介入治疗左锁骨下动脉闭塞术中胸膜外血肿1例

患者男,64岁,体检超声发现右颈内动脉闭塞、左颈内动脉狭窄收入院;3年前接受冠状动脉支架植入术,术后规律口服抗凝及抗血小板药;无高血压、糖尿病等病史。入院后查体及实验室检查均未见明显异常。颈动脉CT血管造影:右颈内动脉闭塞,左颈内动脉狭窄(70%~90%),前交通动脉开放。经股动脉插管全脑血管造影:右颈内动脉闭塞,左颈内动脉狭窄约90%,前交通动脉开放,左锁骨下动脉闭塞,左椎动脉盗血。     

颈动脉支架成形术中脑保护伞释放鞘断裂1例

颈动脉支架成形术(CAS)是当今治疗颈动脉狭窄性病变的主要方法之一。我院血管外科于2007年2月治疗1例一侧颈内动脉高度狭窄,对侧颈内动脉闭塞的高危病人过程中,遇到脑保护伞释放鞘部分断裂的少见情况。本文就其处理技巧及经验总结如下。1病历简介病人男,73岁。因“反复发作右上肢无力”入院,术前诊断为颈动脉狭窄、一过性脑缺血发作及高血压病。术前头颅CT提示双侧基底节区腔梗死灶。颈动脉血管造影显示右颈内动脉起始段85%狭窄,斑块内未见明显龛影;左颈内动脉闭塞;右侧大脑中动脉及大脑前动脉显影良好,部分代偿左侧大脑血供;左椎动脉代偿…     

颈内动脉狭窄83例的血管内支架治疗

目的 探讨颈内动脉狭窄血管内支架治疗的方法。方法 选择颈内动脉狭窄大于85%的患者83例行血管内支架治疗，于围手术期进行抗血小板治疗，并行全脑血管造影及颈部超声检查。手术采用2类支架，分预扩与不预扩两种操作。结果 83例手术操作顺利，无临床并发症，影像学评价完全成功，超声波检查示脑血流恢复正常或好转。56例临床症状消失，27例临床症状不同程度好转。术后随访3～24个月，复查脑血管造影及超声波示支架形态良好，血液通畅，血管无再狭窄。结论 采用正确的围手术期治疗及手术方法对颈内动脉狭窄行血管内支架治疗是安全的，支架的选择与是否预扩尚待商榷。     

80例脑梗死患者脑血管造影分析

目的:探讨脑梗死患者脑血管造影的特点.方法:选择我院2007年11月至2009年11月脑梗死患者80例,以上患者诊断均符合全国第四届脑血管病会议制定的脑梗死的诊断标准.以上患者均行脑血管造影:行主动脉弓造影,观察颅内实质的灌注情况.更换造影管行全脑血管造影:颈总动脉造影、颈内动脉造影、锁骨下动脉造影、椎动脉造影.如果患者颈内动脉出现闭塞或者由严重狭窄时,要行颈外动脉造影,显示颈外动脉的全程.结果:①发现脑供血动脉出现狭窄或者闭塞的有59例,占73.7％.造影结果为阴性的21例,占26.3％.②造影阴性患者偏瘫率与造影显示脑供血动脉狭窄或闭塞患者的偏瘫发生率比较,差异无统计学意义( P＞0.05).③轻度狭窄占36.2％;中度狭窄占20.0％;重度狭窄占18.7％,闭塞25.1％.结论:脑梗死脑血管造影中,多数脑梗死患者存在脑供血动脉狭窄或者闭塞,脑梗死脑血管造影有助于判断脑梗死的病变性质,为临床诊断和治疗提供依据.     

27例多发性大动脉炎血管介入治疗

目的探讨血管介入治疗多发性大动脉炎(Takayasu arteritis,TA)所致血管狭窄或闭塞性病变的临床疗效。方法 2003年6月～2011年6月对27例TA经股动脉穿刺选择性血管造影,确定病变部位,明确诊断,并对因大动脉炎引起的锁骨下动脉、颈动脉、肾动脉、腹主动脉病变进行了选择性球囊扩张或支架植入手术。结果 27例施行血管腔内扩张成形术或支架植入术,其中颈总动脉扩张10例,支架2例;锁骨下动脉扩张6例;腹主动脉扩张4例;肾动脉扩张10例,支架4例;无名动脉扩张1例,支架1例;共置入支架7枚。2例颈动脉扩张时因并发症而终止治疗,其余病例病变血管均获得满意的治疗。27例随访5个月～7年,平均4年,其中<12个月6例,1～3年12例,3～5年6例,>5年3例:11例头晕、视觉异常等脑缺血症状改善;12例肾动脉狭窄所致高血压经球囊扩张及支架植入后血压控制正常;2例肾动脉狭窄在球囊扩张后14、18个月再次发生血压增高,造影显示扩张后肾动脉再次狭窄,再次行肾动脉球囊扩张成形术,扩张后高血压恢复正常。结论介入性血管内成形术治疗TA所致血管狭窄或闭塞性病变疗效满意。     

