I-Javascript ayisebenzi okwangoku kwisiphequluli sakho. Ezinye iimpawu zale webhusayithi azizukusebenza xa i-javascript ingasebenzi.
Bhalisa ngeenkcukacha zakho ezithile kunye neyeza elithile elinomdla kwaye siya kuthelekisa ulwazi olunikayo namanqaku akwisiseko sethu sedatha esibanzi kwaye sikuthumelele ikopi yePDF ngokukhawuleza.
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 Isishwankathelo: Drug-Eluting Stents (DES) inciphisa imida ye bare metal stents (BMS) emva kokungenelela kwe-percutaneous coronary. Nangona kunjalo, nangona ukungeniswa kwe-DES yesizukulwana sesibini kubonakala ngathi kuyilungisile le meko xa kuthelekiswa ne-DES yesizukulwana sokuqala, kusasekho iingxaki ezinkulu malunga neengxaki ezinokubakho emva kwexesha lokufakelwa kwe-stent, ezifana ne-stent thrombosis (ST) kunye ne-stent resection. I-Stenosis (ISR). I-ST sisiganeko esinokuba yintlekele esincitshiswe kakhulu ngenxa yokwenziwa kwe-stenting ephucukileyo, uyilo olutsha lwe-stent, kunye nonyango oluphindwe kabini lwe-antiplatelet. Indlela echanekileyo echaza ukwenzeka kwayo iyaphandwa, kwaye eneneni, kukho izinto ezininzi ezibangela oku. I-ISR kwi-BMS ngaphambili yayithathwa njengemeko ezinzileyo enencopho yokuqala ye-hyperplasia ye-intimal (kwiinyanga ezi-6) ilandelwa lixesha lokubuyela umva elingaphezulu konyaka omnye. Ngokwahlukileyo koko, zombini izifundo zeklinikhi kunye neze-histological ze-DESS zibonise ubungqina bokukhula okuqhubekayo kwe-neointimal ngexesha lokulandelela ixesha elide, into eyaziwa ngokuba yi-"late catch-up phenomenon". Umbono wokuba i-ISR yimeko yeklinikhi engenabungozi kutshanje uphikiswe bubungqina bokuba izigulana ezine-ISR zinokuhlakulela i-acute coronary syndromes. I-Intracoronary imaging yindlela yokungenelela enokuchonga ii-plaque ze-atherosclerotic ezi-stent kunye neempawu zokuphiliswa kwemithambo yegazi emva kwe-stent; Ihlala isetyenziselwa ukugqiba i-angiography ye-coronary diagnostic kunye nokuqhuba iinkqubo zokungenelela. I-Intracoronary optical coherence tomography okwangoku ithathwa njengeyona ndlela iphambili yokufota. Xa ithelekiswa ne-ultrasound yangaphakathi kwemithambo yegazi, inika isisombululo esingcono (ubuncinane ngaphezulu kwezihlandlo ezili-10), ivumela ukucaciswa okuneenkcukacha kwesakhiwo somphezulu wodonga lwemithambo yegazi. "Izifundo zokufota ze-In vivo" ezihambelana neziphumo ze-histological zibonisa ukuba ukudumba okungapheliyo kunye/okanye ukungasebenzi kakuhle kwe-endothelial kunokubangela i-neo-atherosclerosis yesigaba sokugqibela kwi-BMS kunye ne-DES. Ke ngoko, i-neo-atherosclerosis ibe ngumtyholwa oyintloko kwi-pathogenesis yokusilela kwe-stent yamva nje. Amagama angundoqo: i-coronary stent, i-stent thrombosis, i-restenosis, i-neoatherosclerosis
Ukungenelela kwentliziyo nge-percutaneous (PCI) ngokufakelwa kwe-stent yeyona nkqubo isetyenziswa kakhulu kunyango lwesifo semithambo yentliziyo esineempawu, kwaye le ndlela iyaqhubeka nokukhula.1 Nangona ii-stent ezisebenzisa amayeza (DES) zinciphisa imida yee-stent zentsimbi engenanto (ii-BMS), iingxaki ezisemva kwexesha ezifana ne-stent thrombosis (ST) kunye ne-in-stent restenosis (ISR) zinokwenzeka ngokufakelwa kwe-stent. , kusasele iingxaki ezinkulu.2-5
Ukuba i-ST sisiganeko esinokuba yintlekele, ukuqondwa kokuba i-ISR sisifo esingenabungozi kuye kwaphikiswa kutshanje bubungqina be-acute coronary syndrome (ACS) kwizigulane ze-ISR.4
Namhlanje, i-intracoronary optical coherence tomography (OCT)6-9 ithathwa njengendlela yokufota yangoku, enika isisombululo esingcono kune-intravascular ultrasound (IVUS).”Izifundo zokufota ze-In vivo,10-12 ezihambelana neziphumo ze-histological, zibonisa indlela “entsha” yokuphendula kwemithambo yegazi emva kokufakelwa kwe-stent, kunye ne-“neoatherosclerosis” entsha ngaphakathi kwe-BMS kunye ne-DES.
