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UMarta Francesca Brancati, 1 UFrancesco Burzotta, 2 UCarlo Trani, 2 UOrnella Leonzi, 1 UClaudio Cuccia, 1 UFilippo Crea2 1 Isebe leCardiology, Isibhedlele sePoliambulanza Foundation, eBrescia, 2 Isebe leCardiology, IYunivesithi yamaKatolika yeNtliziyo eNgcwele yaseRoma, e-Itali Isishwankathelo: IiDrug Stents ezigqunywe (DES) zinciphisa imida yokusebenzisa ii-stents zesinyithi ezingenanto (BMS) emva kokungenelela kwentliziyo engapheliyo. Nangona kunjalo, nangona ukungeniswa kwe-DES yesizukulwana sesibini kubonakala ngathi kuyinciphisile le nto xa kuthelekiswa ne-DES yesizukulwana sokuqala, kusasele iinkxalabo ezibalulekileyo malunga neengxaki ezinokubakho emva kwexesha zokufakelwa kwe-stent ezifana ne-stent thrombosis (ST) kunye nokususwa kwe-stent, i-stenosis (SSI). I-ST sisiganeko esinokuba yintlekele esincitshiswe kakhulu kukufakelwa kwe-stent optimized, uyilo olutsha lwe-stent, kunye nonyango oluphindwe kabini lwe-antiplatelet. Indlela echanekileyo echaza ukwenzeka kwayo iphantsi kophando, kwaye eneneni kukho izinto ezininzi ezibangela oku. I-ISR kwi-BMS ngaphambili yayithathwa njengemeko ezinzileyo enencopho yokuqala ye-intimal hyperplasia (kwiinyanga ezi-6) ilandelwa lixesha lokubuyela umva elingaphezulu konyaka omnye. Ngokwahlukileyo koko, zombini izifundo zeklinikhi neze-histological ze-DES zibonise ubungqina bokukhula okuqhubekayo kwe-neointimal kwixesha elide lokulandelela, into eyaziwa ngokuba yi-"late catch-up phenomenon". Ingcamango yokuba i-ISR yimeko yeklinikhi engenabungozi isandul' ukuphikiswa bubungqina bokuba izigulana ezine-ISR zinokuba ne-acute coronary syndromes. I-Intracoronary imaging yindlela yokuhlasela yokuchonga ii-plaque ze-atherosclerotic ezithambileyo kunye neempawu zokuphiliswa kwemithambo yegazi emva kokufumana i-stenting, kwaye idla ngokusetyenziselwa ukugqiba i-coronary angiography kunye nokwenza iinkqubo zokungenelela. I-Intracoronary optical coherence tomography okwangoku ithathwa njengeyona ndlela iphambili yokufota. Inika, xa kuthelekiswa ne-ultrasound yangaphakathi kwemithambo yegazi, isisombululo esingcono (ubuncinane ngaphezulu kwezihlandlo ezili-10), ivumela ukucaciswa okuneenkcukacha kwesakhiwo esingaphezulu sodonga lwemithambo yegazi. Inika, xa kuthelekiswa ne-ultrasound yangaphakathi kwemithambo yegazi, isisombululo esingcono (ubuncinane ngaphezulu kwezihlandlo ezili-10), ivumela ukucaciswa okuneenkcukacha kwesakhiwo esingaphezulu sodonga lwemithambo yegazi. оно обеспечивает, по сравнению с внутрисосудистым УЗИ, лучшее разрешение (по крайней мере, >10 раз), что позволяет деавальшение структуру стенки сосуда. Inika, xa kuthelekiswa ne-ultrasound yangaphakathi kwemithambo yegazi, isisombululo esingcono (ubuncinane ngaphezulu kwezihlandlo ezili-10), nto leyo evumela ukucaciswa okuneenkcukacha kolwakhiwo lomphezulu wodonga lwemithambo yegazi.与血管内超声相比，它提供了更好的分辨率（至面少> 10 倍），允许详细表征公管的与血管内超声相比，它提供了更好的分辨率（至面少> 10)Xa kuthelekiswa ne-ultrasound yangaphakathi kwemithambo yegazi, inika isisombululo esingcono (ubuncinane izihlandlo ezili-10), nto leyo evumela ukucaciswa okuneenkcukacha kwesakhiwo somphezulu wodonga lwemithambo yegazi.Izifundo zomfanekiso we-in vivo ezihambelana neziphumo ze-histological zibonisa ukuba ukudumba okungapheliyo kunye/okanye ukungasebenzi kakuhle kwe-endothelial kunokubangela i-neoatherosclerosis eqhubele phambili kwi-HMS kunye ne-DES. Ngoko ke, i-neoatherosclerosis iye yaba ngumrhanelwa oyintloko kwi-pathogenesis yokusilela kwe-stent kamva. Amagama aphambili: i-coronary stent, i-stent thrombosis, i-restenosis, i-neoatherosclerosis.
I-Stented percutaneous coronary intervention (PCI) yeyona nkqubo isetyenziswa kakhulu kunyango lwesifo semithambo yentliziyo esineempawu, kwaye le ndlela iyaqhubeka nokukhula. 1 Nangona ii-drug eluting stents (DES) zinciphisa imida yee-uncoated stents (UES), iingxaki ezisemva kwexesha ezifana ne-stent thrombosis (ST) kunye ne-stent restenosis (ISR) zinokwenzeka ngokufakelwa kwe-stent, kwaye kusasekho iingxaki ezinkulu. 2-5
Ukuba i-ST sisiganeko esinokuba yintlekele, ukwamkelwa kokuba i-ISR sisifo esingenabungozi kuye kwaphikiswa kutshanje bubungqina be-acute coronary syndrome (ACS) kwizigulane ezine-ISR.
