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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Dhipatimendi reCardiology, Poliambulanza Foundation Hospital, Brescia, 2 Dhipatimendi reCardiology, Catholic University of the Sacred Heart of Rome, Italy Pfupiso: Drug-Eluting Stents (DES) inoderedza miganhu ye bare metal stents (BMS) mushure mekupindira kwe percutaneous coronary. Zvisinei, kunyangwe kuunzwa kwechizvarwa chechipiri cheDES kuchiratidzika kunge kwakaderedza chiitiko ichi zvichienzaniswa neDES yechizvarwa chekutanga, kunetseka kwakakomba kuchiripo nezvematambudziko angangoitika ekuiswa kwe stent, akadai se stent thrombosis (ST) uye stent resection. Stenosis (ISR).ST chiitiko chinogona kunge chiri njodzi zvikuru chakaderedzwa zvakanyanya kuburikidza nekushandiswa kwe stenting zvakanaka, magadzirirwo matsva e stent, uye kurapwa kwe antiplatelet kaviri. Nzira chaiyo inotsanangura kuitika kwayo iri kuferefetwa, uye zvechokwadi, zvinhu zvakawanda ndizvo zvinokonzera. ISR muBMS yaimboonekwa semamiriro akadzikama ane peak yekutanga ye intimal hyperplasia (pamwedzi mitanhatu) ichiteverwa nenguva yekudzokera shure kwegore rimwe. Kusiyana neizvi, zvidzidzo zvekiriniki uye histological zveDESS zvakaratidza humbowo hwekukura kwe neointimal kwenguva refu panguva yekutevera kwenguva refu, chiitiko chinozivikanwa se "late catch-up phenomenon". Maonero ekuti ISR ​​chirwere chekiriniki chisina njodzi achangobva kupikiswa nehumbowo hwekuti varwere vane ISR vanogona kuva ne acute coronary syndromes. Intracoronary imaging inzira inopindwa inogona kuona stented atherosclerotic plaques uye zviratidzo zve post-stent vessels healing; Inowanzo shandiswa kupedzisa kuongororwa kwe coronary angiography uye kutungamira maitiro epakati. Intracoronary optical coherence tomography parizvino ndiyo nzira yepamusoro yekufungidzira mifananidzo. Kana ichienzaniswa ne intravascular ultrasound, inopa mhinduro iri nani (kanenge ka10), zvichibvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro etsinga. "Zvidzidzo zvekufungidzira zvemumuviri zvinoenderana nezvakawanikwa ne histological zvinoratidza kuti kuzvimba kusingaperi uye/kana kusashanda zvakanaka kwe endothelial zvinogona kukonzera neo-atherosclerosis muchikamu chekupedzisira mukati meBMS neDES. Saka, neo-atherosclerosis ndiyo inonyanya kufungidzirwa mu pathogenesis ye late stent failure. Mazwi akakosha: coronary stent, stent thrombosis, restenosis, neoatherosclerosis
Kupindira kwemoyo kuburikidza nepfungwa (PCI) uchishandisa stent implantation ndiyo nzira inonyanya kushandiswa pakurapa chirwere chemwoyo chinoratidza zviratidzo, uye nzira iyi inoramba ichichinja.1 Kunyangwe mishonga inorapa stent (DES) ichideredza miganhu ye bare-metal stents (BMSs), matambudziko ekunonoka akadai se stent thrombosis (ST) uye in-stent restenosis (ISR) anogona kuitika ne stent implantation. , kunetseka kukuru kuchiripo.2-5
Kana ST iri chiitiko chinogona kukonzera njodzi huru, kuzivikanwa kwekuti ISR ​​chirwere chisina njodzi kwakapikiswa munguva pfupi yapfuura nehumbowo hwechirwere chemwoyo (ACS) muvarwere vane ISR.4
Nhasi uno, intracoronary optical coherence tomography (OCT)6-9 inoonekwa senzira yemazuva ano yekufungidzira mifananidzo, ichipa mhinduro iri nani pane intravascular ultrasound (IVUS).”Zvidzidzo zvemifananidzo yemumuviri,10-12 zvinoenderana nezvakawanikwa muhistological, zvinoratidza nzira itsva yekupindura kwetsinga mushure mekuisirwa stent, ne "neoatherosclerosis" itsva mukati meBMS neDES.
