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UMarta Francesca Brancati, 1 Francesco Burzotta, 2 Carlo Trani, 2 Ornella Leonzi, 1 Claudio Cuccia, 1 Filippo Crea2 1 Department of Cardiology, Poliambulanza Foundation Hospital, Brescia, 2 Department of Cardiology, Catholic University of the Sacred Heart of Rome, Italy Abstract: Drug-Elutions miningers (BMS) emva kokungenelela kwe-coronary percutaneous.Nangona kunjalo, nangona ukuqaliswa kwe-DES yesizukulwana sesibini kubonakala kumodareyitha le nto xa kuthelekiswa ne-DES yesizukulwana sokuqala, iinkxalabo ezinzulu zihlala malunga neengxaki ezinokwenzeka emva kwexesha lokufakelwa kwe-stent, njenge-stent thrombosis (ST) kunye ne-stent resection. I-Stenosis (ISR) .ST yinto enokuthi ibe yintlekele eye yancitshiswa kakhulu ngokusebenzisa i-stenting ephuculweyo, i-novel stent designs, kunye ne-double antiplatelet therapy.Indlela echanekileyo echaza ukwenzeka kwayo iphantsi kophando, kwaye ngokwenene, izinto ezininzi zinoxanduva.I-ISR kwi-BMS yayicingelwa ngaphambili ukuba yimeko eqhubekayo kunye ne-peak yokuqala ye-hyperplasia yeenyanga ze-16 kwi-intimal regression. Ngokwahlukileyo, zombini izifundo zeklinikhi kunye ne-histological ye-DESs zibonise ubungqina bokukhula okuqhubekayo kwe-neointimal ngexesha lokulandelwa kwexesha elide, into eyaziwa ngokuba yinto "yokubamba emva kwexesha".Ingcamango yokuba i-ISR yimeko yeklinikhi enobungozi isandul 'ukuchaswa bubungqina bokuba izigulane ezine-ISR zinokuhlakulela i-acute coronary syndromes. iiplagi kunye neempawu zokuphulukiswa kwenqanawa emva kwe-stent; isoloko isetyenziselwa ukugqiba ukuxilongwa kwe-coronary angiography kunye nokuqhuba iinkqubo zokungenelela.I-Intracoronary optical coherence tomography okwangoku ithathwa njengeyona ndlela iphakamileyo yokucinga.Xa kuthelekiswa ne-intravascular ultrasound, inika isisombululo esingcono (ubuncinci> amaxesha angama-10), ivumela ukucaciswa okucacileyo kwesakhiwo somphezulu wodonga lomkhumbi. Isigaba sasemva se-neo-atherosclerosis ngaphakathi kwe-BMS kunye ne-DES. Ngoko ke, i-neo-atherosclerosis iye yaba ngumrhanelwa oyintloko kwi-pathogenesis yokungaphumeleli kwe-stent kade.
I-Percutaneous coronary intervention (PCI) ene-stent implantation yinkqubo esetyenziswa kakhulu kunyango lwe-symptomatic coronary artery disease, kwaye ubuchule buyaqhubeka nokuguquka.1 Nangona izidakamizwa-eluting stents (DES) zinciphisa imida ye-bare-metal stents (BMSs), iingxaki emva kwexesha ezifana ne-stent thrombosis (SRST) kunye ne-stent thrombosis ukufakwa kwestent. , kusekho inkxalabo enzulu.2-5
Ukuba i-ST yinto enokuthi ibe yintlekele, ukuqaphela ukuba i-ISR inesifo esincinci sisandul 'ukuphikiswa ngobungqina be-acute coronary syndrome (ACS) kwizigulane ze-ISR.4
Namhlanje, i-intracoronary optical coherence tomography (OCT) 6-9 ithathwa njengeyona ndlela ikhoyo ye-imaging yangoku, enikezela isisombululo esingcono kune-intravascular ultrasound (IVUS)."Izifundo ze-imaging ze-In vivo, i-10-12 ehambelana neziphumo ze-histological, ibonisa indlela "entsha" yempendulo ye-vascular MS emva kokufakelwa kwe-stent ngaphakathi kwe-"Bnevorosulinosis" kunye ne-derosulinosis.
Kwi-1964, uCharles Theodore Dotter kunye noMelvin P Judkins bachaza i-angioplasty yokuqala.Ngo-1978, u-Andreas Gruntzig wenza ibhaluni yokuqala ye-angioplasty (i-angioplasty endala yebhaluni); yayiyi-revolutionary treatment kodwa yayinemiqobo yokuvalwa kwenqanawa ebukhali kunye ne-restenosis.13 Oku kuqhuba ukufunyanwa kwe-coronary stents: I-Puel kunye ne-Sigwart basebenzise i-coronary stent yokuqala kwi-1986, inikezela i-stent yokukhusela ukuvalwa kwenqanawa kunye nokuhlehliswa kwe-systolic emva kwexesha. izilingo ezimbini eziphawulekayo, i-Belgian-Dutch Stent Trial 15 kunye ne-Stent Restenosis Study 16, ikhuthaze ukhuseleko lwe-stenting kunye ne-antiplatelet therapy (DAPT) kunye / okanye iindlela ezifanelekileyo zokusebenzisa.17,18 Emva kwezi zilingo, kukho ukwanda okukhulu kwinani le-PCIs eyenziwayo.