Ngo-1964, uCharles Theodore Dotter kunye noMelvin P Judkins bachaza i-angioplasty yokuqala. Ngo-1978, u-Andreas Gruntzig wenza i-angioplasty yokuqala yebhaluni (i-angioplasty endala yebhaluni); yayilunyango oluguqukayo kodwa lwaluneengxaki zokuvalwa kwemithambo yegazi ngokukhawuleza kunye ne-restenosis.13 Oku kwakhokelela ekufumanekeni kwee-stents zentliziyo: UPuel noSigwart bafaka i-stent yokuqala yentliziyo ngo-1986, bebonelela nge-stent yokuthintela ukuvalwa kwemithambo yegazi ngokukhawuleza kunye nokurhoxa kwe-systolic kade.14 Nangona ezi stents zokuqala zathintela ukuvalwa kwemithambo yegazi ngokukhawuleza, zabangela umonakalo omkhulu we-endothelial kunye nokuvuvukala. Kamva, iimvavanyo ezimbini ezibalulekileyo, iBelgian-Dutch Stent Trial 15 kunye neStent Restenosis Study 16, zakhuthaza ukhuseleko lwe-stenting nge-dual antiplatelet therapy (DAPT) kunye/okanye iindlela ezifanelekileyo zokusasazwa.17,18 Emva kwezi zilingo, kwabakho ukwanda okukhulu kwinani lee-PCI ezenziweyo.
Nangona kunjalo, ingxaki ye-iatrogenic in-stent neointimal hyperplasia emva kokubekwa kwe-BMS yafunyanwa ngokukhawuleza, nto leyo eyabangela i-ISR kwi-20%–30% yezilonda ezinyangiweyo. Ngo-2001, i-DES yaziswa19 ukunciphisa imfuneko yokuphumla kunye nokungenelela kwakhona. Ii-DES zonyuse ukuzithemba kweengcali zentliziyo, zivumela inani elikhulayo lezilonda ezinzima ezinyangwayo ezazicingelwa ukuba zisonjululwa yi-coronary artery bypass grafting. Ngo-2005, i-80%–90% yazo zonke ii-PCI zazihamba ne-DES.
Yonke into ineengxaki zayo, kwaye ukusukela ngo-2005, inkxalabo malunga nokhuseleko lwe-DES "yesizukulwana sokuqala" inyukile, kwaye ii-stents zesizukulwana esitsha ezifana ne-20,21 ziye zaphuhliswa kwaye zaziswa.22 Ukususela ngoko, imizamo yokuphucula ukusebenza kwe-stent ikhule ngokukhawuleza, kwaye ubuchwepheshe obutsha, obumangalisayo buqhubekile nokufunyanwa kwaye buziswa kwimarike ngokukhawuleza.
I-BMS yityhubhu yentsimbi ebhityileyo enemingxuma. Emva kokusebenzisa okokuqala i-“Wall” mount, i-Gianturco-Roubin mount kunye ne-Palmaz-Schatz mount, ngoku kukho ii-BMS ezininzi ezahlukeneyo.
Iintlobo ezintathu ezahlukeneyo zinokwenzeka: ikhoyili, ityhubhu yetyhubhu kunye netyhubhu enezikhewu. Iintlobo ezintathu zeekhoyili zineengcingo zesinyithi okanye imicu eyenziwe yaba yimilo yekhoyili ejikelezayo; iintlobo zeekhoyili ezinezikhewu zineengcingo ezidityaniswe ndawonye kwi-mesh ukwenza ityhubhu; iintlobo zeekhoyili ezinezikhewu zenziwe ngeetyhubhu zesinyithi ezisikiweyo nge-laser. Ezi zixhobo zahlukile ngokwakhiwa kwazo (intsimbi engatyiwayo, i-nichrome, i-cobalt chrome), uyilo lwesakhiwo (iipateni ezahlukeneyo ze-strut kunye nobubanzi, ububanzi kunye nobude, amandla e-radial, i-radiopacity) kunye neenkqubo zokuhambisa (ezizikhulisayo okanye ezinwebekayo ngebhaluni).
Ngokubanzi, i-BMS entsha ine-alloy ye-cobalt-chromium, ekhokelela kwiintambo ezincinci ezinokuphucula ukuhambahamba, okugcina amandla oomatshini.
Ziqulathe iqonga le-stent yesinyithi (ngesiqhelo intsimbi engatyiwayo) kwaye igqunywe nge-polymer engenazo iindlela zonyango ezilwa nokwanda kwamagciwane kunye/okanye ezilwa nokuvuvukala.
I-Sirolimus (ekwaziwa ngokuba yi-rapamycin) ekuqaleni yayiyilwe njenge-arhente yokubola. Indlela esebenza ngayo isuka ekuthinteleni inkqubela phambili yomjikelo weseli ngokuthintela utshintsho ukusuka kwisigaba se-G1 ukuya kwisigaba se-S kunye nokuthintela ukwakheka kwe-neointima. Ngo-2001, amava "okuqala ebantwini" nge-SES abonise iziphumo ezithembisayo, ezikhokelele ekuphuhlisweni kwe-stent yeCypher.23 Izilingo ezinkulu zibonise ukusebenza kwayo ekuthinteleni i-ISR. Amashumi amabini anesine
I-Paclitaxel yavunywa ekuqaleni ukuba inesifo somhlaza wesibeleko, kodwa iipropati zayo ezinamandla ze-cytostatic - eli yeza lizinzisa ii-microtubules ngexesha le-mitosis, likhokelela ekumisweni komjikelo weseli kwaye lithintele ukwakheka kwe-neointimal - lenza ukuba ibe yi-compound ye-Taxus Express PES. Uvavanyo lwe-TAXUS V kunye ne-VI lubonise ukusebenza kwexesha elide kwe-PES kwisifo se-coronary artery esinobungozi obuphezulu nesintsonkothileyo.25,26 I-TAXUS Liberté elandelayo yayineqonga lentsimbi engenasici ukuze kube lula ukuhanjiswa.