Namhlanje, i-intracoronary optical coherence tomography (OCT)6-9 ithathwa njengendlela yokufota yesimanje enika isisombululo esingcono kune-intravascular ultrasound (IVUS). Izifundo zokufota ze-in vivo10-12 ezihambelana neziphumo ze-histological zibonisa indlela "entsha" yokuphendula kwimithambo yegazi emva kokufakelwa kwe-stent nge-de novo "neoatherosclerosis" ngaphakathi kwe-BMS kunye ne-DES.
Ngo-1964 uCharles Theodore Dotter kunye noMelvin P. Judkins bachaza i-angioplasty yokuqala. Ngo-1978, u-Andreas Grunzig wenza i-angioplasty yokuqala yebhaluni (i-angioplasty endala yebhaluni eqhelekileyo); yayilunyango oluguqukayo, kodwa lwaluneengxaki zokuvalwa kwemithambo yegazi ngokukhawuleza kunye ne-restenosis. 13 Oku kwakhokelela ekufumanekeni kwe-coronary stents: UPuel noSigwart bafaka i-coronary stent yokuqala ngo-1986, bebonelela nge-stent yokuthintela ukuvalwa kwemithambo yegazi ngokukhawuleza kunye nokurhoxa kwe-systolic kade. 14 Nangona ezi stents zokuqala zathintela ukuvalwa kwemithambo yegazi ngequbuliso, zabangela umonakalo omkhulu we-endothelial kunye nokuvuvukala. Kutshanje, izifundo ezimbini ezibalulekileyo, iBelgian-Dutch Stent Study 15 kunye neStent Restenosis Study 16, ziye zakhuthaza ukhuseleko lwe-dual antiplatelet therapy (DAPT) stenting kunye/okanye iindlela ezifanelekileyo zokusasazwa. 17,18 Emva kwezi zilingo, inani lee-PCI ezenziweyo landa kakhulu.
Nangona kunjalo, ingxaki ye-iatrogenic in-stent neointima hyperplasia emva kokubekwa kwe-BMS yafunyanwa ngokukhawuleza, nto leyo eyabangela i-ISR kwi-20-30% yezilonda ezinyangiweyo. I-DES19 yaziswa ngo-2001 ukunciphisa imfuneko yokuphumla notyando kwakhona. I-DES yonyuse ukuzithemba kweengcali zentliziyo ngokuvumela unyango lwenani elikhulayo lezilonda ezintsonkothileyo ezazithathwa njengezinokunyangwa ngaphambili nge-coronary artery bypass grafting. Ngo-2005, ama-80-90% azo zonke ii-PCI zazihamba ne-DES.
Yonke into ineengxaki zayo, kwaye ukusukela ngo-2005 inkxalabo malunga nokhuseleko lwe-DES "yesizukulwana sokuqala" inyukile, ii-stents zesizukulwana esitsha ezifana ne-20,21 ziye zaphuhliswa kwaye zaziswa. 22 Ukususela ngoko, imizamo yokuphucula ukusebenza kwee-stents ikhule ngokukhawuleza, kwaye ubuchwepheshe obutsha obunomdla buqhubekile nokufunyanwa kwaye buziswa ngokukhawuleza kwimarike.
I-BMS yityhubhu entle ye-wire mesh. Emva kokusebenzisa okokuqala i-Wall mount, i-Gianturco-Roubin mount kunye ne-Palmaz-Schatz mount, ngoku kukho ii-BMS ezininzi ezahlukeneyo.
Kukho iindlela ezintathu ezahlukeneyo zoyilo ezikhoyo: i-serpentine, i-tubular mesh kunye ne-sloted tube. Uyilo lwe-coil luquka iingcingo zesinyithi okanye imicu eyenza imo ye-coil engqukuva; kwi-tubular mesh designs, i-wire rounded to be a mesh yenza i-tube; uyilo lwe-sloted luquka ii-metal tubes ezisikiweyo nge-laser. Ezi zixhobo zahlukile ngokwakhiwa kwazo (intsimbi engatyiwayo, i-nichrome, i-cobalt chrome), uyilo (ii-spacer shapes ezahlukeneyo kunye nobubanzi, ububanzi kunye nobude, amandla e-radial, i-radiopacity), kunye neenkqubo zokuhambisa (ezizikhulisayo okanye ezinwebekayo ngebhaluni).
Ngokwesiqhelo, i-BMS entsha ine-alloy ye-cobalt-chromium, nto leyo ebangela ukuba ii-struts zibe ncinci, ukusebenza ngcono kokuqhuba kunye namandla oomatshini agcinwe.
Ziqulathe iqonga le-stent yesinyithi (ngesiqhelo intsimbi engatyiwayo) kwaye zigqunywe nge-polymer ekhupha ii-arhente zonyango ezilwa nokwanda kunye/okanye ezilwa nokuvuvukala.
I-Sirolimus (ekwaziwa ngokuba yi-rapamycin) yaqala ukuphuhliswa njenge-arhente yokubola. Indlela esebenza ngayo inxulunyaniswa nokuthintela ukuqhubela phambili komjikelo weseli ngokuthintela utshintsho ukusuka kwisigaba se-G1 ukuya kwisigaba se-S kunye nokuthintela ukwakheka kwe-neointima. Ngo-2001, amava "omntu wokuqala" nge-SES abonise iziphumo ezithembisayo, ezikhokelela ekuphuhlisweni kwe-stent yeCypher. 23 Uvavanyo olukhulu lubonise ukusebenza kwayo ekuthinteleni i-IR. 24
Ekuqaleni iPaclitaxel yavunywa ukuba inyange umhlaza wesibeleko, kodwa iipropati zayo ezinamandla ze-cytostatic—eli yeza lizinzisa ii-microtubules ngexesha le-mitosis, libangela ukunqandwa komjikelo weseli, kwaye lithintele ukwakheka kwe-neointimal—lenza libe yi-compound yeTaxus Express PES. Uvavanyo lwe-TAXUS V kunye ne-VI lubonise ukusebenza kwexesha elide kwe-PES kwisifo sentliziyo esinobungozi obuphezulu. 25,26 I-TAXUS Liberté elandelayo yayineqonga lentsimbi engenasici ukuze kube lula ukuhanjiswa.