Nangona kunjalo, ingxaki ye-iatrogenic in-stent neointimal hyperplasia elandela ukubekwa kwe-BMS yachongwa ngokukhawuleza, okubangele i-ISR kwi-20% -30% yezilonda eziphathwayo.Ngo-2001, i-DES yaziswa19 ukunciphisa imfuno yokuphumla kunye nokungenelela. ngo-2005, i-80% -90% yazo zonke ii-PCIs zakhatshwa yi-DES.
Yonke into ineentsilelo zayo, kwaye ukususela ngo-2005, iinkxalabo malunga nokhuseleko lwe-DES "yesizukulwana sokuqala" ziye zaphakama, kwaye i-stents yesizukulwana esitsha njenge-20,21 iye yaphuhliswa kwaye yaziswa.22 Ukususela ngoko, iinzame zokuphucula ukusebenza kwe-stent ziye zanda ngokukhawuleza, kwaye ubugcisa obutsha, obumangalisayo buqhubekile bufunyanwa kwaye buziswa kwiimarike ngokukhawuleza.
I-BMS yi-mesh yocingo oluncinci ityhubhu.Emva kwamava okuqala kunye nentaba "Yodonga", intaba ye-Gianturco-Roubin kunye nentaba ye-Palmaz-Schatz, ii-BMS ezininzi ezahlukeneyo zikhoyo ngoku.
Uyilo oluthathu olwahlukeneyo lunokwenzeka: ikhoyili, i-tubular mesh kunye ne-slotted tube.Uyilo lwekhoyili lubonisa iingcingo zetsimbi okanye imicu eyenziwe kwimilo yesityhula; Uyilo lwe-tubular mesh lubonisa iingcingo ezisongelwe kunye kumnatha ukwenza ityhubhu; i-slotted tube designs iquka iityhubhu zetsimbi ezenziwe nge-laser cut made.Ezi zixhobo ziyahluka ekubunjweni (insimbi engenasici, i-nichrome, i-cobalt chrome), i-structural design (iipateni ezahlukeneyo ze-strut kunye nobubanzi, iidamitha kunye nobude, amandla e-radial, i-radiopacity) kunye neenkqubo zokuhambisa (ukuzandisa okanye ibhaluni-yandiswa).
Ngokuqhelekileyo, i-BMS entsha iqulethe i-cobalt-chromium alloy, ekhokelela kwimibhobho emincinci kunye nokuhamba okuphuculweyo, ukugcina amandla omatshini.
Ziquka iqonga lentsimbi ye-stent (ngokuqhelekileyo insimbi engenasici) kwaye igqunywe ngepolymer ekhupha i-anti-proliferative kunye / okanye i-anti-inflammatory therapeutics.
I-Sirolimus (eyaziwa ngokuba yi-rapamycin) ekuqaleni yayiyilwe njenge-agent ye-antifungal.Indlela yokusebenza kwayo ivela ekuthinteleni ukuqhubela phambili komjikelo weseli ngokuthintela ukuguquka ukusuka kwisigaba se-G1 ukuya kwisigaba se-S kunye nokuthintela ukubunjwa kwe-neointima.Ngo-2001, amava "wokuqala kumntu" kunye ne-SES abonise iziphumo ezithembisayo zovavanyo, ekhokelela ekuphuhlisweni kwe-Cy23. ukuphumelela ekuthinteleni i-ISR.amashumi amabini anesine
I-Paclitaxel yavunywa ekuqaleni umhlaza we-ovarian, kodwa iipropati zayo ezinamandla ze-cytostatic - ichiza lizinzisa i-microtubules ngexesha le-mitosis, likhokelela ekubanjweni kweeseli zeseli kunye nokuthintela ukubunjwa kwe-neointimal - yenze i-compound ye-Taxus Express PES.I-TAXUS V kunye ne-VI izilingo zibonise ukusebenza kwexesha elide le-PES kwi-high-risk art5, i-TAX26 yesifo se-coronary26. ILiberté ibonise iqonga lentsimbi engatyiwayo ukuze kube lula ukuhanjiswa.
Ubungqina obucacileyo obuvela kwiingxelo ezimbini ezicwangcisiweyo kunye nohlalutyo lwe-meta lubonisa ukuba i-SES inenzuzo ngaphezu kwe-PES ngenxa yezinga eliphantsi le-ISR kunye ne-target ye-revascularization ye-revascularization (TVR), kunye nomkhwa wokunyuka kwe-acute myocardial infarction (AMI) kwi-PES cohort. 27,28
Izixhobo zesizukulwana sesibini zinciphise ubukhulu be-strut, ukuphucula ukuguquguquka / ukuhanjiswa, ukuphuculwa kweeprofayili zepolymer biocompatibility / iziyobisi elution, kunye ne-endothelialization re-endothelialization kinetics.Kwinkqubo yangoku, zezona ziyilo eziphambili zeDES kunye ne-coronary stents emiliselwe kwihlabathi jikelele.