Muna 1964, Charles Theodore Dotter naMelvin P Judkins vakatsanangura angioplasty yekutanga. Muna 1978, Andreas Gruntzig akaita angioplasty yekutanga yebharuni (angioplasty yekare yebharuni); yaive nzira yekurapa yakachinja asi yaive nematambudziko ekuvharwa kwemidziyo yeropa nekukurumidza uye restenosis.13 Izvi zvakatungamira kuwanikwa kwe coronary stents: Puel naSigwart vakaisa stent yekutanga ye coronary muna 1986, vachipa stent yekudzivirira kuvharwa kwemidziyo yeropa nekukurumidza uye systolic retraction yekupedzisira.14 Kunyangwe aya ma stents ekutanga akadzivirira kuvharwa kamwe kamwe kwemidziyo yeropa, akakonzera kukuvara kwakanyanya kwe endothelial uye kuzvimba. Gare gare, miedzo miviri mikuru, Belgian-Dutch Stent Trial 15 uye Stent Restenosis Study 16, yakatsigira kuchengetedzeka kwe stenting ne dual antiplatelet therapy (DAPT) uye/kana matekiniki akakodzera ekuisa.17,18 Mushure memiedzo iyi, kwakava nekuwedzera kukuru kwehuwandu hwePCIs dzakaitwa.
Zvisinei, dambudziko re iatrogenic in-stent neointimal hyperplasia mushure mekuiswa kweBMS rakakurumidza kuonekwa, zvikaita kuti ISR ​​ive ne20%–30% yemaronda airapwa. Muna 2001, DES yakaunzwa19 kuderedza kudiwa kwe restenosis uye kupindirazve. DES dzakawedzera chivimbo chevanachiremba vemwoyo, zvichibvumira huwandu huri kuwedzera hwemaronda akaomarara ekurapwa ayo aifungidzirwa kuti akagadziriswa ne coronary artery bypass grafting. Muna 2005, 80%–90% yemaPCI ese akaperekedzwa neDES.
Zvese zvine zvazvinokanganisa, uye kubvira muna 2005, kunetseka nezvekuchengetedzeka kweDES "yechizvarwa chekutanga" kwakawedzera, uye ma stenti matsva akadai se20,21 akagadzirwa uye akaunzwa.22 Kubva ipapo, kuedza kuvandudza mashandiro e stent kwakawedzera nekukurumidza, uye matekinoroji matsva, anoshamisa akaramba achiwanikwa uye achiunzwa kumusika nekukurumidza.
BMS ichubhu yewaya yakatetepa ine mesh. Mushure mekushandisa kekutanga "Wall" mount, Gianturco-Roubin mount uye Palmaz-Schatz mount, maBMS akasiyana-siyana ava kuwanikwa.
Magadzirirwo matatu akasiyana anogoneka: coil, tubular mesh uye slotted tube. Magadzirirwo ecoil ane waya dzesimbi kana zvidimbu zvakagadzirwa kuita denderedzwa coil; magadzirirwo etubular mesh ane waya dzakaputirwa pamwe chete mu mesh kuti dzigadzire chubhu; magadzirirwo etubhu dzine slotted anosanganisira machubhu esimbi anochekwa ne laser. Zvishandiso izvi zvinosiyana mukugadzirwa (stainless steel, nichrome, cobalt chrome), dhizaini yezvivakwa (maitiro akasiyana estrut nehupamhi, dhayamita nehurefu, simba re radial, radiopacity) uye masisitimu ekutumira (anozvikudza ega kana anowedzerwa nebharumu).
Kazhinji, BMS itsva ine cobalt-chromium alloy, izvo zvinoita kuti pave nezvidimbu zvakatetepa zvine simba rekufamba, zvichichengetedza simba remuchina.
Zvine puratifomu yesimbi ine stent (kazhinji simbi isina ngura) uye yakafukidzwa nepolymer isingabatanidzi mishonga inodzivirira kukura kwemasero uye/kana yekudzivirira kuzvimba.
Sirolimus (inozivikanwawo se rapamycin) pakutanga yakagadzirwa semushonga wefungus. Maitiro ayo ekushanda anobva pakuvharira kufambira mberi kwemasero nekuvharira kuchinja kubva pachikamu cheG1 kuenda kuchikamu cheS uye kudzivirira kuumbwa kweneointima. Muna 2001, ruzivo rwe "kutanga-muvanhu" neSES rwakaratidza mhedzisiro yakanaka, zvichitungamira mukuvandudzwa kweCypher stent.23 Miedzo mikuru yakaratidza kushanda kwayo mukudzivirira ISR. Makumi maviri nemana
Paclitaxel pakutanga yakatenderwa kenza yemuchibereko, asi simba rayo guru re cytostatic - mushonga uyu unodzikamisa microtubules panguva ye mitosis, unoita kuti masero amire uye udzivise kuumbwa kwemasero matsva - zvinoita kuti ive mushonga weTaxus Express PES. Miedzo yeTAXUS V neVI yakaratidza kushanda kwenguva refu kwePES muzvirwere zvemwoyo zvine njodzi huru uye zvakaoma.25,26 TAXUS Liberté yakatevera yaive nepuratifomu yesimbi isina ngura kuti ive nyore kutakura.
