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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: Mishonga yeStents yakaputirwa (DES) inoderedza zvipingamupinyi zvekushandisa bare metal stents (BMS) mushure mekupindira kwemoyo kwepaganda. Zvisinei, kunyangwe kuunzwa kweDES yechizvarwa chechipiri kuchiita sekunge kwakaderedza chiitiko ichi zvichienzaniswa neDES yechizvarwa chekutanga, kunetseka kukuru kuchiripo nezvematambudziko angangoitika ekuiswa kwestent akadai sestent thrombosis (ST) uye stent resection, stenosis (SSI). ST chiitiko chinogona kunge chiri njodzi chakaderedzwa zvakanyanya nekushandiswa kwestent, magadzirirwo matsva estent, uye kurapwa kwedouble antiplatelet. Nzira chaiyo inotsanangura kuitika kwayo iri kuferefetwa, uye zvechokwadi zvinhu zvinoverengeka ndizvo zvinokonzera. ISR muBMS yaimboonekwa seyakagadzikana ine huwandu hwepamusoro hwe intimal hyperplasia (pamwedzi mitanhatu) ichiteverwa nenguva yekudzokera shure kweanopfuura gore rimwe. Kusiyana neizvi, zvidzidzo zvekiriniki uye zvehistological zveDES zvakaratidza humbowo hwekukura kwevana vadiki kwenguva refu yekutevera, chiitiko chinozivikanwa se "late catch-up phenomenon". Pfungwa yekuti ISR ​​chirwere chekiriniki chisina njodzi yakarambwa munguva pfupi yapfuura nehumbowo hwekuti varwere vane ISR vanogona kuva neacute coronary syndromes. Intracoronary imaging inzira inorwisa kuona stented atherosclerotic plaques uye zviratidzo zvekupora kwetsinga mushure mekupiswa, uye inowanzoshandiswa kupedzisa kuongororwa kwe coronary angiography uye kuita maitiro ekupindira. Intracoronary optical coherence tomography parizvino inoonekwa senzira yepamusoro yekufungidzira. Izvi zvinoita kuti, zvichienzaniswa neultrasound yemukati metsinga, zvive nani (zvinenge ka10), zvichibvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro etsinga. Izvi zvinoita kuti, zvichienzaniswa neultrasound yemukati metsinga, zvive nani (zvinenge ka10), zvichibvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro etsinga. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, >10 раз), что позволяет деавальшение структуру стенки сосуда. Zvinopa, zvichienzaniswa ne ultrasound yemukati metsinga, resolution iri nani (kanenge ka10), izvo zvinobvumira kutsanangurwa kwakadzama kwechimiro chepamusoro chemadziro etsinga.与血管内超声相比，它提供了更好的分辨率（至面少> 10 倍），允许论细表征征血的时候。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。Kana tichienzanisa ne ultrasound yemukati metsinga, inopa mhinduro iri nani (kanenge kagumi), izvo zvinoita kuti pave nekutsanangurwa kwakadzama kwechimiro chemadziro etsinga.Zvidzidzo zvekufungidzira zviri muuropi zvinoenderana nezvakawanikwa mukuongorora kwehistology zvinoratidza kuti kuzvimba kwenguva refu uye/kana kusashanda zvakanaka kwe endothelial kunogona kukonzera kukura kwechirwere che neoatherosclerosis muHMS neDES. Saka, chirwere che neoatherosclerosis chave chinhu chinonyanya kufungidzirwa mukukura kwe stent failure. Mashoko akakosha: coronary stent, stent thrombosis, restenosis, neoatherosclerosis.
Kupindira kweropa nemutsipa (PCI) kunoshandiswa zvakanyanya pakurapa chirwere chemwoyo chinoratidza zviratidzo, uye nzira iyi inoramba ichichinja. 1 Kunyangwe mishonga inobvisa ma stents (DES) ichideredza miganhu ye stents dzisina kuvharwa (UES), matambudziko ekunonoka akadai se stent thrombosis (ST) uye stent restenosis (ISR) anogona kuitika kana stent ikaiswa, uye kunetseka kwakanyanya kuchiripo. 2-5
Kana ST iri chiitiko chinogona kukonzera njodzi huru, kugamuchirwa kwekuti ISR ​​chirwere chisina njodzi kwakapikiswa munguva pfupi yapfuura nehumbowo hwechirwere chemwoyo (ACS) muvarwere vane ISR.
Nhasi uno, intracoronary optical coherence tomography (OCT)6-9 inoonekwa senzira yemazuva ano yekufungidzira inopa mhinduro iri nani pane intravascular ultrasound (IVUS). Zvidzidzo zvekufungidzira zviri mumuviri zvinoenderana nezvakawanikwa mu histological zvinoratidza nzira itsva ye "vascular response" mushure mekuiswa kwe stent ne de novo "neoatherosclerosis" mukati meBMS neDES.