I-Taxus Elements yinkqubela phambili eyongezelelweyo kunye ne-polymer ekhethekileyo eyenzelwe ukunyusa ukukhululwa kwangaphambili kunye nenkqubo entsha ye-platinum-chromium strut ebonelela nge-struts encinci kunye ne-radiopacity ephuculweyo.Ilingo le-PERSEUS i-29 liqaphele iziphumo ezifanayo phakathi kwe-Element kunye ne-Taxus Express ukuya kwiinyanga ze-12. Nangona kunjalo, izilingo ezithelekisa i-yew ye-yew kunye nezinye izinto ze-yew ze-DES zesibini.
I-zotarolimus-eluting stent (ZES) Endeavour isekelwe kwiqonga eliqinileyo le-cobalt-chromium stent kunye nokuguquguquka okuphezulu kunye nobukhulu obuncinci be-stent strut.Zotarolimus yi-sirolimus analog eneziphumo ezifanayo ze-immunosuppressive kodwa i-lipophilicity eyongeziweyo yokuphucula udonga lwenqanawa ye-polyline.ZE i-biocompatibility kunye nokunciphisa ukuvuvukala.Amachiza amaninzi ahlanjululwa ngexesha lesigaba sokuqala sokulimala, kulandelwa ukulungiswa kwe-arterial.Emva kovavanyo lokuqala lwe-ENDEAVOUR, uvavanyo olulandelayo lwe-ENDEAVOUR III luthelekisa i-ZES kunye ne-SES, ebonise ukulahleka kwe-lumen kade kunye ne-ISR kodwa imbalwa kakhulu iziganeko ezimbi ze-cardiovascular (MACE) kune-SES .30 I-ENDEAVOUR, ethelekisa i-PAS, i-ENDEAVOUR, kodwa iphinda ifanise ne-PASRE isiganeko esisezantsi se-AMI, ngokubonakalayo ukusuka kwi-ST ephezulu kakhulu kwiqela le-ZES.31 Nangona kunjalo, ulingo lwe-PROTECT aluphumelelanga ukubonisa ukungafani kwemilinganiselo ye-ST phakathi kwe-Endeavor kunye ne-Cypher stents.32
I-Endeavor Resolute yinguqulelo ephuculweyo ye-stent ye-Endeavour kunye ne-polymer entsha yamanqanaba amathathu.I-Resolute Integrity entsha (ngamanye amaxesha ebizwa ngokuba yi-DES yesizukulwana sesithathu) isekelwe kwiqonga elitsha elinamandla okuhanjiswa okuphezulu (i-Integrity BMS platform), kunye noveli, i-biocompatible ngaphezulu kwe-biocompatible ye-resolute ye-resolute ye-resolute ye-polymer elandelayo, kunye ne-resolute ye-polymer elandelayo Iintsuku ezingama-60. Ulingo oluthelekisa i-Resolute kunye ne-Xience V (everolimus-eluting stent [EES]) lubonise ukungabi phantsi kwenkqubo ye-Resolute malunga nokufa kunye nokungaphumeleli kwezilonda ekujoliswe kuzo.33,34
I-Everolimus, i-derivative of sirolimus, ikwayi-inhibitor ye-cell cycle inhibitor esetyenziselwa ukuphuhliswa kwe-Xience (i-Multi-link Vision BMS platform) / Promus (iplatinam yePlatinum Chromium) EES.Uvavanyo lwe-SPIRIT 35-37 lubonise ukusebenza okuphuculweyo kunye nokunciphisa i-MACE kunye ne-Xience V xa kuthelekiswa ne-PES, ngelixa i-EXfeCELLES yayibonisa ukuba i-EXfeCELLES yayibonisa ukuba uvavanyo lwe-Spirip Ukulahleka kwexesha elide kwiinyanga ze-9 kunye neziganeko zeklinikhi kwiinyanga ze-12.38 Ekugqibeleni, i-Xience stent ibonise inzuzo ngaphezu kwe-BMS kwindawo yokubeka i-ST-segment elevation myocardial infarction (MI) .39.
