复合手术技术治疗复杂颈动脉狭窄和闭塞性疾病

目的分析复合手术技术在复杂颈动脉狭窄或闭塞性疾病中的应用,探讨其临床意义。方法回顾分析12例因颈动脉闭塞和颈动脉串联性病变施行复合手术患者之临床资料,初步分析手术安全性和有效性。结果 8例颈动脉闭塞患者,7例实现血管再通;4例颈动脉串联性病变患者,均实现血管再通。术后无一例发生脑卒中或死亡。结论采用复合手术技术治疗颈动脉闭塞和串联性病变疗效安全可靠,值得在临床推荐开展。     

慢性颈内动脉闭塞的复合手术再通治疗

目的探讨慢性颈内动脉闭塞复合手术再通治疗的有效性和安全性。方法与结果对2017年9月至2018年9月行颈动脉内膜切除术联合颈动脉支架成形术的8例慢性颈内动脉闭塞患者的临床资料、影像学及随访资料进行回顾分析。结果显示,所有患者均实现闭塞血管再通、颅内血流改善、临床症状好转,仅1例术后24 h MRI可见点状新鲜梗死灶但无临床症状,3例出现同侧舌下神经、喉上神经、面神经下颌缘支损伤症状,术后2周自行恢复。术后3和6个月影像学检查均未见明显异常。结论颈动脉内膜切除术联合颈动脉支架成形术的复合手术实现闭塞的颈内动脉再通安全、有效。     

慢性颈动脉闭塞的血管再通治疗

目的总结慢性颈动脉闭塞血管再通治疗的手术体会和围手术期并发症。方法纳入2018年8月至2019年7月共12例慢性颈动脉闭塞患者,均行血管再通治疗,术前通过多模态影像学方法评估闭塞部位、闭塞节段、闭塞近端残端形态和血管壁病变性质,并记录围手术期并发症。结果共10例患者实现血管再通,成功率为10/12;2例血管再通失败病例,分别为累及岩骨段以上的长节段动脉夹层(1例)和闭塞近端残端呈钝头型(1例)。6例患者发生围手术期并发症包括术中栓子脱落(3例)、术中血管痉挛(1例)、术后脑高灌注综合征(1例)和术后严重低血压(1例)。结论累及岩骨段以上的长节段闭塞、闭塞近端残端形态和血管壁病变性质均可能影响血管再通成功率,栓子脱落、脑血管痉挛、脑高灌注综合征和低血压是主要的围手术期并发症。     

复合手术治疗颈动脉全程闭塞1例

目的 探讨复合手术解决复杂缺血性血管病的诊疗策略。方法 回顾性分析1例右侧颈动脉全程闭塞病人的临床资料，采用血管介入技术加传统外科手术开通颈动脉，一期行复合手术开通闭塞颈动脉，二期行颈动脉支架植入术，结合治疗中的问题分析诊疗策略。结果 一期复合手术顺利开通颈动脉，取出大量血栓性物质，残留有颈动脉狭窄。二期支架植入后病人精神状态佳、肢体肌力恢复正常；颈部血管彩超显示颈动脉畅通；病人临床治愈出院。术后1个月电话随访病人情况良好。结论 颈动脉全程闭塞为罕见病例，其血管闭塞范围大，传统颈动脉内膜剥脱术或介入支架取栓均无法解决；复合手术可取得良好疗效。     

