经局部动脉内溶栓治疗急性脑梗死

目的　研究经血管内选择性溶栓治疗 49例 8h内发病的急性脑梗死患者 ,以评估动脉内溶栓治疗急性脑梗死的疗效。方法　患者均急诊行头颅CT检查 ,31例经股动脉插管 ,全脑血管造影确认脑梗死 ,再选择性将导管插入患侧颈内动脉和椎动脉并注入尿激酶 5 0～ 75万单位行接触性和区域性溶栓治疗。对照组 18例行常规治疗。结果　溶栓后血管再通率为 71% ,有效率为 83%。 2 3例颈内动脉系和 4例椎基动脉系梗死在溶栓后 2周内神经损害体征明显改善 ,2例死亡。溶栓组改良爱丁堡 斯堪的纳维亚脑卒中量表 (MESSS)评分改善 (2 1.6± 13.6 )分 ;对照组改善 (5 .9± 5 .3)分。溶栓组发病时间越短其疗效越好。结论　选择性动脉内溶栓治疗是一种治疗急性脑梗死的有效方法 ,具有较高的血管再通率     

血管内机械再通治疗急性基底动脉闭塞的疗效分析

目的探讨机械再通治疗急性基底动脉闭塞患者的近期疗效。方法回顾性分析12例基底动脉急性闭塞并接受支架辅助血管内再通治疗的患者资料。对8例患者使用Apollo或Wingspan支架,4例使用Solitaire AB支架。血管内介入治疗后按照脑梗死溶栓等级系统(TICI)分级评定血管再通情况。评估3个月后的临床结局。结果①基底动脉远段闭塞3例,近段闭塞4例,椎动脉颅内段延伸至基底动脉近段闭塞3例,基底动脉全程闭塞2例。术前美国国立卫生研究院卒中量表(NIHSS)评分的中位数为20(15～24)分。②血管内机械再通治疗的技术成功率为100%,10例达到充分再通标准。2例患者术中发生血管痉挛,无临床症状。1例发生症状性颅内出血。③患者出院时NIHSS评分中位数为10(4～22)分,同最初NIHSS评分相比,7例患者NIHSS评分改善≥5分。④4例术后3个月的功能转归良好,死亡3例。结论血管内机械再通治疗急性基底动脉闭塞具有较高的再通率,可改善3个月时的临床结局。针对基底动脉闭塞不同病因需要个性化的血管内治疗方法。     

Effects of pressure-controlled intermittent coronary sinus occlusion on regional ischemic myocardial function

Pressure-controlled intermittent coronary sinus occlusion has been reported to reduce infarct size in dogs with coronary artery occlusion, possibly because of increased ischemic zone perfusion and washout of toxic metabolites. The influence of this intervention on regional myocardial function was investigated in open and closed chest dogs. In six open chest dogs with severe stenosis of the left anterior descending coronary artery and subsequent total occlusion, a 10 minute application of intermittent coronary sinus occlusion increased ischemic myocardial segment shortening from 5.5 +/- 1.2 to 8.2 +/- 2.6% (NS) and from -0.1 +/- 2.1 to 2.3 +/- 1.2% (NS), respectively. In eight closed chest anesthetized dogs, intermittent coronary sinus occlusion was applied for 2.5 hours between 30 minutes and 3 hours of intravascular balloon occlusion of the proximal left anterior descending coronary artery. Standardized two-dimensional echocardiographic measurements of left ventricular function were performed to derive systolic sectional and segmental fractional area changes in five short-axis cross sections of the left ventricle. Fractional area change in all the severely ischemic segments (less than 5% systolic wall thickening) was -4.0 +/- 4.7% at 30 minutes after occlusion, and increased with subsequent 60 and 150 minutes of treatment to 13.1 +/- 3.3 and 7.0 +/- 3.3%, respectively (p less than 0.05). At the most extensively involved low papillary muscle level of the ventricle, regional ischemic fractional area change was increased by intermittent coronary sinus occlusion between 30 and 180 minutes of coronary occlusion from -0.4 +/- 0.1 to 14.4 +/- 4% (p less than 0.05), whereas a further deterioration was noted in untreated dogs with coronary occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)     