I-EPCs yi-subset yeeseli ezijikelezayo ezibandakanyekayo kwi-homeostasis ye-vascular kunye nokulungiswa kwe-endothelial.Ukuphuculwa kwe-EPCs kwindawo yokulimala kwe-vascular kuya kukhuthaza ukutshatyalaliswa kwakhona kwe-endothelialization kwangaphambili, okunokunciphisa umngcipheko we-ST.EPC umzamo wokuqala webhayoloji kwintsimi yoyilo lwe-stent yi-CD34 antibody-coated-coated ye-Genous stent, ekwazi ukuphawula i-Genous stent, ekwaziyo ukuphawula phucula ukupheliswa kwakhona kwe-endothelialization.Nangona izifundo zokuqala bezikhuthaza, ubungqina bamva nje bukhomba kumazinga aphezulu e-TVR.40
Ukuqwalasela imiphumo enokuba yingozi yokuphulukisa ukulibaziseka kwe-polymer, ehambelana nomngcipheko we-ST, iipolymers ze-bioabsorbable zibonelela ngeenzuzo ze-DES, ukuphepha iinkxalabo ezihlala ixesha elide malunga nokuphikelela kwe-polymer.Kuze kube ngoku, iinkqubo ezahlukeneyo ze-bioabsorbable ziye zavunywa (umz. Nobori kunye ne-Biomatrix, i-biolimus eluting stent, i-Sylrgy, i-Sylrgy, i-Synergy), iziphumo zexesha elide zilinganiselwe.41
Izinto ze-Bioabsorbable zinenzuzo yethiyori yokuqala yokubonelela ngenkxaso yomatshini xa kuqwalaselwa kwakhona i-elastic recoil kunye nokunciphisa iingozi zexesha elide ezinxulumene ne-metal struts ekhoyo.Ubuchwephesha obutsha bukhokelele kuphuhliso lweepolymers ezisekelwe kwi-lactic acid (i-poly-l-lactic acid [PLLA]), kodwa iinkqubo ezininzi ze-stent zisekuphuhlisweni, nangona ukugqiba i-elunetics ye-ABS okanye i-degrad ihleli. Uvavanyo lubonise ukhuseleko kunye nokusebenza kakuhle kwe-everolimus-eluting PLLA stents.43 Isizukulwana sesibini sokuhlaziywa kwe-Absorb stent sasiphuculwe ngaphezu kwangaphambili kunye nokulandelwa kakuhle kweminyaka eyi-2.44 Ulingo oluqhubekayo lwe-ABSORB II, ulingo lokuqala olungenamkhethe oluthelekisa i-Absorb stent kwi-Xience Prime stent, kufuneka lubonelele ngeziphumo ezingaphezulu, nangona kunjalo, i-promising5 yokuqala kufuneka ibonelele ngeziphumo ezingaphezulu. ubuchule bokufakelwa, kunye neprofayili yokhuseleko lwezilonda ze-coronary kufuneka zicaciswe ngcono.
I-Thrombosis kuzo zombini i-BMS kunye ne-DES ineziphumo ezibi kakhulu zeklinikhi.Kwirejista yezigulane ezifumana ukufakelwa kwe-DES, i-47 i-24% yeemeko ze-ST zibangele ukufa, i-60% evela kwi-MI engabulali, kunye ne-7% esuka kwi-angina.PCI engazinzanga kwi-ST engxamisekileyo ngokuqhelekileyo i-suboptimal, kunye nokuphindaphinda kwi-12% yamatyala.48
I-ST ephezulu ineziphumo ezibi kakhulu zeklinikhi.Kwisifundo se-BASKET-LATE, i-6 kwiinyanga ze-18 emva kokubekwa kwe-stent, izinga lokufa kwentliziyo kunye ne-MI engabulaliyo yayiphezulu kwiqela le-DES kuneqela le-BMS (i-4.9% kunye ne-1.3%, ngokulandelanayo) .20 Uhlalutyo lwe-meta-uhlalutyo lwezigulane ezi-1, i-PES2, i-randomized, i-PES2, i-random, i-5 okanye i-S2. I-BMS, ibike ukuba kwiminyaka eyi-4 yokulandelelana, i-SES (0.6% vs 0%, p = 0.025) kunye ne-PES (0.7%)) yandisa iziganeko ze-ST ngokukhawuleza kakhulu xa kuthelekiswa ne-BMS nge-0.2%, p = 0.028) .49 Ngokwahlukileyo, kwi-meta-analysis equka i-5,108 izigulane, i-0% ye-MIMS ichazwe ngokufa kwe-6 okanye i-21 ihlobene nokufa kwe-21. (p=0.03), ngelixa i-PES yayanyaniswa nokunyuka okungabalulekanga kwe-15% (Ukulandelela iinyanga ezi-9 ukuya kwiminyaka emi-3).