Ubungqina obupheleleyo obuvela kuphononongo olucwangcisiweyo olubini kunye nohlalutyo lwe-meta lubonisa ukuba i-SES inenzuzo kune-PES ngenxa yamazinga aphantsi e-ISR kunye ne-target vessel revascularization (TVR), kunye nomkhwa wokunyuka kwe-acute myocardial infarction (AMI) kwiqela le-PES. 27,28
Izixhobo zesizukulwana sesibini zinciphise ubukhulu be-strut, ziphucule ukuguquguquka/ukuhanjiswa, ziphucule ukuhambelana kwe-polymer/iiprofayili zokucoca amayeza, kunye ne-kinetics egqwesileyo yokubuyisela i-endothelialization. Kwindlela yanamhlanje, zezona zakhiwo ziphambili ze-DES kunye ne-coronary stents ezinkulu ezifakwe kwihlabathi liphela.
I-Taxus Elements yinkqubela phambili engakumbi ene-polymer eyahlukileyo eyenzelwe ukwandisa ukukhululwa kwangoko kunye nenkqubo entsha ye-platinum-chromium strut enika ii-struts ezincinci kunye ne-radiopacity ephuculweyo. Uvavanyo lwe-PERSEUS 29 luphawule iziphumo ezifanayo phakathi kwe-Element kunye ne-Taxus Express ukuya kuthi ga kwiinyanga ezili-12. Nangona kunjalo, iimvavanyo zokuthelekisa ii-yew elements nezinye i-DES zesizukulwana sesibini azikho.
I-zotarolimus-eluting stent (ZES) Endeavor isekelwe kwiqonga le-cobalt-chromium stent elinamandla elinokuguquguquka okuphezulu kunye nobukhulu obuncinci be-stent strut. I-Zotarolimus yi-analog ye-sirolimus eneziphumo ezifanayo zokucinezela amasosha omzimba kodwa i-lipophilicity ephuculweyo ukuphucula indawo yodonga lwemithambo yegazi. I-ZES isebenzisa i-polymer coating entsha ye-phosphorylcholine eyenzelwe ukwandisa ukuhambelana kwezinto eziphilayo kunye nokunciphisa ukudumba. Uninzi lwamayeza alunakucinywa ngexesha lesigaba sokuqala sokwenzakala, kulandele ukulungiswa kwemithambo yegazi. Emva kovavanyo lokuqala lwe-ENDEAVOR, uvavanyo olulandelayo lwe-ENDEAVOR III luthelekise i-ZES ne-SES, eyabonisa ukulahleka okukhulu kwe-lumen emva kwexesha kunye ne-ISR kodwa zimbalwa iziganeko ezimbi zentliziyo (MACE) kune-SES.30 Uvavanyo lwe-ENDEAVOR IV, oluthelekise i-ZES ne-PES, luphinde lwafumana ukwanda okuphezulu kwe-ISR, kodwa ukwanda okuphantsi kwe-AMI, okubonakala ngathi kuvela kwi-ST ephucukileyo kakhulu kwiqela le-ZES.31 Nangona kunjalo, uvavanyo lwe-PROTECT aluzange lubonise umahluko kumazinga e-ST phakathi kwe-Endeavor kunye ne-Cypher stents.32
I-Endeavor Resolute yinguqulelo ephuculweyo ye-stent ye-Endeavor ene-polymer entsha enamaleko amathathu. I-Resolute Integrity entsha (ngamanye amaxesha ibizwa ngokuba yi-DES yesizukulwana sesithathu) isekelwe kwiqonga elitsha elinamandla aphezulu okuhambisa (iqonga le-Integrity BMS), kwaye i-polymer entsha, ehambelana ne-bio-layer ezintathu, inokuthintela impendulo yokuqala yokuvuvukala kwaye isuse uninzi lwamayeza kwiintsuku ezingama-60 ezizayo. Uvavanyo oluthelekisa i-Resolute ne-Xience V (i-everolimus-eluting stent [EES]) lubonise ukungabi phantsi kwenkqubo ye-Resolute ngokubhekiselele ekufeni nasekusileleni kwesilonda ekujoliswe kuso.33,34
I-Everolimus, isiphumo se-sirolimus, ikwangunobangela wokungasebenzi kakuhle kweseli osetyenziswa ekuphuhlisweni kwe-Xience (i-Multi-link Vision BMS platform)/Promus (i-Platinum Chromium platform) EES. Uvavanyo lwe-SPIRIT 35-37 lubonise ukusebenza okuphuculweyo kunye nokunciphisa i-MACE nge-Xience V xa kuthelekiswa ne-PES, ngelixa uvavanyo lwe-EXCELLENT lubonise ukuba i-EES yayingaphantsi kwe-SES ekuthinteleni ukulahleka kade kwiinyanga ezili-9 kunye neziganeko zeklinikhi kwiinyanga ezili-12.38 Okokugqibela, i-Xience stent ibonise iingenelo kune-BMS kwimeko ye-ST-segment elevation myocardial infarction (MI).39