颅内大动脉慢性闭塞血管内再通的可行性和安全性分析

目的探讨血管内介入再通颅内大动脉慢性闭塞的可行性和安全性。方法回顾性分析2009年1月至2017年1月首都医科大学宣武医院神经外科血管内介入再通的15例颅内大动脉慢性闭塞患者的临床和影像学资料。12例为椎动脉V4段闭塞,3例为颈内动脉颅内段闭塞。术前采用全脑DSA评估闭塞长度和位置,用高分辨率MRI评估闭塞性质和再通可行性;术中双侧股动脉置鞘13例,一侧用于再通置入支架,另一侧通过侧支循环代偿充盈闭塞动脉远端作为参考路径图,增加再通可行性。术后根据脑梗死溶栓(TICI)分级系统评估再通后的顺向血流,定义≥2b级为血管成功再通。结果 15例患者首次症状发作到再通时间中位数为50(18~365)d。再通成功13例,2例椎动脉颅内段再通失败。13例再通成功患者中,12例再通后复查造影正向血流恢复至TICI 3级,1例TICI 2b级;7例症状好转,4例症状无变化,1例术后出现短暂性脑缺血发作、1例出现卒中。11例患者随访中位数时间39(3~89)个月后,改良Rankin量表评分中位数为1(0~2)分。结论颅内大动脉慢性闭塞再通,术前采用高分辨率MRI评估以及术中双侧置鞘技术,可能会增加开通率和降低围手术期并发症。     

Ultrasound energy improves myocardial perfusion in the presence of coronary occlusion

OBJECTIVES: We evaluated whether ultrasound improves myocardial tissue perfusion in 14 animals with coronary artery occlusion. BACKGROUND: A recent study demonstrated that low-frequency ultrasound improves tissue perfusion in the rabbit ischemic limb, but there are no data on ultrasound enhancement of myocardial perfusion. METHODS: Fourteen animals (9 dogs, 5 pigs) underwent thoracotomy and occlusion of a diagonal branch of the left anterior descending coronary artery. Myocardial tissue perfusion units (TPUs) and pH were measured before coronary occlusion, after occlusion, and after direct exposure of the ischemic myocardium in the presence of fixed occlusion to low-frequency ultrasound (27 kHz). RESULTS: The TPU decreased from 100.9 +/- 13 at baseline to 71.1 +/- 13 (p < 0.01) after 60 min occlusion but rose by 19.7% to 85.1 +/- 8 (p < 0.01) after ultrasound exposure for 60 min. After 60-min coronary occlusion, myocardial pH fell from 7.43 +/- 14 to 7.05 +/- 0.15 (p < 0.01) but then improved to normal (7.46 +/- 0.32) after ultrasound for 60 min. Administration of L-Nomega-nitro-arginine methyl esther (L-NAME), an inhibitor of nitric oxide synthase, before ultrasound exposure, blocked improvement in myocardial tissue perfusion and pH by ultrasound. Quantitative histomorphology showed a significant increase in the capillary area of myocardium exposed to ultrasound versus non-exposed myocardium (16.2 +/- 7.9 vs. 8.2 +/- 2.1, p < 0.02). CONCLUSIONS: Low-frequency, low-intensity ultrasound improves myocardial tissue perfusion and pH in the presence of a fixed coronary artery occlusion.     