Ubhaliso oluninzi, iimvavanyo ezingahleliwe, kunye nohlalutyo lwe-meta luphande umngcipheko onxulumene ne-ST emva kokufakelwa kwe-BMS kunye ne-DES kwaye baye babika iziphumo eziphikisanayo. Kwirejista yezigulane ze-6,906 ezifumana i-BMS okanye i-DES, kwakungekho nantlukwano kwiziphumo zeklinikhi okanye imilinganiselo ye-ST ngexesha lokulandela iminyaka eyi-1. I-0.6% / ngonyaka xa kuthelekiswa ne-BMS.49 I-meta-analysis yezilingo ezithelekisa i-SES okanye i-PES kunye ne-BMS ibonise umngcipheko wokufa kunye ne-MI kunye ne-DES yesizukulwana sokuqala xa kuthelekiswa ne-BMS, i-21 kunye nolunye uhlalutyo lwe-meta yezigulane ze-4,545 ezingahleliwe kwi-SES okanye Kwakungekho nantlukwano kwisiganeko se-STup phakathi kweminyaka eyi-450 kunye ne-BMS yokwenyuka kwezifundo eziye zanda kwi-PES kunye ne-BMS yangempela. umngcipheko we-ST ephezulu kunye ne-MI kwizigulane ezifumana isizukulwana sokuqala se-DES emva kokuyeka i-DAPT.51
Ukunikezelwa kobungqina obuphikisanayo, uhlalutyo oluninzi oluhlanganisiweyo kunye nohlalutyo lwe-meta kunye lugqibe ukuba isizukulwana sokuqala se-DES kunye ne-BMS asizange sahluke kakhulu kumngcipheko wokufa okanye i-MI, kodwa i-SES kunye ne-PES babenomngcipheko okhulayo we-ST ephezulu kakhulu xa kuthelekiswa ne-BMS. Ukuphonononga Ubungqina obukhoyo, i-US Food and Drug Administration (FDA) yamisela iphaneli yeengcali53 ekhuphe ingxelo evuma ukuba isizukulwana sokuqala se-DES sasisebenza kakuhle kwizibonakaliso ezibhalwe kwileyibhile kwaye ingozi ye-ST ehamba phambili kakhulu yayincinci kodwa encinci. Ukunyuka okuphawulekayo.Ngenxa yoko, i-FDA kunye nombutho uncoma ukwandisa ixesha le-DAPT ukuya kwi-1 ngonyaka, nangona kukho idatha encinci yokuxhasa eli bango.
Njengoko kukhankanyiwe ngaphambili, isizukulwana sesibini se-DES esineempawu zokuyila eziphambili ziye zaphuhliswa.I-CoCr-EESs ziye zafumana izifundo ezinzulu kakhulu zeklinikhi.Uhlalutyo lwe-meta ngu-Baber et al, i-54 equka izigulane ze-17,101, i-CoCr-EES yanciphisa kakhulu i-ST ecacileyo / enokwenzeka kunye ne-MI xa kuthelekiswa ne-PES, i-SES, kunye ne-ZES emva kweenyanga ze-21 ze-Palmerini, i-Palmerini-analysis ebonisa i-metanally ye-Palmerini, i-metanally ye-21. Izigulane ze-16,775 ukuba i-CoCr-EES yayiphantsi kakhulu ekuqaleni, emva kwexesha, i-1- kunye ne-2 iminyaka eqinisekileyo ye-ST xa kuthelekiswa nezinye i-DES.55 Izifundo ze-Real-world ziye zabonisa ukunciphisa ingozi ye-ST kunye ne-CoCr-EES xa kuthelekiswa nesizukulwana sokuqala se-DES.56
I-Re-ZES yafaniswa ne-CoCr-EES kwi-RESOLUTE-AC kunye ne-TWENTE izilingo.33,57 Kwakungekho mmahluko omkhulu kwisiganeko sokufa, i-myocardial infarction, okanye i-ST ecacileyo phakathi kwee-stents ezimbini.
Kwi-intanethi ye-meta-analysis yezigulane ze-50,844 ezibandakanya i-49 RCTs, i-58CoCr-EES yayinxulumene nesiganeko esisezantsi kakhulu se-ST ecacileyo kune-BMS, umphumo awubonwanga kwenye i-DES; ukunciphisa kwakungekho kuphela Okubalulekileyo kwangaphambili kunye neentsuku ze-30 (i-odd ratio [OR] i-0.21, i-95% yexesha lokuzithemba [CI] 0.11-0.42) kunye nakwi-1 ngonyaka (OKANYE 0.27, 95% CI 0.08-0.74) kunye ne-2 iminyaka (OKANYE 0.35% 0.90 0.CI 0.CI , 0.9 0.CI ebomvu). I-PES, i-SES, kunye ne-ZES, i-CoCr-EES yadibaniswa nesiganeko esisezantsi se-ST kwi-1 ngonyaka.
I-ST yangaphambili inxulumene nezinto ezahlukeneyo.I-plaque morphology ephantsi kunye nomthwalo we-thrombus ibonakala inempembelelo kwiziphumo emva kwe-PCI; I-59 Ukungena kwe-strut ejulile ngenxa ye-necrotic core (NC) prolapse, iinyembezi zangaphakathi kubude be-stent, i-dissection yesibini kunye nemida eshiyekileyo, okanye i-margin ephawulekayo yokunciphisa Ukuqina okufanelekileyo, ukufakwa okungaphelelanga, kunye nokwandiswa okungagqibekanga60 Irejimeni yonyango kunye ne-antiplatelet ayichaphazeli kakhulu i-ST ngexesha leziyobisi ze-ST ngexesha leziyobisi. I-DAPT kwisilingo esingenasiphelo esithelekisa i-BMS kunye ne-DES Amaxabiso ayefana (<1%).61 Ngaloo ndlela, i-ST yangaphambili ibonakala inxulumene ngokukodwa nezilonda eziphantsi zonyango kunye nezinto zokuhlinzwa.