Humbowo hwakakwana kubva muongororo mbiri dzakarongwa uye meta-analyses hunoratidza kuti SES ine mukana pamusoro pePES nekuda kwekudzikira kwehuwandu hweISR uye target vessel revascularization (TVR), pamwe nekuwedzera kwe acute myocardial infarction (AMI) muPES cohort. 27,28
Midziyo yechizvarwa chechipiri ine ukobvu hwakaderera hwe strut, kushanduka/kuburitswa kuri nani, ma polymer biocompatibility/drug elution profiles akawedzerwa, uye kinetics yakanaka kwazvo ye re-endothelialization. Mumazuva ano, ndiwo madhizaini eDES epamusoro-soro uye ma coronary stents makuru akaiswa pasi rose.
Taxus Elements ikufambira mberi kwakawedzerwa nepolymer yakasiyana yakagadzirirwa kuwedzera kuburitswa kwekutanga uye sisitimu itsva yeplatinum-chromium strut inopa struts dzakatetepa uye radiopacity yakawedzerwa. Muedzo wePERSEUS 29 wakaona mhedzisiro yakafanana pakati peElement neTaxus Express kwemwedzi inosvika gumi nemiviri. Zvisinei, miedzo yekuenzanisa zvinhu zveyew nezvimwe zvechizvarwa chechipiri cheDES haipo.
Endeavor ye zotarolimus-eluting stent (ZES) yakavakirwa papuratifomu yakasimba ye cobalt-chromium stent ine kuchinjika kwakanyanya uye saizi diki ye stent strut. Zotarolimus i sirolimus analog ine mhedzisiro yakafanana yekudzvinyirira immune asi inowedzera lipophilicity yekuwedzera nzvimbo yemadziro etsinga.ZES inoshandisa phosphorylcholine polymer coating itsva yakagadzirirwa kuwedzera biocompatibility uye kuderedza kuzvimba. Mishonga mizhinji inobviswa panguva yekutanga yekukuvara, ichiteverwa nekugadzirisa arterial. Mushure mekuyedzwa kwekutanga kwe ENDEAVOR, kuyedzwa kwakatevera kwe ENDEAVOR III kwakaenzanisa ZES ne SES, iyo yakaratidza kurasikirwa kukuru kwe lumen uye ISR asi zviitiko zvishoma zvakaipa zvemwoyo (MACE) kupfuura SES .30 Muyedzo we ENDEAVOR IV, uyo wakaenzanisa ZES ne PES, wakawana zvakare kuwanda kwe ISR, asi kuwanda kwe AMI, kunoratidzika kunge kuri kubva ku ST yakakwira zvikuru muboka re ZES.31 Zvisinei, kuyedzwa kwe PROTECT kwakakundikana kuratidza mutsauko mu ST rates pakati pe Endeavor ne Cypher stents.32
Endeavor Resolute ishanduro yakagadziridzwa yestent yeEndeavor ine polymer itsva ine layer nhatu. Iyo itsva Resolute Integrity (dzimwe nguva inonzi DES yechizvarwa chechitatu) yakavakirwa papuratifomu itsva ine kugona kukuru kwekutumira (puratifomu yeIntegrity BMS), uye polymer itsva, inoenderana nehupenyu, inogona kudzvinyirira mhinduro yekutanga yekuzvimba uye kubvisa mushonga wakawanda mumazuva makumi matanhatu anotevera. Kuedzwa kwakaenzanisa Resolute neXience V (everolimus-eluting stent [EES]) kwakaratidza kusaderera kweResolute system maererano nekufa uye kukundikana kwekukuvara kwakanangana.33,34
Everolimus, inobva mu sirolimus, inodzivirirawo masero emushonga wemasero anoshandiswa mukugadzira Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform) EES. Kuedzwa kweSPIRIT 35-37 kwakaratidza kushanda kuri nani uye kwakadzikira MACE neXience V zvichienzaniswa nePES, nepo kuyedzwa kweEXCELLENT kwakaratidza kuti EES yakanga isiri pasi peSES mukudzora kurasikirwa kunonoka pamwedzi mipfumbamwe uye zviitiko zvekiriniki pamwedzi gumi nemiviri.38 Pakupedzisira, stent yeXience yakaratidza zvakanakira kupfuura BMS muchiitiko cheST-segment elevation myocardial infarction (MI).39
MaEPC iboka remasero anotenderera anobatanidzwa mukugadzirisa tsinga dzeropa uye kugadzirisa endothelial. Kuvandudzwa kweEPCs panzvimbo yekukuvara kwetsinga kuchakurudzira kugadziriswa kwetsinga dzeropa nekukurumidza, zvichigona kuderedza njodzi yekutanga yekuedza kweST.EPC biology mukugadzira stent ndeyeCD34 antibody-coated Genous stent, inokwanisa kusunga maEPC anotenderera kuburikidza nezviratidzo zvayo zveropa kuti iwedzere kugadziriswa kwetsinga dzeropa. Kunyangwe zvidzidzo zvekutanga zvaikurudzira, humbowo hwazvino hunoratidza huwandu hwakakwira hweTVR.40.
