I-Javascript ivaliwe esipheqululini sakho okwamanje.Ezinye izici zale webhusayithi ngeke zisebenze uma i-javascript ivaliwe.
Bhalisa ngemininingwane yakho ethile kanye nomuthi othile othakazelisayo futhi sizofanisa ulwazi olunikezayo nama-athikili kusizindalwazi sethu esibanzi futhi sikuthumelele ikhophi ye-PDF ngokushesha.
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 mining stemints (BMS) ngemva kokungenelela kwe-coronary percutaneous.Nokho, nakuba ukwethulwa kwe-DES yesizukulwane sesibili kubonakala sengathi kulinganise lesi simo uma kuqhathaniswa ne-DES yesizukulwane sokuqala, ukukhathazeka okukhulu kusele mayelana nezinkinga ezingenzeka sekwephuzile zokufakelwa kwe-stent, njenge-stent thrombosis (ST) kanye nokukhishwa kwe-stent. I-Stenosis (ISR) .ST isenzakalo esingaba inhlekelele esiye sancishiswa kakhulu ngokusebenzisa i-stenting ethuthukisiwe, imiklamo ye-novel stent, kanye nokwelashwa okubili kwe-antiplatelet.Indlela eqondile echaza ukwenzeka kwayo iyaphenywa, futhi ngempela, izici eziningi zinesibopho.I-ISR ku-BMS ngaphambili yayibhekwa njengesimo esiqinile esinezinga eliphakeme lokuqala le-hyperplasia yezinyanga ezingu-1 Ngonyaka.Ngokuphambene, kokubili izifundo zomtholampilo kanye ne-histological ze-DESs zibonise ubufakazi bokukhula okuqhubekayo kwe-neointimal ngesikhathi sokulandela isikhathi eside, into eyaziwa ngokuthi "i-late catch-up" phenomenon.Umbono wokuthi i-ISR iyisimo somtholampilo esilinganiselwe usanda kufakwa inselele ngobufakazi bokuthi iziguli ezine-ISR zingase zihlakulele i-acute coronary syndromes. ama-plaque kanye nezici zokuphulukiswa kwemikhumbi ye-post-stent; kuvame ukusetshenziselwa ukuqedela i-coronary angiography yokuxilongwa nokushayela izinqubo zokungenelela.I-Intracoronary optical coherence tomography okwamanje ibhekwa njengendlela ephakeme kakhulu yokucabanga.Uma kuqhathaniswa ne-intravascular ultrasound, inikeza ukulungiswa okungcono (okungenani> izikhathi ezingu-10), okuvumela ukucaciswa okuningiliziwe kwesakhiwo esingaphezulu sodonga lomkhumbi. I-neo-atherosclerosis yesigaba sekwephuzile ngaphakathi kwe-BMS ne-DES.Ngakho-ke, i-neo-atherosclerosis isiphenduke umsolwa oyinhloko ku-pathogenesis yokuhluleka kwe-stent sekwephuzile.Amagama angukhiye: i-coronary stent, i-stent thrombosis, i-restenosis, i-neoatherosclerosis.
I-Percutaneous coronary intervention (PCI) ene-stent implantation iyindlela esetshenziswa kabanzi yokwelashwa kwesifo se-coronary artery esinezimpawu, futhi inqubo iyaqhubeka nokuguquka.1 Nakuba izidakamizwa-eluting stents (DES) zinciphisa ukulinganiselwa kwe-bare-metal stents (BMSs), izinkinga eziphuzile ezifana ne-stent restens (SRST) ne-stent thrombosis (SRST) ukufakwa kwe-stent. , kusele ukukhathazeka okukhulu.2-5
Uma i-ST iyisenzakalo esingase sibe yinhlekelele, ukuqashelwa ukuthi i-ISR iyisifo esibucayi muva nje inselele yobufakazi be-acute coronary syndrome (ACS) ezigulini ze-ISR.4
Namuhla, i-intracoronary optical coherence tomography (OCT) 6-9 ibhekwa njengendlela yamanje yokucabanga yesimanje, enikeza isisombululo esingcono kune-intravascular ultrasound (IVUS).
Ngo-1964, u-Charles Theodore Dotter noMelvin P Judkins bachaza i-angioplasty yokuqala.Ngo-1978, u-Andreas Gruntzig wenza i-angioplasty yokuqala ye-balloon (i-angioplasty ye-balloon endala); kwakuyi-revolutionary treatment kodwa yayinezingqinamba zokuvalwa komkhumbi okunamandla kanye ne-restenosis.13 Lokhu kwaxosha ukutholakala kwama-coronary stents: U-Puel no-Sigwart basebenzise i-coronary stent yokuqala ku-1986, behlinzeka nge-stent ukuvimbela ukuvalwa komkhumbi okunamandla kanye nokuhlehliswa kwe-systolic sekwephuzile. izilingo ezimbili eziyingqopha-mlando, i-Belgian-Dutch Stent Trial 15 kanye ne-Stent Restenosis Study 16, ikhuthaze ukuphepha kwe-stenting nge-double antiplatelet therapy (DAPT) kanye / noma amasu okuthunyelwa afanelekile.17,18 Ngemva kwalezi zilingo, kube nokwanda okukhulu kwenani lama-PCIs awenziwe.