Solitaire支架半释放保护技术治疗急性颈内动脉串联闭塞患者的效果分析

目的探讨使用Solitaire支架半释放保护(SHARP)技术逆行处理串联闭塞的安全性和疗效。方法回顾性连续纳入2017年1月至2019年3月陆军特色医学中心神经内科接受血管内治疗的14例急性缺血性卒中颈内动脉串联闭塞患者的临床及影像学资料,且均使用SHARP技术。采用急性卒中Org 10172治疗试验(TOAST)病因分型:大动脉粥样硬化型、心源性栓塞型、小血管病变型、其他病因型和不明原因型。先将导引导管及中间导管挤过近端闭塞处进行颅内血管闭塞段支架取栓,然后使用SHARP技术,将SolitaireAB支架半释放至颈内动脉,起到类似于远端栓塞保护装置的作用,再将导管退至颈总动脉,经血管造影确认是否存在远端栓塞,同时根据造影评估结果选择近端取栓或支架置入。若造影显示前向血流无法维持或残余狭窄过重,则行颈动脉支架置入术。术后成功再通定义为脑梗死溶栓(TICI)分级达2b级或3级。术后即刻及术后(24±6)h复查头部平扫CT评估不良事件,包括术中并发症(血管痉挛、远端栓塞事件)、与SHARP技术相关并发症[支架半释放后和(或)导引导管后退至颈内动脉狭窄近端时,经DSA证实出现了远端栓塞事件]、出血转化(出血性梗死Ⅰ型、出血性梗死Ⅱ型、脑实质出血Ⅰ型、脑实质出血Ⅱ型)、蛛网膜下腔出血、症状性颅内出血。术后7 d或出院时美国国立卫生研究院卒中量表(NIHSS)评分较入院时至少降低4分为神经功能改善。以90 d随访记录评价临床预后,以改良Rankin量表(mRS)评分≤2分为神经功能独立,mRS评分>2分为预后不良,其中6分为死亡。结果14例串联闭塞患者均为颈内动脉起始部闭塞,有8例合并颈内动脉终末闭塞(C7段闭塞),6例合并大脑中动脉M1段闭塞;病因分型以大动脉粥样硬化型9例,心源性栓塞型3例,动脉夹层2例。14例患者均成功再通,达TICI分级2b级或3级;穿刺至再通的平均时间为(63±6)min;4例患者再通后因前向血流无法维持而行颈内动脉支架置入术(大动脉粥样硬化型3例,动脉夹层1例)。未发生SHARP技术相关并发症(远端栓塞事件)。14例患者中,术后发生脑实质出血1例、出血性梗死3例、蛛网膜下腔出血1例,无症状性颅内出血。术后90 d随访,1例因神经功能恶化死亡,10例患者达神经功能独立(mRS评分≤2分),3例预后不良。结论对急性缺血性卒中串联闭塞患者使用SHARP技术逆行处理的初步分析显示,该技术可减少操作步骤,使手术时间缩短,一定程度上减少了急性期支架置入。但该项技术的安全性及有效性仍需进一步验证。     

Endovascular recanalization of chronic long-segment occlusions of the inferior vena cava: midterm results.

PURPOSE: To report the midterm results of endovascular recanalization of chronic long-segment (> 5 cm) occlusions of the inferior vena cava (IVC) with stent placement. METHODS: Nine patients (5 men; median age 30 years, range 14-58) with disabling complaints for more than 6 months caused by IVC occlusions were treated by endovascular recanalization. Mean occlusion length was 11 cm (range 6-22); some occlusions extended to the iliac (n = 3) or common femoral (n = 2) veins. All procedures were performed under local anesthesia via a bilateral femoral (n = 7) or popliteal (n = 2) approach. In 3 patients, combined access to the brachial or internal jugular vein was necessary. Patients with acute-on-chronic thrombosis were pretreated with urokinase. After guidewire recanalization, the chronic occlusions were predilated and self-expanding Wallstents were implanted. RESULTS: The initial technical and clinical success was 100%. The venous clinical severity score (pain, venous edema, inflammation, and active ulceration) decreased from a mean 8 +/- 2 to 5 +/- 1 after the procedure. Over a median follow-up of 9 months (mean 21, range 4- 110), 3 patients died. One rethrombosis occurred, and an asymptomatic restenosis was discovered on routine imaging. The primary patency rate was 78%, and the 9-month occlusion-free survival rate was 56%. CONCLUSION: Endovascular recanalization of chronic long-segment occlusions of the IVC is a safe and worthwhile technique to offer patients with debilitating symptoms.     