恢复灌注-球囊扩张-机械取栓-支架成形技术在颈动脉串联病变中的应用

目的探讨恢复灌注-球囊扩张-机械取栓-支架成形(RETS)技术在急性颈动脉串联病变血管内治疗的可行性及临床疗效。方法回顾性分析2018年1月至2020年12月于临沂市人民医院神经内科行急诊血管内治疗的颈动脉串联病变患者的临床资料,以改良Rankin量表(mRS)评分作为标准评价患者90 d随访时预后情况,并对不同开通方式患者的临床资料进行分析,包括术后血管成功再通(改良脑梗死溶栓血流分级≥2b级)率、围手术期并发症、90 d良好预后(mRS评分≤2分)率等。结果共纳入88例颈动脉串联病变患者,其中采用RETS技术治疗者48例,采用顺向开通40例。与顺向开通组[(98.88±26.09)min]相比,采用RETS技术组穿刺至再通时间更短[(72.06±17.29)min,t=-5.56,P<0.001],远端一次取栓再通率更高[35/48(73.0%)比21/40(52.5%),χ²=3.93,P=0.047],差异有统计学意义;两组在患者临床预后及手术并发症方面差异无统计学意义(均P>0.05)。结论RETS技术能缩短手术时间,提高远端一次取栓再通率,用以治疗颈动脉串联病变安全可行。     

伴大核心梗死的前循环串联闭塞的急性期同期血管内治疗研究

目的 评价伴大核心梗死的前循环串联病变急性期同期血管内治疗的安全性及有效性。方法 回顾性分析2018年3月-2020年5月收治的伴大核心梗死的前循环串联病变患者的临床及影像资料,对患者的术前评估、手术方式、手术要点及术中不同处理方式、围手术期的管理及手术结果和预后进行总结分析。结果 5例患者中男性4例,女性1例;年龄61～71岁,颈内动脉（internal carotid artery,ICA）起始段闭塞合并远端C7段闭塞1例,合并同侧大脑中动脉（middle cerebral artery,MCA）M1段闭塞4例。5例患者均采用取栓支架半释放保护（solitaire stent-retriever half-release protection,Sharp）技术先处理远端病变、后处理近端病变。2例患者MCA再通后即刻行同侧ICA支架置入;2例患者MCA再通后予以较长时间观察,等待颅内灌注得到一定恢复后再予以ICA支架置入;1例患者MCA再通后仅行颈动脉球囊扩张治疗。5例患者的闭塞血管均成功再通,且未出现症状性颅内出血及远端血栓事件。患者从发病到再通时间为637.2±172.2（451～814）min,再通至颈ICA支架置入时间为152.5±92.2（59～270）min。2例患者术后发生高灌注损伤导致死亡,其余3例患者术后90 d预后良好（mRS均为3分）。结论 伴大核心梗死的前循环串联病变进行急性血管内治疗可使部分患者获益,为降低术后的高灌注损伤风险,予以适当的“再灌注预适应”时间再同期处理颅外病变可能降低术后的高灌注损伤风险,但最佳的预适应时间仍需进一步探讨与实践。     

下期内容预告

正本刊2020年第5期报道专题为急性血管再通治疗,重点内容包括:串联病变是急性基底动脉闭塞血管内治疗预后不良的预测因素:单中心队列研究;急性基底动脉闭塞血管内治疗不良结局的影响因素分析;颈动脉夹层致急性大血管闭塞性缺血性卒中血管内治疗的单中心研究;急性颈内动脉起始部和颅内大动脉串联闭塞的血管内治疗;心源性栓塞患者阿替     

多层CT评价颈动脉重度狭窄性病变的初步研究

目的探讨多层CT脑灌注技术和头颈部CT灌注成像(CTA)技术联合应用评价颈动脉重度狭窄性病变的临床价值。方法对23例有症状的颈动脉重度狭窄性病变进行颅脑平扫、脑CT灌注和头颈部CTA联合检查。利用CTA对血管的狭窄程度、狭窄部位进行评价,利用CT灌注对脑血流动力学状态进行评价。选10名年龄相匹配的志愿者行CT灌注检查,作为CT灌注的对照组。结果CTA显示一侧颈内动脉闭塞12例,一侧颈内动脉重度狭窄11例。7例为单侧颈内动脉病变,16例为多血管多部位狭窄,包括对侧颈动脉狭窄,单侧或双侧椎动脉狭窄或闭塞,颅内血管狭窄或闭塞。脑CT灌注显示病变同侧灌注异常17例,闭塞组(8例)和重度狭窄组(9例)在灌注异常的发生率上差异无统计学意义。单发组(3例)和多发组(14例)在灌注异常发生率上差异有统计学意义(P<0·05)。结论颈动脉重度狭窄性病变多伴有同侧脑灌注的异常(17/23),多血管病变脑内灌注异常的发生率多于单发的颈动脉狭窄或闭塞。CTA和CT灌注技术联合应用可更加全面地评价颈动脉狭窄性病变,具有较高的临床应用价值。     

