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Marta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Lefapha la Cardiology, Sepetlele sa Motheo sa Poliambulanza, Brescia, 2 Lefapha la Cardiology, Univesithi ea K'hatholike ea Sacred Heart of Rome, Italy Abstract: Drug-Eluting metal stemize (BMS) ka mor'a ho kenella ha pelo ea percutaneous. Leha ho le joalo, le hoja ho kenyelletsoa ha moloko oa bobeli oa DES ho bonahala ho lekanyelitse ketsahalo ena ha e bapisoa le moloko oa pele oa DES, ho tšoenyeha ho tebileng ho ntse ho le teng mabapi le mathata a ka 'nang a e-ba teng ka mor'a nako ea ho kenngoa ha stent, joalo ka stent thrombosis (ST) le stent resection. Stenosis (ISR) .ST ke ketsahalo e ka 'nang ea e-ba kotsi e fokotsehileng haholo ka optimized stenting, novel stent designs, le dual antiplatelet therapy.Mokhoa o tobileng o hlalosang ho etsahala ha oona o ntse o hlahlojoa,' me ka sebele, mabaka a mangata a ikarabella.ISR ho BMS pele e ne e nkoa e le boemo bo tsitsitseng le tlhōrō ea pele ea nako ea 16 hyperplasia Ka lehlakoreng le leng, lithuto tsa bongaka le tsa histological tsa DESs li bontšitse bopaki ba khōlo e tsitsitseng ea neointimal nakong ea ho latela nako e telele, ketsahalo e tsejoang e le "late-catch-up" phenomenon. Maikutlo a hore ISR ke boemo bo botle ba kliniki bo sa tsoa qholotsoa ke bopaki ba hore bakuli ba ISR ba ka 'na ba hlahisa li-syndromes tse matla tsa coronary. li-plaque le likarolo tsa pholiso ea sekepe ka mor'a stent; hangata e sebelisoa ho tlatsa li-coronary angiography le ho khanna mekhoa ea ho kenella.Intracoronary optical coherence tomography hajoale e nkoa e le mokhoa o tsoetseng pele oa ho etsa litšoantšo.Ha ho bapisoa le intravascular ultrasound, e fana ka tharollo e molemonyana (bonyane> makhetlo a 10), e lumellang tlhaloso e qaqileng ea sebopeho sa bokaholimo ba lerako la sekepe. neo-atherosclerosis ea morao-rao ka har'a BMS le DES. Ka hona, neo-atherosclerosis e fetohile 'melaelloa ea ka sehloohong oa pathogenesis ea ho hlōleha ha stent ka morao.Mantsoe a bohlokoa: lefu la pelo, stent thrombosis, restenosis, neoatherosclerosis
Percutaneous coronary intervention (PCI) e nang le stent implantation ke mokhoa o sebelisoang ka ho fetisisa bakeng sa phekolo ea matšoao a lefu la methapo ea pelo, 'me mokhoa ona o ntse o tsoela pele ho fetoha.1 Le hoja lithethefatsi-eluting stents (DES) li fokotsa mefokolo ea bare-metal stents (BMSs), mathata a morao-rao a kang stent thrombosis (SRST) le stent thrombosis ho kenya stent. , ho ntse ho e-na le matšoenyeho a tebileng.2-5
Haeba ST e le ketsahalo e ka 'nang ea e-ba kotsi, ho lemoha hore ISR ke lefu le batlang le le kotsi e sa tsoa phephetsoa ke bopaki ba acute coronary syndrome (ACS) ho bakuli ba ISR.4.
Kajeno, intracoronary optical coherence tomography (OCT) 6-9 e nkoa e le mokhoa oa morao-rao oa ho nahana ka mokhoa oa morao-rao, o fanang ka tharollo e molemo ho feta intravascular ultrasound (IVUS)." Liphuputso tsa litšoantšo tsa "In vivo", 10-12 e lumellanang le liphuputso tsa histological, e bonts'a "mocha" o mocha oa karabo ea vascular MS ka mor'a ho kenngoa ka matla ka har'a "Bnevoa" le DES novos.