Muna 1964 Charles Theodore Dotter naMelvin P. Judkins vakatsanangura angioplasty yekutanga. Muna 1978, Andreas Grunzig akaita angioplasty yekutanga yebharuni (angioplasty yekare yebharuni); yaive nzira yekurapa yakachinja-chinja, asi yaivewo nedambudziko rekuvharwa kwetsinga dzeropa zvakanyanya uye restenosis. 13 Izvi zvakaita kuti pawanikwe ma coronary stents: Puel naSigwart vakaisa stent yekutanga yecoronary muna 1986, vachipa stent yekudzivirira kuvharwa kwetsinga dzeropa zvakanyanya uye kudzoserwa kwesystolic kunonoka. 14 Kunyangwe ma stents aya ekutanga akadzivirira kuvharwa kamwe kamwe kwetsinga, akakonzera kukuvara kwakanyanya kwe endothelial uye kuzvimba. Munguva pfupi yapfuura, zvidzidzo zviviri zvakakosha, Belgian-Dutch Stent Study 15 uye Stent Restenosis Study 16, zvakatsigira kuchengetedzeka kwe dual antiplatelet therapy (DAPT) stenting uye/kana nzira dzakakodzera dzekuisa. 17,18 Mushure memiedzo iyi, huwandu hwePCI dzakaitwa hwakawedzera zvakanyanya.
Zvisinei, dambudziko re iatrogenic in-stent neointima hyperplasia mushure mekuiswa kweBMS rakakurumidza kuonekwa, zvikaita kuti ISR ​​ive ne20-30% yemaronda airapwa. DES19 yakaunzwa muna 2001 kuderedza kudiwa kwekuzorora uye kuvhiyiwazve. DES yakawedzera chivimbo chevanachiremba vemwoyo nekubvumira kurapwa kwehuwandu huri kuwedzera hwemaronda akaomarara aimboonekwa seanogona kurapwa ne coronary artery bypass grafting. Muna 2005, 80-90% yePCI dzese dzakaperekedzwa neDES.
Zvese zvine zvazvakaipira, uye kubvira muna 2005 kunetseka nezvekuchengetedzeka kweDES "yechizvarwa chekutanga" kwakawedzera, ma stenti matsva echizvarwa akadai se20,21 akagadzirwa uye akaunzwa. 22 Kubva ipapo, kuedza kuvandudza mashandiro ema stenti kwakawedzera nekukurumidza, uye matekinoroji matsva anonakidza akaramba achiwanikwa uye achikurumidza kuunzwa kumusika.
BMS ichubhu ine waya yakanaka. Mushure mekushandisa Wall mount, Gianturco-Roubin mount uye Palmaz-Schatz mount kekutanga, maBMS akasiyana-siyana ava kuwanikwa.
Magadzirirwo matatu akasiyana anowanikwa: serpentine, tubular mesh uye slotted tube. Magadzirirwo e coil anosanganisira waya dzesimbi kana zvidimbu zvinoumba chimiro che coil chakatenderera; mumagadzirirwo e tubular mesh, waya yakakomberedzwa pamwe chete kuita mesh inoumba chubhu; magadzirirwo e slotted anosanganisira machubhu esimbi anochekwa ne laser. Midziyo iyi inosiyana mukugadzirwa kwayo (stainless steel, nichrome, cobalt chrome), magadzirirwo (akasiyana-siyana spacer maumbirwo nehupamhi, dhayamita nehurefu, radial strength, radiopacity), uye ma delivery systems (anozvikudza ega kana kuti anowedzerwa nebharumu).
Kazhinji, BMS itsva ine cobalt-chromium alloy, zvichiita kuti tambo dzakatetepa dziite zvidimbu, kutyaira kuri nani uye simba remuchina rirambe riripo.
Zvine puratifomu yesimbi ine stent (kazhinji simbi isina ngura) uye zvakaputirwa nepolymer inoburitsa mishonga inodzivirira kukura kwemasero uye/kana yekudzivirira kuzvimba.
Sirolimus (inozivikanwawo se rapamycin) yakatanga kugadzirwa semushonga wefungus. Maitiro ayo ekushanda anobatanidzwa nekuvharira kufambira mberi kwemasero nekuvharira kuchinja kubva pachikamu cheG1 kuenda kuchikamu cheS uye kudzivirira kuumbwa kweneontima. Muna 2001, ruzivo rwe "munhu wekutanga" neSES rwakaratidza mhedzisiro inovimbisa, zvichitungamira mukuvandudzwa kweCypher stent. 23 Miedzo mikuru yakaratidza kushanda kwayo mukudzivirira IR. 24
Paclitaxel pakutanga yakatenderwa kurapa kenza yemuchibereko, asi simba rayo guru re cytostatic - mushonga uyu unodzikamisa microtubules panguva ye mitosis, unokonzeresa kumisa kwemasero, uye unodzivisa kuumbwa kwemasero matsva - zvinoita kuti ive mushonga weTaxus Express PES. Miedzo yeTAXUS V neVI yakaratidza kushanda kwenguva refu kwePES muzvirwere zvemwoyo zvine njodzi huru. 25,26 TAXUS Liberté yakatevera yaive nepuratifomu yesimbi isina ngura kuti zvive nyore kutakura.