Tichifunga nezvemigumisiro inogona kukuvadza yekunonoka kupora kunokonzerwa nepolymer, iyo inobatanidzwa nenjodzi yeST, mapolymer anonyungudika mumuviri anopa mabhenefiti eDES, achidzivirira kunetseka kwenguva refu nezvekuramba aripo kwepolymer. Kusvika pari zvino, masisitimu akasiyana anonyungudika mumuviri akatenderwa (semuenzaniso Nobori neBiomatrix, biolimus eluting stent, Synergy, EES, Ultimaster, SES), asi mabhuku anotsigira mhedzisiro yavo yenguva refu akaganhurirwa.41
Zvinhu zvinonyungudika mumuviri zvine mukana wepfungwa wekutanga kupa rutsigiro rwemakanika kana elastic recoil ichifungwa uye kuderedza njodzi dzenguva refu dzine chekuita nesimbi dziripo. Matekinoroji matsva akatungamira mukugadzirwa kwepolymers dze lactic acid (poly-l-lactic acid [PLLA]), asi masisitimu mazhinji e stent ari kugadzirwa, kunyangwe kusarudza chiyero chakanaka pakati pe elution yemishonga uye degradation kinetics ichiri dambudziko. Kuedzwa kwe ABSORB kwakaratidza kuchengetedzeka uye kushanda kwe everolimus-eluting PLLA stents.43 Kugadziriswa kwe Absorb stent yechizvarwa chechipiri kwaive kuvandudza pane yapfuura nekutevera kwakanaka kwemakore maviri.44 Kuedzwa kwe ABSORB II kuri kuenderera mberi, kuyedzwa kwekutanga kwakasarudzika kuenzanisa Absorb stent ne Xience Prime stent, kunofanirwa kupa rumwe ruzivo, uye mhedzisiro yekutanga iripo inovimbisa.45 Zvisinei, nzvimbo yakakodzera, nzira yakanakisisa yekuisa, uye kuchengetedzeka kwezvirwere zvemoyo zvinofanirwa kujekeswa zviri nani.
Kuora kweropa muBMS neDES hakuna zvakunobatsira pakurapa. Mubhuku revarwere vanoiswa muDES, 47% yezvirwere zveST zvakakonzera rufu, 60% kubva kuMI isingauraye, uye 7% kubva kuangina isina kugadzikana. PCI muemergency ST inowanzo kuve isina kunaka, uye kudzoka kwayo mu12% yezvirwere.48
ST yepamusoro inogona kunge iine mhedzisiro yakaipa yekiriniki. Muchidzidzo cheBASKET-LATE, mwedzi 6 kusvika 18 mushure mekuiswa stent, mwero wekufa kwemwoyo uye MI isingauraye wakakwira muboka reDES pane muboka reBMS (4.9% uye 1.3%, zvichiteerana).20 Kuongororwa kwemeta-ongororo yemiedzo mipfumbamwe, umo varwere 5,261 vakaiswa muSES, PES, kana BMS zvisina kurongeka, kwakaratidza kuti mumakore mana ekutevera, SES (0.6% vs 0%, p=0.025) uye PES (0.7%) yakawedzera kuwanda kweST yanonoka zvikuru zvichienzaniswa neBMS ne0.2%, p=0.028).49 Kusiyana neizvi, mukuongorora kwemeta-ongororo kunosanganisira varwere 5,108, 21 kuwedzera kwe60% murufu kana MI kwakashumwa neSES zvichienzaniswa neBMS (p=0.03), nepo PES yakabatana nekuwedzera kwe15% kusingakoshi (Kutevera kwemwedzi 9 kusvika 3). makore).
