近端血流阻塞式脑保护装置下颈动脉支架成形术的临床研究

目的 研究近端血流阻塞式脑保护装置MO.MA系统在颈动脉支架成形术中预防脑血管栓塞的疗效,并评价其安全性及可操作性.方法 2007年10月至2008年7月,23例符合外科治疗指征的颈动脉硬化狭窄患者入选本研究,其中19例(82.6%)患者有神经系统症状.全脑血管造影后在脑保护装置MO.MA系统下行颈动脉球囊扩张及支架成形术,计算术中脑缺血时间,观察术中及术后30 d神经系统事件的发生情况.结果 颈动脉造影示,6例(26.1%)颈动脉狭窄50%～70%,17例(73.9%)颈动脉狭窄>70%.所有病例在MO.MA系统保护下颈动脉球囊扩张及支架植入均顺利进行,颈动脉平均阻断时间(5.3±1.2)min.术中及围手术期无死亡及脑卒中发生;2例在颈总动脉球囊阻断时出现短暂意识丧失伴对侧肢体短暂抽搐;2例术后出现心动过缓和低血压,持续时间分别为6 h及1周.9例患者术中颈动脉抽血中可见细小斑块碎片.术后30 d随访有1例TIA发作,1例对侧新发脑卒中,术后30 d累积脑卒中发生率及病死率为4.3%.结论 应用近端血流阻断式脑保护装置MO.MA系统在颈动脉支架成形术中预防神经系统事件发生是安全有效的,尤其适合重度及不稳定性斑块的颈动脉硬化狭窄支架成形术治疗.     

右侧肱动脉入路左颈动脉支架成形术治疗颈内动脉狭窄合并牛型主动脉弓1例报告

2013年10月我科收治1例63岁女性左颈动脉狭窄,有左侧脑梗死病史并频繁出现一过性脑缺血发作（transient ischemic attack,TIA）。术前CTA检查为牛型主动脉弓,左侧颈内动脉起始部重度狭窄,但位于C2水平不适合行颈动脉内膜切除术。采用全麻下经右侧肱动脉人路穿刺,造影导管选人左颈外动脉,加硬导丝引导F6长鞘选人左颈总动脉建立手术通路,然后常规进行保护伞下的颈动脉球囊扩张和支架成形术。手术成功,未发生任何并发症。术后1个月随访,TIA症状完全消失,颈动脉超声提示左颈内动脉支架术后血流通畅。我们认为经右侧肱动脉人路行支架成形术治疗牛型主动脉弓变异的左侧颈内动脉狭窄是安全、可行的。     

应用脑保护装置的颈动脉支架成形术治疗颈动脉狭窄

目的 总结应用脑保护装置的颈动脉支架成形术的体会,并探讨其围手术期处理要点.方法 2002年1月至2007年12月共收治122例(125侧)颈动脉狭窄性病变患者,成功完成颈动脉支架成形术123侧,均使用了脑保护装置,共置人支架124枚.结果 技术成功率为98.4%(123/125).围手术期发生一过I生脑缺血6例(4.9%),小卒中2例(1.6%),完伞性卒中1例(O.8%),严重脑缺血再灌注损伤2例(1.6%),其余113例次(91.9%)无神经系统并发症发生.无围手术期死亡.总卒中/死亡率为2.4%.86例患者术后获随访,平均随访时间为18.5(3～36)个月,超声检查提示50%～70%狭窄5例(5.8%),70%以上狭窄1例(1.2%),均无临床症状.非相关原因死亡2例.其余78例(90.7%)支架通畅,无神经系统并发症发生.结论 颈动脉支架成形术是治疗颈动脉狭窄性病变安全、有效的方法.不断提高围手术期处理水平是进一步提高疗效、降低并发症发生率的重要保证.     