Ubungqina obuqinileyo obuvela kuphononongo olucwangcisiweyo olubini kunye nohlalutyo lwe-meta lubonisa ukuba i-SES inenzuzo kune-PES ngenxa yamazinga aphantsi e-IVR kunye ne-target vessel revascularization (TVA), kunye nomkhwa wokunyuka kwe-acute myocardial infarction (AMI) kwiqela le-PES. 27.28
Izixhobo zesizukulwana sesibini zinobukhulu obuphantsi bomngxuma, ukuguquguquka/ukuhanjiswa okuphuculweyo, iiprofayili eziphuculweyo ze-polymer biocompatibility/drug clearance, kunye ne-reendothelialization kinetics ephezulu. Okwangoku, ezi zezona zicwangciso ze-DES ziphambili kunye ne-coronary stents eziphambili ezifakwe kwihlabathi liphela.
I-Taxus Elements ithatha eli nyathelo linye phambili nge-polymer eyahlukileyo eyenzelwe ukukhululwa kwangoko okukhulu kunye nenkqubo entsha ye-platinum-chromium spacer enika ii-spacers ezincinci kunye nokwanda kwe-radiopacity. Uphononongo lwe-PERSEUS 29 luphawule iziphumo ezifanayo phakathi kwe-Element kunye ne-Taxus Express ukuya kuthi ga kwiinyanga ezili-12. Nangona kunjalo, akukho zilingo zaneleyo zokuthelekisa izinto ze-yew kunye nezinye ii-DESS zesizukulwana sesibini.
I-Endeavor Zotarolimus Coated Stent (ZES) isekelwe kwiqonga le-stent le-cobalt-chromium elinamandla elinokuguquguquka okuphezulu kunye ne-stent strut encinci. I-Zotarolimus yi-analogue ye-sirolimus eneziphumo ezifanayo zokucinezela amasosha omzimba, kodwa i-lipophilicity eyonyukileyo ukuphucula indawo eludongeni lwemithambo yegazi. I-ZES isebenzisa i-polymer coating entsha ye-phosphorylcholine eyenzelwe ukwandisa ukuhambelana kwezinto eziphilayo kunye nokunciphisa ukudumba. Uninzi lwamayeza luhlanjwa kwisigaba sokuqala sokwenzakala, kulandele ukulungiswa kwemithambo yegazi. Emva kovavanyo lokuqala lwe-ENDEAVOR, uvavanyo olulandelayo lwe-ENDEAVOR III luthelekise i-ZES ne-SES, eyabonisa ukulahleka okuphezulu kwe-lumen emva kwexesha kunye ne-HR kodwa iziganeko ezimbalwa ezimbi zentliziyo (MACEs) kune-SES. 30 Uphononongo lwe-ENDEAVOR IV oluthelekisa i-ZES ne-PES luphinde lwafumanisa ukwanda kwe-SIS kodwa ukwanda kwe-MI, mhlawumbi ngenxa ye-ST eqhelekileyo kwiqela le-ZES. 31 Nangona kunjalo, uphando lwe-PROTECT aluphumelelanga ukubonisa umahluko kwi-ST frequency 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) kunye ne-polymer entsha, ehambelanayo ne-bio-compatible enemaleko amathathu enokuthintela impendulo yokuqala yokuvuvukala kwaye ikhuphe ngaphezulu kwesiyobisi kwiintsuku ezingama-60 ezizayo. Uvavanyo oluthelekisa i-Resolute ne-Xience V (everolimus eluting stent [EES]) lubonise ukuba inkqubo ye-Resolute yayisebenza ngokulinganayo ngokubhekiselele ekufeni kunye nokungaphumeleli kwesilonda ekujoliswe kuso. 33.34
I-Everolimus, i-sirolimus derivative, ikwayi-cell cycle inhibitor esetyenziswa ekuphuhlisweni kwe-EES Xience (i-Multi-link Vision BMS platform)/Promus (i-Platinum Chromium platform). Uvavanyo lwe-SPIRIT 35-37 lubonise iziphumo eziphuculweyo kwaye lwanciphisa i-MACE nge-Xience V xa kuthelekiswa ne-PES, ngelixa uvavanyo lwe-EXCELLENT lubonise ukuba i-EES yayilungile njenge-SES ekuthinteleni ukulahleka kade kwiinyanga ezili-9 kunye neziganeko zeklinikhi kwiinyanga ezili-12. 38 Okokugqibela, i-Xience stent ibonakalisiwe ukuba ingcono kune-BMS kwimeko ye-ST elevation myocardial infarction (MI). 39
Ii-EPC liqela leeseli ezijikeleza igazi ezibandakanyeka kwi-vascular homeostasis kunye nokulungiswa kwe-endothelial. Ukwanda kwe-EPC kwindawo yokwenzakala kwemithambo yegazi kuya kukhuthaza ukubuyiselwa kwe-endothelialization kwangoko, okunokunciphisa umngcipheko we-ST. Ukungena kokuqala kwe-EPC Biology kuyilo lwe-stent yi-Genous stent, egqunywe ngama-anti-CD34 antibodies, ekwaziyo ukubopha ii-EPC ezijikelezayo ngee-hematopoietic markers zayo ukuphucula ukubuyiswa kwe-endothelialization. Nangona izifundo zokuqala bezikhuthaza, ubungqina bamva nje bubonisa amazinga aphezulu e-TVR. 40