Marejistri akawanda, miedzo yakasarudzika, uye meta-analyses zvakaongorora njodzi yeST mushure mekuisirwa BMS neDES uye zvakashuma mhedzisiro inopikisana. Mune rejistri yevarwere 6,906 vaigamuchira BMS kana DES, pakanga pasina mutsauko mumhedzisiro yekiriniki kana huwandu hweST panguva yekutevera kwegore rimwe.48 Mune imwe rejistri yevarwere 8,146, njodzi yeST yakawandisa yakawanikwa iri 0.6% pagore zvichienzaniswa neBMS.49 Kuongororwa kwakafanana kwemiedzo kuenzanisa SES kana PES neBMS kwakaratidza njodzi yakawedzera yekufa uye MI neDES yechizvarwa chekutanga zvichienzaniswa neBMS, 21 uye imwe meta-analysis yevarwere 4,545 yakasarudzika kuSES kana Pakanga pasina mutsauko mukuitika kweST pakati pePES neBMS mumakore mana ekutevera.50 Zvimwe zvidzidzo zvepasirese zvakaratidza njodzi yakawedzera yeST neMI yepamusoro muvarwere vanogamuchira DES yechizvarwa chekutanga mushure mekumira kushandisa DAPT.51
Zvichienderana neuchapupu hunopesana, ongororo dzakawanda dzakaunganidzwa pamwe chete dzakaratidza kuti DES neBMS zvechizvarwa chekutanga hazvina kusiyana zvakanyanya panjodzi yekufa kana MI, asi SES nePES dzaive nenjodzi yakawedzera yeST yakakwira zvakanyanya zvichienzaniswa neBMS. Kuti vaongorore humbowo huripo, US Food and Drug Administration (FDA) yakagadza boka renyanzvi53 iro rakaburitsa chirevo richibvuma kuti DES yechizvarwa chekutanga yaishanda pazviratidzo zviri pachiratidzo uye kuti njodzi yeST yakakwira zvakanyanya yaive diki asi diki. Kuwedzera kukuru. Nekuda kweizvozvo, FDA nesangano vanokurudzira kuwedzera nguva yeDAPT kusvika pagore rimwe, kunyangwe paine data shoma rekutsigira izvi.
Sezvambotaurwa, maDES echizvarwa chechipiri ane magadzirirwo epamusoro akagadzirwa. MaCoCr-EES akaongororwa zvakanyanya. Muongororo yakaitwa naBaber et al, 54 kusanganisira varwere 17,101, CoCr-EES yakaderedza zvakanyanya ST neMI chaiyo/ingangovepo zvichienzaniswa nePES, SES, neZES mushure memwedzi 21. Pakupedzisira, Palmerini et al vakaratidza muongororo yakaitwa nevarwere 16,775 kuti CoCr-EES yaive neST yakaderera zvakanyanya pakutanga, kunonoka, yegore rimwe chete nerechipiri yakatsanangurwa zvichienzaniswa nedzimwe DES dzakaunganidzwa.55 Zvidzidzo zvepasi rese zvakaratidza kudzikira kwenjodzi yeST neCoCr-EES zvichienzaniswa neDES yechizvarwa chekutanga.56
Re-ZES yakaenzaniswa neCoCr-EES muRESOLUTE-AC neTWENTE bvunzo.33,57 Pakanga pasina musiyano wakakosha mukuwanda kwekufa, myocardial infarction, kana ST chaiyo pakati pema stents maviri.
Mukuongorora kwenetwork meta-analysis yevarwere 50,844 kusanganisira maRCT 49, 58CoCr-EES yakabatana nekuwanda kweST chaiyo kupfuura BMS, mhedzisiro isina kuonekwa mune mamwe maDES; kudzikira kwacho hakuna kungoitika mukutanga kwechirwere uye pamazuva makumi matatu (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.11-0.42) uye zvakare mugore rimwe (OR 0.27, 95% CI 0.08-0.74) uye makore maviri (OR 0.35, 95% CI 0.17–0.69). Zvichienzaniswa nePES, SES, uye ZES, CoCr-EES yakabatana nekuwanda kweST mugore rimwe chete.
ST yekutanga ine chekuita nezvinhu zvakasiyana. Magadzirirwo eplaque ari pasi uye mutoro we thrombus zvinoita sekunge zvinokanganisa mhedzisiro mushure mePCI; 59 Kupinda kwakadzika kwe strut nekuda kwe necrotic core (NC) prolapse, kubvaruka kwe medial mu stent lengths, secondary dissection with residual margins, kana significant margin decrease. Optimal stenting, incomplete apposition, uye incomplete expansion60. Kurapa nemishonga ye antiplatelet hakukanganisi zvakanyanya kuitika kweST yekutanga: kuwanda kweST nekukurumidza uye subacute panguva yeDAPT mukuyedza kwakasarudzika kuenzanisa BMS neDES Rates kwaive kwakafanana (<1%).61 Saka, ST yekutanga inoita kunge yakabatana zvakanyanya nezvirwere zvekurapa uye zvinhu zvekuvhiya.