Uchapupu hwakasimba kubva muongororo mbiri dzakarongwa uye meta-analyses hunoratidza kuti SES ine mukana pamusoro pePES nekuda kwekudzikira kwehuwandu hweIVR uye target vessel revascularization (TVA), pamwe nekuwedzera kwe acute myocardial infarction (AMI) muboka rePES. 27.28
Midziyo yechizvarwa chechipiri ine ukobvu hwakaderera hwemugodhi, kuchinjika/kuburitswa kwacho kwakawedzera, mapurofayiri epolymer biocompatibility/drug clearance ari nani, uye kinetics yepamusoro ye reendothelialization. Parizvino, aya ndiwo madhizaini eDES epamusoro-soro uye ma coronary stents makuru akaiswa pasi rese.
Taxus Elements inoenderera mberi neiyi nhanho imwe nepolymer yakasarudzika yakagadzirirwa kuburitswa nekukurumidza uye sisitimu itsva yeplatinum-chromium spacer inopa ma spacer akatetepa uye kuwedzera kwe radiopacity. Chidzidzo chePERSEUS 29 chakaratidza mhedzisiro yakafanana pakati peElement neTaxus Express kwemwedzi inosvika gumi nemiviri. Zvisinei, hapana miedzo yakakwana yekuenzanisa zvinhu zveyew nezvimwe zvechizvarwa chechipiri zveDESS.
Endeavor Zotarolimus Coated Stent (ZES) yakavakirwa papuratifomu yakasimba ye cobalt-chromium stent ine kuchinjika kwakanyanya uye stent strut diki. Zotarolimus imhando ye sirolimus ine mhedzisiro yakafanana yekudzvinyirira immune system, asi ine lipophilicity yakawedzera yekuvandudza nzvimbo mumadziro etsinga. ZES inoshandisa phosphorylcholine polymer coating itsva yakagadzirirwa kuwedzera biocompatibility uye kuderedza kuzvimba. Mishonga mizhinji inogezwa muchikamu chekutanga chekukuvara, ichiteverwa nekugadzirisa arterial. Mushure mekuyedzwa kwekutanga kwe ENDEAVOR, kuyedzwa kwakatevera kwe ENDEAVOR III kwakaenzanisa ZES ne SES, iyo yakaratidza kurasikirwa kwakanyanya kwe lumen uye HR asi zviitiko zvishoma zvakakomba zvemwoyo (MACEs) pane SES. 30 Chidzidzo che ENDEAVOR IV chakaenzanisa ZES ne PES zvakare chakawana kuwanda kweSIS asi kuwanda kweMI, zvichida nekuda kweST yakajairika muboka re ZES. 31 Zvisinei, chidzidzo che PROTECT chakakundikana kuratidza mutsauko mukuwanda kweST pakati pe Endeavor ne Cypher stents. 32
Endeavor Resolute ishanduro yakagadziridzwa yeEndeavor stent ine polymer itsva ine layer nhatu. Resolute Integrity itsva (dzimwe nguva inonzi third generation DES) yakavakirwa papuratifomu itsva ine kugona kukuru kwekutumira (puratifomu yeIntegrity BMS) uye polymer itsva, inoenderana nemuviri ine layer nhatu inogona kudzvinyirira mhinduro yekutanga yekuzvimba uye kubvisa mushonga wakawanda mumazuva makumi matanhatu anotevera. Kuedzwa kwakaenzanisa Resolute neXience V (everolimus eluting stent [EES]) kwakaratidza kuti Resolute system yaishanda zvakaenzana maererano nekufa uye kutadza kwegomarara. 33.34
Everolimus, inogadzirwa ne sirolimus, inodzivirirawo masero emushonga wemasero anoshandiswa mukugadzira EES Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform). Kuedzwa kweSPIRIT 35-37 kwakaratidza mhedzisiro iri nani uye kwakaderedza MACE neXience V zvichienzaniswa nePES, nepo kuyedzwa kweEXCELLENT kwakaratidza kuti EES yaive yakanaka seSES mukudzora kurasikirwa kunonoka pamwedzi mipfumbamwe uye zviitiko zvekiriniki pamwedzi gumi nemiviri. 38 Pakupedzisira, stent yeXience yakaratidzwa kuva iri nani pane BMS mumamiriro ezvinhu eST elevation myocardial infarction (MI). 39
MaEPC iboka remasero anotenderera anobatanidzwa mukugadzirisa tsinga dzeropa uye kugadziriswa kwe endothelial. Kuwedzera kweEPC panzvimbo yekukuvara kwetsinga kuchaita kuti tsinga dzidzokezve nekukurumidza, zvichigona kuderedza njodzi yeST. Kupinda kwekutanga kweEPC Biology mukugadzirwa kwestent iGenous stent, yakaputirwa nema antibodies e-anti-CD34, inokwanisa kusunga maEPC anotenderera kuburikidza nema markers ayo eropa kuti iwedzere tsinga dzidzokezve. Kunyange hazvo zvidzidzo zvekutanga zvave zvichikurudzira, humbowo hwazvino hunoratidza kuti huwandu hweTVR hwakakwira. 40
Zvichienderana nemigumisiro inogona kukuvadza yekunonoka kupora kunokonzerwa nepolymer iyo inobatanidzwa nenjodzi yeST, mapolymer anosurbable anopa mabhenefiti eDES nekudzivisa kunetseka kwenguva refu nezvekugara kwenguva refu kwepolymer. Kusvika pari zvino, masisitimu akasiyana-siyana anosurbable akagamuchirwa (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 wekupa rutsigiro rwemakanika pakutanga kana elastic recoil ikatariswa uye kuderedza njodzi dzenguva refu dzine chekuita nesimbi dziripo. Matekinoroji matsva akatungamira mukugadzirwa kwelactic acid polymers (poly-l-lactic acid [PLLA]), asi masisitimu mazhinji estent ari kugadzirwa, kunyangwe kuwana chiyero chakanaka pakati pekugadzirisa zvinodhaka uye kinetics yekuora kwemasero kuchiri dambudziko. Chidzidzo cheABSORB chakaratidza kuchengetedzeka uye kushanda kwe everolimus-coated PLLA stents. 43 Kugadziriswa kwechizvarwa chechipiri cheAbsorb stent kwaive nani pane kwakapfuura nekutevera kwakanaka kwemakore maviri. 44 Chidzidzo cheABSORB II chazvino, kuyedzwa kwekutanga kwakasarudzika kuenzanisa Absorb stent neXience Prime stent, kunofanirwa kupa rumwe ruzivo, uye mhedzisiro yekutanga iripo inovimbisa. 45 Zvisinei, mamiriro akakodzera, nzira yakanakisisa yekuisa, uye chimiro chekuchengetedza muchirwere checoronary artery zvinofanirwa kujekeswa.