Ka 1964, Charles Theodore Dotter le Melvin P Judkins ba ile ba hlalosa angioplasty ea pele.Ka 1978, Andreas Gruntzig o ile a etsa balloon angioplasty ea pele (plain old balloon angioplasty); e ne e le phekolo ea phetoho empa e ne e e-na le mefokolo ea ho koaloa ha sekepe se matla le ho phomola.13 Sena se ile sa khanna ho sibolloa ha li-coronary stents: Puel le Sigwart ba ile ba sebelisa "coronary stent" ea pele ka 1986, ba fana ka stent ho thibela ho koaloa ha sekepe se matla le ho khutlela morao ha systolic. liteko tse peli tsa bohlokoa, Belgian-Dutch Stent Trial 15 le Stent Restenosis Study 16, li ile tsa buella tšireletseho ea stenting ka phekolo ea li-antiplatelet tse peli (DAPT) le / kapa mekhoa e nepahetseng ea ho tsamaisa.17,18 Ka mor'a liteko tsena, ho bile le keketseho e kholo ea palo ea li-PCI tse entsoeng.
Leha ho le joalo, bothata ba iatrogenic in-stent neointimal hyperplasia ka mor'a ho behoa ha BMS bo ile ba tsejoa ka potlako, e leng se ileng sa fella ka ISR ho 20% -30% ea maqeba a phekoloang. ho hlomathiseletsoa.Ka 2005, 80%–90% ea li-PCI kaofela li ne li tsamaea le DES.
Ntho e 'ngoe le e' ngoe e na le mefokolo ea eona, 'me ho tloha 2005, ho ameha ka tšireletseho ea "moloko oa pele" oa DES e tsohile,' me li-stents tse ncha tse kang 20,21 li 'nile tsa ntlafatsoa le ho hlahisoa.22 Ho tloha ka nako eo, boiteko ba ho ntlafatsa ts'ebetso ea stent bo eketsehile ka potlako,' me theknoloji e ncha, e makatsang e tsoetse pele ho fumanoa le ho tlisoa 'marakeng ka potlako.
BMS ke letlooeng le tšesaane la terata tube.Ka mor'a phihlelo ea pele ka "Wall" mount, Gianturco-Roubin mount le Palmaz-Schatz mount, li-BMS tse ngata tse fapaneng li fumaneha hona joale.
Meetso e meraro e fapaneng e ka khoneha: khoele, letlooeng la tubula le li-tube tse slotted. meralo ea letlooeng la tubular e na le likhoele tse phuthetsoeng hammoho ka letlooeng ho etsa tube; slotted tube designs e na le li-tubes tsa tšepe tse sehiloeng ka laser.Lisebelisoa tsena li fapana ka sebopeho (tšepe e sa hloekang, nichrome, cobalt chrome), moralo oa sebopeho (mefuta e fapaneng ea strut le bophara, bophara le bolelele, matla a radial, radiopacity) le litsamaiso tsa ho fana (ho ikemela kapa ho atolosoa ha balune) .
Ka kakaretso, BMS e ncha e na le motsoako oa cobalt-chromium, o fellang ka li-struts tse tšesaane tse nang le mokhoa o ntlafetseng oa ho tsamaea, ho boloka matla a mochine.
Li na le sethala sa tšepe se entsoeng ka tšepe (hangata tšepe e sa hloekang) 'me se koahetsoe ka polymer e hlahisang phekolo e thibelang ho ata le / kapa e khahlanong le ho ruruha.
Sirolimus (eo hape e tsejoang e le rapamycin) e ne e entsoe qalong e le moemeli oa antifungal. Mokhoa oa eona oa ts'ebetso o bakoa ke ho thibela tsoelo-pele ea potoloho ea lisele ka ho thibela phetoho ho tloha karolong ea G1 ho ea ho S le ho thibela ho thehoa ha neointima. matla a ho thibela ISR.mashome a mabeli a metso e mene
Paclitaxel e ile ea amoheloa qalong bakeng sa kankere ea mahe a bomme, empa thepa ea eona e matla ea cytostatic - sethethefatsi se tsitsisa li-microtubules nakong ea mitosis, se lebisa ho ts'oaroe ha lisele le ho thibela ho thehoa ha neointimal - ho etsa hore e be motsoako oa Taxus Express PES. Liberté e na le sethala sa tšepe e sa hloekang bakeng sa ho tsamaisoa habonolo.