Kodwa-ke, inkinga ye-iatrogenic in-stent neointimal hyperplasia elandela ukubekwa kwe-BMS yabonakala ngokushesha, okuholele ku-ISR ku-20%–30% wezilonda ezilashwayo.Ngo-2001, i-DES yethulwa19 ukuze kuncishiswe isidingo sokuphumula nokungenelela. ukuxhunyelelwa.Ngo-2005, ama-80%–90% awo wonke ama-PCI ayehambisana ne-DES.
Yonke into inezingqinamba zayo, futhi kusukela ngo-2005, ukukhathazeka mayelana nokuphepha kwe-DES "yesizukulwane sokuqala" kuye kwaphakama, futhi ama-stents esizukulwane esisha njenge-20,21 athuthukisiwe futhi wethulwa.
I-BMS iyishubhu yentambo encane enemeshi. Ngemva kokuhlangenwe nakho kokuqala ngokukhweza "Wall", i-Gianturco-Roubin mount kanye ne-Palmaz-Schatz, ama-BMS amaningi ahlukene manje ayatholakala.
Imiklamo emithathu ehlukene ingenzeka: ikhoyili, i-tubular mesh kanye neshubhu ecijile.Imiklamo yekhoyili ifaka izintambo zensimbi noma amapheshana akheke abe yisimo sekhoyili esiyindilinga; imiklamo ye-tubular mesh ihlanganisa izintambo ezisongwe ndawonye nge-mesh ukuze zenze ishubhu; imiklamo yamashubhu afakwe amashubhu enziwe nge-laser cut made.Lawa madivayisi ayahlukahluka ekubunjweni kwawo (insimbi engagqwali, i-nichrome, i-cobalt chrome), ukwakheka kwesakhiwo (amaphethini ahlukene we-strut nobubanzi, amadayamitha nobude, amandla e-radial, i-radiopacity) kanye nezinhlelo zokudiliva (ezizandisayo noma ibhaluni-inwetshiwe) .
Ngokuvamile, i-BMS entsha iqukethe ingxubevange ye-cobalt-chromium, ephumela kuma-struts azacile anokuzulazula okuthuthukisiwe, okugcina amandla emishini.
Ahlanganisa inkundla yensimbi eqinile (imvamisa insimbi engagqwali) futhi embozwe nge-polymer ekhipha imithi yokwelapha evimbela ukwanda kanye/noma eqeda ukuvuvukala.
I-Sirolimus (eyaziwa nangokuthi i-rapamycin) ekuqaleni yayiklanywe njenge-ejenti ye-antifungal.Indlela yayo yokusebenza isukela ekuvimbeleni ukuqhubeka komjikelezo wamaseli ngokuvimbela uguquko olusuka esigabeni se-G1 ukuya esigabeni se-S futhi luvimbele ukwakheka kwe-neointima.Ngo-2001, okuhlangenwe nakho "kokuqala kumuntu" nge-SES kubonise imiphumela ethembisayo yocwaningo, okuholela ekuthuthukisweni kwe-Cy23r ku-23 phethis ukusebenza kahle ekuvimbeleni i-ISR.amashumi amabili nane
I-Paclitaxel yavunywa ekuqaleni umdlavuza we-ovarian, kodwa izici zayo ezinamandla ze-cytostatic - umuthi uzinzisa ama-microtubules ngesikhathi se-mitosis, uholela ekuboshweni komjikelezo weseli futhi uvimbele ukwakheka kwe-neointimal - kwenze kube inhlanganisela ye-Taxus Express PES.Izilingo ze-TAXUS V kanye ne-VI zibonise ukusebenza kahle kwesikhathi eside kwe-PES ku-coronary526 isifo esiyingozi kakhulu, i-TAX26, isifo se-coronary26 esiyinkimbinkimbi. I-Liberté ifake inkundla yensimbi engagqwali ukuze ilethwe kalula.
Ubufakazi obuqand’ ikhanda obuvela ekubuyekezweni okubili okuhlelekile nokuhlaziywa kwemeta kubonisa ukuthi i-SES inenzuzo ngaphezu kwe-PES ngenxa yamazinga aphansi e-ISR kanye ne-target vessel revascularization (TVR), kanye nokuthambekela kokukhuphuka kwe-acute myocardial infarction (AMI) eqenjini le-PES. 27,28
Amadivayisi esizukulwane sesibili anciphise ukujiya kwe-strut, ukuguquguquka okuthuthukisiwe/ukulethwa, amaphrofayili e-polymer biocompatibility/ukukhishwa kwezidakamizwa athuthukisiwe, kanye ne-kinetics ye-re-endothelialization ehle kakhulu.Ekujwayezeni kwesimanje, ayimiklamo ye-DES ethuthuke kakhulu kanye nama-coronary stents afakwe emhlabeni jikelele.