Ii-EPC liqela leeseli ezijikeleza igazi ezibandakanyeka kwi-vascular homeostasis kunye nokulungiswa kwe-endothelial. Ukuphuculwa kwee-EPC kwindawo yokwenzakala kwemithambo yegazi kuya kukhuthaza ukubuyiselwa kwe-endothelialization kwangoko, okunokunciphisa umngcipheko womzamo wokuqala webhayoloji ye-ST.EPC kwicandelo loyilo lwe-stent yi-CD34 antibody-coated Genous stent, ekwaziyo ukubopha ii-EPC ezijikelezayo ngokusebenzisa iimpawu zayo ze-hematopoietic ukuphucula ukubuyiswa kwe-endothelialization. Nangona izifundo zokuqala zazikhuthaza, ubungqina bamva nje bubonisa amazinga aphezulu e-TVR.40
Ukuqwalasela iziphumo ezinokuba yingozi zokuphiliswa okulibazisekileyo okubangelwa yipolymer, okunxulunyaniswa nomngcipheko we-ST, iipolymers ezifunxwa yibio zibonelela ngeenzuzo ze-DES, ziphepha inkxalabo yexesha elide malunga nokuqina kwepolymer. Ukuza kuthi ga ngoku, iinkqubo ezahlukeneyo ezifunxwa yibio ziye zavunywa (umz. iNobori kunye neBiomatrix, i-biolimus eluting stent, iSynergy, i-EES, i-Ultimaster, i-SES), kodwa uncwadi oluxhasa iziphumo zazo zexesha elide lulinganiselwe.41
Izinto ezifunxwa yi-biobiological zinenzuzo yethiyori yokubonelela ngenkxaso yoomatshini ekuqaleni xa kucingwa ngokubuyela umva kwe-elastic kunye nokunciphisa iingozi zexesha elide ezinxulumene ne-metal struts ezikhoyo. Ubuchwepheshe obutsha bukhokelele ekuphuhlisweni kweepolymers ezisekelwe kwi-lactic acid (i-poly-l-lactic acid [PLLA]), kodwa iinkqubo ezininzi ze-stent ziyaphuhliswa, nangona ukumisela ibhalansi efanelekileyo phakathi kwe-drug elution kunye ne-degradation kinetics kusengumngeni. Uvavanyo lwe-ABSORB lubonise ukhuseleko kunye nokusebenza kakuhle kwee-everolimus-eluting PLLA stents.43 Uhlaziyo lwesizukulwana sesibini lwe-Absorb stent lwaluphuculo kunolwangaphambili kunye nokulandelela okuhle kweminyaka emi-2.44 Uvavanyo oluqhubekayo lwe-ABSORB II, uvavanyo lokuqala olucwangcisiweyo oluthelekisa i-Absorb stent kunye ne-Xience Prime stent, kufuneka lubonelele ngedatha engaphezulu, kwaye iziphumo zokuqala ezikhoyo ziyathembisa.45 Nangona kunjalo, indawo efanelekileyo, indlela efanelekileyo yokufaka, kunye neprofayili yokhuseleko lwezilonda zentliziyo kufuneka zicaciswe ngcono.
I-Thrombosis kwi-BMS nakwi-DES ineziphumo ezimbi zeklinikhi. Kwirejista yezigulana ezifumana i-DES implantation, ama-47% eemeko ze-ST abangele ukufa, ama-60% avela kwi-MI engabulaliyo, kunye nama-7% avela kwi-angina engazinzile. I-PCI kwi-ST engxamisekileyo idla ngokuba yinto engalunganga, kwaye ukuphinda kwayo kwenzeke kwi-12% yeemeko.48
I-ST ePhambili ineziphumo ezibi zeklinikhi. Kwisifundo se-BASKET-LATE, kwiinyanga ezi-6 ukuya kwezi-18 emva kokubekwa kwe-stent, amazinga okufa kwentliziyo kunye ne-MI engabulaliyo ayephezulu kwiqela le-DES kunakwiqela le-BMS (4.9% kunye ne-1.3%, ngokulandelanayo).20 Uhlalutyo lwe-meta-analysis lweemvavanyo ezisithoba, apho izigulane ezingama-5,261 zathathwa ngokungacwangciswanga kwi-SES, PES, okanye i-BMS, zibike ukuba kwiminyaka emi-4 yokulandelela, i-SES (0.6% vs 0%, p=0.025) kunye ne-PES (0.7%) zonyuse ukwenzeka kwe-ST esemva kakhulu xa kuthelekiswa ne-BMS ngo-0.2%, p=0.028).49 Ngokwahlukileyo koko, kuhlalutyo lwe-meta oluquka izigulane ezingama-5,108, ezingama-21 ukwanda okunxulumene nokufa okanye i-MI kwaxelwa nge-SES xa kuthelekiswa ne-BMS (p=0.03), ngelixa i-PES yayinxulunyaniswa nokunyuka okungabalulekanga kwe-15% (Ukulandelela iinyanga ezi-9 ukuya kwezi-3). iminyaka).
