脑保护下的颈动脉狭窄内支架治疗

目的 评价经皮血管内支架成形术联合应用颈动脉滤器对颈动脉狭窄的治疗效果。方法12例有临床症状的颅外颈动脉狭窄患者接受血管内支架植入治疗，术中同时使用颈动脉滤器进行脑保护，并对颈动脉滤器所回收的物质进行病理学分析。结果12例患者支架及滤器均成功植入，滤器均成功回收。回收物质为微小血栓颗粒、泡沫细胞、胆固醇颗粒。结论经皮血管内支架成形术联合应用颈动脉滤器，可有效缓解颈动脉狭窄所致的血流障碍，预防术中脱落的微小栓子进入脑内。     

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.     

颈动脉滤伞下颈动脉支架成形术的并发症分析

目的 初步总结颈动脉滤伞保护下行颈动脉支架成形术的应用和并发症的处理体会.方法 对35例颈动脉硬化性狭窄患者的38处病变(无症状的狭窄超过70%,有症状的狭窄超过50%)行颈动脉滤伞保护下颈动脉支架成形术,对操作过程及并发症发生、处理和预后进行分析.使用超声、CTA和MRA进行随访.结果 本组38处病变成功完成所有操作,支架后即时造影示病变处管径明显改善(残余狭窄<20%),血流通畅.21例(55.3%)回收后的栓塞防护装置中可见拦截的斑块碎片,其中3例斑块甚至填满保护装置.并发症包括术后脑出血死亡者1例(2.6%);术中出现脑梗塞,一侧肢体运动障碍者1例(2.6%);出现一过性TIA表现,收伞后症状消失者2例(5.3%);出现一过性术中术后心率、血压下降者10例(26.3%).平均随访32个月(6～54个月),颈动脉支架处血流通畅,除1例使用覆膜支架患者支架处闭塞外,其他病例均无明显再狭窄.随访期无新的TIA或脑梗塞出现.结论 初步应用显示颈动脉滤伞下颈动脉支架成形术是安全、有效的.精细、轻柔的操作可减少并发症的发生.     

颈动脉狭窄的外科治疗

目的:探讨颈动脉狭窄的外科治疗方法.方法:根据狭窄的部位和程度对82例颅外颈动脉狭窄患者采取不同的手术方法,其中颈动脉内膜切除术65例,颈动脉支架成形术10例.结果:手术均获成功,但颈动脉内膜切除术的术后并发症发生率最低.结论:颈动脉内膜切除术仍然是治疗颅外颈动脉狭窄的主要方法,而颈动脉支架成形术则可以解决颈动脉内膜切除术无法到达部位的狭窄.     

颈动脉狭窄支架植入术55例

目的 介绍颈动脉支架植入术的基本方法,探讨该术式治疗颈动脉狭窄的理论和临床意义。方法 55例颈动脉狭窄患者行腔内成形、支架植入术,共放支架58个,其中Wallstent支架41个,Smart支架14个,OptiMed支架3个。18例患者应用脑保护装置。结果 术中2例患者出现较重卒中,其中l例术中出现左眼视野缺损,3个月后仍有残余症状,1例术中出现意识丧失、右侧肢体偏瘫,经救治神志恢复。2例出现轻度卒中。6例出现一过性血压降低、心动过缓,其后逐渐恢复。神经系统并发症发生率为6．9％,严重卒中为3．5％。循环系统并发症为10．3％。应用脑保护装置的患者没有神经系统并发症。结论 颈动脉支架植入术是治疗颈动脉狭窄的有效手段,在有经验的医生治疗下,操作是安全的。使用脑保护装置可明显减少神经系统并发症。     