Kuora kweropa muBMS neDES kune migumisiro yakaipa yekiriniki. Mubhuku revarwere vakaisirwa DES, 47% yezvirwere zveST zvakakonzera rufu, 60% muMI isingauraye, uye 7% muangina isina kugadzikana. PCI yekukurumidza ST inowanzo kuve isina kunaka, uye kudzokazve mu12% yezvirwere. 48
ST yakawedzerwa inogona kunge ine migumisiro yakaipa yekiriniki. Muchidzidzo cheBASKET-LATE, mwedzi 6-18 mushure mekuiswa stent, mwero wekufa kwemwoyo uye MI isingauraye wakakwira muboka reDES pane muboka reSMP (4.9% uye 1.3%, zvichiteerana). 20 Kuongororwa kwakaitwa patsva kwezvidzidzo zvipfumbamwe umo varwere 5261 vakaiswa muSES, PES, kana BMS zvakaratidza kuti mushure memakore mana ekutevera, SES (0.6% zvichienzaniswa ne0%, p = 0.025) uye PES (0.7%) zvakawedzera kuwanda kweST yanonoka zvichienzaniswa neBMS ne0.2%, p = 0.028). 49 Kusiyana neizvi, mukuongorora kwakadzama kunosanganisira varwere 5108, 21 kuwedzera kwe60% mukufa kana MI kwakashumwa neSES zvichienzaniswa neBMS (p = 0.03), nepo PES yakabatana nekuwedzera kusingakoshi kwe15% (ona - kusvika kumwedzi 9 kusvika kumakore matatu).
Marejistri akawanda, miedzo yakasarudzika, uye meta-analyses zvakaongorora njodzi yeST mushure mekuisirwa BMS neDES uye zvakashuma mhedzisiro inopikisana. Mune rejistri yevarwere 6906 vakarapwa neBMS kana DES, pakanga pasina mutsauko mumhedzisiro yekiriniki kana huwandu hweST mugore rimwe rekutevera. 48 Mune imwe rejistri yevarwere 8146, njodzi yeST yakawandisa yakawanikwa iri 0.6% pagore zvichienzaniswa neBMS. 49 Kuongorora kwakafanana kwezvidzidzo zvakaenzanisa SES kana PES neSMPs kwakaratidza njodzi yakawedzera yekufa uye MI neDES yechizvarwa chekutanga zvichienzaniswa neSMPs, 21 uye kumwe kuongorora kwakafanana kwevarwere 4545 vakasarudzirwa kuSES kana ST pakati pePES neBMS mumakore mana ekutevera. 50 Zvimwe zvidzidzo zvechokwadi zvakaratidza njodzi yakawedzera yeST neMI inofambira mberi muvarwere vakarapwa neDES yechizvarwa chekutanga mushure mekumira kushandisa DAPT. 51
Zvichienderana nedata rinopesana, ongororo dzakawanda dzakaunganidzwa pamwe chete dzakaratidza kuti DES neSGM yechizvarwa chekutanga hazvina kusiyana zvakanyanya panjodzi yekufa kana MI, asi SES nePES dzaive nenjodzi yakawedzera yeST yakajairika zvichienzaniswa neSGM. Kuti vaongorore humbowo huripo, US Food and Drug Administration (FDA) yakagadza panel yenyanzvi53 yakaburitsa chirevo ichiziva kuti DES yechizvarwa chekutanga inoshanda sezvakanyorwa uye kuti njodzi yeST yedanho repamusoro idiki, asi kwete hombe. , Kuwedzera kukuru. Nekuda kweizvozvo, FDA nesangano vanokurudzira kuwedzera nguva yeDAPT kusvika pagore rimwe, kunyangwe paine humbowo hushoma hwekutsigira izvi.