Iirejista ezininzi, izilingo ezingacwangciswanga, kunye nohlalutyo lwe-meta ziye zaphanda umngcipheko we-ST emva kokufakelwa kwe-BMS kunye ne-DES kwaye zibike iziphumo ezingqubanayo. Kwirejista yezigulana ezingama-6,906 ezifumana i-BMS okanye i-DES, bekungekho mahluko kwiziphumo zeklinikhi okanye amazinga e-ST ngexesha lokulandelelana konyaka omnye.48 Kwenye irejista yezigulana ezingama-8,146, umngcipheko we-ST engapheliyo egqithisileyo ufunyenwe uyi-0.6%/ngonyaka xa kuthelekiswa ne-BMS.49 Uhlalutyo lwe-meta lwezilingo ezithelekisa i-SES okanye i-PES kunye ne-BMS lubonise umngcipheko ophezulu wokufa kunye ne-MI kunye ne-DES yesizukulwana sokuqala xa kuthelekiswa ne-BMS, ezingama-21 kunye nolunye uhlalutyo lwe-meta lwezigulana ezingama-4,545 ezingacwangciswanga kwi-SES okanye Bekungekho mahluko kwiziganeko ze-ST phakathi kwe-PES kunye ne-BMS kwiminyaka emi-4 yokulandelelana.50 Ezinye izifundo zehlabathi lokwenyani zibonise umngcipheko ophezulu we-ST kunye ne-MI ephucukileyo kwizigulane ezifumana i-DES yesizukulwana sokuqala emva kokuyeka i-DAPT.51
Ngenxa yobungqina obuphikisanayo, uhlalutyo oluninzi oludibeneyo kunye nohlalutyo lwe-meta kunye lubonise ukuba i-DES kunye ne-BMS yesizukulwana sokuqala azihlukanga kakhulu kumngcipheko wokufa okanye i-MI, kodwa i-SES kunye ne-PES zazinomngcipheko ophezulu we-ST ephucukileyo kakhulu xa kuthelekiswa ne-BMS. Ukuphonononga ubungqina obufumanekayo, i-US Food and Drug Administration (FDA) yonyule iphaneli yeengcali53 eyakhupha ingxelo evumayo ukuba i-DES yesizukulwana sokuqala yayisebenza kwiimpawu ezikwileyibhile kwaye umngcipheko we-ST ephucukileyo kakhulu wawumncinci kodwa umncinci. Ukwanda okukhulu. Ngenxa yoko, i-FDA kunye nombutho bacebisa ukuba kwandiswe ixesha le-DAPT liye kunyaka omnye, nangona kukho idatha encinci yokuxhasa eli bango.
Njengoko bekutshiwo ngaphambili, i-DES yesizukulwana sesibini eneempawu zoyilo eziphambili iye yaphuhliswa. IiCoCr-EES ziye zadlula kwizifundo zeklinikhi ezibanzi kakhulu. Kuhlalutyo lwe-meta olwenziwe nguBaber et al, 54 kuquka izigulane ezili-17,101, iCoCr-EES inciphise kakhulu i-ST eqinisekileyo/enokwenzeka kunye ne-MI xa kuthelekiswa ne-PES, SES, kunye ne-ZES emva kweenyanga ezingama-21. Okokugqibela, uPalmeri et al ubonise kuhlalutyo lwe-meta lwezigulane ezili-16,775 ukuba iCoCr-EES yayine-ST eqinisekileyo ephantsi kakhulu kwangethuba, kade, kunyaka omnye kunye nowesibini xa kuthelekiswa nezinye ii-DES ezidityanisiweyo.55 Izifundo zehlabathi lokwenyani zibonise ukuncipha komngcipheko we-ST ngeCoCr-EES xa kuthelekiswa ne-DES yesizukulwana sokuqala.56
I-Re-ZES ithelekiswe ne-CoCr-EES kwizilingo ze-RESOLUTE-AC kunye ne-TWENTE.33,57 Akukho mahluko abalulekileyo kwiziganeko zokufa, i-myocardial infarction, okanye i-ST ecacileyo phakathi kwe-stents ezimbini.
Kwi-network meta-analysis yezigulane ezingama-50,844 kuquka ii-RCT ezingama-49, i-58CoCr-EES yayinxulunyaniswa nokuhla kwe-ST ecacileyo kune-BMS, isiphumo asibonwanga kwezinye ii-DES; ukwehla akuzange kube kuphela kwi-Important early nakwiintsuku ezingama-30 (umlinganiselo we-odds [OR] 0.21, 95% confidence interval [CI] 0.11-0.42) kwaye nakwiminyaka eli-1 (OR 0.27, 95% CI 0.08-0.74) kunye neminyaka emi-2 (OR 0.35, 95% CI 0.17–0.69). Xa kuthelekiswa ne-PES, SES, kunye ne-ZES, i-CoCr-EES yayinxulunyaniswa nokuhla kwe-ST kunyaka eli-1.
I-ST yasekuqaleni inxulumene nezinto ezahlukeneyo. Ukwakheka kweplaque esisiseko kunye nomthwalo we-thrombus kubonakala ngathi kunefuthe kwiziphumo emva kwe-PCI; 59 Ukungena okunzulu kwe-strut ngenxa ye-necrotic core (NC) prolapse, ukukrazula kwe-medial kubude be-stent, ukuqhekeka kwesibini kunye nemida eseleyo, okanye ukunciphisa umda okubalulekileyo I-stenting efanelekileyo, i-apposition engaphelelanga, kunye nokwandiswa okungaphelelanga60 Inkqubo yonyango ngamayeza e-antiplatelet ayichaphazeli kakhulu ukuvela kwe-ST yasekuqaleni: ukuvela kwe-ST ebukhali kunye ne-subacute ngexesha le-DAPT kuvavanyo olucwangcisiweyo oluthelekisa i-BMS ne-DES Amanani ayefana (<1%).61 Ke ngoko, i-ST yasekuqaleni ibonakala inxulumene kakhulu nezilonda zonyango ezisisiseko kunye nezinto zotyando.
