatamи. Imiterere y’imitsi yo hasi n’imitsi yo mu maraso bisa nkaho bigira ingaruka ku musaruro nyuma ya PCI; 59 kwinjira mu gice cy’imbere cy’umutsi bitewe no gucika kw’uturemangingo (NC) mu maraso, gucika kw’imitsi mu gice cy’imbere cy’umutsi, gucika kw’imitsi mu buryo butari bwiza hamwe n’igabanuka ry’imitsi cyangwa stenosis ikomeye, gucika kw’imitsi no kwaguka kw’imitsi yo mu maraso bishobora kongera ibyago byo kurwara ST.60. Uburyo bwo kuvura imiti igabanya platelet ntabwo bugira ingaruka zikomeye ku kurwara ST yo hambere: mu igerageza ryakozwe ku buryo butunguranye rigereranya BMS na DES, kugaragara kwa ST yo mu maraso n’iyo mu gihe cya DAPT byari bimwe (<1%).61 Bityo, ST yo hambere isa nkaho ifitanye isano ahanini n’ibisebe byavuwe n’ibintu byo mu maraso.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 的随机试验中， DAPT 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 血栓 似乎 ci ci pci 后 结果 ； ； ； ； ； 坏 死 核心 核心 核心 核心 的 支柱 穿透 内长 次 次 次 次 次 次 次 次 次 的 的 ms ms ms ms ms ms ms ms ms ms ms ms ms ms 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 1 1 1 1 1 1 <1%） .61Imiterere y’imitsi yo mu bwoko bwa plaque na thrombosis bigaragara ko bigira ingaruka ku ngaruka nyuma ya PCI; 59 Kwinjira mu buryo bwimbitse bitewe no gucika kw’imitsi yo mu bwoko bwa necrotic nucleus (NC), gucika kw’imitsi yo mu bwoko bwa medial mu burebure bwa stent, gucikamo ibice bya kabiri hamwe n’imirongo isigaye, cyangwa kugabanya imirongo ikomeye Gufata stent neza, kugabanya imitsi, no kwaguka ku buryo budahagije60 Gahunda yo kurwanya platelet nta ngaruka nini igira ku gucika kwa ST hakiri kare: gukwirakwira kwa ST ikabije n’iyoroheje mu gihe cya DAPT mu igerageza ryakozwe ku buryo butunguranye rigereranya BMS na DES. ahanini bifitanye isano n’ibisebe by’inyuma n’ibintu byo kubaga.
Muri iki gihe, hibandwa kuri ST itebye cyangwa itinze cyane. Nubwo ibintu by’imikorere n’ikoranabuhanga bisa nkaho bigira uruhare runini mu iterambere rya ST ikabije n’ifite ubukana buto, 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 gutera ST ikomeza kandi iteye imbere cyane: diyabete, ACS mu gihe cyo kubagwa bwa mbere, impyiko zinanirwa gukora neza, gusaza, kugabanuka k’igice cyo gusohora amaraso, ingaruka mbi zikomeye z’umutima mu minsi 30 uhereye igihe cyo kubagwa bwa mbere. Kuri BMS na DES, ibintu by’imikorere nk’ingano y’imitsi mito, kubyimba kw’imitsi myinshi, indwara ya calcite, kuziba kw’imitsi, stent ndende bisa nkaho bifitanye isano n’ibyago byo gutera ST ikomeza. 62,63 Kwitabira nabi imiti igabanya ubukana bw’imitsi ni ikintu gikomeye gishobora gutera thrombosis ikomeza ya DES 51. Iyi myitwarire ishobora guterwa no kutubahiriza amabwiriza y’umurwayi, kugabanya urugero rw’imiti, imikorere y’imiti, ibindi bintu bigira ingaruka ku buryo imiti ikora, polymorphism y’uturemangingo tw’umubiri (cyane cyane clopidogrel resistance), no gukora izindi nzira zo gutuma platelet ikora. Indwara ya Stent neoatherosclerosis ifatwa nk'uburyo bw'ingenzi bwo kunanirwa kwa stent nyuma yo gucika intege, harimo na ST64 ya nyuma (igice cya “Stent Neoatherosclerosis”). Endothelium idahinduka itandukanya urukuta rw'imitsi n'inkingi za stent zirimo amaraso kandi igasohora ibintu birwanya thrombosis