Ngenxa yeziphumo ezinobungozi zokuphiliswa okulibazisekileyo okubangelwa yipolymer okunxulunyaniswa nomngcipheko we-ST, iipolymers ezibolayo zibonelela ngeenzuzo ze-DES ngokuthintela inkxalabo yexesha elide malunga nokuqina kwepolymer. Ukuza kuthi ga ngoku, iinkqubo ezahlukeneyo ezibolayo zivunyiwe (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-bioabiloba zinenzuzo yethiyori yokubonelela ngenkxaso yoomatshini ekuqaleni xa kuthathelwa ingqalelo i-elastic recoil kunye nokunciphisa iingozi zexesha elide ezinxulumene ne-metal struts ezikhoyo. Ubuchwepheshe obutsha bukhokelele ekuphuhlisweni kwee-polymers ze-lactic acid (i-poly-l-lactic acid [PLLA]), kodwa iinkqubo ezininzi ze-stent ziyaphuhliswa, nangona ukufumana ibhalansi efanelekileyo phakathi kokulungiswa kwamayeza kunye ne-degradation kinetics kusengumngeni. Uphononongo lwe-ABSORB lubonise ukhuseleko kunye nokusebenza kakuhle kwee-stents ze-PLLA ezine-everolimus. 43 Uhlaziyo lwesizukulwana sesibini se-Absorb stent lwalungcono kunelo lwangaphambili kunye nokulandelela okuhle kweminyaka emi-2. 44 Uphononongo lwangoku lwe-ABSORB II, uvavanyo lokuqala olucwangcisiweyo oluthelekisa i-Absorb stent kunye ne-Xience Prime stent, kufuneka lubonelele ngedatha eyongezelelweyo, kwaye iziphumo zokuqala ezikhoyo ziyathembisa. 45 Nangona kunjalo, iimeko ezifanelekileyo, indlela efanelekileyo yokufaka, kunye neprofayili yokhuseleko kwisifo se-coronary artery kufuneka zicaciswe.
I-Thrombosis kwi-BMS nakwi-DES ineziphumo ezibi zeklinikhi. Kwirejista yezigulana ezifakwe i-DES, ama-47% eemeko ze-ST abangele ukufa, ama-60% kwi-MI engabulaliyo, kunye nama-7% kwi-angina engazinzile. I-PCI ye-ST engxamisekileyo idla ngokuba yeyona ifanelekileyo, kwaye ukuphinda kwayo kwenzeke kwi-12% yeemeko. 48
I-ST eyongeziweyo ineziphumo ezibi zeklinikhi. Kwisifundo se-BASKET-LATE, kwiinyanga ezi-6-18 emva kokubekwa kwe-stent, amazinga okufa kwentliziyo kunye ne-MI engabulaliyo ayephezulu kwiqela le-DES kunakwiqela le-SMP (4.9% kunye ne-1.3%, ngokulandelanayo). 20 Uhlalutyo lwe-meta-analysis lwezifundo ezisithoba apho izigulane ezingama-5261 zathathwa ngokungacwangciswanga kwi-SES, PES, okanye i-BMS zibonise ukuba emva kweminyaka emi-4 yokulandelela, i-SES (0.6% ngokuchasene ne-0%, p = 0.025) kunye ne-PES (0.7%) zonyuse ukuxhaphaka kwe-ST esemva kakhulu xa kuthelekiswa ne-BMS nge-0.2%, p = 0.028). 49 Ngokwahlukileyo koko, kuhlalutyo lwe-meta oluquka izigulane ezingama-5108, ezingama-21 ukunyuka okumalunga nama-60% kokufa okanye i-MI kuxelwe nge-SES xa kuthelekiswa ne-BMS (p = 0.03), ngelixa i-PES inxulunyaniswa nokunyuka okungengomlinganiselo kwe-15% (jonga - ukuya kuthi ga kwiinyanga ezili-9 ukuya kwiminyaka emi-3).
Iirejista ezininzi, izilingo ezingacwangciswanga, kunye nohlalutyo lwe-meta ziye zahlola umngcipheko we-ST emva kokufakelwa kwe-BMS kunye ne-DES kwaye zibike iziphumo ezingqubanayo. Kwirejista yezigulana ezingama-6906 ezinyangwe nge-BMS okanye i-DES, bekungekho mahluko kwiziphumo zeklinikhi okanye amazinga e-ST kunyaka omnye wokulandelela. 48 Kwenye irejista yezigulana ezingama-8146, umngcipheko wokugqithisa kwe-ST okuqhubekayo ufunyenwe uyi-0.6% ngonyaka xa kuthelekiswa ne-BMS. 49 Uhlalutyo lwe-meta lwezifundo ezithelekisa i-SES okanye i-PES kunye ne-SMP lubonise umngcipheko ophezulu wokufa kunye ne-MI kunye ne-DES yesizukulwana sokuqala xa kuthelekiswa ne-SMP, ezingama-21 kunye nolunye uhlalutyo lwe-meta lwezigulana ezingama-4545 ezicwangciswe kwi-SES okanye i-ST phakathi kwe-PES kunye ne-BMS kwiminyaka emi-4 yokulandelela. 50 Ezinye izifundo zehlabathi lokwenyani zibonise umngcipheko ophezulu we-ST kunye ne-MI eqhubekayo kwizigulane ezinyangwe nge-DES yesizukulwana sokuqala emva kokuyeka i-DAPT. 51
Ngenxa yedatha ephikisanayo, uhlalutyo oluninzi oludibeneyo kunye nohlalutyo lwe-meta lugqibe ukuba i-DES kunye ne-SGM yesizukulwana sokuqala azihlukanga kakhulu kumngcipheko wokufa okanye i-MI, kodwa i-SES kunye ne-PES zazinomngcipheko ophezulu we-ST eqhelekileyo xa kuthelekiswa ne-SGM. Ukuphonononga ubungqina obufumanekayo, i-US Food and Drug Administration (FDA) yonyule iphaneli yeengcali53 ekhuphe ingxelo eqonda ukuba i-DES yesizukulwana sokuqala isebenza njengoko ibhalwe kwaye umngcipheko we-ST yamanqanaba aphezulu kakhulu umncinci, kodwa awukhulu. , Ukwanda okuphawulekayo. Ngenxa yoko, i-FDA kunye nombutho bacebisa ukwandiswa kwexesha le-DAPT ukuya kunyaka omnye, nangona kukho ubungqina obuncinci bokuxhasa eli bango.