Sezvambotaurwa, chizvarwa chechipiri cheDES chakagadzirwa nemaitiro akavandudzwa. CoCr-EES yakaongororwa zvakanyanya nevarwere 17,101. Muongororo yakaitwa naBaber et al.54 pavarwere 17,101, CoCr-EES yakaderedza zvakanyanya ST neMI chaiyo/ingangovepo zvichienzaniswa nePES, SES, neZES pamwedzi 21. Pakupedzisira, Palmerini et al vakaratidza muongororo yakaitwa nevarwere 16,775 kuti CoCr-EES ine ST yakaderera zvikuru pakutanga, kunonoka, yegore 1 ne2 yakatsanangurwa zvichienzaniswa nedzimwe DES dzakaunganidzwa. 55 Zvidzidzo zvechokwadi zvakaratidza kudzikira kwenjodzi yekubatwa neST neCoCr-EES zvichienzaniswa neDES yechizvarwa chekutanga. 56
Re-ZES yakaenzaniswa neCoCr-EES muzvidzidzo zveRESOLUTE-AC neTWENTE. 33,57 Pakanga pasina musiyano wakakosha mukufa, myocardial infarction, kana ST segment yakatsanangurwa pakati pema stents maviri.
Mukuongorora kwenetwork meta-analysis yevarwere 50,844, kusanganisira maRCT 49, 58 CoCr-EES yakabatana nekuwandisa kweST yakatsanangurwa kupfuura BMS, kuwanikwa kusina kuonekwa kune mamwe maDES; kudzikira kwacho kwaisangova "pakutanga zvakanyanya" uye mushure memazuva 30 (58). Odds ratio [OR] 0.21, 95% confidence interval [CI] 0.11-0.42) uye mugore rimwe chete (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 neST rate yakaderera mugore rimwe chete.
ST yekutanga inobatanidzwa nezvinhu zvakasiyana-siyana. Maitiro eplaque ari pasi uye mutoro we thrombus zvinoita sekunge zvinokanganisa mhedzisiro mushure mePCI; 59 kupinda kwe struts dzakadzika ne necrotic core (NC) prolapse, kubvaruka kwenguva refu mukati me stent, suboptimal stenting ine residual edge dissections kana significant edge stenosis, incomplete apposition, uye incomplete completion ye implanted stent zvinogona kuwedzera njodzi ye ST.60 Kurapa kwemishonga ye antiplatelet hakukanganisi zvakanyanya kuwanda kwe ST yekutanga: mukuyedza kwakasarudzika kuenzanisa BMSs ne DESs, mwero we ST acute ne subacute panguva ye DAPT waive wakafanana (<1%).61 Saka, ST yekutanga inoita kunge yakabatana zvakanyanya nemaronda ari pasi pekurapwa uye kune zvinhu zvinoitwa. Maitiro eplaque ari pasi uye mutoro we thrombus zvinoita sekunge zvinokanganisa mhedzisiro mushure mePCI; 59 kupinda kwe struts dzakadzika ne necrotic core (NC) prolapse, kubvaruka kwenguva refu mukati me stent, suboptimal stenting ine residual edge dissections kana significant edge stenosis, incomplete apposition, uye incomplete completion ye implanted stent zvinogona kuwedzera njodzi ye ST.60 Kurapa kwemishonga ye antiplatelet hakukanganisi zvakanyanya kuwanda kwe ST yekutanga: mukuyedza kwakasarudzika kuenzanisa BMSs ne DESs, mwero we ST acute ne subacute panguva ye DAPT waive wakafanana (<1%) .61 Saka, ST yekutanga inoita kunge yakabatana zvakanyanya nemaronda ari pasi pekurapwa uye kune zvinhu zvinoitwa. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВ;59 более глубокая пенетрация враспас некротического ядра (NC), длинного медиального разрыва внутри стента, субоптимального стентирования с остаточными краевыми расслоеничиямильного стентирования стенозом, неполной аппозицией и неполным расширением имплантированного стента может увеличить риск ST.60 Терапевтический режим антитромбетрацитарный песни антитромбетрацитарный существенного влияния на частоту раннего ST: в рандомизированном исследовании, сравнивающем BMS and DES, частота острого и подострого Господой от дом на правда на дом на друг. .61 Таким образом, ранняя ST, по-видимом, в первую очередь связана лежащими в основе пролеченными поражениями и процедурными факторами. Maitiro epasi peplaque uye thrombosis zvinoita sekunge zvinokanganisa mhedzisiro mushure mePCI;59 kupinda kwe strut yakadzika nekuda kwe necrotic nucleus (NC) prolapse, kubvaruka kwenguva refu mukati me stent, suboptimal stent ine residual marginal delaminations kana significant marginal stenosis, incomplete apposition uye incomplete expansion ye implanted stent zvinogona kuwedzera njodzi ye ST.60 Kurapa kwemishonga ye antiplatelet hakukanganisi zvakanyanya kuwanda kwe ST yekutanga: mukuyedza kwakasarudzika kuenzanisa BMS ne DES, kuwanda kwe ST yakasimba uye subacute panguva ye DAPT kwaive kwakafanana (<1%) .61 Saka, ST yekutanga inoita kunge yakabatana zvakanyanya nemaronda ari pasi pekurapwa uye zvinhu zvinoitwa.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的随机诚期间急性和亚急性ST 的发生率相似（<1%） .61 因此，早期ST 似乎主要与潜在的治疗旅因潜在 斑块 形态 和血栓 似乎 影响 影响 pci 后 结果 ; ; ; ; ; ; ;脱垂 导致的 支柱 穿透 , 内长 的 内侧 , 具有 残余 边缘 或 显着 边缘 次 次 次 的 的 的 的 ,            小板 药物的 治疗 方案 不 显着 影响 影响 早期的 ： 在 项 比较 比较 bms 与 中 洁 早期的 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 发生 发生 发生率相似（<1%） .61 .Maitiro eplaque ari pasi uye thrombosis zvinoita sekunge zvine chekuita nemigumisiro mushure mePCI; 59 Kupinda kwakadzika kwe strut nekuda kwe necrotic nucleus (NC) prolapse, kuputika kwepakati mu stent length, secondary dissection ne residual margins, kana significant margin decrease. Optimal stenting, incomplete apposition, uye incomplete expansion60. Antiplatelet regimen haina mhedzisiro yakakura pakuvandudzika kwekutanga kweST: kuwanda kwe acute uye subacute ST panguva yeDAPT mukuyedza kwakasarudzika kuenzanisa BMS neDES. zvinonyanya kuenderana nekuvandudzika kwekurapa uye zvinhu zvekuvhiya.