I-Taxus Elements iyintuthuko eyengeziwe ene-polymer eyingqayizivele eklanyelwe ukukhulisa ukukhishwa kwangaphambi kwesikhathi kanye nesistimu entsha ye-platinum-chromium strut ehlinzeka ngama-struts amancane kanye ne-radiopacity ethuthukisiwe.Isivivinyo se-PERSEUS 29 siphawule imiphumela efanayo phakathi kwe-Element ne-Taxus Express kufika ezinyangeni ezingu-12. Nokho, izivivinyo eziqhathanisa izakhi ze-yew zesibili ze-DES nezinye.
I-zotarolimus-eluting stent (ZES) Endeavor isekelwe kuplathifomu ye-cobalt-chromium stent enamandla enokuguquguquka okuphezulu kanye nosayizi we-stent strut encane.I-Zotarolimus iyi-analog ye-sirolimus enemiphumela efanayo yokuvikela amasosha omzimba kodwa i-lipophilicity ethuthukisiwe ukuze kuthuthukiswe ukwenziwa kodonga lomkhumbi. i-biocompatibility kanye nokunciphisa ukuvuvukala.Izidakamizwa eziningi zikhishwa ngesikhathi sesigaba sokuqala sokulimala, kulandelwa ukulungiswa kwe-arterial.Ngemva kokuhlolwa kokuqala kwe-ENDEAVOR, ukuhlolwa okulandelayo kwe-ENDEAVOR III kuqhathanise i-ZES ne-SES, ebonise ukulahlekelwa okukhulu kwe-lumen sekwephuzile kanye ne-ISR kodwa izenzakalo ezimbalwa ezimbi ezimbi kakhulu zenhliziyo (MACE) kune-SES .30 I-ENDEAVOUR, kodwa i-ENDEAVOUR etholwe futhi i-PASR, eqhathanise i-ZIV ne-ISR isigameko esiphansi se-AMI, ngokusobala esivela ku-ST ethuthuke kakhulu eqenjini le-ZES.31 Kodwa-ke, ukuhlolwa kwe-PROTECT kwehlulekile ukubonisa umehluko kumazinga we-ST phakathi kwe-Endeavor kanye ne-Cypher stents.32
I-Endeavor Resolute inguqulo ethuthukisiwe ye-stent ye-Endeavor ene-polymer entsha enezendlalelo ezintathu.I-Resolute Integrity entsha (ngezinye izikhathi ebizwa ngokuthi i-DES yesizukulwane sesithathu) isekelwe endaweni entsha enamandla okulethwa okuphezulu (inkundla ye-Integrity BMS), kanye nenoveli, i-biocompatible more Izinsuku ezingu-60.Isivivinyo esiqhathanisa i-Resolute ne-Xience V (everolimus-eluting stent [EES]) ibonise ukungabi phansi kwesistimu ye-Resolute mayelana nokufa kanye nokwehluleka kwesilonda esihlosiwe.33,34
I-Everolimus, okuphuma ku-sirolimus, iphinde ibe i-cell cycle inhibitor esetshenziswa ekuthuthukisweni kwe-Xience (Multi-link Vision BMS platform)/Promus (Platinum Chromium platform) EES.Isivivinyo se-SPIRIT 35-37 sibonise ukusebenza okuthuthukisiwe futhi yehlisa i-MACE nge-Xience V uma iqhathaniswa ne-PES, kuyilapho i-EXfeCELLES ikhombisa ukuthi ukucindezela kwe-SFECELLES kwakungenasici. ukulahlekelwa sekwephuzile ezinyangeni ezingu-9 kanye nezenzakalo zomtholampilo ezinyangeni ze-12.38 Ekugcineni, i-Xience stent ibonise izinzuzo ngaphezu kwe-BMS ekumisweni kwe-ST-segment elevation myocardial infarction (MI) .39