颈内动脉闭塞术的初步临床应用

目的探讨颈内动脉闭塞术治疗颈内动脉血管性病变的价值。方法共5例患者,1例鼻咽癌行放疗后清创术,并发难以制止的鼻咽部大出血,双侧后鼻孔填塞无效;1例巨大颈内动脉眼段动脉瘤,无法手术夹闭;3例外伤后颈内动脉海绵窦瘘,单纯闭塞瘘口失败。采用Seldinger技术经股动脉穿刺置管行全脑血管造影,经球囊闭塞试验或病变侧压颈试验,病人耐受良好后方行闭塞术。闭塞材料为3例应用可脱弹簧圈,2例应用可脱球囊,闭塞位置为病变近端及瘘口。结果所有病例闭塞颈内动脉后,即行对侧颈动脉造影复查,可见前交通动脉和/或后交通动脉代偿良好,患者无明显并发症发生,病变未见显影。临床症状消失、无合并症发生,病变未见复发。结论颈内动脉闭塞术作为一种治疗颈动脉血管性疾病的方法,可以在不危及病人生命、加重病人病情的情况下,取得良好的治疗效果。     

脑保护下症状性颈动脉狭窄支架置入术并发症

目的探讨颈内动脉狭窄血管内支架治疗的并发症。方法对36例颈内动脉狭窄患者行全脑血管造影及颈部CTA或MRA检查。所有患者全部使用脑保护装置,均采用脑保护下预扩张,无术后扩张病例。所有病例均采用自膨式支架置入,共置入支架37枚（1例双侧狭窄病例）。结果 36例患者技术成功率为100%,患者症状消失或好转率为95.47%。随访率为83.33%,失访6例。再狭窄1例,占2.78%。结论颈内动脉狭窄的血管内支架治疗是安全的,操作规范细心可以减少并发症。     

伴脑动脉狭窄的症状性腔隙性脑梗死患者脑血管造影分析

目的分析伴脑供血动脉狭窄的症状性腔隙性脑梗死患者的全脑血管造影结果。方法选择经CT或MRI确诊的51例症状性腔隙性脑梗死患者,全部接受全脑血管造影检查,均存在脑供血动脉狭窄,观察统计病变血管的狭窄程度及闭塞血管的侧支代偿情况。结果全部患者均成功接受全脑血管造影,无严重并发症发生,狭窄程度：9例（17.65%）≤50%,12例（23.53%）50%～70%,14例（27.45%）71%～99%,16例（31.37%）闭塞。51例中,40例（78.43%）存在梗死相关病变血管。16例闭塞病例中,12例有侧支循环形成。结论对伴脑供血动脉狭窄的症状性腔隙性脑梗死患者行全脑血管造影具有较高的阳性率,梗死主要由前循环系统血管病变引起,观察血管病变程度及侧支代偿建立情况对疾病下一步治疗具有重要指导作用。     

可脱性球囊血管内栓塞治疗外伤性颈动脉海绵窦瘘

目的探讨外伤性颈动脉海绵窦瘘(TCCF)的诊断及血管内治疗。方法对11例经脑血管造影数字减影(DSA)确诊和治疗的外伤性颈动脉海绵窦瘘病人的临床资料进行回顾性分析。结果10例闭塞瘘口,1例闭塞颈动脉主干,11例病例症状恢复或明显改善。结论随着神经介入栓塞技术和材料的迅速发展,血管内介入栓塞治疗具有方法简单、操作方便、并发症少、病死率低,保持颈内动脉通畅率高的优点,已成为TCCF的治疗首选。     