Nhasi uno, chinangwa chiri paST yekupedzisira/yanonoka. Kunyange zvazvo zvinhu zvemaitiro nehunyanzvi zvichiita sezviri kuita 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 yeST inofambira mberi uye yakakwira zvikuru: chirwere cheshuga, ACS panguva yekuvhiyiwa kwekutanga, kutadza kweitsvo, kukwegura, kuderedzwa kwechikamu chekubuda kweropa, zviitiko zvikuru zvemwoyo mukati memazuva makumi matatu ekuvhiyiwa kwekutanga. Kune BMS neDES, zvinhu zvinochinja-chinja zvakaita sehukuru hwemidziyo midiki, bifurcations, chirwere chevascular yakawanda, calcification, complete occlusion, long stents zvinoita sezvine chekuita nenjodzi yeST inofambira mberi. 62,63 Kusapindura zvakanaka kukurapa kweantiplatelet chinhu chikuru chine njodzi yeDES thrombosis inofambira mberi 51. Mhinduro iyi inogona kunge iri nekuda kwekusatevedzera mitemo yemurwere, kusashandisa mishonga zvakakwana, kusangana nemishonga, zvimwe zvirwere zvinokanganisa mhinduro yemishonga, receptor-level genetic polymorphism (kunyanya clopidogrel resistance), uye kushanda kwemamwe maitiro ekuita kuti platelet ashande. Stent neoatherosclerosis inoonekwa senzira yakakosha yekukundikana kwestent kunonoka, kusanganisira ST64 yekupedzisira (chikamu "Stent Neoatherosclerosis"). Endothelium isina kusimba inoparadzanisa madziro emidziyo ine thrombo uye stent posts kubva muropa uye inoburitsa zvinhu zvinorwisa thrombosis uye vasodilatory. DES inoisa madziro emidziyo kumishonga inodzivirira kuwedzera kweropa uye nzvimbo yekuburitsa mishonga, ine mhedzisiro yakasiyana pakuporesa uye kushanda kwe endothelial, nenjodzi ye thrombosis kunonoka. 65 Zvidzidzo zvezvirwere zvakaratidza kuti ma polymers eDES echizvarwa chekutanga akasimba anogona kubatsira mukuzvimba kusingaperi, chronic fibrin deposition, kutadza kuporesa endothelial, uye nekudaro kuwedzera njodzi ye thrombosis. 3 Kunzwa kunonoka kweDES kunoita seimwe nzira inotungamira kuST. Virmani et al. [66] vakataura zvakawanikwa mushure mekufa mushure mekunge ST yaratidza kuwedzera kwe aneurysm muchikamu che stent ne local hypersensitivity reactions inosanganisira T-lymphocytes uye eosinophils; izvi zvinogona kuratidza pesvedzero yema polymers asingaparare. 67 Kusakwana kwestent kunogona kunge kuri nekuda kwekuwedzera kwestent kusinganyatso shanda zvakanaka kana kuti kunoitika mwedzi yakati wandei mushure mePCI. Kunyangwe kusakwana kweprocedural inyaya ine njodzi yeST yakaoma uye yakapfava, kukosha kwekiriniki kwekusakwana kwestent kunogona kutsamira pakugadzirisa arterial zvakanyanya kana kunonoka kupora kunokonzerwa nemishonga, asi kukosha kwayo mukiriniki kunokakavadzana. 68
Mhedzisiro yekudzivirira yeDES yechizvarwa chechipiri inogona kusanganisira kukurumidza uye kusakanganiswa 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, mascaffolds matete (81 µm) ecobalt-chromium stent, antithrombotic fluoropolymers, low polymer content, uye drug loading zvinogona kubatsira kudzikisa ST rates. Zvidzidzo zvekuyedza zvakaratidza kuti thrombosis uye platelet deposition yakaderera zvakanyanya mu fluoropolymer-coated stents pane mu uncoated stents. 69 Kana mamwe maDES echizvarwa chechipiri ane hunhu hwakafanana hunofanirwa kuongororwa zvakanyanya.