Ama-EPC ayingxenye yamangqamuzana ajikelezayo ahilelekile ku-homeostasis yemithambo kanye nokulungiswa kwe-endothelial.Ukuthuthukiswa kwama-EPC endaweni yokulimala kwemithambo kuzothuthukisa ukuvuselelwa kabusha kwangaphambi kwesikhathi, okungenzeka kunciphise ubungozi bomzamo wokuqala we-ST.EPC biology emkhakheni wokuklama okuqinile i-CD34 antibody-coated coated Genous stenting ekwazi ukumaka i-Genous stent yayo ukuthuthukisa kabusha i-endothelialization.Nakuba izifundo zokuqala zazikhuthaza, ubufakazi bamuva bukhomba amazinga aphezulu e-TVR.40
Uma kucatshangelwa imiphumela engase ibe yingozi yokuphulukiswa okubambezeleke okwenziwe nge-polymer, okuhlotshaniswa nengozi ye-ST, ama-polymers atholakalayo anikeza izinzuzo ze-DES, ukugwema ukukhathazeka isikhathi eside mayelana nokuphikelela kwe-polymer.Kuze kube manje, izinhlelo ezahlukene ze-bioabsorbable zivunyelwe (isb. Nobori kanye ne-Biomatrix, i-biolimus eluting stent, i-Sylrgy, i-Sylrgy, i-Sylrgy yabo yezincwadi imiphumela yesikhathi eside ilinganiselwe.41
Izinto ezisetshenziswa yi-bioabsorbable zinenzuzo yethiyori ekuqaleni zinikeza ukusekelwa komshini lapho ukunwebeka okunwebekayo kucatshangelwa futhi kuncishiswe izingozi zesikhathi eside ezihlobene nezinsimbi zensimbi ezikhona.Ubuchwepheshe obusha buye baholela ekuthuthukisweni kwama-polymer asekelwe ku-lactic acid (i-poly-l-lactic acid [PLLA]), kodwa izinhlelo eziningi ze-stent zisathuthukiswa, nakuba kunqunywa inselele ye-kinetics noma i-degrad ye-ABS. Uhlolo lubonise ukuphepha nokusebenza kahle kwe-everolimus-eluting PLLA stents.43 Ukubuyekezwa kwe-Absorb stent kwesizukulwane sesibili kwaba ngcono kuneyangaphambili ngokulandelelwa okuhle kweminyaka engu-2.44 Uhlolo oluqhubekayo lwe-ABSORB II, uhlolo lokuqala olungahleliwe oluqhathanisa i-Absorb stent ne-Xience Prime stent, kufanele lunikeze imiphumela etholakalayo yokuqala, nokho-ke imiphumela etholakalayo45 yokuqala. indlela yokufakelwa, kanye nephrofayili yokuphepha yezilonda ze-coronary idinga ukucaciswa kangcono.
I-Thrombosis kukho kokubili i-BMS ne-DES inemiphumela emibi yomtholampilo.Ebhukwini leziguli ezithola ukufakelwa kwe-DES, i-47 24% ye-ST ibangele ukufa, i-60% isuka ku-MI engabulali, kanye ne-7% isuka ku-angina engaqinile.
I-ST ethuthukisiwe inemiphumela engase ibe mibi emitholampilo.Ocwaningweni lwe-BASKET-LATE, izinyanga ezingu-6 kuya kwezingu-18 ngemva kokubekwa kwe-stent, amazinga okufa kwenhliziyo kanye ne-MI engabulali ayephezulu eqenjini le-DES kuneqembu le-BMS (4.9% no-1.3%, ngokulandelana) .20 Ukuhlaziywa kwe-meta kweziguli eziyisishiyagalolunye, i-PES2 ezivivinyweni eziyisishiyagalolunye, i-PES2 ezivivinyweni eziyisishiyagalolunye, i-PES2 eziyisishiyagalolunye noma eziyisishiyagalolunye, i-PS2. I-BMS, ibike ukuthi eminyakeni engu-4 yokulandelela, i-SES (0.6% vs 0%, p = 0.025) kanye ne-PES (0.7%)) yandisa isigameko se-ST sekwephuzile kakhulu uma kuqhathaniswa ne-BMS ngo-0.2%, p = 0.028) .49 Ngokuphambene, ekuhlaziyweni kwe-meta okubandakanya i-5,108 iziguli, i-0% isihlobo se-ES sibikwe ngokufa kwe-S. (p=0.03), kuyilapho i-PES ihlotshaniswa nokwenyuka okungabalulekile okungu-15% (Ukulandelela izinyanga eziyi-9 kuye eminyakeni emi-3).