三维动态增强磁共振血管造影用于犬颈动脉支架植入术后随访的可行性

目的分析颈动脉支架在犬三维动态增强磁共振血管造影（3DCE-MRA）图像上的信号及伪影特点,评价3DCE—MRA用于颈动脉支架术后随访的可行性。方法通过外科手术方法在6只犬的颈动脉成功建立非粥样硬化性狭窄,选用3枚镍钛合金自膨式带膜支架及3枚不锈钢（316L）球囊膨胀式支架行经皮血管腔内成形术及颈动脉支架植入术（PTA＋CAs）。于支架植入术后行颈动脉造影及3DCE-MRA。结果PTA＋CAS技术成功率为100％。造影证实2支颈动脉轻度狭窄（〈50％）,1支中度狭窄（≥50o．4且〈700．4）,3支重度狭窄（≥70％）。3DCE-MRA显示镍钛合金支架表现为支架腔边缘呈锯齿样细小的暗带状伪影,伪影引起的腔内假性狭窄约0-30％;不锈钢球囊膨胀式支架表现为支架腔内信号完全丢失。结论3DCE-MRA可用于评价镍钛合金支架腔内是否通畅,尚无法对狭窄程度进行分级;但对于不锈钢球囊膨胀式支架,由于伪影严重,无法评价支架腔内情况。     

Stenosis of the proximal external carotid artery in an adult with moyamoya disease: moyamoya or atherosclerotic change?

A 55-year-old woman presented with moyamoya disease manifesting as recurrent transient ischemic attacks despite taking aspirin and antihypertensive agent. Angiography showed the characteristic angiographic appearance with bilateral internal carotid artery occlusion and abnormal collateral vessels. Left external carotid angiography demonstrated moderate stenosis of the proximal external carotid artery (ECA). A self-expandable stent was successfully placed in the left ECA to improve ipsilateral cerebral perfusion. The patient had an uneventful outcome after a 1-year follow up. Involvement of the proximal ECA is very unusual in moyamoya disease, and might result from hemodynamic stress or degenerative atherosclerosis. Revascularization procedures for stenoses of proximal ECA may improve cerebral perfusion in patients with moyamoya disease.     

Internal carotid artery hemorrhage after irradiation and osteoradionecrosis of the skull base.

OBJECTIVE: To evaluate the clinical presentation and management of internal carotid artery rupture after irradiation and osteoradionecrosis of the skull base. STUDY DESIGN AND SETTING: A retrospective review of the patients in an otorhinolaryngology-head and neck secondary and tertiary referral center. METHODOLOGY: From January 1993 to December 1996, patients with hemorrhage from internal carotid artery as a complication of irradiation and osteoradionecrosis of skull base were reviewed and analyzed. RESULTS: Four patients with internal carotid arterial rupture were included in this study. Angiography was performed in all cases. Embolization of the aneurysm was performed on 2 patients and the remaining 2 patients underwent occlusion of their internal carotid arteries. Three of the 4 patients did not survive. The fourth is currently alive and well 18 months after embolization of 1 internal carotid artery. CONCLUSION: Skull base osteoradionecrosis with bleeding from internal carotid artery is a potentially fatal complication of irradiation. Angiography was the mainstay of diagnosis with embolization of the aneurysm and embolization or ligation of the internal carotid artery being the management options. Internal carotid artery occlusion is the definitive treatment provided cross circulation is adequate. SIGNIFICANCE: The advantages and disadvantages of the treatment options are discussed and a management protocol is proposed.     

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。     

灌注核磁共振技术对颈动脉系统狭窄或闭塞的血流动力学和外科疗效的评价

目的 利用灌注磁共振技术分析颈动脉系统狭窄或闭塞时血流动力学特点,并以此评价外科治疗疗效。方法 21例接受外科治疗的颈动脉狭窄或闭塞患者中,行颈内动脉内膜切除者2例,行颅内外血管吻合者10例,行支架血管成形术者9例。结果 21例患者术前局部脑血流量正常,但大脑中动脉分布区及分水岭区的灌注明显延迟;术后分水岭区的灌注恢复正常,与术前比较,21例患者灌注延迟的区域均明显减少,其中内膜切除与支架血管成形术的近期疗效好。结论 灌注磁共振技术可以准确评价单侧前循环供血动脉狭窄的血流动力学状况,外科治疗可以明显改善这种血流动力学障碍。     

Viabahn覆膜支架植入术急诊治疗医源性髂股动脉破裂出血

目的观察Viabahn覆膜支架急诊治疗医源性髂股动脉损伤的安全性和有效性。方法回顾性分析7例接受Viabahn覆膜支架急诊治疗的医源性髂股动脉损伤患者,统计技术成功率、手术时间、治疗效果及并发症。结果 7例各均成功植入1枚Viabahn支架,技术成功率100%(7/7)。手术时间30～55 min,平均(34.36±9.13)min。术后出血均停止。随访1个月,病情均稳定。术中及术后1个月内均未出现腔内治疗并发症(穿刺点血肿、动脉及支架内血栓形成、内瘘或支架移位等)。结论采用Viabahn覆膜支架腔内修复治疗医源性髂股动脉破裂出血安全有效。     

Wird die Karotischirurgie konkurrenzfähig bleiben?