双路途引导下非急性颅内段颈内动脉闭塞的血管内再通治疗体会

目的探讨动脉硬化基础上的非急性颈内动脉颅内段闭塞后血管内再通治疗的安全性及手术技术要点。方法分析河北医科大学第二医院神经内科收治的1例在动脉硬化基础上的右侧颈内动脉颅内段闭塞,非急性期双路途引导下血管内再通治疗的手术方案设计及结果。结果本例患者就诊时临床症状主要表现为左侧肢体无力,口角偏斜及言语不利。头颅MRI示右侧放射冠、基底核区脑梗死。给予药物治疗稳定症状后,双路途引导下行非急性期颈内动脉颅内段闭塞血管内再通治疗,恢复远端脑组织血流灌注,患者临床症状好转。结论颅内段颈内动脉闭塞可致远端脑组织灌注不足、栓子清除率下降而引起缺血性脑卒中反复发作,非急性期闭塞血管内再通治疗可改善临床预后,双路途引导下的血管内再通治疗可有效降低手术风险。     

直接抽吸取栓术与机械支架取栓术在急性颅内血管闭塞中的疗效对比

目的 比较直接抽吸取栓术（a direct aspiration first-pass technique,ADAPT）与机械支架取栓术治 疗急性颅内血管闭塞的有效性和安全性。 方法 回顾性纳入2019年3-12月于四川大学华西医院连续收治的急性颅内血管闭塞患者,根据采 用手术方法不同将患者分为ADAPT组和支架组。血管成功再通定义为血流mTICI≥2b级,治疗技术相关 指标为穿刺-血管再通时间、一次完全再通比例、一次完全再通手术时间、全部闭塞血管再通比例;主 要疗效评价指标为90 d预后良好（mRS≤2分）比例;主要安全性评价指标为术中血栓逃逸与术后症 状性颅内出血发生率。 结果 本研究最终纳入106例患者,年龄24～90岁,平均69.6±13.5岁,男性51例（48.1%）;其中 ADAPT组46例,支架组60例。ADAPT组中43例（93.5%）患者实现全部闭塞血管再通;支架组中52例 （86.7%）患者实现全部闭塞血管再通。ADAPT组穿刺-血管再通时间短于支架组[52.5（31.5～87.7）min vs 64.0（51.0～98.7）min,P =0.036];一次完全再通时间短于支架组（37.2±12.4 min vs 59.5±21.4 mi n, P＜0.001）;两组一次完全再通、全部闭塞血管再通比例差异无统计学意义。ADAPT组90 d预后良好患 者比例高于支架组（63.0% vs 36.7%,P =0.007）;两组术中血栓逃逸及症状性颅内出血发生率差异无 统计学意义。 结论 与支架组比较,采用ADAPT技术较支架取栓治疗急性颅内血管闭塞患者,手术时间更短,患 者临床预后更佳。     

颈动脉内膜切除术的手术技巧与疗效简

目的探讨颈动脉内膜切除术治疗颈动脉狭窄的手术技巧,提高手术疗效,降低术中不良事件及术后并发症发生率。方法共53例颈动脉狭窄患者,右侧狭窄26例、左侧15例、双侧12例;中度狭窄（30％～69％）35例、重度狭窄（70％～99％）16例、完全闭塞2例。结果其中50例单纯行颈动脉内膜切除术、2例行颈动脉内膜切除术联合动脉瘤夹闭术、1例颈动脉支架成形术后管腔狭窄者行颈动脉内膜切除术并支架取出术。术后颈部CTA及灌注成像提示颈动脉血管形态良好、血流通畅,脑组织灌注不同程度改善。随访3～24个月,1例因心肌梗死死亡、2例术侧颈部皮肤麻木、1例声音嘶哑、3例仍有轻度短暂性脑缺血发作,无脑卒中病例。结论颈动脉内膜切除术是治疗颈动脉狭窄性病变安全、有效的外科方法,正确选择手术适应证及娴熟的手术技巧是保证手术成功、提高疗效的关键。     