n'imitsi igabanya ubukana bw'amaraso. DES ishyira urukuta rw'imitsi ku miti igabanya ubukana bw'amaraso n'uburyo bwo kurekura imiti, bikagira ingaruka zitandukanye ku gukira no gukora kw'imitsi, hamwe n'ibyago byo kugabanuka kw'imitsi nyuma yo gucika intege. Ubushakashatsi bwakozwe ku ndwara bwagaragaje ko polymeri zikomeye za DES zo mu gisekuru cya mbere zishobora kugira uruhare mu kubyimba guhoraho, kwishyira kwa fibrin mu buryo buhoraho, gukira nabi kw'imitsi nyuma yo gucika intege, bityo ibyago byo kugabanuka kw'imitsi nyuma yo gucika intege bigaragara ko ari ubundi buryo butuma ST itera. Virmani et al. [66] batangaje ibyavuye mu bushakashatsi nyuma yo gupfa nyuma ya ST bagaragaje ko hari ikwirakwira ry'imitsi mu gice cya stent hamwe n'ingaruka zo kugabanuka kw'imitsi zigizwe na T-lymphocytes na eosinophils; ibi byavumbuwe bishobora kugaragaza ingaruka za polymeri zidapfa. 67 Kudakora neza kwa stent bishobora guterwa no kwaguka kwa stent mu buryo butari bwiza cyangwa bikabaho amezi menshi nyuma ya PCI. Nubwo kudakora neza kwa stent ari ikintu gishobora gutera ST ikaze kandi ingana na subacute, akamaro ko kutagira stent mu buryo bugaragara gashobora 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 endothelialization yihuta kandi idahinduka, hamwe n'itandukaniro mu miterere n'imiterere ya stent, ubunini bwa strut, imiterere ya polymer, n'ubwoko bw'imiti irwanya ikwirakwira ry'imitsi, urugero, na kinetics.
Ugereranyije na CoCr-EES, uduce duto twa cobalt-chromium stent scaffold (81 µm), fluoropolymers zirwanya thrombosis, polymer nkeya, hamwe n'umuvuduko w'imiti bishobora kugira uruhare mu kugabanya igipimo cya ST. Ubushakashatsi bwagaragaje ko thrombosis na platelet deposition biri hasi cyane muri stents za fluoropolymer-coated ugereranyije na stents zitarapfukwa. 69 Niba izindi DES zo mu gisekuru cya kabiri zifite imiterere nk'iyo bikwiye kwigwaho cyane.
Imisemburo yo mu mitsi yo mu mutima ituma habaho intsinzi mu kubaga indwara z’umutima ugereranije na PTCA gakondo yo mu mitsi yo mu mutima (percutaneous transluminal coronary angioplasty), ifite ibibazo bya tekiniki (gufunga imitsi, gutandukanya imitsi, nibindi) ndetse n’umubare munini w’imitsi yo mu mutima (kugeza kuri 40–50% by’abarwaye). Mu mpera z’imyaka ya 1990, hafi 70% bya PCIs byakozwe hakoreshejwe BGM implantation. 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%。MS BMSAriko, nubwo hari iterambere mu ikoranabuhanga, tekiniki, no kuvura, ibyago byo kurwara restenosis nyuma yo gutera BMS ni hafi 20%, aho igipimo kirenga 40% mu matsinda amwe n’amwe. 71 Muri rusange, ubushakashatsi bwagaragaje ko restenosis nyuma yo gutera BMS, nk’uko bigaragara kuri PTCA isanzwe, igera ku rwego rwo hejuru mu mezi 3-6 ikarangira mu mwaka 1. 72
DES irushaho kugabanya igipimo cya ISR,73 nubwo uku kugabanuka gushingiye ku ndwara ya angiographic no ku buvuzi. Ifu ya DES polymer irekura imiti irwanya ububyimbirwe n'ubwiyongere bw'imitsi, ikabuza ishingwa rya neointima, kandi igatinza gusana imitsi mu mezi cyangwa imyaka. 74 Mu bushakashatsi bw'ubuvuzi n'amateka, gukura kwa neointima guhoraho kwagaragaye mu gihe kirekire gikurikiranwa nyuma yo gushyirwa muri DES, ikintu kizwi nka "gufata nyuma" 75.