Namhlanje, ugxininiso oluthile luyi-ST.Ukuba izinto zenkqubo kunye nezobugcisa zibonakala zidlala indima enkulu ekuphuhliseni i-ST enzima kunye ne-subacute, indlela yokulibaziseka kweziganeko ze-thrombotic ibonakala iyinkimbinkimbi.Kuye kwacetyiswa ukuba iimpawu ezithile zesigulane zinokuba yimingcipheko ye-ST ephezulu kunye nephezulu kakhulu: isifo sikashukela, i-ACS ngexesha lotyando lokuqala, ukungaphumeleli kwe-renal, ubudala obudala, ukuncipha kweziganeko ze-30 ze-cardio yokuqala, i-acjection ye-30 iintsuku zokuqala Utyando.Kwi-BMS kunye ne-DES, iinguqu zenkqubo, ezifana nobukhulu beenqanawa ezincinci, i-bifurcations, isifo se-polyvascular, i-calcification, i-occlusion epheleleyo, i-stents ende, ibonakala ihambelana nomngcipheko we-ST.62,63 impendulo enganeleyo kwi-antiplatelet therapy yinto eyingozi enkulu kwi-DES thrombosis 51. impendulo, i-polymorphisms yofuzo kwinqanaba le-receptor (ingakumbi ukuchasana kwe-clopidogrel), kunye nokulawulwa kwezinye iindlela zokuvuselela iiplatelet.I-neoatherosclerosis ye-stent ithathwa njengento ebalulekileyo yokungaphumeleli kwe-stent kade, kuquka i-ST64 emva kwexesha (icandelo "In-stent neoatherosclerosis"). izinto ze-vasodilatory.DES iveza udonga lwenqanawa kwi-antiproliferative platform kunye ne-platform ye-drug-eluting kunye nemiphumo eyahlukileyo kwi-endothelial impiliso kunye nomsebenzi, kunye nomngcipheko we-thrombosis kade.65 Izifundo ze-Pathological zibonisa ukuba i-polymers ehlala ixesha elide ye-DES yesizukulwana sokuqala inokubangela ukuvuvukala okungapheliyo, i-fibrin engapheliyo deposition, i-endothelial endothelithrombosis eyandayo, kunye ne-DES ye-hypersensitivity eyandayo, kunye nomngcipheko we-hyperensibility ye-D3. ukuba ibe enye indlela ekhokelela kwi-ST.Virmani et al66 ingxelo ye-post-mortem post-ST iziphumo ezibonisa ukwanda kwe-aneurysm kwinqanaba le-stent kunye neempendulo ze-hypersensitivity zendawo eziqulunqwe yi-T lymphocytes kunye ne-eosinophils; ezi ziphumo zingabonisa impembelelo yeepolymers ezingenayo i-nonerodible.67 I-stent malapposition inokuba ngenxa yokwandiswa kwe-stent encinci okanye yenzeke kwiinyanga emva kwe-PCI.Nangona i-procedural malapposition is a risk factor for acute and subacute ST, ukubaluleka kweklinikhi yokufunyanwa kwe-stent malapposition kunokuxhomekeka ekuhlaziyweni kwe-arterial aggressional okanye ukulibaziseka kweyeza. impikiswano.68
Iziphumo zokukhusela ze-DES zesizukulwana sesibini zingabandakanya ukuphelisa ngokukhawuleza kunye nokunyanzeliswa kwe-intact, kunye nokungafani kwe-stent alloy kunye nesakhiwo, ubukhulu be-strut, izakhiwo ze-polymer, kunye nohlobo lweziyobisi ezichasayo, umthamo kunye ne-kinetics.
Ngokunxulumene ne-CoCr-EES, i-cobalt-chromium stent stent ebhityileyo (81 µm), i-antithrombotic fluoropolymers, i-polymer ephantsi, kunye nokulayishwa kweziyobisi kunokuba negalelo kwizehlo ezisezantsi ze-ST. Uphononongo lovavanyo lubonise ukuba i-thrombosis kunye ne-platelet deposition ye-fluoropolymer-coated-coated kakhulu kunezinye ii-stents-9 ze-stents ezisezantsi kakhulu. isizukulwana sesibini i-DES ineepropati ezifanayo zifanelwe ukufundwa ngakumbi.