应用脑保护装置实施颈动脉支架成形术的临床经验

目的探讨脑保护装置在颈动脉支架成形术中的价值。方法自2000年10月至2006年8月对65例颈动脉狭窄患者实施了颈动脉支架成形术。共植入支架75个,其中颈内动脉支架68个,颈总动脉支架2个,同时植入锁骨下动脉支架2个,椎动脉支架3个,4例术前安装了临时起搏器。结果65例中2例脑保护装置置放失败,63例成功。63例脑保护装置中26例可见斑块碎片,1例术中出现一过性脑缺血,1例同时置入椎动脉支架后发生椎动脉血栓形成;9例术中出现一过性低血压、心动过缓,4例术前安装临时起搏器者未发生术中低血压。5例出现术后低血压,1例术后原有神经系统症状加重。1例双颈动脉支架成形术后出现高血压。结论颈动脉支架成形术是治疗颈动脉狭窄的有效手段,在有脑保护装置的条件下,正规熟练的操作和严格的预防措施能有效提高安全性,减少并发症。     

显微颈动脉内膜切除术治疗放疗后颈动脉狭窄

目的探讨颈动脉内膜切除术(carotid endarterectomy,CEA)治疗放疗后颈动脉狭窄的安全性及有效性。方法 2015年1月～2019年8月我科采用标准式或补片式CEA治疗10例放疗后颈动脉狭窄,术后采用头颈动脉CTA或颈动脉彩色多普勒超声评估颈动脉是否再狭窄。结果 10例共实施12次CEA,术中证实均为斑块所致狭窄,狭窄部位可不局限于颈动脉分叉部,多为混合性斑块伴有血管壁纤维化。3例术中发生血管内膜撕裂,2例术后出现一过性声音嘶哑,2例术后颅脑磁共振DWI发现无临床症状的脑实质点状高信号影。围手术期未出现脑出血、心肌梗死等并发症。术后24 h复查头颈动脉CTA和颈动脉彩色多普勒超声示9例斑块消失、颈动脉通畅,1例支架内再狭窄术后再发颈内动脉血栓性闭塞。9例随访8～48个月,中位随访时间23个月,颈动脉均通畅未见再狭窄,未再出现缺血性脑血管事件。结论 CEA是放疗后颈动脉狭窄的有效治疗方法。术前详细的综合评估、个体化手术方案设计、严密的术后随访是保证治疗效果的前提。     

血管内支架成形术治疗脑供血动脉狭窄的研究

目的 探讨血管内支架成形术治疗脑供血动脉狭窄患者的近期疗效,并发症及安全性.方法 行血管内支架成形术治疗的19例脑供血动脉狭窄患者,其中颈内动脉起始段狭窄13例[5例表现为短暂性脑缺血发作(TIA),8例表现为脑梗死],椎动脉开口部狭窄6例,均表现为TIA.结果 19例患者支架全部成功置入,术前动脉狭窄程度平均为86%,术后残余狭窄程度平均为10%;明显增高的血流动力学恢复正常且持续保持;颈内动脉系统腩梗死患者NIHSS评分在术后明显改善.3例颈内动脉支架置入术患者出现一过性心率下降和血压下降,经药物治疗后均恢复正常.随访仅1例颈内动脉支架术后22周症状有所加重;1例椎动脉狭窄患者在术后19周出现1次TIA发作;其余患者术后随访6个月无症状复发.结论 血管内支架成形术是治疗脑供血动脉狭窄的一种安全、有效的治疗方法.     

颈动脉狭窄支架血管内成形术并发症23例分析

目的探讨颈动脉狭窄支架血管内成形术并发症发生的机制、预防和预后。方法回顾性分析 1997～ 2 0 0 3年接受颈动脉支架术的 312例患者中 2 3例并发症的资料。结果本组 2 3例并发症包括轻微并发症 19例 (6 1% ) ,其中 10例表现为术中一过性心率和血压下降 (3 2 % ) ;6例在球囊扩张时表现为一过性脑缺血症状 (1 9% ) ;3例在成功置入支架后出现血压下降 ,对症处理后恢复。严重并发症 4例 (1 3% ) ,其中术中栓子脱落 1例术后偏瘫经对症治疗后恢复 ;支架移位 1例、颈外动脉闭塞 1例无神经功能障碍以及术后过度灌注出血 1例 ,患者死亡。结论颈动脉狭窄支架血管内成形术可能发生严重的并发症 ,熟悉并发症产生的机制有利于预防其发生。     