Ukubhaliswa okuningi, ukuhlolwa okungahleliwe, nokuhlaziywa kwe-meta kuphenye ingozi ehlobene ye-ST ngemva kokufakelwa kwe-BMS ne-DES futhi kubike imiphumela engqubuzanayo.Erejista yeziguli ezingu-6,906 ezithola i-BMS noma i-DES, kwakungekho umehluko emiphumeleni yomtholampilo noma amanani we-ST phakathi nokulandelwa konyaka we-1. I-0.6% / ngonyaka uma kuqhathaniswa ne-BMS.49 Ukuhlaziywa kwe-meta yokuhlolwa okuqhathanisa ne-SES noma i-PES ne-BMS kubonise ingozi eyengeziwe yokufa kanye ne-MI nge-DES yesizukulwane sokuqala uma kuqhathaniswa ne-BMS, i-21 kanye nolunye uhlaziyo lwe-meta yeziguli ze-4,545 ezingahleliwe ku-SES noma Kwakungekho mehluko ekutholakaleni kwe-ST phakathi kweminyaka engu-450 ne-BMS eyandisiwe-i-BMS eyandisiwe emhlabeni jikelele. ingozi ye-ST ne-MI ethuthukisiwe ezigulini ezithola i-DES yesizukulwane sokuqala ngemva kokuqedwa kwe-DAPT.51
Njengoba kunikezwe ubufakazi obuphikisanayo, ukuhlaziya okuhlanganisiwe okuningana kanye nokuhlaziywa kwe-meta ndawonye kunqume ukuthi i-DES yesizukulwane sokuqala ne-BMS ayizange ihluke kakhulu engozini yokufa noma i-MI, kodwa i-SES ne-PES babe nengozi eyengeziwe ye-ST ethuthuke kakhulu uma kuqhathaniswa ne-BMS. Ukuze kubuyekezwe Ubufakazi obutholakalayo, i-US Food and Drug Administration (FDA) yaqoka iphaneli yochwepheshe53 eyakhipha isitatimende evuma ukuthi i-DES yesizukulwane sokuqala yayisebenza kahle ezinkomba ezikulebula nokuthi ingozi ye-ST ethuthuke kakhulu yayincane kodwa incane. Ukwenyuka okukhulu.Ngenxa yalokho, i-FDA kanye nenhlangano batusa ukwelula isikhathi se-DAPT sibe unyaka ongu-1, nakuba kunedatha encane yokusekela lesi simangalo.
Njengoba kushiwo ngaphambili, i-DES yesizukulwane sesibili enezici ezithuthukisiwe zokuklama iye yathuthukiswa.I-CoCr-EESs yenze izifundo zomtholampilo ezibanzi kakhulu.Ekuhlaziyweni kwe-meta okwenziwa ngu-Baber et al, i-54 ehlanganisa iziguli ze-17,101, i-CoCr-EES yehlise kakhulu i-ST ecacile / engenzekayo kanye ne-MI uma kuqhathaniswa ne-PES, i-SES, ne-ZES ngemva kwezinyanga ezingu-21 zokuhlaziya i-Palmerini, i-Palmerini-analy-anally, i-Palmerini-analysis. Iziguli ezingu-16,775 i-CoCr-EES eyayinazo eziphansi kakhulu ngaphambi kwesikhathi, sekwephuzile, i-ST eqondile engu-1- kanye neminyaka emi-2 uma kuqhathaniswa nezinye izifundo ezihlanganisiwe ze-DES.55 Real-world ziye zabonisa ukuncipha kwengozi ye-ST nge-CoCr-EES uma kuqhathaniswa ne-DES.56 yesizukulwane sokuqala.
I-Re-ZES iqhathaniswe ne-CoCr-EES ekuhlolweni kwe-RESOLUTE-AC kanye ne-TWENTE.33,57 Kwakungekho umehluko ophawulekayo ezenzakalweni zokufa, i-myocardial infarction, noma i-ST eqondile phakathi kwama-stents amabili.
Ekuhlaziyweni kwe-meta yenethiwekhi yeziguli ze-50,844 ezihlanganisa i-49 RCTs, i-58CoCr-EES ihlotshaniswa nesigameko esiphansi kakhulu se-ST ecacile kune-BMS, umphumela ongabonwanga kwenye i-DES; ukuncishiswa bekungekona nje kuphela Okubalulekile kusenesikhathi nangezinsuku ezingama-30 (isilinganiso sokungezwani [OR] 0.21, 95% isikhawu sokuzithemba [CI] 0.11-0.42) futhi nangonyaka ongu-1 (NOMA 0.27, 95% CI 0.08-0.74) kanye neminyaka engu-2 (NOMA 0.35% 0.5 0.CI 0.06 . I-PES, i-SES, ne-ZES, i-CoCr-EES ihlotshaniswe nesigameko esiphansi se-ST onyakeni ongu-1.
I-ST yakuqala ihlobene nezici ezihlukahlukene.I-morphology ye-plaque engaphansi kanye nomthwalo we-thrombus kubonakala kuthonya imiphumela ngemva kwe-PCI; I-59 Ukungena okujulile kwe-strut ngenxa ye-necrotic core (NC) prolapse, izinyembezi ezimaphakathi ngobude obuqinile, ukuhlukaniswa kwesibili ngamamajini asele, noma ukuncishiswa kwe-margin ebalulekile Ukuqina okuphezulu, ukufakwa okungaphelele, nokwanda okungaphelele60 Umuthi wokwelashwa nge-antiplatelet ayithinti kakhulu i-ST ngesikhathi semithi ye-ST: I-DAPT esivivinyweni esingahleliwe esiqhathanisa ne-BMS ne-DES Amazinga ayefana (<1%).61 Ngakho, i-ST yakuqala ibonakala ihlobene ngokuyinhloko nezilonda eziyisisekelo zokwelapha nezici zokuhlinzwa.