Ma stenti emoyo anovandudza kubudirira kwekuvhiyiwa kwemoyo zvichienzaniswa ne percutaneous transluminal coronary angioplasty (PTCA) yechinyakare, iyo ine matambudziko emakanika (kuvharika kweropa, kupatsanurwa kweropa, nezvimwewo) uye huwandu hwakawanda hwe restenosis (kusvika 40–50% yezviitiko). Pakupera kwema1990, inoda kusvika 70% yePCIs dzakaitwa neBGM 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為于献獻生牲生亲给亲獻亲给亲统给亲给亲给。 40%.然而，尽管技术、技术和药物治疗取得了进步，但BMSZvisinei, pasinei nekufambira mberi mune tekinoroji, matekiniki, uye kurapwa, njodzi yekusagadzikana mushure mekuisirwa BMS inenge 20%, nehuwandu hunopfuura 40% mune mamwe mapoka madiki. 71 Kazhinji, zvidzidzo zvekiriniki zvakaratidza kuti kusagadzikana mushure mekuisirwa BMS, kwakafanana nekwakaonekwa nePTCA yakajairika, kunopera pamwedzi 3-6 uye kunopera pagore. 72
DES inowedzera kuderedza mwero weISR,73 kunyange zvazvo kudzikira uku kuchitsamira paangiography uye pakiriniki. DES polymer coating inoburitsa mishonga inodzivirira kuzvimba uye inodzivirira kuwedzera kwemasero, inodzivisa kuumbwa kwemasero matsva, uye inononoka kugadzirisa tsinga dzeropa nemwedzi kana makore.74 Muzvidzidzo zvekiriniki uye zvehistological, kukura kwemasero matsva kwenguva refu kwakaonekwa kwenguva refu yekutevera mushure mekuisirwa kweDES, chiitiko chinozivikanwa se "late catch-up"75.
Kukuvara kwetsinga dzeropa panguva yePCI kunokonzera maitiro akaomarara ekuzvimba uye kugadziriswa kwenguva pfupi (mavhiki kusvika kumwedzi), zvichikonzera endothelialization uye kuvharwa kwemasero matsva. Zvinoenderana nekuongorora kwehistopathological, neointimal hyperplasia (HMS neDES) mushure mekuisirwa stent zvakanyanya kwaisanganisira masero emhasuru akapfava muproteoglycan-rich extracellular matrix. 70
Saka, neointimal hyperplasia inzira yekugadzirisa inosanganisira kuonda uye kuzvimba, pamwe chete nemasero anokonzera kuwanda kwemasero emhasuru akatsetseka uye kuumbwa kwematrix ekunze. Mushure mePCI, maplatelet nefibrin zvinoiswa pamadziro etsinga uye zvinokwezva maleukocyte kuburikidza nemamorekuru akawanda anonamatira masero. Maleukocyte anotenderera anonamatira kumaplatelet akabatanidzwa kuburikidza nekubatana pakati peleukocyte integrin Mac-1 (CD11b/CD18) uye platelet glycoprotein Ibα 53 kana fibrinogen inobatanidzwa neplatelet glycoprotein IIb/IIIa. 76.77
Zvichienderana nedata idzva, masero emapfupa anotungamira muropa anobatanidzwa mukuita kwetsinga dzeropa uye maitiro ekugadzirisa. Kufamba kweEPC kubva mumapfupa kuenda kuropa reperipheral kunokurudzira kugadzirwazve kwe endothelial uye neovascularization mushure mekusununguka. Zvinoita sekuti masero emapfupa emapfupa akapfava (SMPCs) anotamira kunzvimbo yekukuvara kwetsinga, zvichikonzera kuwanda kwemasero matsva. 78 Kare, masero eCD34-positive aionekwa sehuwandu hwakaganhurirwa hweEPCs, zvimwe zvidzidzo zvakaratidza kuti CD34 surface antigen inoziva masero emapfupa asina kupatsanurwa ane kugona kusiyanisa kuita EPCs nePBMCs. Kuchinja kwemasero eCD34-positive kuita EPC kana SMPC lineage kunoenderana nenzvimbo yemuno; mamiriro eischemic anokonzera kusiyana kune EPC phenotype, iyo inokurudzira reendothelialization, nepo mamiriro ekuzvimba anokonzera kusiyana kune SMPC phenotype, iyo inokurudzira kuwanda kwemasero matsva. 79
Chirwere cheshuga chinowedzera njodzi yeISR ne30–50% mushure mekuisirwa BMS, uye huwandu hwakanyanya hwe restenosis muvarwere vane chirwere cheshuga zvichienzaniswa nevarwere vasina chirwere cheshuga hwakaramba huripo munguva yeDES. Nzira dziripo pakucherechedza uku dzinogona kunge dziri dzakawanda, dzinosanganisira systemic (semuenzaniso, kusiyana kwekuzvimba) uye anatomic (semuenzaniso, mitsipa midiki, maronda marefu, chirwere chinopararira, nezvimwewo), izvo zvinowedzera njodzi yeISR. 70
Upamhi hwemudziyo nehurefu hwemaronda zvakakanganisa mwero weISR zvakazvimirira, neupamhi hudiki/maronda marefu zvakawedzera zvakanyanya mwero we restenosis zvichienzaniswa neupamhi hukuru/maronda mapfupi.