Assessment of percutaneous coronary intervention on regional and global left ventricular function in patients with chronic total occlusions

BACKGROUND: The improvement of regional and global ventricular function following percutaneous coronary intervention (PCI) with reperfusion of the artery supplying the infarct area in acute myocardial infarction is well-described. However, little is known of the potential effects of late recanalization of chronic coronary artery occlusion on left ventricular function. OBJECTIVE: To determine whether PCI improves regional and global left ventricular function in patients with chronic coronary artery occlusions. PATIENTS AND METHODS: Thirty-five patients having at least one coronary artery occluded for six weeks or longer were included in the present prospective study. Exercise thallium-201 myocardial perfusion scintigraphy, multiple-gated acquisition ventriculography and two-dimensional echocardiography were performed in 19 patients (16 men; mean age of 58+/-5 years) who underwent a successful PCI to assess both regional and global left ventricular function before and six weeks following the procedure. RESULTS: The mean ejection fractions before and after reperfusion were 51+/-7% and 58+/-6% using Simpson's method (P<0.001) by echocardiography, and 45+/-1% and 53+/-1% (P=0.01) by multiple-gated acquisition ventriculography, respectively. The echocardiographic wall motion score was 24+/-9 before and 15+/-6 after PCI (P<0.001). The exercise perfusion score (21+/-1 and 14+/-1 [P=0.01]), rest perfusion score (15+/-1 and 12+/-1 [P=0.02]) and reinjection perfusion score (14+/-1 and 11.1+/-1 [P=0.07]) also improved after PCI. The presence of angina was strongly associated with an improvement in left ventricular function and wall motion score (P<0.01). CONCLUSIONS: PCI significantly improved the regional and global left ventricular function in patients with chronic total coronary occlusion. This procedure may provide symptom benefits in selected patients.     

Carotid Stenting With Antithrombotic Agents and Intracranial Thrombectomy Leads to the Highest Recanalization Rate in Patients With Acute Stroke With Tandem Lesions

Objectives

The aim of this study was to identify the optimal endovascular approach in patients with acute stroke with tandem lesions.

Percutaneous interventions in patients with acute ischemic stroke related to obstructive atherosclerotic disease or dissection of the extracranial carotid artery.

PURPOSE: To determine the safety, feasibility, and efficacy of carotid artery stenting (CAS) in patients with acute stroke who underwent angioplasty of the extracranial internal carotid artery (ICA). METHODS: Patients were eligible for CAS if they presented within 6 hours of symptom onset and had a National Institutes of Health Stroke Scale (NIHSS) score >4. The records of all 18 acute stroke patients (11 men; mean age 68.3+/-14.3 years) who underwent endovascular intervention in the stroke-related extracranial ICA between May 2003 and February 2006 were reviewed. Fourteen (77.8%) had atheromatous obstructions and 4 (22.2%) had dissection of the extracranial ICA. Major adverse cerebral and cardiac events (MACCEs) and neurological status, including NIHSS and the modified Rankin Scale (mRS) scores, were recorded for all patients. RESULTS: Successful revascularization was achieved in 83.3% (15/18) of the patients. Cerebral protection devices were applied successfully in 13 (72.2%). At discharge, a neurological improvement (NIHSS reduction > or =4) was observed in 77.8% (14/18) of patients. The clinical success rate was 72.2% (13/18). The median NIHSS was 8.5 on admission versus 4.5 at discharge (p<0.01). The 30-day death and stroke rate was 11.1%. During the 14.6+/-9.3-month follow-up, the MACCE and the death/stroke rates were 33.3% and 27.8%, respectively. The median mRS scores at 30 days and at midterm follow-up were 1 and 2.5, respectively (p = NS). CONCLUSION: Endovascular revascularization of the extracranial ICA in patients with acute ischemic stroke is associated with high procedural success rates and favorable midterm outcome.     