Namuhla, ukugxila okukhethekile ku-ST sekwephuzile / sekwephuzile kakhulu.Uma izici zezinqubo nezobuchwepheshe zibonakala zidlala indima enkulu ekuthuthukiseni i-ST enzima ne-subacute, indlela yezenzakalo ze-thrombotic ebambezelekile ibonakala iyinkimbinkimbi kakhulu.Kuye kwaphakanyiswa ukuthi izici ezithile zesiguli zingase zibe yizici zengozi ye-ST ethuthukile futhi ethuthuke kakhulu: isifo sikashukela, i-ACS ngesikhathi sokuhlinzwa kokuqala, ukwehluleka kwezinso, ukuguga, ukuguga, i-accessories enkulu ye-30 izinsuku zokuqala ze-ejection ye-cardio. Ukuhlinzwa.Ngokwe-BMS ne-DES, ukuguquguquka kwezinqubo, njengosayizi womkhumbi omncane, ama-bifurcations, isifo se-polyvascular, ukubala, ukuvaleka okuphelele, ama-stents amade, kubonakala sengathi kuhlotshaniswa nengozi ye-ST.62,63 Ukusabela okunganele kokwelashwa kwe-antiplatelet kuyingozi enkulu ye-DES thrombosis 51. impendulo, i-polymorphisms yofuzo ezingeni le-receptor (ikakhulukazi ukumelana ne-clopidogrel), kanye nokulawulwa kwezinye izindlela zokwenza i-platelet activation.I-In-stent neoatherosclerosis ibhekwa njengendlela ebalulekile yokwehluleka kwe-stent sekwephuzile, okuhlanganisa sekwephuzile kwe-ST64 (isigaba "I-In-stent neoatherosclerosis"). izinto ze-vasodilatory.DES iveza udonga lomkhumbi emithini ye-antiproliferative kanye nesiteji sokukhipha izidakamizwa esinemiphumela ehlukile ekuphulukiseni nasekusebenzeni kwe-endothelial, ngengozi ye-thrombosis sekwephuzile.Izifundo ze-Pathological ze-65 ziphakamisa ukuthi ama-polymers ahlala isikhathi eside e-DES yesizukulwane sokuqala angase abe nomthelela ekuvuvukeni okungapheli, ukufakwa kwe-fibrin okungapheli, ingozi ye-endothelial consensibility eyandayo ye-3 endothelithrombosis eyandayo, kanye ne-3 hypersensitivity ku-DES. ukuze kube enye indlela eholela ku-ST.Virmani et al66 ibike imiphumela ye-post-mortem post-ST ebonisa ukunwetshwa kwe-aneurysm engxenyeni ye-stent ngokusabela kwe-hypersensitivity yendawo eyakhiwe ngama-T lymphocyte nama-eosinophils; lokhu okutholakele kungase kubonise ithonya lama-polymers angenakunyakaziswa.67 I-stent malapposition ingase ibe ngenxa yokwandiswa kwe-stent encane noma kwenzeke ezinyangeni ngemva kwe-PCI.Nakuba i-procedural malapposition iyingozi engozini ye-ST ebukhali ne-subacute, ukubaluleka komtholampilo kokutholakala kwe-stent malapposition kungase kuncike ekulungisweni kabusha kwe-arterial enonya noma ukulibaziseka kokwelashwa kwezidakamizwa. impikiswano.68
Imiphumela yokuvikela ye-DES yesizukulwane sesibili ingase ihlanganise i-endothelialization esheshayo futhi eqinile, kanye nomehluko we-stent alloy nesakhiwo, ukushuba kwe-strut, izakhiwo ze-polymer, kanye nohlobo lwezidakamizwa ezilwa nokuvuvukala, umthamo, kanye ne-kinetics.
Ngokuphathelene ne-CoCr-EES, ama-stent stent e-cobalt-chromium azacile (81 µm), ama-antithrombotic fluoropolymers, i-polymer ephansi, kanye nokulayishwa kwezidakamizwa kungase kube nomthelela ezenzakalweni eziphansi ze-ST. Ucwaningo lokuhlola lubonise ukuthi i-thrombosis ne-platelet deposition ye-fluoropolymer-coated-coated stents ephansi kakhulu kunalawo ma-stether6 angaphansi kakhulu. I-DES yesizukulwane sesibili inezakhiwo ezifanayo ifanelwe ukufundelwa okwengeziwe.