脑保护装置下支架置入术治疗重度颈动脉狭窄

目的探讨脑保护装置下行颈动脉支架置入术(CAS)治疗重度颈动脉狭窄的近期疗效和安全性。方法回顾性分析2013年10月—2014年12月收治的48例接受CAS治疗的重度颈动脉狭窄患者临床资料,术后随访观察支架内再狭窄、短暂性脑缺血发作(TIA)、脑卒中及死亡事件的发生率。结果48例患者均CAS成功,术前平均狭窄率为(85.27±11.52)%,术后残余狭窄率为(18.12±3.36)%,差异有统计学意义(P0.01)。术后随访无新发TIA、脑梗死及死亡患者,但3例患者出现支架内重度再狭窄。结论支架置入术治疗重度颈动脉狭窄是安全、有效的,但远期疗效有待观察。     

颈动脉球囊扩张与支架置入术后血清一氧化氮和内皮素变化的实验与临床观察

目的:观察小型猪颈动脉球囊扩张前后和颈动脉狭窄患者狭窄扩张、支架置入术前后血清一氧化氮(NO)和内皮素(ET)的变化.方法:选取12头广西巴马小型猪,分别于颈动脉球囊损伤前、损伤后2周和3周检测静脉血血清中NO和ET的浓度.同样方法检测19例颈动脉狭窄患者支架置入术前、术后静脉血及支架置入处动脉血血清中NO和ET的浓度.结果:小型猪颈动脉损伤后2周NO浓度较损伤前显著降低(P<0.05),ET浓度较损伤前升高,但无显著差异;损伤后3周ET浓度明显升高(P<0.01).支架置入患者中,术前、术后即刻和术后6 h周围静脉血的NO浓度和同一时间点的ET浓度变化差异均尢统计学意义.结论:小型猪颈动脉球囊损伤后可观察到NO降低和ET升高,可能与猪颈动脉粥样硬化性狭窄的发生相关;人颈动脉狭窄支架置入术后NO、ET的变化及其在术后动脉冉狭窄中的作用尚需进一步研究.     

颈动脉狭窄手术及介入治疗的围术期管理

背景 脑卒中是造成人类死亡的主要原因之一.15％～20％的缺血性脑血管病归因于颈动脉狭窄或闭塞,颈动脉内膜剥脱术(carotid endarterectomy,CEA)和颈动脉血管腔内球囊成形及支架植入术(carotid angioplasty and stenting,CAS)对预防缺血事件发生有效,但围手术期卒中、死亡等并发症对围术期管理提出挑战. 目的 对颈动脉狭窄手术及介入治疗围术期管理进行综述. 内容 重点阐述CEA和CAS围术期危险因素控制、术前评估、麻醉方法与管理、术中神经功能监测和脑保护. 趋向 积极谨慎的围术期管理是保证颈动脉狭窄患者围术期脑氧供需平衡、降低围术期并发症的有效措施.     

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。     

冠心病合并颈动脉狭窄的围术期处理

背景 冠心病(coronary artery bypass grafting,CABG)合并颈动脉狭窄者临床上并不少见.如何正确处理CABG患者并存颈动脉狭窄的问题应引起重视.目的 为了探索CABG患者并存颈动脉狭窄的最佳处理方法,此文将CABG患者并存颈动脉狭窄的外科治疗及麻醉处理进行了分析汇总.内窖对于合并颈动脉狭窄的CABG患者,最佳治疗策略尚未达成共识.既往外科治疗多采用分期或同期颈动脉内膜剥脱术(carotid endarterectomy,CEA),但近年来随着经皮介入治疗技术的发展,大多数可以采用分期或同期经皮颈动脉支架置人术(carotid artery stenting,CAS).CABG合并颈动脉狭窄患者围术期麻醉处理的关键是维持血流动力学平稳,保证大脑的有效灌注压,避免脑缺血和栓塞.趋向 同日CAS-CABG"杂交"手术已显示出可行性,并有待进一步研究.     