Bopaki bo tiileng bo tsoang litlhahlobong tse peli tse hlophisitsoeng le litlhahlobo tsa meta li fana ka maikutlo a hore SES e na le molemo ho feta PES ka lebaka la litheko tse tlase tsa ISR le sepheo sa sekepe sa revascularization (TVR), hammoho le mokhoa o lebisang ho eketsehile ha acute myocardial infarction (AMI) sehlopheng sa PES. 27,28
Lisebelisoa tsa moloko oa bobeli li fokolitse botenya ba strut, ho ntlafala ho fetoha ha maemo / ho fana ka thepa, ho ntlafatsa li-polymer biocompatibility / li-drug elution profiles, le li-kinetics tse babatsehang tsa re-endothelialization.
Taxus Elements ke tsoelo-pele e 'ngoe e nang le polymer e ikhethang e etselitsoeng ho eketsa ho lokolloa pele le tsamaiso e ncha ea platinum-chromium strut e fanang ka li-struts tse tšesaane le ho ntlafatsa radiopacity.Teko ea PERSEUS 29 e hlokometse liphello tse tšoanang pakeng tsa Element le Taxus Express ho fihlela likhoeli tse 12. Leha ho le joalo, liteko li bapisa likarolo tsa yew tsa bobeli le DES tse ling tsa lageneration.
Zotarolimus-eluting stent (ZES) Endeavor e ipapisitse le sethala se matla sa cobalt-chromium stent se nang le maemo a holimo a feto-fetohang le boholo bo bonyenyane ba stent. biocompatibility le ho fokotsa ho ruruha.Lithethefatsi tse ngata li hlakoloa nakong ea mohato oa pele oa kotsi, o lateloa ke ho lokisoa ha methapo.Ka mor'a teko ea pele ea ENDEAVOUR, teko e latelang ea ENDEAVOR III e bapisoa le ZES le SES, e ileng ea bontša tahlehelo e kholo ea lumen ea morao-rao le ISR empa liketsahalo tse fokolang tse kholo tsa pelo (MACE) ho feta SES .30 The ENDEAVOUR, e ileng ea bapisa teko ea ZIV, e ileng ea boela ea bapisoa le ZIVSR ketsahalo e tlaase ea AMI, e bonahalang eka e tsoa ho ST e tsoetseng pele haholo sehlopheng sa ZES.31 Leha ho le joalo, teko ea PROTECT e ile ea hlōleha ho bontša phapang pakeng tsa litekanyetso tsa ST pakeng tsa Endeavor le Cypher stents.32
Endeavor Resolute ke phetolelo e ntlafetseng ea Endeavor stent e nang le polymer e ncha ea lera.The New Resolute Integrity (eo ka linako tse ling e bitsoang DES ea moloko oa boraro) e thehiloe sethaleng se secha se nang le bokhoni bo phahameng ba ho fana ka thepa (sethala sa Botšepehi BMS), le buka e ncha, e mengata ea biocompatible ea lithethefatsi tse tharo tse ka holimo le tse ling tse ka holimo ho tse tharo tse ka holimo le tse ling tse ngata. Matsatsi a 60. Teko e bapisang Resolute le Xience V (everolimus-eluting stent [EES]) e bontšitse ho se be tlaase ho tsamaiso ea Resolute mabapi le lefu le ho hlōleha ha leqeba la sepheo.33,34
Everolimus, derivative of sirolimus, e boetse e le cell cycle inhibitor e sebelisoang ho nts'etsopele ea Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform) EES.The SPIRIT test 35-37 bonts'a ts'ebetso e ntlafetseng le ho fokotsa MACE le Xience V ha e bapisoa le PES, ha e ntse e bontša hore teko ea EXfenin e ne e le ea SEXCELLES. tahlehelo ea morao likhoeling tsa 9 le liketsahalo tsa kliniki likhoeling tsa 12. 38 Qetellong, stent ea Xience e ile ea bontša melemo ho feta BMS sebakeng sa ST-segment elevation myocardial infarction (MI) 39.