Nhasi, chinangwa chikuru chiri paST yekupedzisira/yanonoka. Kana zvinhu zvekurapa uye zvehunyanzvi zvichiita sezviri kutamba basa guru mukukura kweST inokurumidza uye subacute, mashandiro ezviitiko zvinononoka zvethrombotic anoita seakanyanya kuoma. Zvakataurwa kuti humwe hunhu hwemurwere hunogona kunge huri zvinhu zvine njodzi kune ST yakakwira uye yakakwira zvikuru: chirwere cheshuga, ACS panguva yekuvhiyiwa kwekutanga, kutadza kweitsvo, kukwegura, kuderedzwa kwechikamu chekubuda kweropa, zviitiko zvikuru zvemoyo zvisina kunaka mukati memazuva makumi matatu ekuvhiyiwa kwekutanga. Kune BMS neDES, zvinhu zvinochinja-chinja, zvakaita sehukuru hwemidziyo midiki, bifurcations, chirwere chepolyvascular, calcification, total occlusion, long stents, zvinoita sekunge zvine chekuita nenjodzi yeST.62,63 Kusakwana kwemhinduro yekurapa kweantiplatelet chinhu chikuru chine njodzi yeDES thrombosis yepamusoro 51. Mhinduro iyi inogona kunge iri nekuda kwekusatevedzera kwemurwere, kusashandisa mishonga zvakakwana, kusangana kwemishonga, zvimwe zvinhu zvinokanganisa mhinduro yemishonga, majini polymorphisms padanho rereceptor (kunyanya clopidogrel resistance), uye kuwedzera kwemamwe ma platelet activation pathways. In-stent neoatherosclerosis inoonekwa senzira yakakosha yekunonoka Kukundikana kwestent, kusanganisira ST64 yekupedzisira (chikamu "In-stent neoatherosclerosis"). Endothelium isina kusimba inoparadzanisa madziro emidziyo yeropa yakapwanyika uye stent struts kubva pakuyerera kweropa uye inoburitsa zvinhu zvinorwisa thrombosis uye vasodilatory.DES inoisa madziro emidziyo yeropa kune mishonga inorwisa proliferative uye nzvimbo inobvisa mishonga ine mhedzisiro yakasiyana pakuporesa uye kushanda kwe endothelial, nenjodzi ye thrombosis yekupedzisira.65 Zvidzidzo zvezvirwere zvinoratidza kuti mapolymers akasimba eDES yechizvarwa chekutanga anogona kukonzera kuzvimba kusingaperi, fibrin isingaperi, kuporesa kutadza kwe endothelial, uye njodzi yakawedzera ye thrombosis.3 Kunzwa kunonoka kweDES kunoita seimwe nzira inotungamira kuST.Virmani et al66 vakashuma zvakawanikwa mushure mekufa mushure meST zvichiratidza kuwedzera kwe aneurysm pachikamu che stent ne local hypersensitivity reactions inoumbwa neT lymphocytes uye eosinophils; Zvakawanikwa izvi zvinogona kuratidza simba rema polymers asingadzoreki.67 Kusashanda zvakanaka kwe stent kunogona kukonzerwa nekuwedzera kwe stent kusinganyatso shanda zvakanaka kana kuti kunoitika mwedzi mushure mePCI.Kunyangwe kusashanda zvakanaka kwe stent kuchikonzera njodzi ye ST yakaoma uye yakapfava, kukosha kwe stent inogona kuenderana nekuvandudzwa kwetsinga dzeropa kana kunonoka kupora kunokonzerwa nemishonga, asi kukosha kwayo kwekiriniki kunokakavadzana.68
Mhedzisiro yekudzivirira yeDES yechizvarwa chechipiri inogona kusanganisira kukurumidza uye kusachinja-chinja kwe endothelialization, pamwe nekusiyana kwe stent alloy uye chimiro, ukobvu hwe strut, hunhu hwe polymer, uye rudzi rwemushonga unodzivirira kukura kwemasero, dose, uye kinetics.
Zvichienzaniswa neCoCr-EES, zvidimbu zvitete zve cobalt-chromium stent (81 µm), fluoropolymers dzinorwisa thrombosis, polymer yakaderera, uye drug loading zvinogona kukonzera kudzikira kwehuwandu hweST. Zvidzidzo zvekuyedza zvakaratidza kuti thrombosis uye platelet deposition ye fluoropolymer-coated stents yakaderera zvakanyanya pane ye bare-metal stents.69 Kana mamwe maDES echizvarwa chechipiri aine hunhu hwakafanana hunofanirwa kuongororwa zvakanyanya.