高危颈动脉狭窄患者的血管腔内治疗

目的探讨高危颈动脉狭窄患者血管腔内治疗的短期疗效和并发症预防。方法对41例高危颈动脉狭窄患者行颈动脉支架植入术,术前狭窄程度为75.0%～98.0%,狭窄长度1.3～3.6 cm,患者均合并一种或多种内科疾病。结果本组均采用脑保护伞及自膨式支架,操作均获得成功,术中颈动脉造影残余狭窄率≤30%。12例患者于术中出现一过性不同程度心率下降,1例患者支架释放后近端出现动脉夹层,1例患者在支架置入后出现失语及右侧肢体偏瘫,无脑出血,经保守治疗14天后症状缓解。随访33例患者,随访时间3～18个月。随访期间,1例死于恶性肿瘤,1例死于心肌梗死,2例出现支架内再狭窄,但无临床症状,其余患者支架无移位,支架内血流通畅,无脑缺血症状。结论对于高危患者,血管腔内治疗近期疗效较好,规范操作可减少并发症的发生。     

颈动脉狭窄患者围手术期脑部并发症的诊治

目的 探讨颈动脉狭窄患者围手术期脑部并发症的原因及其防治措施.方法 回顾性分析2004年5月至2009年6月间接受外科治疗的133例颈动脉狭窄患者围手术期脑部并发症的原因及其处理方式.结果 本组133例颈动脉狭窄患者,其中男97例,女36例;年龄62～78岁,平均(67±8)岁.其中94例接受颈动脉内膜剥脱术(carotid endarterectomy,CEA),39例接受颈动脉支架植入术(carotid artery stenting,CAS);围手术期16例出现脑部并发症,其中3例发病次数在2次以上;术前5例出现短暂性脑缺血发作(transient ischemic attacks,TIA)及一过性脑供血不足等并发症;CEA术中5例、CAS术中4例出现TIA发作和脑过度灌注综合征(cerebral hyperperfusion syndrome,CHPS)等并发症;术后8例患者出现TIA发作、脑过度灌注综合征、脑梗死及脑出血等并发症.结论 有效控制围手术期脑部并发症的发生是外科治疗颈动脉狭窄成败的关健,脑部并发症的防治应贯穿整个围手术期.     

颈动脉狭窄支架成形术中应对血流动力学变化的临床探讨

目的探讨颈动脉狭窄支架成形术中应对血流动力学变化处理措施的有效性。方法对前期80例患者术中未作特殊处理;后期125例行支架成形术的患者术中严格控制血压在个体正常值的下限,心率升高至80次／min后开始扩张狭窄并放置支架。结果前80例患者并发症为8．8％,严格调控血流动力学的125例患者未见明显并发症。随访1个月～5年,均无严重再狭窄发生。结论重视调整颈动脉狭窄支架成形术中的血流动力学变化对减少并发症,提高治疗效果有益。     

Carotid artery stenting with routine cerebral protection in high-risk patients

BACKGROUND: Carotid artery stenting has emerged as an alternative treatment modality in carotid occlusive disease. This study examined our experience of carotid stenting with routine cerebral embolization protection in high-risk patients. METHODS: Clinical variables and treatment outcome of high-risk patients who underwent carotid stenting with neuroprotection were analyzed during a 26-month period. RESULTS: Sixty-eight high-risk patients with 72 carotid artery stenoses were treated. Procedural success was achieved in 70 cases (97%), and symptomatic lesions existed in 17 (24%) patients. Monorail Wallstents stents were used in all cases. Neuroprotective devices used were PercuSurge (28%) and Filterwire (72%). There was no periprocedural mortality or neuroprotective device-related complications. The 30-day stroke and death rate was 2.7%, and the overall complication rate was 6.9%. All stented vessels remained patent during the follow-up period (mean 15.3 +/- 4.2, range 1 to 23 months). Two asymptomatic in-stent restenosis (3%) occurred at 6 and 8 months, which were both successfully treated with balloon angioplasty. CONCLUSIONS: Our study showed that percutaneous carotid stenting with routine use of a cerebral protection device is a feasible and effective treatment in high-risk patients with carotid occlusive disease.     