颈动脉内膜切除术400例临床经验简

目的探讨颈动脉内膜切除术围手术期管理策略和临床疗效。方法356例颈动脉粥样硬化性重度狭窄（70％-99％）患者共实施400例次（双侧狭窄44例）颈动脉内膜切除术,分别采用标准式（120例次）、外翻式（255例次）和补片式（25例次）术式,其中368例次未行术中转流。结果所有患者手术均获成功,12例术后出现缺血性卒中（4例）、脑出血（1例）、声音嘶哑（1例）、癫痫发作（2例）、术后再闭塞（2例）、再狭窄（1例）和切口血肿（1例）等并发症。术后随访1。36个月,无一例出现脑卒中和其他严重并发症,患者生活质量明显改善。结论成熟的医疗团队对颈动脉重度狭窄患者颈动脉内膜切除术治疗成功的意义至关重要。于围手术期密切监测患者病情变化,可有效预防术后并发症,对降低病死率、提高患者生活质量和延长寿命具有重要临床意义。     

高龄颈动脉狭窄患者颈动脉内膜切除术和颈动脉支架成形术的安全性比较简

目的回顾接受颈动脉内膜切除术和颈动脉支架成形术的高龄（≥70岁）颈动脉狭窄患者的临床资料,分析手术安全性。方法共691例颈动脉狭窄患者,121例行颈动脉内膜切除术、570例行颈动脉支架成形术,分析两组患者危险因素、临床特征和术后并发症发生率,评价两种手术方法之安全性。结果术后30d时,两组患者病死率（0．83％对1．05％,P=1．000）、脑卒中（4．13％对1．93％,P=0．258）和心肌梗死（0．83％对0,P=0．175）发生率差异均无统计学意义;但颈动脉内膜切除术组患者术后心脏不良事件（8．26％对1．05％,P=0．000）和脑神经损伤（4．96％对0,P=0．000）发生率高于颈动脉支架成形术组,而窦性心动过缓或低血压发生率低于颈动脉支架成形术组（0对7．54％,P=0．002）。结论高龄患者接受颈动脉内膜切除术或颈动脉支架成形术均有较高的安全性,术前应全面评价患者基础情况,以减少术后并发症发生率。     

Recanalization of extracranial internal carotid artery occlusion A 12-year retrospective study*

This study aimed to summarize therapy experience of carotid endarterectomy, carotid endarterec-tomy combined with Fogarty catheter embolectomy, and hybrid surgery for the treatment of extrac-ranial internal carotid artery occlusion. The study included 65 patients with extracranial internal ca-rotid artery occlusion who underwent carotid endarterectomy, carotid endarterectomy combined with Fogarty catheter embolectomy, or hybrid surgery in the Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China between January 2006 and December 2012. Prior to surgery, all patients underwent perfusion CT or xenon CT to evaluate the occlusion. The procedure for each patient was chosen according to digital subtraction angiography data. The carotid artery was successfully recanalized in 46 of 51 patients who underwent carotid endarterectomy, 9 of 10 patients who underwent carotid endarterectomy combined with Fogarty catheter embolectomy, and 3 of 4 patients who underwent hybrid surgery. In patients with symptomatic carotid artery occlusion, the carotid artery can be recanalized by choosing a treatment procedure based on imaging ex-amination findings.     

Feasibility of percutaneous transluminal angioplasty for carotid artery stenosis.