Changes in Left Ventricular Function After Coronary Recanalization by Percutaneous Transluminal Coronary Angioplasty (PTCA)

Forty-six patients (21 with stable angina and 25 with chronic myocardial infarction, 37 men) with a total chronic proximal coronary occlusion and collateral vessels to the distal part of the occluded artery (30 LAD, 10 RCA and 6 CX properly distributed in both groups) were studied angiographically before and 2 to 8 months (mean 6) after balloon angioplasty. The patients were divided in six subgroups: A) Angina pectoris no matter the result of recanalization (n = 21); B) Myocardial infarction no matter the result of recanalization (n = 25); C) Angina pectoris with successful recanalization and open coronary (O.C.) > 50% at follow-up (n = 13); D) Angina pectoris with unsuccessful recanalization and/or restenosis or closed coronary (C.C.) at follow-up (n = 8); E) Myocardial infarction with successful recanalization and O.C. > 50% at follow-up (n = 8); F) Myocardial infarction with unsuccessful recanalization and/or restenosis or C.C. at follow-up (n = 17). No subgroup showed statistical differences (p > 0.05) in LVEDP before (B) and at follow-up (FU). On the other hand, several measurements were statistically different in the subgroup A at B and at FU: Ejection fraction (EF) [57.3 +/- 12.3 and 64.2 +/- 19.4%; p = 0.02]; Regional wall motion (RWM) measured in the region of the affected coronary [18.7 +/- 9.6 and 23.6 +/- 11.8%; p = 0.05]; Minimal wall motion (MWM) measured in the site of lesser parietal movement [14.3 +/- 13.1 and 25.8 +/- 26.2%; p = 0.02]. In the subgroup C the following differences were observed: EF [58.4 +/- 12.3 and 69.0 +/- 12.4%; p = 0.003]; RWM [16.3 +/- 8.4 and 25.4 +/- 8.2%; p = 0.005]; MWM [14.7 +/- 15.1 and 27.9 +/- 18.0%; p = 0.0001]. In the other considered subgroups we did not reach significant differences (p > 0.05) in these measurements. We conclude that recanalization of a chronic coronary occlusion improves left ventricular contractile function in the presence of viable myocardium and that MSF is the most sensitive among the studied variables to separate anginal patients from the patients without viable myocardium after successful recanalization.     

Correlation between echocardiographically demonstrated segmental dyskinesis and regional myocardial perfusion.

In order to evaluate the relationship between regional myocardial perfusion and segmental dyskinesis, 22 open chest dogs were studied using ultrasound to register cardiac wall motion and radioactive labeled microspheres to determine myocardial perfusion. In six dogs, motion and perfusion were correlated at two levels of partial circumflex coronary artery occlusion followed by complete occlusion. A good correlation between declining myocardial perfusion of all the ischemic segments and development of aneurysmal bulging (during isometric contraction) was seen: r = minus 0.80. A similar correlation between myocardial perfusion and endocardial wall velocity (during systolic ejection) was observed: r = 0.92. In nine dogs, the effect of 45 minutes of complete coronary occlusion followed by 30 minutes of reperfusion was evaluated with respect to perfusion and motion. After coronary reperfusion myocardial perfusion of the ischemic area returned to control levels (from 32.6 +/- 3.5 to 130.3 +/- 13.3 ml/100 g/min), but aneurysmal bulging during isometric contraction persisted. Endocardial wall velocity during systolic ejection showed a variable response to reperfusion, achieving values ranging from 32% to 162% of the preocclusion levels. In seven dogs the ultrasound beam was reflected off nonischemic myocardium adjacent to areas of ischemia resulting from coronary occlusion. Despite preservation of normal myocardial perfusion in these nonischemic areas wall motion abnormalities were evident: endocardial wall velocity declined from 25.8 +/- 5.8 to 14.0 +/- 4.9 mm/sec (P less than 0.01), and aneurysmal bulging in three animals. These changes may be due to transient undetected ischemia in the segments struck by the ultrasound beam, or to passive alteration of the motion of the normally perfused areas by the severe dyskinesis of the adjacent ischemic myocardium.     

Effect of intra-aortic balloon counterpulsation on the motion and perfusion of acutely ischemic myocardium. An experimental echocardiographic study.