I-coronary stents iphucula izinga lokuphumelela kotyando lokungenelela kwe-coronary xa kuthelekiswa ne-traditional percutaneous transluminal coronary angioplasty (PTCA), eneengxaki zomatshini (i-vascular occlusion, dissection, njl.) kunye namazinga aphezulu okubuyisela (ukuya kwi-40% -50% yamatyala). Ngasekupheleni kwe-1990, phantse i-70% ye-PCIs yenziwa nge-BMS implantation.70
Nangona kunjalo, nangona ukuqhubela phambili kwezobuchwepheshe, ubuchule, kunye nonyango lwezonyango, umngcipheko wokubuyisela emva kokufakelwa kwe-BMS malunga ne-20%, kunye> 40% kumacandelo athile.71 Ngokubanzi, izifundo zeklinikhi zibonise ukuba i-restenosis emva kokufakelwa kwe-BMS, efana neyokubonwa kwe-PTCA eqhelekileyo, iphakamileyo kwiinyanga ze-3-6 kwaye isombulule emva kwe-1 ngonyaka.72.
I-DES iyancipha ngakumbi iziganeko ze-ISR, i-73 nangona oku kuncitshiswa kuxhomekeke kwi-angiography kunye ne-clinic setting.I-polymer coating kwi-DES ikhupha i-anti-inflammatory and anti-proliferative agents, inqanda ukubunjwa kwe-neointima, kunye nokulibazisa inkqubo yokulungiswa kwemithambo kwiinyanga ukuya kwiminyaka.74 Ukukhula okuqhubekayo kwe-neointimal ngexesha lokulandelelana kwexesha elide emva kokuba "i-DES i-implantation" eyaziwayo emva kokuba "i-DES implantation" eyaziwa ngokuba yi-clinical implantation, eyaziwa ngokuba yi-DES. izifundo ze-histological. 75
Ukulimala kwe-Vascular ngexesha le-PCI kuvelisa inkqubo eyinkimbinkimbi yokuvuvukala kunye nokulungiswa kwexesha elifutshane (iiveki ukuya kwiinyanga), okukhokelela ekuphelisweni kwe-endothelialization kunye ne-neointimal coverage.Ngokoqwalaselo lwe-histopathological, i-neointimal hyperplasia (BMS kunye ne-DES) emva kokufakelwa kwe-stent yayiqulunqwe ngokuyininzi i-proliferative prolifecellularsmooth-matrix ye-matrix.
Ngaloo ndlela, i-hyperplasia ye-neointimal imele inkqubo yokulungisa ebandakanya i-coagulation kunye nezinto ezivuthayo kunye neeseli ezenza ukwanda kweeseli ze-muscle kunye nokwakheka kwe-matrix ye-extracellular.Kwangoko emva kwe-PCI, iiplatelet kunye ne-fibrin idiphozithi kudonga lomkhumbi kwaye igaye i-leukocyte ngokusebenzisa uchungechunge lwee-molecule ze-cell adhesion.I-Rolling leukocytes ye-leukocyte idibanisa i-adherent integrated1 (CD11b / CD18) kunye neplatelet glycoprotein Ibα 53 okanye i-fibrinogen ebotshelelwe kwiplatelet glycoprotein IIb/IIIa.76,77
Ngokutsho kwedatha ekhulayo, iiseli ze-progenitor ze-bone marrow zibandakanyeka kwiimpendulo ze-vascular kunye neenkqubo zokulungisa.Ukuhlanganiswa kwe-EPCs ukusuka kwi-bone marrow kwi-peripheral blood ikhuthaza ukuvuselelwa kwe-endothelial kunye ne-postnatal neovascularization.Kubonakala ngathi i-bone marrow i-smooth muscle progenitor cells (SMPC) ifudukela kwindawo yokulimala kwe-vascular, ekhokelela kwi-CD4 ye-proliferation ye-CD48 ngaphambili, i-CD3. ukuba ngabantu abamiselweyo bee-EPCs; Uphononongo olongezelelweyo lubonise ukuba i-CD34 surface antigen ibona ngokwenene iiseli ze-stem zethambo ezingahlukanisiweyo ezikwaziyo ukwahlula kwii-EPCs kunye ne-SMPCs.Ukutshintshwa kweeseli ze-CD34-positive kwi-EPC okanye i-SMPC yomnombo ixhomekeke kwimeko yendawo; iimeko ze-ischemic zibangela ukuhlukana ngokubhekiselele kwi-phenotype ye-EPC ukukhuthaza ukuphindaphinda kwe-endothelialization, ngelixa iimeko ezivuthayo zenza ukuhlukana kwi-phenotype ye-SMPC ukukhuthaza ukwanda kwe-neointimal.79
Isifo sikashukela sonyusa umngcipheko we-ISR nge-30% -50% emva kokufakelwa kwe-BMS, i-80 kunye neziganeko eziphezulu ze-restenosis kwizigulane zesifo sikashukela xa kuthelekiswa nezigulane ezingenasifo se-diabetic nazo ziqhubekile kwixesha le-DES. isifo, njl.njl) izinto ezanda ngokuzimeleyo Ingozi ye-ISR.70
Ubukhulu besitya kunye nobude be-lesion buchaphazele ngokuzimeleyo iziganeko ze-ISR, kunye nobukhulu obuncinci / izilonda ezide kakhulu zokwandisa amazinga okuphumla xa kuthelekiswa nobukhulu obukhulu / izilonda ezimfutshane.71
Iiplatifti ze-stent zesizukulwana sokuqala zibonise i-stent stent struts kunye namazinga aphezulu e-ISR xa kuthelekiswa namaqonga e-stent esizukulwana sesibini aneentsimbi ezincinci.