Li-EPC ke karoloana ea lisele tse potolohang tse amehang ho vascular homeostasis le endothelial repair.Ho ntlafatsoa ha li-EPC sebakeng sa kotsi ea methapo ho tla khothalletsa ho khutlisetsoa morao pele ho nako, ho ka fokotsa kotsi ea teko ea pele ea ST.EPC biology tšimong ea stent design ke CD34 antibody-coated coated Genous stent, e khonang ho tšoaea Genous stent, ntlafatsa re-endothelialization.Le hoja lithuto tsa pele li ne li khothatsa, bopaki ba morao-rao bo supa litekanyetso tse phahameng tsa TVR.40
Ha ho nahanoa ka liphello tse ka 'nang tsa e-ba kotsi tsa pholiso e liehang ho etsoa ke polymer, e amanang le kotsi ea ST, li-polymers tse nang le bioabsorbable li fana ka melemo ea DES, ho qoba ho tšoenyeha ka nako e telele mabapi le ho phehella ha polymer.Ho fihlela joale, mekhoa e fapaneng ea bioabsorbable e amohetsoe (mohlala, Nobori le Biomatrix, biolimus eluting stent, EESl, Lingoliloeng tsa bona tsa Synergy), Sylrgy liphello tsa nako e telele li lekanyelitsoe.41
Thepa ea bioabsorbable e na le monyetla oa ho fana ka ts'ehetso ea mochini qalong ha recoil recoil e nahanoa le ho fokotsa likotsi tsa nako e telele tse amanang le litšepe tse teng. Theknoloji e ncha e lebisitse ho nts'etsopele ea li-polymers tse thehiloeng ho lactic acid (poly-l-lactic acid [PLLA]), empa litsamaiso tse ngata tsa stent li ntse li tsoela pele, leha ho lekoa hore ho na le phephetso ea ho theola boima ba 'mele. teko e bontšitse tšireletseho le katleho ea everolimus-eluting PLLA stents.43 Moloko oa bobeli oa Absorb stent revision e bile ntlafatso ho feta e fetileng e nang le ts'ebetso e ntle ea lilemo tsa 2. mokhoa oa ho kenya, le boemo ba polokeho bakeng sa maqeba a pelo bo hloka ho hlakisoa hamolemo.
Thrombosis ka bobeli BMS le DES e na le liphello tse mpe tsa kliniki.Bongolisong ba bakuli ba fumanang ho kenngoa ha DES, 47 24% ea linyeoe tsa ST li ile tsa fella ka lefu, 60% ho tloha ho MI e sa bolaeang, le 7% ho tsoa ho angina e sa tsitsang.PCI maemong a tšohanyetso ST hangata e le suboptimal, le ho pheta-pheta ho 12% ea linyeoe.48
Advanced ST e na le liphello tse mpe tsa kliniki tse ka 'nang tsa e-ba kotsi.Thutong ea BASKET-LATE, likhoeli tse 6 ho isa ho tse 18 ka mor'a hore ho behoe stent, litekanyetso tsa lefu la pelo le MI e sa bolaeang li ne li phahame sehlopheng sa DES ho feta sehlopha sa BMS (4.9% le 1.3%, ka ho latellana). BMS, e tlalehile hore lilemong tsa 4 tsa ho latela, SES (0.6% vs 0%, p = 0.025) le PES (0.7%)) e ile ea eketsa ts'oaetso ea ST ea morao haholo ha e bapisoa le BMS ka 0.2%, p = 0.028) .49 Ka lehlakoreng le leng, tlhahlobo ea meta e kenyeletsang 5,108 bakuli, 0 ES MMS e ile ea tlalehoa ka lefu la 6% kapa 21% ha e bapisoa le lefu la SMI le 21. (p=0.03), athe PES e ne e amahanngoa le keketseho e seng ea bohlokoa ea 15% (Tlhaloso ea likhoeli tse 9 ho isa ho lilemo tse 3).