The effect of intra-aortic balloon counterpulsation (IABC) on the motion and perfusion of ischemic left ventricular posterior myocardium was studied in 30 open-chest dogs, using ultrasound to register motion and 7-10 mu radioactive microspheres to determine perfusion. Circumflex coronary artery ligation produced acute aneurysmal bulging during isovolumetric contraction and diminished ischemic wall velocity during systolic ejection. Myocardial perfusion was determined in five dogs; perfusion of the area supplied by the ligated coronary artery fell from a control value of 72.9 +/- 13.8 (SE) to 30.0 +/- 2.3 cc/100 g/min (P less than 0.05) at 5 minutes after coronary occlusion. IABC was then administered for one hour, with a fall in aortic systolic pressure (112 +/- 6 to 105 +/- 7 mm Hg, P less than 0.05) and rise in peak aortic diastolic pressure (94 +/- 6 to 102 +/- 7 mm Hg, P less than 0.05). Despite this the ischemic area showed no change in perfusion (measured at the same time): 30.0 +/- 2.3 to 28.0 +/- 2.4 cc/100 g/min. Little change in wall motion occurred: aneurysmal bulging decreased modestly (4.5 +/- 0.3 to 3.6 +/- 0.3 mm, P less than 0.05), but ischemic wall velocity did not increase. After cessation of counterpulsation and one hour of coronary reperfusion aneurysmal bulging disappeared and wall velocity improved. The addition of norepinephrine (eight dogs) or nitroprusside (seven dogs) to intraaortic balloon counterpulsation did not cause a significant further improvement in the response of the dyskinesis during the period of ischemia. We conclude that IABC has little effect on ischemic dyskinesis, probably due to its failure to improve perfusion of the acutely ischemic myocardium.     

Spontaneous recanalization of internal carotid artery occlusion evaluated with color flow imaging and contrast arteriography.

AIM: In strokes of embolic origin a partial recanalization of the intracranial occluded vessel occurs with a high incidence (as high as 80%). In the literature, we find few cases of revascularization, detected with color flow imaging (CFI) or with arteriography (AGF), at carotid siphon or at the origin of an occluded internal carotid artery (ICA). Up to now there have been no reliable data on the incidence and clinical consequences of SR of an extracranial ICA occlusion. In this case-report we document 8 cases of SR of occluded ICA observed in the last 10 years in our Care Unit. METHODS: We observed 8 complete ICA occlusion at the origin, detected with CFI (8 of 8) and with AGF (7 of 8). All symptomatic patients and 2 of 5 asymptomatic patients underwent CT scan in the acute phase of stroke. All patients underwent CFI follow-up (every 6-12 monhts) to evaluate contralateral CCA and ICA and the presence of new focal neurological symptoms. All patients assumed BMT (antiplatelet or anticoagulant therapy). RESULTS: SR occurred in 6 patients between 24 and 96 months, in 1 patient within 8 months and 1 patient within 6 months from the diagnosis of ICA occlusion. Diagnosis of SR was based in all patients with CFI and in 4 patients confirmed with AGF. Five patients underwent CT scan that excluded haemorrhagic transformation of previous ischemic areas or new ischemic events (2 patients did CT scan only after SR). All patients underwent CFI follow-up in a 3-88 months period. There were no new focal neurological symptoms in 7 of 8 patients, 1 patient presented aspecific neurological symptoms. CONCLUSION: Diagnosing SR of occluded extracranical ICA seems to be more frequent than expected. SR is an event that has to be researched in follow-up of these patients; besides, it seems to have a relatively benign outcome with respect to the onset of new neurological symptoms.     