Ma stenti emoyo anovandudza mwero wekubudirira kwekuvhiyiwa kwemoyo kana tichienzanisa ne percutaneous transluminal coronary angioplasty (PTCA), iyo ine matambudziko emagetsi (kuvharika kweropa, kupatsanurwa kweropa, nezvimwewo) uye mwero wepamusoro wekuzorora (kusvika 40%–50% yezviitiko). Pakupera kwema1990, inoda kusvika 70% yePCIs yakanga yaitwa neBMS implantation.70
Zvisinei, pasinei nekufambira mberi mune tekinoroji, matekiniki, uye kurapwa, njodzi yekusagadzikana mushure mekuisirwa BMS inenge 20%, ne>40% mumapoka madiki chaiwo.71 Zvose, zvidzidzo zvekiriniki zvakaratidza kuti kusagadzikana mushure mekuisirwa BMS, kwakafanana nekwakaonekwa nePTCA yakajairika, kunopera mushure memwedzi 3-6 uye kunopera mushure megore rimwe chete.72
DES inoderedzawo kuwanda kweISR,73 kunyangwe kudzikira uku kuchienderana ne angiography uye mamiriro ekiriniki. Kuputira kwepolymer paDES kunoburitsa mishonga inodzivirira kuzvimba uye inodzivirira kuwedzera kwemasero, kunodzivisa kuumbwa kwemasero matsva, uye kunononotsa kugadzirisa kwetsinga kwemwedzi kusvika kumakore.74 Kukura kwemasero matsva nguva dzose panguva yekutevera kwenguva refu mushure mekuisirwa kweDES, chiitiko chinozivikanwa se "kunonoka kubata-up", chakaonekwa muzvidzidzo zvekiriniki uye zvehistological.75
Kukuvara kwetsinga dzeropa panguva yePCI kunokonzera maitiro akaomarara ekuzvimba uye kugadziriswa munguva pfupi (mavhiki kusvika kumwedzi), zvichikonzera endothelialization uye neointimal coverage. Sekureva kwekuongorora kwehistopathological, neointimal hyperplasia (BMS neDES) mushure mekuisirwa stent yaive yakavakirwa zvakanyanya nemasero emhasuru akapfava muproteoglycan-rich extracellular matrix.70
Saka, neointimal hyperplasia inomiririra nzira yekugadzirisa inosanganisira kuonda uye zvinhu zvinozvimba pamwe chete nemasero anokonzera kuwanda kwemasero emhasuru akatsetseka uye kuumbwa kwematrix ekunze. Pakarepo mushure mePCI, maplatelet nefibrin zvinogara pamadziro etsinga uye zvinounganidza maleukocyte kuburikidza nemamorekuru akawanda anonamatira masero. Maleukocyte anotenderera anonamatira kumaplatelet anonamatira kuburikidza nekubatana pakati peleukocyte integrin Mac-1 (CD11b/CD18) neplatelet glycoprotein Ibα 53 kana fibrinogen yakabatana neplatelet glycoprotein IIb/IIIa.76,77
Zvichienderana neruzivo rwuri kubuda, masero ekuberekwa anobva mumapfupa anobatanidzwa mukupindura kwetsinga uye maitiro ekugadzirisa. Kuunganidzwa kweEPCs kubva mumapfupa emapfupa kuenda kuropa reperipheral kunokurudzira kugadziriswa kwe endothelial uye neovascularization mushure mekusununguka. Zvinoita sekuti masero ekuberekwa emapfupa emapfupa emapfupa (SMPC) anotamira kunzvimbo yekukuvara kwetsinga, zvichikonzera kuwanda kwemasero emapfupa.78 Kare, masero eCD34-positive aionekwa sehuwandu hwakaganhurirwa hweEPCs; zvimwe zvidzidzo zvakaratidza kuti CD34 surface antigen inoziva masero emapfupa emapfupa asina kusiyanisa ane kugona kusiyanisa kuita EPCs neSMPCs. Kuchinja kwemasero eCD34-positive kuenda kuEPC kana SMPC lineage kunoenderana nenzvimbo yemuno; mamiriro eischemic anokonzera kusiyana kune EPC phenotype kukurudzira re-endothelialization, nepo mamiriro ekuzvimba anokonzera kusiyana kune SMPC phenotype kukurudzira kuwanda kwemasero emapfupa.79
Chirwere cheshuga chinowedzera njodzi yeISR ne30%–50% mushure mekuisirwa BMS,80 uye kuwanda kwe restenosis muvarwere vane chirwere cheshuga zvichienzaniswa nevarwere vasina chirwere cheshuga kwakaramba kuripowo munguva yeDES. Nzira dziri pasi pekucherechedza uku dzinogona kunge dziri dzakawanda, dzinosanganisira systemic (semuenzaniso, kusiyana kwekuzvimba) uye anatomic (semuenzaniso, mitsipa midiki yeropa, maronda marefu, chirwere chinopararira, nezvimwewo) zvinhu zvinowedzera zvakazvimiririra Njodzi yeISR.70
Upamhi hwemudziyo nehurefu hwemaronda zvakakanganisa kuwanda kweISR, nedhayamita diki/maronda marefu zvichiwedzera zvakanyanya mwero we restenosis zvichienzaniswa nedhayamita yakakura/maronda mapfupi.71
Mapuratifomu estent echizvarwa chekutanga akaratidza ma stent struts akakora uye mwero weISR wakakwira zvichienzaniswa nemapuratifomu estent echizvarwa chechipiri ane ma struts akatetepa.