Ama-coronary stents athuthukisa izinga lokuphumelela kokuhlinzwa kokungenelela kwe-coronary uma kuqhathaniswa ne-traditional percutaneous transluminal coronary angioplasty (PTCA), enezinkinga zemishini (i-vascular occlusion, dissection, njll.) kanye namazinga aphezulu okubuyisela emuva (kufika ku-40% -50% wamacala). Ngasekupheleni kwawo-1990, cishe amaphesenti angu-70 ama-PCI enziwa ngokufakwa kwe-BMS.70
Kodwa-ke, naphezu kwentuthuko kwezobuchwepheshe, amasu, kanye nokwelashwa kwezokwelapha, ingozi yokuphumula ngemva kokufakelwa kwe-BMS cishe i-20%, ne> 40% emaqenjini athile athile.71 Sekukonke, izifundo zomtholampilo zibonise ukuthi ukuphumula ngemva kokufakwa kwe-BMS, okufana nalokho okuphawulwe nge-PTCA evamile, iphakama ezinyangeni ze-3-6 futhi ixazulula ngemva konyaka we-1.72.
I-DES iphinde inciphise ukwenzeka kwe-ISR,73 nakuba lokhu kuncipha kuncike ku-angiography kanye nesilungiselelo somtholampilo.I-polymer coating ku-DES ikhulula ama-anti-inflammatory and anti-proliferative agents, ivimbela ukwakheka kwe-neointima, futhi ilibazise inqubo yokulungisa imithambo yegazi izinyanga kuya eminyakeni.74 Ukukhula okuqhubekayo kwe-neointimal ngesikhathi sokulandelwa kwesikhathi eside okubizwa ngokuthi "i-DES implantation" eyaziwa ngokuthi "i-phenomenon-implantation", eyaziwa ngokuthi i-DES, eyaziwa ngokuthi i-phenomenon-implantation emtholampilo eyaziwa ngokuthi i-DES izifundo ze-histological. 75
Ukulimala kwe-Vascular ngesikhathi se-PCI kukhiqiza inqubo eyinkimbinkimbi yokuvuvukala nokulungisa ngesikhathi esifushane kakhulu (amasonto kuya ezinyangeni), okuholela ekuqedeni kwe-endothelialization kanye ne-neointimal coverage.Ngokokubonwa kwe-histopathological, i-neointimal hyperplasia (BMS ne-DES) ngemva kokufakelwa okuqinile kwakuhlanganiswe ngokuyinhloko ngamaseli e-proliferative proliferative-smooth-matrix e-muscle e-extracellular prolifecellular0.
Ngakho-ke, i-neointimal hyperplasia imelela inqubo yokulungisa ehilela ukuhlangana kanye nezici ezivuthayo kanye namaseli abangela ukwanda kwamaseli emisipha ebushelelezi kanye nokwakheka kwe-matrix ye-extracellular.Ngokushesha ngemva kwe-PCI, i-platelet kanye ne-fibrin idiphozi odongeni lomkhumbi futhi iqoqa ama-leukocyte ngochungechunge lwama-molecule e-cell adhesion.I-Rolling leukocyte ye-leukocyte ihlanganisa i-leukocyte ye-adherent1 inamathisele i-adherent integrated leukocyte. (CD11b/CD18) kanye ne-platelet glycoprotein Ibα 53 noma i-fibrinogen eboshwe ku-platelet glycoprotein IIb/IIIa.76,77
Ngokusho kwedatha evelayo, amangqamuzana okhokho atholakala emnkantshani abandakanyeka ekuphenduleni kwe-vascular kanye nezinqubo zokulungisa.Ukuhlanganiswa kwe-EPCs kusuka kumnkantsha wethambo kuya egazini le-peripheral kukhuthaza ukuvuselelwa kwe-endothelial kanye ne-postnatal neovascularization.Kubonakala sengathi i-bone marrow smooth muscle progenitor cells (SMPC) ithuthela endaweni yokulimala kwe-vascular, okuholela ekukhuleni kwe-CD48 ngaphambili, i-CD38 ibhekwa njenge-neointi8 cell. ukuba isibalo esimisiwe sama-EPC; ucwaningo olwengeziwe lubonise ukuthi i-CD34 surface antigen empeleni ibona ama-stem cell stem cells angahlukanisiwe anekhono lokuhlukanisa abe ama-EPC kanye nama-SMPC.Ukuhlukaniswa kwamaseli e-CD34-positive kuya ku-EPC noma uzalo lwe-SMPC kuncike endaweni yendawo; izimo ze-ischemic zenza umehluko maqondana ne-EPC phenotype ukukhuthaza ukuphindaphinda kwe-endothelialization, kuyilapho izimo ezivuthayo zenza umehluko ku-phenotype ye-SMPC ukukhuthaza ukwanda kwe-neointimal.79
Isifo sikashukela sandisa ingozi ye-ISR ngo-30% -50% ngemva kokufakelwa kwe-BMS, i-80 kanye nesigameko esiphezulu se-restenosis ezigulini ezinesifo sikashukela uma kuqhathaniswa neziguli ezingenasifo sikashukela nazo zaqhubeka esikhathini se-DES. isifo, njll.) izici ezikhuphuka ngokuzimela Ingozi ye-ISR.70
Ububanzi bomkhumbi kanye nobude be-lesion buthinte ngokuzimela ukwenzeka kwe-ISR, ngezilonda ezincane zobubanzi / ezinde ezikhulisa kakhulu izinga lokuphumula uma kuqhathaniswa nezilonda ezinkulu / ezifushane.71
Amaplathifomu aqinile esizukulwane sokuqala abonise ama-stent stent aminyene kanye namazinga e-ISR aphezulu uma kuqhathaniswa nezinkundla zesizukulwane sesibili eziqinile ezinezintambo ezincane.