Njengoko bekutshiwo ngaphambili, isizukulwana sesibini se-DES siye saphuhliswa ngeempawu zoyilo eziphuculweyo. I-CoCr-EES iye yaphanda kakhulu ngeklinikhi. Kuhlalutyo lwe-meta olwenziwe nguBaber et al.54 kwizigulane ezili-17,101, i-CoCr-EES iye yanciphisa kakhulu i-ST kunye ne-MI ecacileyo/enokwenzeka xa ithelekiswa ne-PES, SES, kunye ne-ZES kwiinyanga ezingama-21. Ekugqibeleni, uPalmeri et al ubonise kuhlalutyo lwe-meta lwezigulane ezili-16,775 ukuba i-CoCr-EES ine-ST echazwe kancinci ekuqaleni, emva kwexesha, kunyaka omnye kunye nowesibini xa ithelekiswa nezinye ii-DES ezidityanisiweyo. Izifundo zokwenyani ezingama-55 zibonise ukuncipha komngcipheko we-ST kunye ne-CoCr-EES xa kuthelekiswa ne-DES yesizukulwana sokuqala. 56
I-Re-ZES ithelekiswe ne-CoCr-EES kwizifundo ze-RESOLUTE-AC kunye ne-TWENTE. 33,57 Akukho mahluko abalulekileyo ekufeni, kwi-myocardial infarction, okanye kwicandelo le-ST elichaziweyo phakathi kwe-stents ezimbini.
Kwi-network meta-analysis yezigulane ezingama-50,844, kuquka ii-RCT ezingama-49, i-58 CoCr-EES yayinxulunyaniswa nokuhla okukhulu kwe-ST echaziweyo kune-BMS, into engakhange ibonwe kwezinye ii-DES; ukwehla akuzange kube "kwasekuqaleni kakhulu" kwaye emva kweentsuku ezingama-30 (58). Umlinganiselo we-odds [OR] 0.21, 95% i-confidence interval [CI] 0.11-0.42) kwaye kunyaka o-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 ne-ST rate ephantsi kunyaka o-1.
I-ST yasekuqaleni inxulunyaniswa nezinto ezahlukeneyo. Ukwakheka kweplaque engaphantsi kunye nomthwalo we-thrombus kubonakala ngathi kuyayichaphazela isiphumo emva kwe-PCI; ukungena kwe-59 struts ezinzulu yi-necrotic core (NC) prolapse, ukukrazula okude kwe-medial ngaphakathi kwe-stent, i-stent engaphantsi kwe-optimal ene-residual edge dissections okanye i-significant edge stenosis, i-apposition engaphelelanga, kunye nokwandiswa okungaphelelanga kwe-stent efakwe ngaphakathi kunokunyusa umngcipheko we-ST.60 Inkqubo yonyango yamayeza e-antiplatelet ayichaphazeli kakhulu ukwanda kwe-ST yokuqala: kuvavanyo olucwangcisiweyo oluthelekisa ii-BMS kunye nee-DESS, amazinga e-ST ebukhali kunye ne-subacute ngexesha le-DAPT ayefana (<1%).61 Ngoko ke, i-ST yokuqala ibonakala inxulumene kakhulu nezilonda ezingaphantsi ezinyangiweyo kunye nezinto zenkqubo. Ukwakheka kweplaque engaphantsi kunye nomthwalo we-thrombus kubonakala ngathi kuyayichaphazela isiphumo emva kwe-PCI; ukungena kwe-59 struts ezinzulu yi-necrotic core (NC) prolapse, ukukrazula okude kwe-medial ngaphakathi kwe-stent, i-stent engaphantsi kwe-optimal ene-residual edge dissections okanye i-significant edge stenosis, i-apposition engaphelelanga, kunye nokwandiswa okungaphelelanga kwe-stent efakwe ngaphakathi kunokunyusa umngcipheko we-ST.60 Inkqubo yonyango yamayeza e-antiplatelet ayichaphazeli kakhulu ukwanda kwe-ST yokuqala: kuvavanyo olucwangcisiweyo oluthelekisa ii-BMS kunye nee-DESS, amazinga e-ST ebukhali kunye ne-subacute ngexesha le-DAPT ayefana (<1%) .61 Ngoko ke, i-ST yokuqala ibonakala inxulumene kakhulu nezilonda ezingaphantsi ezinyangiweyo kunye nezinto zenkqubo. Морфология лежащей в основе бляшки и тромбоз, по-видимому, влияют на исход после ЧКВ;59 более глубокая пенетразапопас некротического ядра (NC), длинного медиального разрыва внутри стента, субоптимального стентирования с остаточными краевыми расслоениямильного стенозом, неполной аппозицией и неполным расширением имплантированного стента может увеличить риск ST.60 Uluhlu lweencwadi существенного влияния на частоту раннего ST: в рандомизированном исследовании, сравнивающем BMS ne DES, частота острого и подострого ST во DA DA врекой .61 Таким образом, ранняя ST, по-видимому, в первую очередь связана с лежащими в основе пролеченными поражениями и процедурными факторами. I-plaque morphology engaphantsi kunye ne-thrombosis zibonakala zinefuthe kwisiphumo emva kwe-PCI;59 ukungena kwe-strut enzulu ngenxa ye-necrotic nucleus (NC) prolapse, ukukrazuka okude kwe-medial ngaphakathi kwe-stent, i-stent engaphantsi kwe-optimal ene-residual marginal delaminations okanye i-significant marginal stenosis, i-apposition engaphelelanga kunye nokwandiswa okungaphelelanga kwe-stent efakwe ngaphakathi kunokunyusa umngcipheko we-ST.60 Inkqubo yonyango yamayeza e-antiplatelet ayichaphazeli kakhulu ukuvela kwe-ST yokuqala: kuvavanyo olucwangcisiweyo oluthelekisa i-BMS kunye ne-DES, ukuvela kwe-ST ebukhali kunye ne-subacute ngexesha le-DAPT yayifana (<1%) .61 Ke ngoko, i-ST yokuqala ibonakala inxulumene kakhulu nezilonda ezingaphantsi ezinyangiweyo kunye nezinto zenkqubo.