Li-registries tse ngata, liteko tse sa tloaelehang, le litlhahlobo tsa meta li batlisisitse kotsi e lekanyelitsoeng ea ST ka mor'a ho kenngoa ha BMS le DES 'me ba tlalehile liphello tse hanyetsanang.Lengolong la bakuli ba 6,906 ba fumanang BMS kapa DES, ha hoa ka ha e-ba le phapang pakeng tsa liphello tsa kliniki kapa litekanyetso tsa ST nakong ea ho latela lilemo tsa 1. 0.6% / selemo ha e bapisoa le BMS.49 Meta-analysis ea liteko tse bapisoang le SES kapa PES le BMS e bontšitse kotsi e eketsehileng ea ho shoa le MI e nang le DES ea moloko oa pele ha e bapisoa le BMS, 21 le tlhahlobo e 'ngoe ea bakuli ba 4,545 ka mokhoa o sa tloaelehang ho SES kapa Ho ne ho se na phapang pakeng tsa liketsahalo tsa ST pakeng tsa lilemo tsa 450 le liphuputso tse ling tse ntseng li eketseha ho latela liphuputso tse ling tsa PES pakeng tsa lilemo tse 450 le BMS e eketsehileng. kotsi ea ST le MI e tsoetseng pele ho bakuli ba fumanang DES ea moloko oa pele ka mor'a ho khaotsa DAPT.51
Ho fanoe ka bopaki bo hanyetsanang, litlhahlobo tse 'maloa tse kopantsoeng le litlhahlobo tsa meta hammoho li ile tsa etsa qeto ea hore moloko oa pele oa DES le BMS ha oa ka oa fapana haholo kotsing ea lefu kapa MI, empa SES le PES li ne li e-na le kotsi e eketsehileng ea ST e tsoetseng pele haholo ha e bapisoa le BMS. Ho hlahloba Bopaki bo fumanehang, US Food and Drug Administration (FDA) e khethile sehlopha sa litsebi53 se faneng ka polelo e amohelang hore moloko oa pele oa DES o ne o sebetsa hantle bakeng sa matšoao a label le hore kotsi ea ST e tsoetseng pele haholo e ne e le nyenyane empa e nyenyane. Keketseho e kholo.Ka lebaka leo, FDA le mokhatlo o khothalletsa ho eketsa nako ea DAPT ho selemo sa 1, le hoja ho na le boitsebiso bo fokolang ba ho tšehetsa tseko ena.
Joalokaha ho boletsoe pejana, DES ea moloko oa bobeli e nang le likarolo tse tsoetseng pele tsa moralo li 'nile tsa ntlafatsoa.CoCr-EESs e 'nile ea e-ba le lithuto tsa kliniki tse pharaletseng ka ho fetisisa.Ka tlhahlobo ea meta ea Baber et al,54 e kenyeletsang bakuli ba 17,101, CoCr-EES e fokotsehile haholo ka mokhoa o hlakileng / o ka khonehang oa ST le MI ha o bapisoa le PES, SES, le ZES ka mor'a likhoeli tse 21 tsa Palmerini, tlhahlobo ea metanally ea Palmerini. Bakuli ba 16,775 bao CoCr-EES e neng e le tlase haholo pele ho nako, morao, 1- le 2 ea lilemo tse hlakileng tsa ST ha li bapisoa le tse ling tse kopantsoeng tsa DES.55 Liphuputso tsa sebele tsa lefatše li bontšitse ho fokotseha ha kotsi ea ST le CoCr-EES ha e bapisoa le moloko oa pele oa DES.56
Re-ZES e ne e bapisoa le CoCr-EES litekong tsa RESOLUTE-AC le TWENTE.33,57 Ho ne ho se na phapang e khōlō ketsahalong ea ho shoa, lefu la myocardial infarction, kapa ST e tobileng pakeng tsa li-stents tse peli.
Meta-analysis ea marang-rang ea bakuli ba 50,844 ho kenyelletsa le 49 RCTs, 58CoCr-EES e ne e amahanngoa le boemo bo tlaase haholo ba ST e hlakileng ho feta BMS, sephetho se sa hlokomeloe ho tse ling tsa DES; phokotso e ne e se feela ka Bohlokoa pele le matsatsing a 30 (karolelano ea liphapang [OR] 0.21, 95% nako ea tšepo [CI] 0.11-0.42) hape le ka selemo sa 1 (OR 0.27, 95% CI 0.08-0.74) le lilemo tse 2 (OR 0.35% 0.7 0.7 e khubelu). PES, SES, le ZES, CoCr-EES e ne e amahanngoa le boemo bo tlaase ba ST ho 1 selemo.
Early ST e amana le lintlha tse fapaneng.Moropholoji oa plaque le moroalo oa thrombus o bonahala o susumetsa liphello ka mor'a PCI; 59 Ho kenella ka ho teba ka lebaka la necrotic core (NC) prolapse, meokho e bohareng ka bolelele bo tsitsitseng, ho arohana ha bobeli ka marang-rang a setseng, kapa ho fokotseha ho hoholo ha moeli o lekaneng, ho kenngoa ho sa phetheheng, le katoloso e sa fellang DAPT tekong e sa tloaelehang e bapisoang le BMS le Litefiso tsa DES li ne li tšoana (<1%).61 Ka hona, ST ea pele e bonahala e amana haholo-holo le lisosa tsa motheo tsa phekolo le lintlha tsa ho buuoa.