Namhlanje, ingqwalasela ethile ikwi-ST esemva/emva kakhulu. Ukuba izinto zenkqubo kunye nezobuchwephesha zibonakala zidlala indima enkulu ekuphuhlisweni kwe-ST ebukhali neyi-subacute, indlela yokusebenza kweziganeko ze-thrombotic ezibambezelekileyo ibonakala iyinkimbinkimbi ngakumbi. Kuye kwacetyiswa ukuba iimpawu ezithile zesigulana zinokuba zizinto ezinobungozi kwi-ST ephucukileyo nephucukileyo kakhulu: isifo seswekile, i-ACS ngexesha lotyando lokuqala, ukungaphumeleli kwezintso, ubudala obudala, iqhezu lokukhupha elinciphileyo, iziganeko ezinkulu ezimbi zentliziyo kwiintsuku ezingama-30 zotyando lokuqala. Kwi-BMS kunye ne-DES, izinto eziguquguqukayo zenkqubo, ezifana nobukhulu bomthambo omncinci, ukuqhekeka kwemithambo yegazi, isifo se-polyvascular, i-calcification, ukuvaleka okupheleleyo, ii-stents ezinde, zibonakala zinxulunyaniswa nomngcipheko we-ST.62,63 Impendulo enganeleyo kunyango lwe-antiplatelet yinto ephambili enobungozi kwi-DES thrombosis ephucukileyo 51. Le mpendulo inokubangwa kukunganamatheli kwesigulana, ukungasebenzi kakuhle kwedosi, ukusebenzisana kwamayeza, ezinye izinto ezichaphazela impendulo yamayeza, ii-polymorphisms zemfuza kwinqanaba le-receptor (ingakumbi ukumelana ne-clopidogrel), kunye nokunyuka kwezinye iindlela zokuvula iiplatelet. I-In-stent neoatherosclerosis ithathwa njengendlela ebalulekileyo yemva nje ukusilela kwe-stent, kuquka i-ST64 yamva nje (icandelo elithi “In-stent neoatherosclerosis”). I-endothelium engaguqukiyo yahlula udonga lwemithambo yegazi olune-thrombosed kunye ne-stent struts ukusuka ekuphumeni kwegazi kwaye ikhuphe izinto ezilwa noxinzelelo lwegazi kunye ne-vasodilator. I-DES iveza udonga lwemithambo yegazi kumayeza okuthintela ukwanda kwamalungu omzimba kunye neqonga lokuthintela amayeza elinemiphumo eyahlukileyo ekuphilisweni nasekusebenzeni kwe-endothelial, kunye nomngcipheko we-thrombosis yamva nje.65 Izifundo ze-pathological zibonisa ukuba ii-polymers ezihlala ixesha elide ze-DES yesizukulwana sokuqala zinokuba negalelo ekuvuvukeni okungapheliyo, ukufakwa kwe-fibrin engapheliyo, ukuphiliswa kakubi kwe-endothelial, kunye nomngcipheko owandisiweyo we-thrombosis.3 Uxinzelelo oluvela emva kwexesha kwi-DES lubonakala lulunye uhlobo lwendlela olukhokelela kwi-ST. UVirmani et al66 babike iziphumo ze-post-mortem post-ST ezibonisa ukwanda kwe-aneurysm kwicandelo le-stent kunye neempendulo ze-hypersensitivity zasekuhlaleni ezenziwe yi-T lymphocytes kunye ne-eosinophils; ezi ziphumo zinokubonakalisa impembelelo yeepolymers ezingenakubola.67 Ukungasebenzi kakuhle kwe-stent kusenokuba ngenxa yokwandiswa kwe-stent engaphantsi okanye kwenzeke kwiinyanga emva kwe-PCI. Nangona ukungasebenzi kakuhle kwenkqubo kuyingozi kwi-ST ebukhali neyi-subacute, ukubaluleka kweklinikhi kokungasebenzi kakuhle kwe-stent kunokuxhomekeka ekuguqulweni kwemithambo yegazi ngendlela ebukhali okanye ukuphiliswa okulibazisekileyo okubangelwa ngamayeza, kodwa ukubaluleka kwayo kweklinikhi kuyaphikiswana.68
Iziphumo zokukhusela ze-DES yesizukulwana sesibini zinokubandakanya i-endothelialization ekhawulezayo nengaguqukiyo, kunye nomahluko kwi-stent alloy kunye nesakhiwo, ubukhulu be-strut, iipropati ze-polymer, kunye nohlobo lweyeza elichasene nokwanda, idosi, kunye ne-kinetics.
Xa kuthelekiswa neCoCr-EES, ii-struts ze-cobalt-chromium ezibhityileyo (81 µm), ii-fluoropolymers ezilwa noxinzelelo lwegazi, i-polymer ephantsi, kunye nomthwalo wamayeza kunokubangela ukuba i-ST ibe sezantsi. Izifundo zovavanyo zibonise ukuba i-thrombosis kunye ne-platelet deposition ye-fluoropolymer-coated stents ziphantsi kakhulu kunezo ze-bare-metal stents.69 Nokuba ezinye i-DES zesizukulwana sesibini zineempawu ezifanayo na kufuneka zifundwe ngakumbi.