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: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 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 狭 次 次 次的 的 的 的 的 的 的 的 的 的 优 支架 , 不 完全 并置和小板 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 发生率相似（<1%） .61Imo yeplaque engaphantsi kunye ne-thrombosis zibonakala zinefuthe kwiziphumo emva kwe-PCI; 59 Ukungena okunzulu kwe-strut ngenxa ye-necrotic nucleus (NC) prolapse, ukuqhekeka kwe-medial kubude be-stent, ukuqhekeka kwesibini kunye nemida eseleyo, okanye ukunciphisa umda okubalulekileyo I-Optimal stenting, i-apposition engaphelelanga, kunye nokwandiswa okungaphelelanga60 Irejimeni ye-Antiplatelet ayinampembelelo ibalulekileyo kwi-ST yasekuqaleni: ukuvela kwe-ST ebukhali kunye ne-subacute ngexesha le-DAPT kuvavanyo olucwangcisiweyo oluthelekisa i-BMS kunye ne-DES. ngokuyintloko zinxulumene nezilonda zonyango ezingaphantsi kunye nezinto zotyando.
Namhlanje, ingqwalasela ikwi-ST esemva/emva kakhulu. Nangona izinto zenkqubo kunye nezobuchwephesha zibonakala zidlala indima enkulu ekuphuhlisweni kwe-ST ebukhali neyi-subacute, indlela yokusebenza kweziganeko ze-thrombotic ezibambezelekayo ibonakala iyinkimbinkimbi ngakumbi. Kuye kwacetyiswa ukuba iimpawu ezithile zesigulana zinokuba zizinto ezinobungozi kwi-ST eqhubekayo nephambili kakhulu: isifo seswekile, i-ACS ngexesha lotyando lokuqala, ukungaphumeleli kwezintso, ubudala obuphezulu, 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 semithambo yegazi emininzi, i-calcification, ukuvaleka okupheleleyo, ii-stents ezinde zibonakala zinxulunyaniswa nomngcipheko we-ST eqhubekayo. 62,63 Impendulo engalunganga kunyango lwe-antiplatelet yinto ephambili enobungozi kwi-DES thrombosis eqhubekayo 51. Le mpendulo inokubangelwa kukungathobeli isigulane, ukungasebenzi kakuhle kwedosi, ukusebenzisana namayeza, ezinye izinto ezichaphazela impendulo yamayeza, i-receptor-level genetic polymorphism (ingakumbi ukumelana ne-clopidogrel), kunye nokusebenza kwezinye iindlela zokusebenza kweplatelet. I-Stent neoatherosclerosis ithathwa njengendlela ebalulekileyo yokusilela kwe-stent kade, kuquka i-ST64 kade (icandelo elithi “Stent Neoatherosclerosis”). I-endothelium engaguqukiyo yahlula udonga lwemithambo yegazi olune-thrombosed kunye ne-stent posts egazini kwaye ikhuphe izinto ezilwa noxinzelelo lwegazi kunye ne-vasodilator. I-DES iveza udonga lwemithambo yegazi kumayeza alwa nokwanda kwamalungu omzimba kunye neqonga lokukhulula amayeza, kunye neziphumo ezahlukeneyo ekupholiseni nasekusebenzeni kwe-endothelial, kunye nomngcipheko we-thrombosis kade. Izifundo ze-pathological ezingama-65 zibonise ukuba ii-polymers ze-DES ezinamandla zesizukulwana sokuqala zinokuba negalelo ekuvuvukeni okungapheliyo, ukubekwa kwe-fibrin engapheliyo, ukuphiliswa kakubi kwe-endothelial, kwaye ngenxa yoko kwandise umngcipheko we-thrombosis. 3 Ukungaziva kakuhle emva kwexesha kwi-DES kubonakala ngathi yenye indlela ekhokelela kwi-ST. UVirmani et al. [66] baxele iziphumo emva kokufa emva kwe-ST ebonisa ukwanda kwe-aneurysm kwicandelo le-stent kunye neempendulo ze-hypersensitivity zasekuhlaleni ezibandakanya ii-T-lymphocytes kunye nee-eosinophils; ezi ziphumo zinokubonakalisa impembelelo yeepolymers ezingenakutshabalaliswa. 67 Ukungasebenzi kakuhle kwe-stent kusenokuba ngenxa yokwanda kwe-stent okungenamsebenzi okanye kwenzeke kwiinyanga ezimbalwa emva kwe-PCI. Nangona ukungasebenzi kakuhle kwenkqubo kuyingozi kwi-ST ebukhali nengaphantsi kwe-ST, ukubaluleka kweklinikhi kokungasebenzi kakuhle kwe-stent kunokuxhomekeka ekuguqulweni kwemithambo yegazi ngendlela ebukhali okanye ukuphiliswa okulibazisekayo 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, iiscaffolds ze-cobalt-chromium stent ezibhityileyo (81 µm), ii-fluoropolymers ezilwa noxinzelelo lwegazi, umxholo ophantsi we-polymer, kunye nomthwalo wamayeza kunokubangela amazinga aphantsi e-ST. Izifundo zovavanyo zibonise ukuba i-thrombosis kunye ne-platelet deposition ziphantsi kakhulu kwi-fluoropolymer-coated stents kunakwi-uncoated stents. 69 Ukuba ezinye ii-DES zesizukulwana sesibini zineempawu ezifanayo kufuneka zifundwe ngakumbi.