Pamusoro pezvo, kuwanda kwe restenosis kwakabatana nehurefu hwe stent, nehurefu hwe stent >35 mm hwakareba kaviri kupfuura uhwo huri pasi pe 20 mm. Urefu hwekupedzisira hwe stent hudiki hwakatambawo basa rakakosha: dhayamita diki yekupedzisira ye lumen yakaratidza kuwedzera kwakanyanya kwenjodzi ye restenosis.81,82
Pachivanhu, intimal hyperplasia mushure mekuisirwa BMS inoonekwa seyakagadzikana, ine nguva yekutanga pakati pemwedzi mitanhatu negore rimwe, ichiteverwa nenguva yekupedzisira yekunyarara. Kukura kweintimal kwakambotaurwa kare, kuchiteverwa ne intimal regression ne lumen enlargement makore akati wandei mushure mekuisirwa stent;71 kukura kwemasero emhasuru dzakatsetseka uye shanduko mu extracellular matrix zvakanzi inzira dzinogona kushandiswa pakunonoka kwekudzokera kumashure kwe neointimal.83 Zvisinei, zvidzidzo zvine kuteverwa kwenguva refu zvakaratidza mhinduro yetriphasic mushure mekuisirwa kweBMS, ne early restenosis, intermediate regression, uye late lumen restenosis.84
Munguva yeDES, kukura kwemwana mudiki kwakaratidzwa pakutanga mushure mekuisirwa kweSES kana PES mumhando dzemhuka.85 Zvidzidzo zvakati wandei zveIVUS zvakaratidza kudzikira kwekukura kwemwana mudiki zvichiteverwa nekunonoka kubata nekufamba kwenguva mushure mekuisirwa kweSES kana PES, pamwe nekuda kwekuzvimba kuri kuramba kuchiitika.86
Pasinei ne "kugadzikana" kwagara kuchinzi kunokonzerwa neISR, inenge chikamu chimwe muzvitatu chevarwere veBMS ISR vanowana ACS.4
Pane humbowo huri kuramba huchikura hwekuti kuzvimba kwenguva refu uye/kana kusakwana kwe endothelial kunokonzera kukura kwe neoatherosclerosis mukati meBMS neDES (kunyanya DES yechizvarwa chekutanga), iyo ingave nzira yakakosha yeISR yepamusoro kana ST. Inoue et al. 87 vakataura zvakawanikwa kubva kumasampuli ekuongorora muviri mushure mekuiswa kwePalmaz-Schatz coronary stents, zvichiratidza kuti kuzvimba kweperi-stent kunogona kukurumidzisa shanduko itsva dze atherosclerotic mukati me stent. Zvimwe zvidzidzo10 zvakaratidza kuti restenotic tissue mukati meBMS, mumakore mashanu apfuura, ine atherosclerosis itsva, ine kana isina kuzvimba kweperi-stent; Mienzaniso kubva kuACS cases inoratidza maplaque akajairika mutsinga dzemoyo dzemoyo. Histological morphology ye block ine foamy macrophages uye cholesterol crystals. Pamusoro pezvo, pakuenzanisa BMS neDES, musiyano mukuru panguva yekukura kwe atherosclerosis itsva wakaonekwa.11,12 Shanduko dzekutanga dze atherosclerotic mu foamy macrophage infiltration dzakatanga mwedzi mina mushure mekuisirwa kweSES, nepo shanduko dzakafanana mumaronda eBMS dzakaitika makore maviri gare gare uye dzakaramba dziri kuwanikwa zvisingawanzoitiki kusvika makore mana. Uyezve, DES stenting yemaronda asina kugadzikana akadai se thin-cap fibroatherosclerosis (TCFA) kana intimal rupture ine nguva pfupi yekukura zvichienzaniswa neBMS. Saka, neoatherosclerosis inoita seinowanzoonekwa uye inoitika kare muDES yechizvarwa chekutanga pane muBMS, pamwe nekuda kwe pathogenesis yakasiyana.
Kukanganiswa kweDES kana DES yechizvarwa chechipiri mukukura kuchiri kuda kudzidzwa; kunyangwe zvimwe zvakaonekwa paDES yechizvarwa chechipiri zvichiratidza kuti kuzvimba kwakaderera, kuwanda kwechirwere che neoatherosclerosis kwakafanana nekwechizvarwa chekutanga, asi kumwe kutsvagurudza kuchiri kudiwa.