Carotid artery stenting in a vascular surgery practice

PURPOSE: We tested the clinical applicability, technical results, and morbidity of carotid angioplasty-stenting (CAS) in the treatment of severe stenosis of the internal carotid artery (ICA) in patients deemed to be high-risk candidates for carotid endarterectomy (CEA). METHOD: After an initial series (1994-1997) of 52 interventions, we adopted the use of a transfemoral access technique and self-expanding stents in late 1997. From Dec 1, 1997, to Mar 31, 2001, 135 CAS procedures were performed on 132 patients with more than 70% (symptomatic) or more than 80% (asymptomatic) stenoses of the ICA. Sixty percent of the patients had no symptoms, and 40% of patients had symptoms. The interventional technique was standardized with the use of a 7F long interventional sheath, balloon pre-dilatation of the stenotic lesion, placement of a self-expanding stent (Wallstent in 12 patients and a SMART stent in 120 patients), and post-balloon dilatation when necessary. Brain protection devices were not used. Patients were given clopidogrel and aspirin before and after the procedure and heparin during the intervention. RESULTS: All procedures except two were completed as planned, with access failure in three patients (2.2%). Residual in-stent stenosis of less than 20% was detected in 14 of 132 stented vessels (11%) and accepted as a satisfactory angiographic outcome. Neurologic complications included one patient with a single-episode transient ischemic attack (TIA; motor-sensory deficit of the hand) occurring 2 hours after CAS. One patient sustained a major stroke after thrombosis of the stented ICA, which occurred 3 days after the CAS procedure and 24 hours after open-heart surgery. A third patient sustained a minor stroke that began intraprocedurally after post-balloon dilatation of the stent, and a fourth patient had another minor stroke with transient aphasia (beginning during the procedure and resolving after 4 hours) and monoparesis of the hand, which resolved after 1 week. All stented vessels remained patent during the follow-up period (range, 2-41 months; mean, 16 plus minus 9 months), with four instances of hemodynamically significant in-stent restenosis. Re-intervention with balloon angioplasty was undertaken successfully at 4 months in one patient with restenosis. The periprocedural mortality rate was 0. CONCLUSION: Carotid stenting can be performed with acceptable safety on carefully selected patients by using meticulous, standardized interventional techniques. It may offer a possibly superior therapeutic alternative for non-CEA candidates. Evolving technological improvements and brain protection devices are likely to enhance its role in the treatment of carotid artery disease in the future. Surgical endarterectomy remains the standard of care for most patients at the present time.     

Resection and reconstruction of the carotid bifurcation with polytetrafluoroethylene grafts; operative technique. Preliminary results in 25 procedures and indications

Although carotid endarterectomy is the standard procedure, the purpose of this paper is to describe a new surgical technique and indicate its role in the surgery of cervical cerebrovascular disease. The technique consists of resection of the pathologic carotid artery bifurcation followed by its total replacement with a bifurcated thin-wall polytetrafluoroethylene (PTFE) graft constructed by the surgeon. Prosthetic graft reconstruction of the carotid bifurcation (PGRCB) was performed in 21 patients (25 procedures) from November 1984 to May 1987. Many patients were over 70 years old. The indications for surgery were transient ischemic attacks (TIA)'s in 10 patients (high-grade stenosis), established stroke with mild deficit in 3 patients (high-grade stenosis). Eight patients (high-grade stenosis) were asymptomatic and 4 had vertebro-basilar symptoms. In 11 procedures the indications were the same as for standard carotid endarterectomy (significant stenosis and/or ulcerated plaque). In 14 cases, the procedure was justified by extensive lesions involving a long segment of the internal carotid artery (2 restenoses, 12 calcified lesions). In the perioperative period, there were no deaths and no TIA's. The 25 procedures were assessed one month postoperatively by ultrasonic imaging and venous substraction angiography. All the grafts were patent with perfect restoration of the carotid bifurcation anatomy. Systematic follow-up study was carried out in 1987. Three patients had died of non-neurologic causes and one was lost to study. The remaining 19 procedures were evaluated with an average follow-up of 19 months (range 7 to 32 months). The patients were asymptomatic and all the grafts remained patent including one stenosis (greater than 50%) at the common carotid artery anastomosis. Because recent studies have documented a much higher rate of technical defects or recurrent stenosis after carotid endarterectomy, we believe that PGRCB merits consideration, particularly in difficult endarterectomies, and in recurrent carotid stenosis. Furthermore it seems acceptable to advocate PGRCB in aneurysms of the internal carotid artery and in post-irradiation arteritis.     