Distal coronary artery perfusion during percutaneous transluminal coronary angioplasty

Perfusion of the coronary artery distal to an occluding angioplasty balloon was performed in 34 patients undergoing coronary angioplasty (PTCA). A randomized crossover study was employed using two exogenous substances as perfusates: lactated Ringer's solution (LR) and a fluorocarbon emulsion (FL), Fluosol-DA 20%. Both substances are electrolyte solutions, but the FL will dissolve more oxygen than the LR. During two attempted coronary artery occlusions of 90 seconds each, we perfused through the central lumen (guidewire channel) of the PTCA catheter at 60 ml/min. With FL perfusion the mean time to onset of angina after occlusion was delayed (41 +/- 21 vs 33 +/- 16 seconds, mean +/- SD; p less than 0.05), the mean duration of angina was shortened (77 +/- 58 vs 92 +/- 70 seconds, p less than 0.05), and the rise in the ST segment of the ECG was reduced (0.15 +/- 0.24 vs 0.2 +/- 0.23 mV, p less than 0.001) when compared to LR perfusion. Balloon occlusion time was able to be extended with FL perfusion (71 +/- 22 vs 59 +/- 22 seconds p less than 0.001). These results indicate that perfusion of the distal coronary artery is possible during PTCA and can reduce ischemia during a prolonged balloon occlusion time.     

Thrombo‐embolic complications in takotsubo syndrome: Review and demonstration of an illustrative case

Thrombo‐embolism is one of the serious complications of takotsubo syndrome (TS) in addition to heart failure, pulmonary edema, cardiogenic shock, cardiac arrest, life‐threatening arrhythmias, left ventricular outlet tract obstruction, mitral regurgitation, cardiac rupture, and death. The most common cardio‐embolic events in TS are cerebral, renal, and peripheral embolism. Approximately, one‐third of patients with left ventricular thrombus (LVT) in TS develop embolic complications. Cardio‐embolism in TS may occur with or without the presence of detectable LVT. In the present report, the thrombo‐embolic complications in TS with the emphasis on the association of TS to both acute coronary syndrome (ACS) including coronary embolism and ischemic stroke including cerebral embolism are reviewed. This serious complication is elucidated by demonstration of the case of a 67‐year‐woman with mid‐apical TS complicated by LVT, left anterior descending artery (LAD) and left middle cerebral artery (segment M2) thrombo‐embolic occlusions. The cerebral artery thrombotic occlusion was treated successfully with endovascular thrombectomy with complete resolution of the neurological deficits. There was spontaneous recanalization of the apical LAD occlusion verified by cardiac computed tomography angiography.     

Immediate and long-term outcome of recanalization of chronic total coronary occlusions

Eighty-three consecutive patients with 85 coronary total occlusions undergoing coronary angioplasty were retrospectively studied. Patients were divided into two groups according to the occlusion age that was < 30 days (subacute total occlusion [STO]: 25 patients; range 1-30 days) or > 30 days (chronic total occlusion [CTO]: 58 patients; range 3-144 months). All procedures were carried out using a hydrophilic guidewire. Clinical success, consisting of crossing the lesion, balloon dilatation, stent deployment without complications, was 96% in STO and 81% in CTO. Multiple stepwise logistic regression analysis identified a family history of coronary artery disease (CAD), left anterior descending and right coronary artery occlusions as independent predictors of a successful procedure. No major events occurred during or immediately after the angioplasty. After a mean follow-up of 24 +/- 2 months, no difference was found in survival or freedom from myocardial infarction or target vessel revascularization among the STO and CTO patients. Successful recanalization by using a hydrophilic guidewire was achieved in a high percentage of chronic total occlusions with a low incidence of complications and a satisfactory late clinical outcome. Family history of CAD and occlusion of left anterior descending or right coronary arteries are independent predictors of procedural success.     

Electromechanical characterization of myocardial hibernation in a pig model.