Ii-Coronary stents ziphucula impumelelo yotyando lokungenelela kwentliziyo xa kuthelekiswa ne-percutaneous transluminal coronary angioplasty (PTCA) yendabuko, eneengxaki zoomatshini (ukuvaleka kwemithambo yegazi, ukuqhaqha, njl.njl.) kunye nesantya esiphezulu se-restenosis (ukuya kuthi ga kwi-40-50% yamatyala). Ekupheleni kweminyaka yoo-1990, phantse i-70% yee-PCI zenziwa nge-BGM 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20%，在特特约息恶恶恶于给约翰。 40%.然而，尽管技术、技术和药物治疗取得了进步，但BMSNangona kunjalo, nangona kukho inkqubela phambili kwezobuchwepheshe, iindlela, kunye nonyango, umngcipheko we-restenosis emva kokufakelwa kwe-BMS umalunga ne-20%, kunye namazinga adlula i-40% kumaqela athile amancinci. 71 Ngokubanzi, izifundo zeklinikhi zibonise ukuba i-restenosis emva kokufakelwa kwe-BMS, efana naleyo ibonwa kwi-PTCA yesiqhelo, ifikelela kwincopho kwiinyanga ezi-3-6 kwaye iphela ngonyaka o-1. 72
I-DES inciphisa ngakumbi amazinga e-ISR,73 nangona olu nciphiso luxhomekeke kwi-angiography nakwiklinikhi. I-DES polymer coating ikhupha ii-anti-inflammatory kunye ne-anti-proliferative agents, ithintela ukwakheka kwe-neointima, kwaye ilibazise ukulungiswa kwemithambo yegazi ngeenyanga okanye iminyaka.74 Kwizifundo zeklinikhi neze-histological, ukukhula kwe-neointima okuqhubekayo kuye kwabonwa kwixesha elide lokulandelela emva kokufakelwa kwe-DES, into eyaziwa ngokuba yi-"late catch-up"75.
Ukulimala kwemithambo yegazi ngexesha le-PCI kubangela inkqubo enzima yokuvuvukala kunye nokulungiswa kwexesha elifutshane (iiveki ukuya kwiinyanga), okubangela ukwakheka kwe-endothelialization kunye nokugubungela kwe-neointimal. Ngokweengxelo ze-histopathological, i-neointimal hyperplasia (i-HMS kunye ne-DES) emva kokufakelwa kwe-stent ikakhulu yayiquka iiseli zemisipha ezithambileyo ezikhulayo kwi-proteoglycan-rich extracellular matrix. 70
Ngoko ke, i-neointimal hyperplasia yinkqubo yokulungisa equka izinto ezibangela ukujiya kunye nokuvuvukala, kunye neeseli ezibangela ukwanda kweeseli zemisipha egudileyo kunye nokwakheka kwe-extracellular matrix. Emva nje kwe-PCI, ii-platelets kunye ne-fibrin zifakwa eludongeni lwemithambo yegazi kwaye zitsala ii-leukocytes ngothotho lwee-molecules zokunamathela kweseli. Ii-leukocytes eziqengqelekayo zinamathela kwii-platelets eziqhotyoshelweyo ngokusebenzisana phakathi kwe-leukocyte integrin Mac-1 (CD11b/CD18) kunye ne-platelet glycoprotein Ibα 53 okanye i-fibrinogen enxulumene ne-platelet glycoprotein IIb/IIIa. 76.77
Ngokwedatha entsha, iiseli zomnombo wethambo zibandakanyeka kwiimpendulo zemithambo yegazi kunye neenkqubo zokulungisa. Ukuhanjiswa kwe-EPC ukusuka kumnombo wethambo ukuya egazini elingaphandle kukhuthaza ukuvuselelwa kwe-endothelial kunye ne-neovascularization emva kokuzalwa. Kubonakala ngathi iiseli zomnombo wethambo ezithambileyo (ii-SMPC) ziyafudukela kwindawo yokwenzakala kwemithambo yegazi, nto leyo ebangela ukwanda kwe-neointimal. 78 Ngaphambili, iiseli ze-CD34-positive zazithathwa njengenani elimiselweyo lee-EPC, izifundo ezongezelelweyo zibonise ukuba i-antigen yomphezulu we-CD34 ngokwenene iyazazi iiseli ze-stem zethambo ezingahlukaniyo ezinokukwazi ukwahlulahlula zibe zii-EPC kunye nee-PBMC. Ukutshintshwa kweeseli ze-CD34-positive zibe ludidi lwe-EPC okanye lwe-SMPC kuxhomekeke kwindawo yasekuhlaleni; iimeko ze-ischemic zibangela ukwahlukana ukuya kwi-phenotype ye-EPC, ekhuthaza ukuphinda kuphele, ngelixa iimeko zokudumba zibangela ukwahlukana ukuya kwi-phenotype ye-SMPC, ekhuthaza ukwanda kwe-neointimal. 79
Isifo seswekile sonyusa umngcipheko we-ISR ngama-30–50% emva kokufakelwa kwe-BMS, kwaye izinga eliphezulu le-restenosis kwizigulane zeswekile xa kuthelekiswa nezigulana ezingengoweswekile nazo zaqhubeka kwixesha le-DES. Iindlela ezisisiseko solu qwalaselo zisenokuba zizinto ezininzi, kubandakanya inkqubo yomzimba (umz., ukuguquguquka kwempendulo yokudumba) kunye ne-anatomical (umz., imithambo emincinci, izilonda ezinde, isifo esisasazekayo, njl.njl.), ezinyusa ngokwazo umngcipheko we-ISR. 70
Ububanzi besitya kunye nobude besilonda buchaphazele amazinga e-ISR ngokuzimeleyo, kunye nobubanzi obuncinci/izilonda ezinde ezinyusa kakhulu amazinga okuphumla xa kuthelekiswa nobubanzi obukhulu/izilonda ezimfutshane.