Ii-coronary stents ziphucula izinga lempumelelo yotyando lokungenelela kwentliziyo xa kuthelekiswa ne-percutaneous transluminal coronary angioplasty (PTCA) yendabuko, eneengxaki zoomatshini (ukuvaleka kwemithambo yegazi, ukuqhaqha, njl.njl.) kunye namazinga aphezulu okuphumla (ukuya kuthi ga kwi-40%–50% yamatyala). Ngasekupheleni kweminyaka yoo-1990, phantse i-70% yee-PCIs zenziwa ngokufakelwa kwe-BMS.70
Nangona kunjalo, nangona kukho inkqubela phambili kwezobuchwepheshe, iindlela, kunye nonyango lwezonyango, umngcipheko we-restenosis emva kokufakelwa kwe-BMS umalunga ne-20%, kunye ne->40% kumaqela athile amancinci.71 Ngokubanzi, izifundo zeklinikhi zibonise ukuba i-restenosis emva kokufakelwa kwe-BMS, efana naleyo ibonwa kwi-PTCA eqhelekileyo, ifikelela kwincopho kwiinyanga ezi-3-6 kwaye iyaphela emva konyaka omnye.72
I-DES inciphisa ngakumbi ukuvela kwe-ISR,73 nangona oku kuncipha kuxhomekeke kwi-angiography kunye nemeko yeklinikhi. I-polymer coating kwi-DES ikhupha ii-anti-inflammatory kunye ne-anti-proliferative agents, ithintela ukwakheka kwe-neointima, kwaye ilibazise inkqubo yokulungiswa kwemithambo yegazi kangangeenyanga ukuya kwiminyaka.74 Ukukhula kwe-neointima okuqhubekekayo ngexesha lokulandelela ixesha elide emva kokufakelwa kwe-DES, into eyaziwa ngokuba yi-"late catch-up", yabonwa kwizifundo zeklinikhi neze-histological.75
Ukulimala kwemithambo yegazi ngexesha le-PCI kuvelisa inkqubo enzima yokuvuvukala nokulungiswa kwixesha elifutshane (iiveki ukuya kwiinyanga), okukhokelela ekufakweni kwe-endothelialization kunye nokugubungela kwe-neointimal. Ngokweengxelo ze-histopathological, i-neointimal hyperplasia (i-BMS kunye ne-DES) emva kokufakelwa kwe-stent yayiqulathe ikakhulu iiseli zemisipha ezithambileyo ezikhula ngokukhawuleza kwi-proteoglycan-rich extracellular matrix.70
Ngoko ke, i-neointimal hyperplasia imele inkqubo yokulungisa equka ukujiya kunye nezinto ezibangela ukudumba kunye neeseli ezibangela ukwanda kweeseli zemisipha egudileyo kunye nokwakheka kwe-extracellular matrix. Ngokukhawuleza emva kwe-PCI, ii-platelets kunye ne-fibrin zibeka eludongeni lwemithambo yegazi kwaye ziqokelela ii-leukocytes ngothotho lwee-molecules zokunamathela kweseli. Ii-leukocytes eziqengqelekayo zinamathela kwii-platelets ezinamathelayo ngokusebenzisana phakathi kwe-leukocyte integrin Mac-1 (CD11b/CD18) kunye ne-platelet glycoprotein Ibα 53 okanye i-fibrinogen ebotshelelwe kwi-platelet glycoprotein IIb/IIIa.76,77
Ngokwedatha evelayo, iiseli zomnombo ezisuka kumongo wethambo zibandakanyeka kwiimpendulo zemithambo kunye neenkqubo zokulungisa. Ukuhlanganiswa kwee-EPCs ukusuka kumongo wethambo ukuya egazini elingaphandle kukhuthaza ukuvuselelwa kwe-endothelial kunye ne-neovascularization emva kokuzalwa. Kubonakala ngathi iiseli zomnombo wethambo ezithambileyo (SMPC) ziya kwindawo yokwenzakala kwemithambo, nto leyo ekhokelela ekwandeni kwemithambo.78 Ngaphambili, iiseli ze-CD34-positive zazithathwa njengenani elimiselweyo lee-EPCs; izifundo ezongezelelweyo zibonise ukuba i-CD34 surface antigen ngokwenene iyazibona iiseli ze-bone marrow ezingahlukaniyo ezinokukwazi ukwahlulahlula zibe zii-EPCs kunye nee-SMPCs. Ukutshintshwa kweeseli ze-CD34-positive ukuya kumgca we-EPC okanye we-SMPC kuxhomekeke kwindawo yasekuhlaleni; iimeko ze-ischemic zibangela ukwahlukana ukuya kwi-phenotype ye-EPC ukukhuthaza ukuphinda kuphele, ngelixa iimeko zokudumba zibangela ukwahlukana ukuya kwi-phenotype ye-SMPC ukukhuthaza ukwanda kwe-neointimal.79
Isifo seswekile sonyusa umngcipheko we-ISR ngama-30%–50% emva kokufakelwa kwe-BMS,80 kwaye ukwanda kwe-restenosis kwizigulane zeswekile xa kuthelekiswa nezigulana ezingenesifo seswekile nako kuqhubeke kwixesha le-DES. Iindlela ezisisiseko solu qwalaselo zisenokuba zizinto ezininzi, ezibandakanya inkqubo yomzimba (umz., ukuguquguquka kwempendulo yokudumba) kunye nezinto zomzimba (umz., imithambo yegazi emincinci, izilonda ezinde, isifo esisasazekayo, njl.njl.) izinto ezikhulisa ngokwazo Umngcipheko we-ISR.70
Ububanzi besitya kunye nobude besilonda buchaphazele ngokuzimeleyo ukwanda kwe-ISR, kwaye ububanzi obuncinci/izilonda ezinde zinyusa kakhulu amazinga okuphumla xa kuthelekiswa nobubanzi obukhulu/izilonda ezimfutshane.71
Amaqonga e-stent esizukulwana sokuqala abonise ii-struts ezityebileyo kunye namazinga aphezulu e-ISR xa kuthelekiswa namaqonga e-stent esizukulwana sesibini anee-struts ezincinci.