颈内动脉狭窄处扭曲的血管内治疗

目的 探讨血管内支架成形术治疗颈内动脉狭窄处扭曲的必要性、可行性和安全性.方法 选择2003年12月至2009年12月经数字减影血管造影(DSA)检查证实的症状性颈内动脉狭窄且狭窄处伴扭曲的12例患者,采用血管内支架成形术处理颈动脉狭窄伴扭曲,分析其临床、影像学、支架成形术和随访观察资料,评价治疗效果.结果 12例颈内动脉狭窄伴扭曲的患者全部成功实施血管内支架成形术,支架置入成功率100%,无支架相关死亡或致残.12例患者共置入自膨式支架14枚,平均狭窄率由术前的85.6%下降至11.2%;扭曲角度(Metz观测分类法)由术前＜90°变为＞120°;无围手术期短暂性脑缺血发作(TIA)和脑卒中发生,临床症状改善或消失.临床随访6～72个月,发生支架同侧和对侧TIA各1例;5例患者行DSA检查,其中1例发生再狭窄并在支架远端发生新的扭曲,再次支架置入治疗,2年后CT血管造影(CTA)复查未见扭曲和支架内再狭窄;另外7例行颈部血管超声检查,未见再狭窄和扭曲.结论 血管内支架成形术治疗颈内动脉狭窄伴扭曲,技术上是可行、安全的,可能有助于减少脑缺血发生,但有待于进一步观察.

Abstract：

Objective To study the necessity, feasibility, security of carotid angioplasty and stenting (CAS) for symptomatic carotid stenosis combined with kinking. Methods Twelve patients with symptomatic carotid stenosis and kinking demonstrated by digital subtraction angiography (DSA) received CAS from December 2003 to December 2009. There were 9 male and 3 female patients, age ranged from 59 to 77 years(mean 69.3 years). All the patients' clinical, imaging, intervention and follow up data were collected and analyzed. Results All CAS procedures were successfully performed with 14 self-expandable stents placed. The mean degree of stenosis was reduced from 85. 6% before stenting to 11.2% after stenting,the angle of kinking, according to Metz' category, were improved from less than 90° to more than 120° in each case. No perioperative procedure related stroke and tranient ichemic attack (TIA) occurred. The clinical symptoms and signs of cerebral ischemia were improved or disappeared for all patients. During follow-up of these 12 patients for 6 to 72 months, one patient experienced ipsilateral carotid territory TIA and another patient experienced contralateral carotid territory TIA. DSA follow up of 5 patients demonstrated 1 case with in-stent restenosis and arterial kinking remote to the stent of internal carotid artery. CAS were performed again and CT angiography follow up demonstrated no kinking and restenosis 2 years after the intervention. Duplex scan of the other 7 patients demonstrated neither kinking nor restenosis. Conclusions CAS seems to be feasible and safe for the patients with symptomatic kinking and stenosis, and maybe helpful to lower the risk of cerebral ischemia, but further study is needed.     