Gukomereka kw'imitsi mu gihe cya PCI bitera inzira igoye yo kubyimba no gusana mu gihe gito cyane (ibyumweru kugeza ku mezi), bigatuma habaho endothelialization no gukwirakwira kwa neointimal. Dukurikije ibyagaragaye mu bushakashatsi bw'imyakura, hyperplasia ya neointimal (HMS na DES) nyuma yo gushyirwamo stent ahanini yari igizwe n'uturemangingo tw'imitsi yoroshye twinshi muri matrix ya excremental iri ku bwinshi bwa proteoglycan. 70
Bityo, hyperplasia ya neointimal ni inzira yo gusana irimo ibintu bituma imitsi ifungana kandi ikagira ingaruka ku burwayi, ndetse n'uturemangingo dutuma imitsi ikura neza ndetse no gukora matrix yo hanze y'uturemangingo. Nyuma gato ya PCI, platelets na fibrin bishyirwa ku rukuta rw'imitsi kandi bigakurura leukocytes binyuze mu ruhererekane rw'uturemangingo dufatana. Leukocytes zizunguruka zifatana na platelets zifatanye binyuze mu mikoranire hagati ya leukocyte integrin Mac-1 (CD11b/CD18) na platelets glycoprotein Ibα 53 cyangwa fibrinogen ifitanye isano na platelets glycoprotein IIb/IIIa. 76.77
Dukurikije amakuru mashya, uturemangingo tw’umusemburo w’amagufwa tugira uruhare mu mikorere y’imitsi no mu mikorere yo gusana. Guhindura EPC kuva mu musemburo w’amagufwa kugera mu maraso yo ku nkengero z’umubiri bituma habaho kuvugurura imitsi no gutera amaraso nyuma yo kubyara. Bigaragara ko uturemangingo tw’umusemburo w’amagufwa (SMPCs) 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 ishobora kumenya uturemangingo tw’umusemburo w’amagufwa tudatandukanye dufite ubushobozi bwo gutandukana muri EPC na PBMCs. Guhindura uturemangingo tw’umusemburo wa CD34 mu muryango wa EPC cyangwa SMPC biterwa n’ibidukikije; indwara ziterwa n’imitsi zitera gutandukana mu buryo bwa EPC, butera kongera gukora imyitozo ngororamubiri, mu gihe indwara ziterwa no kubyimba zitera gutandukana mu buryo bwa SMPC, butera kwiyongera kw’imitsi. 79
Diyabete yongera ibyago byo kurwara ISR ku kigero cya 30-50% nyuma yo gutera BMS, kandi igipimo cyo hejuru cya restenosis ku barwayi ba diyabete ugereranije n’abarwayi batari diyabete nacyo cyakomeje mu gihe cya DES. Uburyo bw’iyi ngingo bushobora kuba butandukanye, harimo uburyo umubiri uhinduka (urugero: guhindagurika mu mikorere y’ububyimbirwe) n’imiterere y’umubiri (urugero: imiyoboro mito y’amaraso, ibisebe birebire, indwara zikwirakwira, nibindi), ibyo byongera ibyago byo kurwara ISR ku giti cyabo. 70
Ubugari bw'ubwato n'uburebure bw'ibisebe byagize ingaruka ku gipimo cya ISR ku buryo bwihariye, aho uburebure buke/uburebure bw'ibisebe byongera cyane igipimo cya restenosis ugereranije n'uburebure bunini/ubugufi.
Uburyo bwo gupima stent bwo mu gisekuru cya mbere bwagaragaje stent struts nini kandi bufite ISR nyinshi ugereranije n'uburyo bwo gupima stent bwo mu gisekuru cya kabiri bufite struts nto.
Byongeye kandi, umubare w’abantu barwaye restenosis ujyana n’uburebure bwa stent, hafi kabiri ku burebure bwa stent >35 mm ugereranije n’abafite uburebure buri munsi ya mm 20. Byongeye kandi, umubare w’abantu barwaye restenosis ufitanye isano n’uburebure bwa stent, hafi kabiri ku burebure bwa stent >35 mm ugereranije n’abafite uburebure buri munsi ya mm 20. Кроме того, частота рестеноза свяаза с длиной мата, поти удваиваясь при длине мта> 35 мим по сравнению с длиной марта <20 mm. Byongeye kandi, igipimo cyo kuruhuka gifitanye isano n'uburebure bwa stent, hafi yikubye kabiri uburebure bwa stent >35 mm ugereranije n'uburebure bwa stent <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 мата: длина мата> 35 мил поти в два раза больше, чем мата <20 mm. Byongeye kandi, inshuro za restenosis zaterwaga n'uburebure bwa stent: uburebure bwa stent >35 mm ni hafi inshuro ebyiri z'uburebure bwa stent <20 mm.Umurambararo muto wa nyuma wa stent na wo wagize uruhare runini: umurambararo muto wa nyuma wa nyuma wa stent wagaragaje ko ibyago byo kurwara restenosis byiyongera cyane.