Amaqonga e-stent esizukulwana sokuqala abonise ii-struts ezityebileyo kunye nee-ISR eziphezulu xa kuthelekiswa namaqonga e-stent esizukulwana sesibini anee-struts ezincinci.
Ngaphezu koko, ukwanda kwe-restenosis kunxulunyaniswa nobude be-stent, phantse buphindwe kabini kubude be-stent obungaphezulu kwama-35 mm xa kuthelekiswa nobo bungaphantsi kwama-20 mm. Ngaphezu koko, ukwenzeka kwe-restenosis kunxulunyaniswa nobude be-stent, phantse buphindwe kabini kubude be-stent obungaphezulu kwama-35 mm xa kuthelekiswa nobo bungaphantsi kwama-20 mm. Кроме того, частота рестеноза связана с длиной стента, почти удваиваясь при длине стента >35 мм по сравнению с длиной стента <20 мм. Ukongeza, izinga lokuphumla linxulumene nobude be-stent, phantse liphindwe kabini ngobude be-stent >35 mm xa kuthelekiswa nobude be-stent <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. Ukongeza, ukuphindaphindeka kwe-restenosis kuxhomekeke kubude be-stent: ubude be-stent >35 mm buphantse buphindwe kabini kunobe-stent <20 mm.Ububanzi bokugqibela be-lumen obuncinci be-stent nabo budlale indima ebalulekileyo: ububanzi obuncinci bokugqibela be-lumen buxele ukuba umngcipheko wokubuyela umva uyanda 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 lokulala emva kwexesha. Incopho yokuqala yokukhula kwe-intimal ilandelwa yi-intimal regression kunye nokwandiswa kwe-lumen kwiminyaka eliqela emva kokufakelwa kwe-stent ibikwe ngaphambili; ukuvuthwa kweeseli zemisipha egudileyo kunye notshintsho kwi-extracellular matrix kuye kwacetyiswa njengeendlela ezinokwenzeka zokubuyela umva kwe-neointima. 83 Nangona kunjalo, izifundo zokulandela ixesha elide zibonise impendulo ye-triphasic emva kokubekwa kwe-BMS kunye ne-restenosis yasekuqaleni, i-intermediate regression, kunye ne-late luminal 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 kulandelwa kukufikelela kade emva kwexesha emva kokufakelwa kwe-SES okanye i-RPE, mhlawumbi ngenxa yenkqubo eqhubekayo yokuvuvukala.86
Nangona “ukuzinza” okuqhele ukuchazwa njenge-ISR, malunga nesinye kwisithathu sezigulana ezine-BMS ISR ziba ne-ACS.
Kukho ubungqina obandayo bokuba ukudumba okungapheliyo kunye/okanye ukungasebenzi kakuhle kwe-endothelial kubangela i-neoatherosclerosis eqhubekayo kwi-HCM kunye ne-DES (ikakhulu i-DES yesizukulwana sokuqala), enokuba yindlela ebalulekileyo yophuhliso lwe-IR eqhubekayo okanye i-ST eqhubekayo. U-Inoue et al [87] babike iziphumo ze-histological autopsy emva kokufakelwa kwe-Palmaz-Schatz coronary stents, nto leyo ebonisa ukuba ukudumba okujikeleze i-stent kunokubangela utshintsho olutsha lwe-atherosclerotic ngaphakathi kwe-stent. Ezinye izifundo10 zibonise ukuba izicubu ze-restenotic ngaphakathi kwe-5-year CGM ziquka i-atherosclerosis eqala kutshanje enokuvuvukala kwe-peritoneal okanye engenako; iisampulu ezivela kwiimeko ze-ACS zibonisa iiplaque eziqhelekileyo ezisengozini kwimithambo ye-coronary yendalo I-Histological block morphology ene-foamy macrophages kunye neekristale ze-cholesterol. Ukongeza, xa kuthelekiswa i-BMS kunye ne-DES, kwaphawulwa umahluko omkhulu ngexesha lophuhliso lwe-atherosclerosis entsha. 11,12 Utshintsho lokuqala lwe-atherosclerotic ekungeneni kwe-foamy macrophage luqale kwiinyanga ezi-4 emva kokufakelwa kwe-SES, ngelixa utshintsho olufanayo kwizilonda ze-CGM lwenzeka emva kweminyaka emi-2 kwaye lwahlala luyinto engaqhelekanga ukuya kuthi ga kwiminyaka emi-4. Ukongeza, i-DES stenting yezilonda ezingazinzanga ezifana ne-thin tegmental fibroatherosclerosis (TCFA) okanye i-intimal rupture inexesha elifutshane lokukhula xa kuthelekiswa ne-BMS. Ke ngoko, i-neoatherosclerosis ibonakala ixhaphake kakhulu kwaye yenzeka kwangoko kwi-DES yesizukulwana sokuqala kunakwi-BMS, mhlawumbi ngenxa ye-pathogenesis eyahlukileyo.
Impembelelo yesizukulwana sesibini i-DES okanye i-DES kuphuhliso isaza kuhlolwa; nangona ezinye izinto ezibonwe kwisizukulwana sesibini i-DES88 zibonisa ukudumba okuncinci, ukwanda kwe-neoatherosclerosis kuyafana xa kuthelekiswa nesizukulwana sokuqala, kodwa kusafuneka uphando olongezelelweyo.