Kajeno, ho tsepamisitsoe maikutlo ka ho khetheha nakong ea morao-rao / morao haholo ST.Haeba lintlha tsa ts'ebetso le tsa theknoloji li bonahala li phetha karolo e kholo ho nts'etsopele ea ST e matla le e nyenyane, mokhoa oa ho lieha ha liketsahalo tsa thrombotic o bonahala o le thata haholoanyane. Ho buuoa.Bakeng sa BMS le DES, mekhoa e fapaneng ea mekhoa, e kang boholo ba sekepe se senyenyane, li-bifurcations, lefu la polyvascular, calcification, occlusion kakaretso, li-stents tse telele, li bonahala li amahanngoa le kotsi ea ST.62,63 Karabelo e sa lekaneng ea phekolo ea antiplatelet ke kotsi e kholo ea kotsi e tsoetseng pele ea DES thrombosis 51. karabelo, liphatsa tsa lefutso tsa polymorphisms boemong ba receptor (haholo-holo clopidogrel resistance), le ho phahama ha litsela tse ling tsa platelet activation.In-stent neoatherosclerosis e nkoa e le mokhoa oa bohlokoa oa ho hlōleha ha stent ka morao, ho akarelletsa le morao ST64 (karolo ea "In-stent neoatherosclerosis"). vasodilatory substances.DES e pepesa lerako la sekepe ho lithethefatsi tse thibelang likokoana-hloko le sethala sa ho hlahisa lithethefatsi se nang le liphello tse fapaneng ho pholiso ea ho qetela le ts'ebetso, ka kotsi ea ho ba le thrombosis ea morao-rao. ho ba mokhoa o mong o lebisang ho ST.Virmani et al66 e tlalehile liphuputso tsa post-mortem post-ST tse bontšang ho atolosoa ha aneurysm karolong ea stent e nang le liketso tsa hypersensitivity sebakeng se entsoeng ka T lymphocyte le eosinophils; liphuputso tsena li ka 'na tsa bontša tšusumetso ea li-polymers tse sa tsitsang.67 Stent malapposition e ka ba ka lebaka la ho atolosoa ha stent ka mokhoa o sa tsitsang kapa ho etsahala likhoeli ka mor'a PCI.Le hoja malapposition ea mekhoa e le kotsi ea ST acute and subacute ST, bohlokoa ba kliniki ba ho fumanoa ha stent malapposition bo ka itšetleha ka ho tsosolosoa ho matla ha methapo ea methapo kapa ho lieha ho fola ha meriana. tsekisanoang.68
Liphello tsa tšireletso tsa moloko oa bobeli oa DES li ka kenyelletsa endothelialization e potlakileng le e tsitsitseng, hammoho le ho se tšoane ha motsoako oa stent le sebopeho, botenya ba strut, thepa ea polymer, le mofuta oa lithethefatsi tse thibelang likokoana-hloko, tekanyo le kinetics.
Mabapi le CoCr-EES, li-stent stent tse tšesaane (81 µm) tsa cobalt-chromium, li-antithrombotic fluoropolymers, polymer e tlase, le phallo ea lithethefatsi li ka tlatsetsa ho fokotseha ha ST. DES ea moloko oa bobeli e na le thepa e ts'oanang e lokeloa ke boithuto bo eketsehileng.
Li-coronary stents li ntlafatsa sekhahla sa katleho ea ho buuoa ha methapo ea pelo ha e bapisoa le setso sa percutaneous transluminal coronary angioplasty (PTCA), se nang le mathata a mechine (vascular occlusion, dissection, joalo-joalo) le litekanyetso tse phahameng tsa ho phomola (ho fihlela ho 40% -50% ea linyeoe). Ho elella bofelong ba lilemo tsa bo-1990, hoo e ka bang 70% ea li-PCI li ne li etsoa ka ho kenngoa ha BMS.70
Leha ho le joalo, ho sa tsotellehe tsoelo-pele ea thekenoloji, mekhoa le phekolo ea meriana, kotsi ea ho phomola ka mor'a ho kenngoa ha BMS ke hoo e ka bang 20%, le> 40% ka lihlopha tse itseng.71 Ka kakaretso, lithuto tsa kliniki li bontšitse hore restenosis ka mor'a ho kenngoa ha BMS, e tšoanang le e hlokometsoeng ka PTCA e tloaelehileng, e fihla tlhōrōng ea likhoeli tsa 3-6 'me e rarolla ka mor'a selemo sa 1.72.