Ukwengeza, isigameko se-restenosis sasihlobene nobude be-stent, ubude be-stent> 35 mm cishe kabili ubude kunalabo <20 mm. Ububanzi bokugcina be-lumen obuncane be-stent bubuye badlala indima ebalulekile: ububanzi obuncane bokugcina obuncane be-lumen bubikezela ingozi eyanda kakhulu ye-restenosis.81,82
Ngokwesiko, i-hyperplasia ye-intimal elandela ukufakwa kwe-BMS ibhekwa njengezinzile, nenani eliphakeme lokuqala phakathi kwezinyanga ze-6 nonyaka we-1, kulandelwa isikhathi sokuthula sekwephuzile. ukuhlehla kwe-neointimal .83 Nokho, izifundo ezilandela isikhathi eside zibonise impendulo ephindwe kathathu ngemva kokubekwa kwe-BMS, nokuphumula kokuqala, ukuhlehla okuphakathi, kanye ne-lumen restenosis sekwephuzile.84
Esikhathini se-DES, ukukhula kwe-neointimal sekwephuzile kwaqala kwaboniswa ngokulandela ukufakwa kwe-SES noma i-PES emifanekisweni yezilwane.85 Ucwaningo oluningana lwe-IVUS luye lwabonisa ukuncishiswa kokuqala kokukhula kwe-intimal okulandelwa ukubamba isikhathi eside ngemva kokufakwa kwe-SES noma i-PES, okungenzeka ngenxa yenqubo yokuvuvukala eqhubekayo.86
Naphezu "kokuzinza" okuvame ukubhekwa njenge-ISR, cishe ingxenye eyodwa kwezintathu yeziguli ze-BMS ISR zenza i-ACS.4
Kunobufakazi obandayo bokuthi ukuvuvukala okungapheli kanye / noma ukungasebenzi kahle kwe-endothelial kudala i-neoatherosclerosis ethuthukisiwe ngaphakathi kwe-BMS ne-DES (ikakhulukazi i-DES yesizukulwane sokuqala), okungase kube indlela ebalulekile ye-ISR ethuthukisiwe noma i-ST.Inoue et al. I-87 ibike okutholwe kwe-histological kusuka kumasampula e-autopsy kulandela ukufakwa kwe-Palmaz-Schatz coronary stents, okuphakamisa ukuthi ukuvuvukala kwe-peri-stent kungase kusheshise izinguquko ezintsha ze-atherosclerotic ezingenzi lutho ngaphakathi kwe-stent.Ezinye izifundo10 zibonise ukuthi izicubu zokuphumula ngaphakathi kwe-BMS, ngaphezu kweminyaka engu-5, iqukethe i-atherosclerosis esanda kuvela; amasampula avela ezimweni ze-ACS abonisa ama-plaque asengozini evamile emithanjeni ye-coronary yomdabu I-Histological morphology ye-block ene-foamy macrophages kanye namakristalu e-cholesterol.Ngaphezu kwalokho, lapho kuqhathaniswa ne-BMS ne-DES, umehluko omkhulu ngesikhathi sokuthuthukiswa kwe-atherosclerosis entsha waphawulwa.11,12 Izinguquko zokuqala ze-atherosclerotic ku-foamy macrophage zaqala ukufakwa kwe-foamy macrophage ngemva kwezinyanga ezingu-4 zokufakelwa kwe-foamy macrophage. Izilonda ze-BMS zenzeke eminyakeni engu-2 kamuva futhi zahlala zitholakala ezingavamile kuze kube yiminyaka engu-4. Ngaphezu kwalokho, i-DES stenting yezilonda ezingazinzile ezifana ne-thin-cap fibroatherosclerosis (TCFA) noma ukuqhuma kwe-intimal kunesikhathi esifushane sokuthuthukiswa uma kuqhathaniswa ne-BMS.
Umthelela we-DES yesizukulwane sesibili noma i-DES ekuthuthukisweni kusazofundwa; nakuba okunye ukubhekwa okukhona kwesizukulwane sesibili i-DESs88 kuphakamisa ukuvuvukala okuncane, izehlakalo ze-neoatherossteosis ziyefana nalezo zesizukulwane sokuqala, kodwa ucwaningo olwengeziwe lusadingeka.