BACKGROUND: This study attempted to assess in-vivo electromechanical changes following gradual coronary artery occlusion in a pig ameroid constrictor model using a novel three-dimensional left ventricular mapping system. METHODS AND RESULTS: We measured unipolar and bipolar voltage potentials and local endocardial shortening in the ischemic lateral and non-ischemic anterior zones in animals at rest (n = 9) 5 weeks after the implantation of ameroid constrictors around the left circumflex artery. Echocardiography was used to assess regional contractility (percentage myocardial thickening), and an echo-contrast perfusion study was performed using acoustic densitometry methods. The ischemic lateral zone showed reduced myocardial perfusion at rest (peak intensity; 3.4 +/- 1.7 versus 20.7 +/- 14.8, P = 0.005), impaired mechanical function (percentage wall thickening 22 +/- 19% versus 40 +/- 11%, P = 0.03; local endocardial shortening 2.9 +/- 5.5% versus 11.7 +/- 2.1%, P = 0.002), and preserved electrical activity (unipolar voltage 12.4 +/- 4.7 versus 14.4 +/- 1.9 mV, P = 0.25; bipolar voltage 4.1 +/- 1.1 versus 3.8 +/- 1.5 mV, P = 0.62), compared with the anterior region. CONCLUSIONS: Gradual coronary artery occlusion resulting in regional reduced perfusion and function at rest (i.e. hibernating myocardium) is characterized by preserved electrical activity. An electromechanical left ventricular mapping procedure such as the one described here may be of diagnostic value for identifying the hibernating myocardium.     

颈动脉内膜切除术治疗颈动脉极重度狭窄或闭塞患者可行性和安全性的评价

目的探讨对颈动脉极重度狭窄（狭窄率为95％～99％）或闭塞患者行颈动脉内膜切除术（CEA）的可行性和安全性。方法回顾性分析首都医科大学宣武医院神经外科2001年1月-2012年12月入院的65例症状性颈动脉极重度狭窄或闭塞患者的临床资料。术前行CT灌注（CTP）或氙CT评价大脑半球的血流灌注情况及经DSA评估病变血管,根据具体病变分别行单纯CEA、CEA＋Fogarty球囊取栓、CEA＋颈动脉支架置入的复合手术。结果①65例患者均接受DSA评估颈动脉病变,其中颈动脉完全闭塞32例,极重度狭窄33例;采用氙CT评价脑血流15例,其中脑血流量（CBF）部分区域下降6例（40．0％）,患侧脑血管反应性（CVR）明显降低11例（73．3％）;采用CTP评价32例,CBF部分区域下降11例（34．4％）,达峰时间延长32例（100％）。②对65例患者行CEA＋Fogarty球囊导管取栓术10例,9例再通;行复合手术4例,一例再通失败;51例单纯行CEA,5例未能再通。本组患者再通率为89．2％。③术后30d内共5例患者出现卒中,3例为出血性卒中,1例死亡;另2例为缺血性卒中。术后卒中和病死率为7．7％。结论对症状性颈动脉极重度狭窄或闭塞患者,经过严格的适应证选择,术前对颈动脉和大脑半球的血流灌注进行充分的影像学评估后,可行血管再通手术。短期随访显示,CEA及其复合手术治疗具有较好的可行性和安全性．     

氙CT指导脑血运重建术治疗症状性前循环动脉狭窄及闭塞

目的 探讨氙CT脑血流灌注成像技术在脑血运重建术前及疗效评估中的作用。方法 回顾性分析15例症状性前循环供血动脉粥样硬化性狭窄或闭塞患者的临床资料,其中行血管内支架置入术8例、颈内动脉内膜切除术1例和颞浅动脉-大脑中动脉旁路移植术6例,对比术前与术后2周内氙CT检测的局部脑血流量(r CBF)及术后6个月改良Rankin量表(mRS)评分。结果 (1)12例术前靶血管远端血流灌注异常患者平均r CBF值为(30±10)ml/(100 g·min),术后为(32±14)ml/(100 g·min),与术前比较差异有统计学意义(P=0.044);3例术前靶血管远端血流灌注正常患者平均r CBF值为(48±6)ml/(100 g·min),术后平均r CBF值为(50±7)ml/(100 g·min),与术前比较差异无统计学意义(P0.05)。(2)术后mRS评分改善8例,稳定7例。15例患者术后mRS评分为[1(0,3)]分,与术前[3(1,3)]分比较,差异有统计学意义(P0.05)。随访期间无一例新发神经功能障碍。结论 血运重建术可改善术前存在血流动力学障碍的症状性前循环供血动脉狭窄或闭塞患者的靶血管远端局部脑血流灌注及神经功能缺损症状,而术前氙CT脑血流灌注成像灌注异常可能较灌注正常患者获益更多。