DES e tsoela pele ho fokotsa liketsahalo tsa ISR, 73 le hoja ho fokotseha hona ho itšetlehile ka angiography le boemo ba kliniki.Seaparo sa polymer ho DES se lokolla li-anti-inflammatory le anti-proliferative agents, se thibela ho thehoa ha neointima, le ho liehisa mokhoa oa ho lokisa methapo ea mali ka likhoeli ho isa ho lilemo.74 Khōlo e tsitsitseng ea neointimal nakong ea ho latela nako e telele ea ho latela nako e telele ka mor'a hore ho be le "phenomepplant" e tsejoang e le "phenomepplant" e tsejoang ka mor'a hore ho be le "phenome-upplant" ea DESlate, e tsejoang e le "phenome" lithuto tsa histological. 75
Kotsi ea methapo nakong ea PCI e hlahisa mokhoa o rarahaneng oa ho ruruha le ho lokisoa ka nako e batlang e le khutšoanyane (libeke ho isa ho likhoeli), e lebisang ho endothelialization le neointimal coverage.Ho ea ka litlhaloso tsa histopathological, hyperplasia ea neointimal (BMS le DES) ka mor'a ho kenngoa ha stent e ne e entsoe haholo-holo ka lisele tsa proliferative proliferative 7 tsa matrix a proliferative 7.
Ka hona, hyperplasia ea neointimal e emela mokhoa oa ho lokisa o amanang le coagulation le mabaka a ho ruruha hammoho le lisele tse etsang hore ho be le mesifa e boreleli le ho thehoa ha matrix a extracellular.Hang-hang ka mor'a PCI, liplatelete le fibrin deposit leboteng la sekepe le ho bokella leukocyte ka letoto la limolek'hule tsa ho khomarela lisele.Rolling leukocyte platelets ho kopanya leukocyte leukocyte ka har'a lekocyte ea ho khomarela1 ka ho kopanya leukocyte le ho kopanya leukocyte. (CD11b/CD18) le platelet glycoprotein Ibα 53 kapa fibrinogen e tlameletsoeng ho platelet glycoprotein IIb/IIIa.76,77
Ho ea ka lintlha tse hlahang, lisele tsa mokokotlo tse entsoeng ka masapo li ameha ka likarabo tsa methapo le mekhoa ea ho lokisa.Ho bokella EPCs ho tloha mokong oa masapo ho ea mali a peripheral ho khothalletsa ho tsosolosoa ha endothelial le postnatal neovascularization.Ho bonahala eka masapo a bone a boreleli a lisele tsa progenitor (SMPC) a fallela sebakeng sa kotsi ea vascular, e lebisang pele ho neoin8 cell proliferation. ho ba palo e tsitsitseng ea EPCs; liphuputso tse ling li bontšitse hore CD34 surface antigen ha e le hantle e lemoha lisele tsa stem tsa moko oa masapo tse nang le bokhoni ba ho arola ka EPCs le SMPCs.Transdifferentiation ea CD34-positive cell to EPC kapa SMPC leloko ho itšetlehile ka tikoloho ea sebaka seo; maemo a ischemic a etsa hore ho be le phapang ho ea ho phenotype ea EPC ho khothalletsa ho tsosolosoa hape, ha maemo a ho ruruha a etsa hore ho be le phapang ho ea ho phenotype ea SMPC ho khothalletsa ho ata ha neointimal.79
Lefu la tsoekere le eketsa kotsi ea ISR ka 30% -50% ka mor'a ho kenngoa ha BMS, 80 le palo e phahameng ea restenosis ho bakuli ba nang le lefu la tsoekere ha ba bapisoa le bakuli ba nondiabetic le bona ba ile ba tsoela pele ka nako ea DES. Mekhoa e thehiloeng ho sena e ka 'na ea e-ba lintho tse ngata, tse kenyelletsang tsamaiso (mohlala, ho feto-fetoha ha karabelo ea ho ruruha, li-diameter tse nyenyane, li-diaper, li-diaper, li-diaper, li-diaper, li-diaper, li-diaper, li-diaper, li-diabets) lefu, joalo-joalo) lintlha tse eketsang ka boikemelo Kotsi ea ISR.70
Bophahamo ba sejana le bolelele ba leqeba ka boikemelo bo ile ba ama liketsahalo tsa ISR, tse nang le maqeba a manyenyane a bophara / a malelele a ntseng a eketseha haholo ha a bapisoa le likhahla tse kholoanyane / tse khutšoanyane.71
Li-platform tsa stent tsa moloko oa pele li bonts'itse li-stent stent tse teteaneng le litekanyetso tse phahameng tsa ISR ha li bapisoa le li-platform tsa stent tsa moloko oa bobeli tse nang le li-thinner struts.