颈动脉狭窄的介入治疗(附40例报告)

目的 总结我科40例颈动脉支架置入术治疗颈动脉狭窄的经验。方法2000年10月～2002年7月40例颈动脉狭窄行腔内成形、支架置入术，共放支架43个，其中Wallstent支架39个，Smart支架4个。应用脑保护装置5例。结果所有病人都完成支架置入，颈内动脉口都恢复到4min以上。术中出现轻度卒中2例，较重卒中2例：1例术中出现左眼视野缺损，3月后仍有残余症状；1例术中出现意识丧失、右侧肢体偏瘫，经救治神志恢复。并发症发生率10％(4／40)，严重卒中发生率5％(2／40)，应用脑保护装置的病人无并发症发生。结论颈动脉支架置入术是治疗颈动脉狭窄的有效手段，用脑保护装置时安全保证更高。     

Combined Carotid and Coronary Artery Disease

Stroke is a devastating complication of coronary artery bypass surgery. It increases the mortality and morbidity of the operation, and prolongs the length of hospital stay. Functional disability from the stroke may dramatically reduce the quality of life post-operatively, and some patients will require permanent institutional care. Although there are many causes of stroke extra-cerebral carotid stenosis is the most important predictor of stroke for patients undergoing coronary artery bypass grafting (CABG). If patients are identified before coronary intervention, they may benefit from treatment of their carotid disease. Carotid endarterectomy can be performed before or simultaneously with coronary artery bypass. However, carotid angioplasty with stenting and cerebral protection may offer a superior method to conventional surgery in this high-risk group of patients.     

Combined carotid and coronary artery disease

Stroke is a devastating complication of coronary artery bypass surgery. It increases the mortality and morbidity of the operation, and prolongs the length of hospital stay. Functional disability from the stroke may dramatically reduce the quality of life post-operatively, and some patients will require permanent institutional care. Although there are many causes of stroke extra-cerebral carotid stenosis is the most important predictor of stroke for patients undergoing coronary artery bypass grafting (CABG). If patients are identified before coronary intervention, they may benefit from treatment of their carotid disease. Carotid endarterectomy can be performed before or simultaneously with coronary artery bypass. However, carotid angioplasty with stenting and cerebral protection may offer a superior method to conventional surgery in this high-risk group of patients.     

Early carotid artery stenting after onset neurologic symptoms

Multicenter clinical trials level 1 evidence favors the application of carotid endarterectomy in symptomatic patients, especially the in the elderly cohort. Carotid artery stenting has been proposed as a possible early alternative in selected patients after onset of ipsilateral neurologic symptoms. It is well known that treatment of acute stroke is time-dependent in patients with acute ischemic stroke caused by high-grade stenosis of the internal carotid artery, but intensive medical treatment in conjunction with intervention to improve stroke severity and clinical outcomes has not been established. Two major clinical concerns exist: (1) the risk of hemorrhagic infarction after cerebral revascularization in the acute stage and (2) application of carotid stenting in the acute embolic stage, which may be associated with continued embolic risk after carotid artery stenting compared to carotid endarterectomy, which removes the symptomatic plaque. This review summarizes the indications and results of early carotid artery stenting after onset of neurologic symptoms, considering the new carotid stents and cerebral protection systems available for clinical use and enhanced stenting techniques.     

Current indications, results, and technique of carotid angioplasty/stenting

Carotid endarterectomy (CEA) remains the treatment of choice for most patients with high-grade carotid artery stenosis. Certain patient subsets, including those with severe cardiac and pulmonary disease and those with local/anatomic risk factors (including recurrent stenosis following CEA, cervical radiation therapy, prior radical neck dissection, and surgically inaccessible lesions) are at increased risk of stroke, cranial nerve injury and non-Q myocardial infarction following CEA, and may be better served by carotid angioplasty and stenting (CAS). Procedural success is dependent upon proper patient selection and meticulous attention to detail. The use of cerebral embolic protection appears to reduce the risk of peri-procedural stroke following CAS.     

Timing of Complications during Carotid Artery Stenting. How Can they Be Predicted ?