Percutaneous transluminal balloon angioplasty was attempted in seven patients with internal carotid artery stenosis, including one patient who had two procedures. All had recurrent, carotid territory, neurological symptoms considered haemodynamic in origin. Six had occlusion of the contralateral internal carotid artery. Cerebral blood flow studies confirmed diminished cerebrovascular reserve in six patients studied. In five patients (six procedures) angioplasty of the stenosed internal carotid artery was carried out successfully. With two patients technical difficulty in crossing the stenosis prevented angioplasty and in one patient with bilateral stenosis the procedure was not attempted on the second side because of the severity of the stenosis. In two patients transient aphasia developed during cannulation of the carotid artery and in another a transient monoparesis developed during the procedure. Both these haemodynamic complications recovered within ten minutes. No other complications occurred. Our experience suggests that balloon angioplasty is technically feasible in the management of stenotic carotid disease associated with haemodynamic stroke. It is a technically simple procedure requiring only a brief admission to hospital. However, its general application to patients with thromboembolic carotid-territory stroke will depend on the risk/benefit ratio compared to carotid endarterectomy or to conventional medical treatment.     

High rate of restenosis after carotid artery stenting in patients with high-grade internal carotid artery stenosis

OBJECTIVE: Carotid endarterectomy (CEA) is the gold-standard procedure for the majority of patients with high-grade symptomatic internal carotid artery stenosis and also for specified high-grade asymptomatic stenoses; however, a proportion of patients are treated with carotid endovascular therapy. We aimed to document medium-term clinical and neurosonographical outcome after carotid artery stenting (CAS). METHODS: 53 patients (mean age: 65 +/- 8 years) with high-grade (> or = 70 % by means of duplex sonography) carotid artery stenosis were enrolled into the study. Nineteen patients had asymptomatic, 34 patients had symptomatic stenoses. All patients had a pre-interventional CT, Doppler and duplex sonography, and digital subtraction angiography (DSA) or magnetic resonance angiography (MRA) prior to the procedural DSA. All patients were offered CEA as the gold-standard procedure and as an alternative to CAS. Both clinical and Duplex sonographical follow-up was obtained at day 1 and 7, month 1, month 3, month 6, month 12, and every subsequent 6 months after the procedure. Mean follow-up time was 22 +/- 1.6 months (+/- SEM). RESULTS: 2/53 patients suffered from stroke. A further 2 patients suffered from carotid artery occlusion shortly after CAS. The cumulative rate of restenosis during follow-up was 24.5 % (13/53). Four of these (7.5 %) were of high-grade and led to further interventional or surgical therapy. CONCLUSIONS: A high rate of restenosis was found during follow-up after CAS. Our analysis of non-selected patients emphasizes that CEA remains the gold-standard procedure for the treatment of symptomatic internal carotid artery stenosis. The frequently performed endovascular treatment of carotid stenosis outside the setting of a randomized controlled trial is not supported by our data.     

Risk of stroke during coronary artery bypass graft surgery in patients with internal carotid artery disease documented by angiography

We retrospectively identified 144 patients who underwent coronary artery bypass graft (CABG) surgery in the presence of angiographically documented greater than or equal to 50% internal carotid stenosis or occlusion. Of these, 115 patients had bilateral carotid lesions and received combined operations involving carotid endarterectomy on only one side. The remaining 29 patients, including 11 with bilateral carotid lesions, underwent coronary bypass alone. Nine cerebral infarcts occurred (6%), but only three strokes (2%) were appropriate to the cerebral hemisphere ipsilateral to unoperated carotid stenosis. There was one stroke (3%) among the 29 patients who did not undergo combined procedures. In the group of 115 patients with bilateral carotid disease who received unilateral combined carotid endarterectomy there were 8 perioperative strokes (7%), of which 6 were ipsilateral to the endarterectomy. Asymptomatic unilateral less than 90% ICA stenosis or ICA occlusion does not increase stroke risk during CABG surgery.     