Ho phaella moo, ketsahalo ea restenosis e ne e amana le bolelele ba stent, ka bolelele ba stent> 35 mm hoo e ka bang habeli ka nako e telele ho feta tse <20 mm. Theko ea ho qetela ea stent bonyane ea lumen e boetse e phetha karolo ea bohlokoa: karolo e nyenyane ea ho qetela e nyenyane ea lumen e boletse esale pele kotsi e eketsehileng ea ho phomola.81,82
Ka tloaelo, hyperplasia ea intimal ka mor'a ho kenngoa ha BMS e nkoa e tsitsitse, e nang le tlhōrō ea pele pakeng tsa likhoeli tsa 6 le selemo sa 1, e lateloa ke nako ea ho khutsisa. neointimal regression .83 Leha ho le joalo, liphuputso tse nang le nako e telele ea ho latela nako e telele li bontšitse karabo ea boraro ka mor'a hore ho behoe BMS, ka ho phomola pele ho nako, ho fokotseha ha bohareng, le ho fokotseha ha lumen morao.84
Nakong ea DES, khōlo ea morao-rao ea neointimal e ile ea bontšoa qalong ka mor'a ho kenngoa ha SES kapa PES mefuteng ea liphoofolo.85 Liphuputso tse 'maloa tsa IVUS li bontšitse ho fokotseha ha pele ho hola ha ka hare ho lateloa ke ho ts'oaroa ha nako e telele ka mor'a ho kenngoa ha SES kapa PES, mohlomong ka lebaka la ts'ebetso e tsoelang pele ea ho ruruha.86
Ho sa tsotellehe "botsitso" boo ka tloaelo ho thoeng bo bakoa ke ISR, hoo e ka bang karolo ea boraro ea bakuli ba BMS ISR e hlahisa ACS.4
Ho na le bopaki bo ntseng bo eketseha ba hore ho ruruha ho sa foleng le / kapa ho se sebetse ha endothelial ho baka neoatherosclerosis e tsoetseng pele ka har'a BMS le DES (haholo-holo moloko oa pele oa DES), e ka 'nang ea e-ba mokhoa oa bohlokoa bakeng sa ISR e tsoetseng pele kapa ST.Inoue et al. 87 e tlalehile liphuputso tsa histological ho tsoa ho disampole tsa autopsy ka mor'a ho kenngoa ha Palmaz-Schatz coronary stents, e fana ka maikutlo a hore ho ruruha ha peri-stent ho ka potlakisa liphetoho tse ncha tsa indolent atherosclerotic ka har'a stent. disampole tse tsoang maemong a ACS li bonts'a li-plaque tse tloaelehileng tse tlokotsing methapong ea matsoalloa a methapo Histological morphology ea block e nang le foamy macrophages le likristale tsa k'holeseterole. Ho phaella moo, ha ho bapisoa BMS le DES, phapang e khōlō nakong ea tsoelo-pele ea atherosclerosis e ncha e ile ea hlokomeloa. Maqeba a BMS a etsahetse lilemo tse 2 hamorao 'me a lula a fumanoa ka seoelo ho fihlela lilemo tsa 4. Ho feta moo, DES stenting bakeng sa liso tse sa tsitsang tse kang thin-cap fibroatherosclerosis (TCFA) kapa ho phatloha ha intimal ho na le nako e khutšoanyane ea tsoelo-pele ha e bapisoa le BMS.
Tšusumetso ea moloko oa bobeli oa DES kapa DES ho nts'etsopele e ntse e lokela ho ithutoa; le hoja litebello tse ling tse teng tsa moloko oa bobeli oa DESs88 li fana ka maikutlo a ho ruruha ho fokolang, ketsahalo ea neoatherosclerosis e tšoana le ea moloko oa pele, empa lipatlisiso tse ling li ntse li hlokahala.