Background

Thromboendarterectomy (TEA) and stenting are in competition for treatment of carotid artery lesions. Both treatment modalities have to improve significantly. The goal of the study was to evaluate the influence of routine intraoperative duplex ultrasound examination.

Methods

In a continuous prospective study, 575 patients underwent 620 carotid operations. Intraoperative duplex ultrasound examination was performed prior to wound closure: 9.5% had significant contralateral ICA stenoses and 6.7% ICA occlusion; 8.5% presented special lesions. An eversion TEA was performed in 20.5% while 78.5% underwent conventional TEA with patch plastyand graft interposition in 1%. Intraoperative quality control revealed unexpected lesions in 10% requiring immediate repair.

Results

The combined morbidity/mortality rate (MMR) of the total series was 2.6%. Women had an elevated risk (4.2%) in comparison to men (1.9%). The risk of elder patients (>75 years, n=151) was remarkably low. The neurological complication rate of the total series was 1.6% and the incidence of major strokes 1.1%.

Conclusions

Routine intraoperative duplex ultrasound examination of the carotid reconstruction allows early diagnosis and immediate correction of morphologic as well as hemodynamic lesions. Competing with stent placement a further reduction of complications of carotid TEA seems to be possible and necessary.     

Stenting of Atherosclerotic Stenoses of the Extracranial Carotid Artery

Summary. Summary. Background: Percutaneous transluminal angioplasty (PTA) and stenting seems to be, at present, the treatment of choice for early restenosis after endarterectomy and for atherosclerotic stenoses of supra-aortic trunks near or at the ostium. In contrast, the role of PTA and stenting for treatment of symptomatic and asymptomatic atherosclerotic stenosis of carotid bifurcation is still debated. Methods: The present study comprises 27 consecutive cases of atherosclerotic lesions of the carotid bifurcation treated with PTA and stenting. All patients were symptomatic, except for 2 suffering from asymptomatic stenosis with contralateral carotid occlusion. There were 23 stenoses occluding 70% or more of the lumen according to the NASCET criteria and 4 mild stenoses (50–60% of the lumen) with large type C ulcers. Criteria for exclusion from surgery in these cases were aged >79 years, previous neck surgery for laryngeal cancer, carotid bifurcation at C2, association with intracranial aneurysms, occlusion of the contralateral carotid artery, and heart, lung and kidney diseases. All procedures were performed under local anaesthesia associated with mild sedation in a few cases. In all cases, self-expandable stents (Wallstent) were used. Follow-up ranged from 6 to 37 months. Findings: Transient neurological deficit occurred in 3 cases (11%). One case (3.7%) experienced a minor stroke at three months. Asymptomatic tight restenosis due to intimal hyperplasia occurred in one case (3.7%). In 8 cases (40%) of complex stenosis involving common and internal carotid arteries there was some loss of contact of the stent with the wall of the common carotid artery in the late follow-up. One case (3.7%) experienced severe and prolonged hypotension and bradycardia during the release of the stent. Interpretation: From literature data and our results it emerges that periprocedural catastrophic embolism is unlikely to occur. The best results are undoubtedly obtained when treating stenosis limited to the internal carotid artery. Nevertheless, the ideal stent to treat vessels of different calibre, as occurs at the carotid bifurcation, is not yet available. The problem of periprocedural cerebral protection has not been resolved. Reported series are heterogeneous and retrospective, and an adequate follow-up of cases is still lacking.     

Evidenzbasierte Therapie radiogener Läsionen der extrakraniellen A. carotis und A. subclavia

Background

Radiation induces intimal damage and can lead to lesions in the peripheral vessels. The plaque morphology after radiation seems to be more stable compared with atherosclerotic plaques. In the case of neurological symptoms from carotid artery stenosis after neck radiation, invasive therapy is clearly indicated.

Methods

A systematic review of the literature in PubMed was performed with regard to the evidence for treatment and treatment options for radiation-induced stenosis of the internal carotid artery and the subclavian artery.