Ukongeza, ukwenzeka kwe-restenosis kwakunxulumene nobude be-stent, ubude be-stent bungaphezulu kwama-35 mm phantse buphindwe kabini kunobo bungaphantsi kwama-20 mm. Ububanzi bokugqibela be-stent minimum lumen nabo budlale indima ebalulekileyo: ububanzi obuncinci bokugqibela be-lumen buxele ukuba umngcipheko wokwanda kwe-restenosis uza kwanda kakhulu.81,82
Ngokwesiko, i-intimal hyperplasia emva kokufakelwa kwe-BMS ithathwa njengezinzileyo, kunye nencopho yokuqala phakathi kweenyanga ezi-6 kunye nonyaka omnye, ilandelwa lixesha lokuthula emva kwexesha. Incopho yokuqala yokukhula kwe-intimal yayixelwe ngaphambili, ilandelwa yi-intimal regression kunye nokwandiswa kwe-lumen kwiminyaka eliqela emva kokufakelwa kwe-stent;71 Ukuvuthwa kweeseli zemisipha egudileyo kunye notshintsho kwi-extracellular matrix kuye kwacetyiswa njengeendlela ezinokwenzeka zokubuyela umva kwe-neointimal.83 Nangona kunjalo, izifundo ezinokulandelwa kwexesha elide zibonise impendulo ye-triphasic emva kokubekwa kwe-BMS, kunye ne-restenosis yasekuqaleni, i-intermediate regression, kunye ne-late lumen restenosis.84
Kwixesha le-DES, ukukhula kwe-neointimal emva kwexesha kwaqala kwabonakala emva kokufakelwa kwe-SES okanye i-PES kwiimodeli zezilwanyana.85 Izifundo ezininzi ze-IVUS zibonise ukuncitshiswa kwangoko kokukhula kwe-intimal kulandele ukubanjwa kade emva kwexesha emva kokufakelwa kwe-SES okanye i-PES, mhlawumbi ngenxa yenkqubo eqhubekayo yokuvuvukala.86
Nangona "ukuzinza" okuqhele ukuthathwa njenge-ISR, malunga nesinye kwisithathu sezigulane ze-BMS ISR ziba ne-ACS.4
Kukho ubungqina obandayo bokuba ukudumba okungapheliyo kunye/okanye ukungasebenzi kakuhle kwe-endothelial kubangela i-neoatherosclerosis ephucukileyo kwi-BMS kunye ne-DES (ikakhulu i-DES yesizukulwana sokuqala), enokuba yindlela ebalulekileyo ye-ISR ephucukileyo okanye i-ST ephucukileyo. Inoue et al. 87 babike iziphumo ze-histological ezivela kwiisampuli ze-autopsy emva kokufakelwa kwe-Palmaz-Schatz coronary stents, nto leyo ebonisa ukuba ukudumba kwe-peri-stent kunokukhawulezisa utshintsho olutsha lwe-atherosclerotic olungasebenziyo kwi-stent. Ezinye izifundo10 zibonise ukuba izicubu ze-restenotic ngaphakathi kwe-BMS, kwiminyaka engaphezu kwemi-5, ziquka i-atherosclerosis entsha, enokuvuvukala kwe-peri-stent okanye engenako; Iisampulu ezivela kwiimeko ze-ACS zibonisa iiplaque eziqhelekileyo ezisengozini kwimithambo yentliziyo yendalo Imo ye-Histological yebhloko ene-foamy macrophages kunye neekristale ze-cholesterol. Ukongeza, xa kuthelekiswa i-BMS kunye ne-DES, umahluko omkhulu kwixesha lokuphuhliswa kwe-atherosclerosis entsha waphawulwa.11,12 Utshintsho lokuqala lwe-atherosclerotic kwi-foamy macrophage infiltration lwaqala kwiinyanga ezi-4 emva kokufakelwa kwe-SES, ngelixa utshintsho olufanayo kwizilonda ze-BMS lwenzeka emva kweminyaka emi-2 kwaye lwahlala luyinto engaqhelekanga de kwaba yiminyaka emi-4. Ngaphezu koko, i-DES stenting yezilonda ezingazinzanga ezifana ne-thin-cap fibroatherosclerosis (TCFA) okanye i-intimal rupture inexesha elifutshane lokuphuhliswa xa kuthelekiswa ne-BMS. Ke ngoko, i-neoatherosclerosis ibonakala ixhaphake kakhulu kwaye yenzeka kwangoko kwi-DES yesizukulwana sokuqala kune-BMS, mhlawumbi ngenxa ye-pathogenesis eyahlukileyo.
Impembelelo ye-DES okanye i-DES yesizukulwana sesibini kuphuhliso isaza kufundwa; nangona ezinye izinto ezibonwe kwi-DES yesizukulwana sesibini zibonisa ukudumba okuncinci, ukwanda kwe-neoatherosclerosis kufana noko kwesizukulwana sokuqala, kodwa uphando olongezelelweyo lusafuneka.