多参数监测在颈动脉内膜斑块剥脱术中的应用

目的 探讨多参数监测在颈动脉内膜斑块剥脱术（CEA）中的作用。方法 回顾性分析2016年5月至2021年12月在多参数联合监测下实施CEA治疗的75例颈动脉狭窄的临床资料。术中应用颈内动脉返流压及体感诱发电位、运动诱发电位监测。结果 72例返流压≥25 mmHg,3例<25 mmHg;58例体感诱发电位无明显变化,2例轻度降低复通后好转,6例下降超过50%但恢复,5例下降超过50%未恢复,4例下降超过75%未恢复。术中5例使用转流管。术后发生脑卒中2例,未发生栓塞事件。术后1周内复查颈动脉CTA显示颈总动脉及颈内动脉均通畅,1例颈外动脉闭塞,1例颈外动脉血栓形成并管腔重度狭窄。术后随访3个月~5年,末次随访GOS评分5分74例,3分1例。结论 CEA是预防缺血性脑卒中的有效方法,术中联合监测颈动脉返流压、体感诱发电位和运动诱发电位,是可行的、有效的,可提高CEA的效果。     

颈内动脉狭窄血管成形及支架置入术临床探讨

目的 分析颈动脉狭窄血管成形及支架置入术的围手术期治疗,总结操作经验,评价长期临床效果.方法 总结32例颈动脉狭窄患者,均经影像学诊断确诊,行DSA再证实,局麻下行血管成形及支架置入术,3例患者由于不配合改用全麻,6例患者由于高度狭窄,术前PWI评价脑灌注,行分次治疗,在支架置入2周后局麻下行球囊扩张术.结果 32例患者支架覆盖斑块良好,术后残余狭窄＜10%,1例患者同侧肢体偏瘫,经治疗6 h后恢复.术后8例低血压,经多巴胺静脉维持后好转,7例一过性心动过缓,经对症治疗后好转.经1 a随访,未出现脑卒中再发作,2例发生再狭窄行球囊扩张.结论 术前综合评价、术中轻柔操作、防止低血压为手术成功和降低并发症的关键,分次治疗可降低高度狭窄病人术后高灌注综合征的发生几率.     

一过性黑朦患者临床及颈动脉狭窄特点分析

目的分析一过性黑朦（amaurosis fugax,AmF）患者临床及颈动脉狭窄的特点,探讨其与脑梗死发生的关系。方法对34例一过性黑朦患者的临床资料进行分析,应用彩色多普照勒颈动脉超声及经颅多普勒超声（TCD）检查颈动脉硬化、狭窄及眼动脉血流方向情况。结果34例AmF患者中有25例（73.5%）以AmF为首发症状,29例（85.3%）为单眼AmF发作,左右两眼发病率无统计学差异（P〉0.05）,70.6%的患者在AmF发作后3个月内发生脑梗死。超声检查显示AmF患者患侧颈动脉内膜增厚伴斑块发生率（82.4%）高于对侧（29.4%,P〈0.05）。颈动脉重度以上狭窄占91.2%,患侧颈内动脉狭窄或闭塞发生率（27例,79.4%）明显高于对侧（10例,29.4%,P〈0.05）。TCD检查显示眼动脉侧支开放14例,无眼动脉侧支20例。眼动脉侧支开放组颈动脉中度以上狭窄发生率（92.9%）与侧支未开放组颈动脉狭窄发生率（70.0%）无明显差异（P〉0.05）。经Logistic回归分析,有短暂性脑缺血病史（OR0.38,95%CI0.07-0.69,P=0.02〈0.05）和颈动脉严重狭窄（OR0.33,95%CI0.08-0.58,P=0.01〈0.05）是AmF发作后近期发生脑梗死的独立危险因素。结论AmF往往提示颈内动脉存在严重狭窄,严重的颈内动脉狭窄是引起AmF的主要原因。伴有短暂性脑缺血病史及颈动脉严重狭窄的AmF患者近期容易发生脑梗死。