Results

Carotid artery stenting (CAS) is recommended as the treatment of choice in radiogenic stenosis in current national and international guidelines. In recent literature, however, it was argued that carotid endarterectomy is also safely applicable in those patients, achieving good short- and long-term results. In comparison, CAS carries a relatively high risk of neurological symptoms during follow up. In addition, restenosis occurs significantly more often after CAS compared with surgery. Radiation following breast cancer can induce lesions in the subclavian artery. This can cause stenotic plaques and also aneurysm formation. Endovascular treatment with angioplasty and stent or stent graft implantation serves as treatment of first choice in these patients.

Conclusion

Radiation-induced stenosis of the internal carotid artery can safely be treated by endovascular and operative means. In case of stenosis in the subclavian artery, angioplasty remains the treatment of choice. Best medical therapy is recommended to avoid disease progression by atherosclerosis.     

Sonographische Verlaufskontrolle nach Karotisstentimplantation (CAS): Graduierung von Rezidivstenosen und Stentdislokation

Background

Color-coded duplex sonography (CCDS) is a recognized method in the diagnostics and grading of recurrent stenoses after carotid artery stent (CAS) placement. The peak systolic velocity (PSV) measured by sonography for quantification of stenoses varies in the literature. Stenosis grading according to the European carotid surgery trial (ECST) criteria for the local stenosis grade and the North American symptomatic carotid endarterectomy trial (NASCET) criteria for the distal stenosis grade has resulted in considerable confusion due to the different grading results for the same velocity limits.

Methods

This article presents a critical review of the literature between 2000 and 2012 on sonographic surveillance and stenosis grading of in-stent recurrent stenoses after CAS placement in consideration of hemodynamic laws and presentation of sonographic grading according to the law of continuity.

Results

The high velocity limits of in-stent stenoses according to the NASCET criteria were transferred to the European stenosis criteria according to the ESCT. As a result the velocity limits for in-stent stenoses were applied which were higher than those of de novo carotid stenoses by more than one third (explained by the rigidity of the stent material). Using an adequate conversion results in only slightly higher PSV values for in-stent recurrent stenoses compared to internal carotid artery (ICA) de novo stenoses. The PSV ratio, defined as PSV in-stent intrastenotic/PSV in-stent prestenotic measurements but in contrast to previous values from the literature in the ICA, not in the common carotid artery (CCA), allows a valid stenosis grading according to the law of continuity (most recurrent stenoses lie in the distal and middle third of stents, away from the bifurcation of the external carotid artery). A ratio >?2 indicates a stenosis of >?50?% and a ratio >?4? a ?>?75?% stenosis. Additionally, the plaque configuration determines the hemodynamic effects (40–75 % reduction in cross-sectional surface with a 50 % reduction in diameter) and as a result the intrastenotic PSV. Stent displacement can be validly assessed due to stent movement in grey value sonography in the time motion mode and color-coded duplex sonography by the current flow signals between the vascular wall and the body of the stent.

Discussion and conclusions

With a standardization of stenosis criteria the velocity limits for in-stent recurrent stenoses are only slightly higher than the known values for de novo stenoses. The PSV ratio (PSV in-stent recurrent stenoses/PSV in-stent prestenotic measured in the ICA) allows the most accurate stenosis grading.     

Intracranial aneurysms in patients with internal carotid artery occlusion: management and outcome in 22 cases

Background

There is little information about clinical characteristics, management, and outcome of patients with intracranial aneurysms and internal carotid artery occlusion. We will describe clinical characteristics, treatment and outcome of patients with coexistent internal carotid artery occlusion and intracranial aneurysms.

Methods

We conducted a retrospective chart review of 22 patients (eight males and 14 females) with coexistent internal carotid artery (ICA) occlusion and intracranial aneurysms.

Results

This series includes 14 females and eight males with a mean age of 63 years (range, 49 to 80). These patients harbored a total of 35 aneurysms, which were located on the same side of the ICA occlusion in five cases, on the contralateral side in 20 cases, while in ten cases the aneurysm had a midline location (AcomA 9, Basilar tip 1). Treatment consisted of surgery for eight aneurysms and endovascular embolization for 13 aneurysms. No invasive treatment was recommended for 14 aneurysms (eight patients with single aneurysm). No permanent perioperative or periprocedural complications occurred in the selected group of patients undergoing invasive treatment. At a mean follow-up of 57?months (range, 3–203), no patient had a subarachnoid hemorrhage and three patients had died of causes not related to the aneurysm.

Conclusion

Surgical and endovascular treatment can be accomplished safely in selected patients with coexistent ICA occlusion and intracranial aneurysms. Conservative treatment is a valid alternative, especially in elderly patients or in patients with very small aneurysms, especially if not located along the collateral pathway.