Carotid artery stenting (CAS) is becoming increasingly common for the treatment of carotid stenosis. Accumulating data, but not randomised data, suggest that CAS has promising efficacy in preventing stroke with an acceptable rate of procedure-related complications when compared to carotid endarterectomy (CEA). However, CAS procedures can carry a risk of non-negligible complications such as cerebral embolization, cerebral hemorrhage, severe hypotension and bradycardia. These may occur after the first 24 hours. Lessons may be learned from the timing of occurrence of CAS adverse events. The most severe neurological complications are generally due to embolism and occur intraprocedurally especially during catheter, wire or sheath manipulation in the aortic arch and common carotid. These strokes, obviously, cannot be prevented by using cerebral protection devices and enhance the importance of an appropriate learning curve that includes proper material choice, patient selection, good technique and the skill of “know when to quit”.     

Current management of extracranial carotid artery disease

Stroke is the third most common cause of death in the United States. There are approximately 700,000 strokes/year; 80% are ischemic, and 20-30% of ischemic strokes are secondary to carotid disease. Carotid stenosis is traditionally treated by carotid endarterectomy (CEA). Multicenter, randomized, controlled trials have shown that surgery significantly reduces the risk of ipsilateral stroke in patients with severe symptomatic and asymptomatic carotid stenosis. Endovascular techniques for treating carotid stenosis have been developed over recent years. Carotid angioplasty and stenting (CAS) with cerebral protection has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. In this review we summarize the existing data regarding the traditional state of management of extracranial carotid artery stenosis and compare these data to a critical analysis of the recent results of CAS.     

Carotid Endarterectomy Versus Carotid Stenting: an Updated Review of Randomized Trials and Subgroup Analyses

Atherosclerotic disease of the carotid arteries is responsible for a significant portion of ischemic strokes. Carotid endarterectomy (CEA) is currently the accepted standard of treatment for patients with severe symptomatic carotid stenosis. In the past few years, however, carotid angioplasty and stenting (CAS) has emerged as a potential alternative endovascular treatment strategy for this disorder. In fact, spurred by the positive results of single center studies and small, pivotal randomized trials, some even consider CAS as the treatment modality of choice, especially in presumably surgical high-risk patients. Yet, randomized trials directly comparing CAS with CEA are sparse and have produced conflicting results.

The aim of this article is to review the current trial data on this issue and to define the role of these techniques for the management of two important subgroups of patients.

An updated meta-analysis of seven randomized trials comparing CEA with CAS demonstrates that CAS is associated with a significantly increased risk of any stroke or death within 30 days (OR. 1.41, 95% CI 1.07-1.87, p<0.05). Focusing on patients with a symptomatic carotid stenosis, there was also a significant difference in the odds of treatment-related stroke and death between CAS and CEA (OR, 1.41; CI 1.05 to 1.88, p < 0.05). Data on all disabling strokes and deaths within 30 days was available from five trials. The odds of disabling stroke or death at 30 days were similar in the endovascular and surgical group (OR, 1.33, 95% CI 0.89 to 1.98).

Overall, these data do not justify a blind enthusiasm for CAS and a widespread use of this procedure for the treatment of carotid artery stenosis. On the other hand, a closer inspection of the current literature on elderly patients and those with a contralateral carotid occlusion clearly indicates that CAS and CEA already now have a complementary role. While elderly patients should preferentially be treated with CEA, CAS appears to be the treatment of choice in patients with a symptomatic carotid artery stenosis and a contralateral carotid occlusion in experienced centers.     

Cerebral protection during retrograde carotid artery stenting for proximal carotid artery stenosis: technical note

Carotid artery stenting for carotid bifurcation stenosis usually uses the transfemoral approach. However, in patients with proximal common carotid artery (CCA) stenosis, the guiding catheter is difficult to introduce into the narrow origin of the CCA without risking cerebral embolization before activation of the protection device. A technique of cerebral protection by internal carotid artery (ICA) clamping with or without simultaneous external carotid artery (ECA) clamping was used to treat patients with proximal CCA stenosis by the retrograde direct carotid approach. The carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the stenosis. The ICA was clamped during angioplasty and stenting to avoid cerebral embolization. The ECA was clamped simultaneously if any extracranial-intracranial anastomosis was present. None of five patients treated with this technique experienced ischemic complications attributable to this technique.