Ubusanzwe, intimal hyperplasia nyuma yo gutera BMS ifatwa nk'ihamye, aho intimal hyperplasia ifata umwanya wa mbere hagati y'amezi 6 n'umwaka 1 igakurikirwa n'igihe cyo gusinzira nyuma yo gusinzira. Hari hamaze kugaragara ko intimal ikura neza cyane, ikurikirwa n'intimal regression hamwe no kwiyongera kwa lumen imyaka myinshi nyuma yo gutera stent; gukura kw'uturemangingo tw'imitsi yoroshye n'impinduka muri extracellular matrix byatanzwe nk'uburyo bushoboka bwo gutera intima regression nyuma yo gusimbuka. 83 Ariko, ubushakashatsi bw'igihe kirekire bwagaragaje ko hari igisubizo cy'impande eshatu nyuma yo gutera BMS hamwe na restenosis kare, regression hagati, na restenosis ya nyuma ya luminal. 84
Mu gihe cya DES, gukura kwa nyuma kwa neontimal kwagaragaye bwa mbere nyuma yo gutera SES cyangwa PES mu nyamaswa. 85 Ubushakashatsi bwinshi bwa IVUS bwagaragaje ko gukura kwa intimal bigabanuka hakiri kare, bigakurikirwa no gufata nyuma y’igihe runaka nyuma yo gutera SES cyangwa RPE, 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.
Hari ibimenyetso byinshi bigaragaza ko ubushyuhe buhoraho n'ubudahagije bw'inyuma y'amaraso bituma habaho ikwirakwira ry'amaraso mu maraso (HCM na DES) (cyane cyane DES yo mu gisekuru cya mbere), ibi bikaba ari ingenzi mu iterambere rya IR cyangwa ST ikomeza kwiyongera. Inoue n'abandi [87] batangaje ibyavuye mu bushakashatsi bwa histological autopsy nyuma yo gushyiramo Palmaz-Schatz coronary stents, bigaragaza ko ubushyuhe bukikije stent bushobora gutera impinduka nshya za atherosclerotic muri stent. Ubundi bushakashatsi bwagaragaje ko ingirabuzimafatizo za restenotic mu myaka 5 ya CGM zigizwe na atherosclerosis iherutse gutangira hamwe cyangwa idafite ubushyuhe bwa peritoneal; ingero zavuye mu barwayi ba ACS zigaragaza plaque zisanzwe zishobora kwibasirwa mu mitsi y'umutima gakondo Histological block morphology hamwe na macrophages y'ifuro na crystals za cholesterol. Byongeye kandi, iyo ugereranya BMS na DES, hari itandukaniro rikomeye mu gihe cyo gutera indwara nshya ya atherosclerosis. 11,12 Impinduka za mbere za atherosclerotic mu kwinjira kwa macrophage y'ifuro zatangiye amezi 4 nyuma yo gushyirwa muri SES, mu gihe impinduka zimwe mu bisebe bya CGM zabayeho nyuma y'imyaka 2 kandi zakomeje kuba ikintu kidasanzwe kugeza ku myaka 4. Byongeye kandi, DES stenting ku bisebe bidahindagurika nka thin tegmental fibroatherosclerosis (TCFA) cyangwa intimal rupture ifite igihe gito cyo gukura ugereranije na BMS. Bityo, neoatherosclerosis isa nkaho ikunze kugaragara cyane kandi ibaho kare muri DES yo mu gisekuru cya mbere kurusha muri BMS, bishoboka ko biterwa n'ubwoko butandukanye bw'indwara.
Ingaruka za DES cyangwa DES zo mu gisekuru cya kabiri ku iterambere ziracyari gutegurwa; nubwo bimwe mu byagaragaye kuri DES88 zo mu gisekuru cya kabiri bigaragaza ko ububyimbirwe buke, umubare w’abarwaye indwara ya neo-atherosclerosis ni nk’uw’abo mu gisekuru cya mbere, ariko haracyakenewe izindi nyigo.