Cerebral protection during carotid stenting using flow reversal

BACKGROUND: Carotid angioplasty and stenting can be used in stroke prevention in high-risk patients. As embolic complications can occur during carotid angioplasty and stenting, a device was developed to protect from cerebral embolization. METHODS: Between September 1999 and May 2002, carotid angioplasty and stenting was performed in 100 patients (84 men; mean age, 69.2 years) with symptomatic (26%) or asymptomatic (74%) severe carotid artery stenosis. Wallstents were used in all cases with selective pre-dilatation. Cerebral protection devices (Parodi Anti-Emboli System [PAES], ArteriA, San Francisco, Calif) were used in all patients. All patients were evaluated by a neurologist, both before and after the procedure. According to the criteria set forth by the large trials, the occurrence of minor, major or fatal stroke and myocardial infarction (end points) within 30 days and follow-up were determined as end points. Data were collected prospectively. RESULTS: The overall perioperative stroke and death rate was 3% (1 noncorresponding minor stroke, 1 hemorrhagic stroke, and 1 cardiac event). Four patients developed postoperative transient neurologic events (three related to hemodynamic instability and the fourth due to postoperative embolization). The overall technical success rate for carotid angioplasty (protection device placed in position percutaneously) was 99%. CONCLUSION: The efficacy and safety of carotid angioplasty and stenting with PAES are confirmed. This innovative protection device may prevent the debris released by angioplasty from entering the cerebral circulation. Further investigation is warranted.     

弹簧支架在下肢动脉硬化性狭窄和闭塞治疗中的应用

目的总结使用弹簧支架对下肢动脉硬化性狭窄和闭塞行介入球囊扩张、支架术的临床经验和近、远期疗效。方法对23例患者的29条肢体的下肢动脉硬化性病变行球囊扩张后置入弹簧支架（Introcoil）。结果成功完成29条肢体的治疗，无术中并发症。置入后即时造影示病变处管径明显增大，血流通畅。所有患者均获2～36个月随访，平均随访20个月。6例患者的6条肢体（20．7％）因重新出现动脉闭塞而行搭桥手术，其他患者下肢原有症状消失，20条足背动脉搏动恢复，超声示支架处血流通畅。结论弹簧支架置入是一种有效的下肢动脉狭窄和闭塞的介入治疗方法。     

In-stent recurrent stenosis after carotid artery stenting: life table analysis and clinical relevance

OBJECTIVES: Carotid artery stenting has been proposed as an alternative to carotid endarterectomy in cerebral revascularization. Although early results from several centers have been encouraging, concerns remain regarding long-term durability of carotid artery stenting. We report the incidence, characteristics, and management of in-stent recurrent stenosis after long-term follow-up of carotid artery stenting. METHODS: Carotid artery stenting (n = 122) was performed in 118 patients between September 1996 and March 2003. Indications included recurrent stenosis after previous carotid endarterectomy (66%), primary lesions in patients at high-risk (29%), and previous ipsilateral cervical radiation therapy (5%). Fifty-five percent of patients had asymptomatic stenosis; 45% had symptomatic lesions. Each patient was followed up with serial duplex ultrasound scanning. Selective angiography and repeat intervention were performed when duplex ultrasound scans demonstrated 80% or greater in-stent recurrent stenosis. Data were prospectively recorded, and were statistically analyzed with the Kaplan-Meier method and log-rank test. RESULTS: Carotid artery stenting was performed successfully in all cases, with the WallStent or Acculink carotid stent. Thirty-day stroke and death rate was 3.3%, attributable to retinal infarction (n = 1), hemispheric stroke (n = 1), and death (n = 2). Over follow-up of 1 to 74 months (mean, 18.8 months), 22 patients had in-stent recurrent stenosis (40%-59%, n = 11; 60%-79%, n = 6; > or =80%, n = 5), which occurred within 18 months of carotid artery stenting in 13 patients (60%). None of the patients with in-stent recurrent stenosis exhibited neurologic symptoms. Life table analysis and Kaplan-Meier curves predicted cumulative in-stent recurrent stenosis 80% or greater in 6.4% of patients at 60 months. Three of five in-stent recurrent stenoses occurred within 15 months of carotid artery stenting, and one each occurred at 20 and 47 months, respectively. Repeat angioplasty was performed once in 3 patients and three times in 1 patient, and repeat stenting in 1 patient, without complications. One of these patients demonstrated asymptomatic internal carotid artery occlusion 1 year after repeat intervention. CONCLUSIONS: Carotid artery stenting can be performed with a low incidence of periprocedural complications. The cumulative incidence of clinically significant in-stent recurrent stenosis (> or =80%) over 5 years is low (6.4%). In-stent restenosis was not associated with neurologic symptoms in the 5 patients noted in this cohort. Most instances of in-stent recurrent stenosis occur early after carotid artery stenting, and can be managed successfully with endovascular techniques.