Mapuratifomu e stent echizvarwa chekutanga akaratidza stent struts dzakakora uye ISR dzakakwira zvichienzaniswa nemapuratifomu e stent echizvarwa chechipiri ane struts dzakatetepa.
Uyezve, kuwanda kwe restenosis kwakabatana nehurefu hwe stent, zvichiwedzera kaviri hurefu hwe stent >35 mm zvichienzaniswa neurefu huri pasi pe20 mm. Uyezve, kuwanda kwe restenosis kwakabatana nehurefu hwe stent, zvichiwedzera kaviri hurefu hwe stent >35 mm zvichienzaniswa neurefu huri pasi pe20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента >35 мм по сравнению с длиной стента <20 мм. Pamusoro pezvo, mwero we restenosis une chekuita nehurefu hwe stent, hunowedzera kaviri ne stent kureba >35 mm zvichienzaniswa ne stent kureba <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 стента: длина стента >35 мм почти в два раза больше, чем стента <20 мм. Pamusoro pezvo, kuwanda kwe restenosis kwaienderana nehurefu hwe stent: hurefu hwe stent >35 mm hwakapetwa kaviri kupfuura hwe stent <20 mm.Dhayamita yekupedzisira ye lumen ye stent yakaitawo basa rakakosha: dhayamita diki ye lumen yekupedzisira yakaratidza kuwedzera kwakanyanya kwenjodzi ye restenosis. 81.82
Pachivanhu, intimal hyperplasia mushure mekuisirwa BMS inoonekwa seyakagadzikana, nechikamu chekutanga chepakati pemwedzi mitanhatu negore rimwe ichiteverwa nenguva yekunonoka kurara. Chikamu chekutanga chekukura kweintimal chinoteverwa nekudzokera shure kweintimal nekukura kwelumen makore akati wandei mushure mekuisirwa stent chakambotaurwa; kukura kwemasero akatsetseka emhasuru uye shanduko mu extracellular matrix zvakakurudzirwa senzira dzinogona kushandiswa pakudzokera shure kwe neointima. 83 Zvisinei, zvidzidzo zvekutevera kwenguva refu zvakaratidza mhinduro yetriphasic mushure mekuisirwa kweBMS ne early restenosis, intermediate regression, uye late luminal restenosis. 84
Munguva yeDES, kukura kwemwana mudiki kwakaratidzwa pakutanga mushure mekuisirwa kweSES kana PES mumhuka. 85 Zvidzidzo zvakati wandei zveIVUS zvakaratidza kudzikira kwekukura kwemwana mudiki zvichiteverwa nekunonoka kubata nekufamba kwenguva mushure mekuisirwa kweSES kana RPE, pamwe nekuda kwekuzvimba kuri kuramba kuchiitika.86
Pasinei ne "kugadzikana" kwagara kuchinzi kunokonzerwa neISR, inenge chikamu chimwe muzvitatu chevarwere vane BMS ISR vanowana ACS.
Pane humbowo huri kuramba huchikura hwekuti kuzvimba kwenguva refu uye/kana kusakwana kwe endothelial kunokonzera progressive neoatherosclerosis muHCM neDES (kunyanya DES yechizvarwa chekutanga), iyo ingave nzira yakakosha yekukura kweprogressive IR kana progressive ST. Inoue et al [87] vakataura zvakawanikwa ne histological autopsy mushure mekuiswa kwe Palmaz-Schatz coronary stents, zvichiratidza kuti kuzvimba kwakakomberedza stent kunogona kukonzera shanduko itsva dzisina simba dze atherosclerotic mukati me stent. Zvimwe zvidzidzo10 zvakaratidza kuti restenotic tissue mukati memakore mashanu eCGM ine atherosclerosis ichangotanga ine kana isina peritoneal inflammation; mienzaniso kubva kuACS cases inoratidza plaques dzakajairika dziri munjodzi mu native coronary arteries Histological block morphology ine foamy macrophages uye cholesterol crystals. Pamusoro pezvo, pakuenzanisa BMS neDES, musiyano mukuru munguva yekukura kwe new atherosclerosis wakaonekwa. 11,12 Kuchinja kwekutanga kwe atherosclerotic mukupinda kwe furo macrophage kwakatanga mwedzi mina mushure mekuisirwa kweSES, nepo kuchinja kwakafanana mumaronda eCGM kwakaitika mushure memakore maviri uye kwakaramba kuri kuwanikwa kusingawanzoitiki kusvika makore mana. Pamusoro pezvo, DES stenting yemaronda asina kugadzikana akadai se thin tegmental fibroatherosclerosis (TCFA) kana intimal rupture kune nguva pfupi yekukura zvichienzaniswa neBMS. Saka, neoatherosclerosis inoita seinowanzoitika uye inoitika kare muDES yechizvarwa chekutanga pane muBMS, pamwe nekuda kwechirwere chakasiyana.
Kukanganiswa kweDES kana DES yechizvarwa chechipiri pakukura kuchiri kutarisirwa; kunyangwe zvimwe zvakaonekwa paDES yechizvarwa chechipiri zvichiratidza kuti kuzvimba kwakaderera, kuwanda kwechirwere che neoatherosclerosis kwakafanana kana tichienzanisa nechizvarwa chekutanga, asi zvimwe zvidzidzo zvichiri kudiwa.