Ukongezelela, iziganeko ze-restenosis zihambelana nobude be-stent, kunye nobude be-stent> 35 mm phantse ngokuphindwe kabini kunabo <20 mm. I-stent ye-lumen ye-lumen encinci ye-lumen ububanzi nayo yadlala indima ebalulekileyo: ubuncinci be-lumen ububanzi obuncinane bokugqibela buqikelele ukuba ingozi yokwandisa kakhulu i-restenosis.81,82
Ngokwesiko, i-hyperplasia ye-intimal elandela ukufakelwa kwe-BMS ithathwa njengezinzile, kunye nencopho yokuqala phakathi kweenyanga ze-6 kunye ne-1 unyaka, ilandelwa lixesha elizolileyo. i-neointimal regression .83 Nangona kunjalo, uphando olunexesha elide lokulandelelana lubonise impendulo ye-triphasic emva kokubekwa kwe-BMS, kunye nokuphumla kwangaphambili, ukuhla okuphakathi, kunye ne-lumen restenosis.84
Ngexesha le-DES, ukukhula kwexesha elide kwe-neointimal kwaqala kwaboniswa ngokulandela i-SES okanye i-PES yokufakelwa kwiimodeli zezilwanyana.85 Izifundo ezininzi ze-IVUS zibonise ukunyanzeliswa kwangaphambili kokukhula kwe-intimal elandelwa kukubamba emva kwexesha emva kwe-SES okanye i-PES yokufakelwa, mhlawumbi ngenxa yenkqubo eqhubekayo yokuvuvukala.86
Nangona "ukuzinza" ngokuqhelekileyo kubhekiselwa kwi-ISR, malunga nesinye kwisithathu sezigulane ze-BMS ISR ziphuhlisa i-ACS.4
Kukho ubungqina obuninzi bokuthi ukuvuvukala okungapheliyo kunye / okanye ukungasebenzi kwe-endothelial kubangela i-neoatherosclerosis ephezulu ngaphakathi kwe-BMS kunye ne-DES (ikakhulukazi i-DES yesizukulwana sokuqala), enokuba yinto ebalulekileyo ye-ISR okanye i-ST.Inoue et al. I-87 ichaze iziphumo ze-histological ezivela kwiisampulu ze-autopsy emva kokufakelwa kwe-Palmaz-Schatz coronary stents, ebonisa ukuba ukudumba kwe-peri-stent kunokukhawulezisa utshintsho olutsha olungenayo i-atherosclerotic ngaphakathi kwe-stent.Ezinye izifundo10 zibonise ukuba izicubu zokuphumla ngaphakathi kwe-BMS, ngaphezu kweminyaka eyi-5, iqulethe i-atherosclerosis esanda kuvela; Iisampulu ezivela kwiimeko ze-ACS zibonisa amacwecwe asemngciphekweni asemngciphekweni kwimibhobho ye-coronary yendalo I-Histological morphology yebhloko ene-foamy macrophages kunye ne-cholesterol crystals.Ukongezelela, xa kuthelekiswa ne-BMS kunye ne-DES, umahluko omkhulu ngexesha lokuphuhliswa kwe-atherosclerosis entsha yaqatshelwa.11,12 Utshintsho lokuqala lwe-atherosclerotic kwi-foamy macrophage yaqala ukutshintshwa kwe-foamy macrophage kwi-foamy macrophage yaqala ukufakwa kwe-foamy macrophage kwi-4. Izilonda ze-BMS zenzeke emva kweminyaka eyi-2 kwaye zahlala zifunyenwe ngokungaqhelekanga kude kube yiminyaka eyi-4. Ngaphezu koko, i-DES stenting yezilonda ezingazinzanga ezifana ne-fibroatherosclerosis ye-fibroatherosclerosis (TCFA) okanye i-intimal rupture inexesha elifutshane lokuphuhlisa xa kuthelekiswa ne-BMS.
Impembelelo yesizukulwana sesibini se-DES okanye i-DES ekuphuhliseni isala ukuba ifundwe; nangona ezinye iingqalelo ezikhoyo zesizukulwana sesibini i-DESs88 zibonisa ukudumba okuncinci, izehlo ze-neoatherosclerosis ziyafana nezo zesizukulwana sokuqala, kodwa Uphando olongezelelweyo lusafuneka.