球囊扩张支架多梯次压力释放在症状性颅内动脉粥样硬化性狭窄中的疗效分析

目的探讨球囊扩张支架多梯次压力释放治疗症状性颅内动脉粥样硬化性狭窄的安全性、可行性。方法回顾性连续纳入邢台市第三医院神经内科2010年1月至2017年12月405例(405处狭窄)症状性颅内动脉粥样硬化性狭窄患者,经DSA检查显示狭窄率均≥70%,接受颅内动脉球囊扩张支架置入术,根据DSA显示病变部位血管是否有侧支血管及成角程度,将成功置入球囊扩张支架的400例症状性颅内动脉粥样硬化性狭窄患者分为多梯次释放组(351例)和单梯次释放组(49例)。记录两组的基线资料,对两组缺血事件、病变部位进行组间比较,分析患者治疗后即刻手术成功(支架覆盖良好,残余狭窄率<30%)率和术后30 d、12个月累积卒中事件[靶血管供血区的出血、梗死、短暂性脑缺血发作(TIA)]。采用Kaplan-Meier方法计算累积卒中发生率,并应用Log-rank方法(χ^2检验)比较组间差异。结果共置入400枚球囊扩张支架(椎动脉颅内段160枚、大脑中动脉108枚、基底动脉72枚、颈内动脉颅内段60枚)。(1)两组患者缺血事件差异无统计学意义(P>0.05),两组病变部位比较有统计学意义(χ^2=26.781,P<0.01)。(2)即刻手术成功率98.8%(400/405),5例因支架未到位而失败。手术操作时间9~35 min,平均(17±3)min;多梯次释放组手术操作时间平均(17±3)min,单梯次释放组平均(17±3)min,两组手术操作时间差异无统计学意义(P=0.063)。术后残余狭窄率为0~20%,中位数狭窄率7(4,10)%,与术前狭窄率比较,差异有统计学意义(Z=17.451,P<0.01)。其中多梯次释放组残余狭窄率为7(4,7)%,单梯次释放组为8(5,10)%,两组术后残余狭窄率差异有统计学意义(Z=1.983,P=0.047)。(3)术后30 d内卒中事件发生率为3.0%(12/400),其中,2例脑出血,10例脑梗死(2例死亡),多梯次释放组与单梯次释放组卒中事件发生率分别为2.0%(7例,1例脑出血,6例脑梗死)和10.2%(5例,1例脑出血,4例脑梗死),差异有统计学意义(χ^2=7.338,P=0.007);12个月累积卒中发生率为10.6%(38例),多梯次释放组8.9%(29例),单梯次释放组18.9%(9例),差异有统计学意义(P=0.027)。结论球囊扩张支架多梯次压力释放治疗症状性颅内动脉粥样硬化性狭窄是安全、可行的。

Analysis of curative effect on multi-step pressure releasing balloon-expandable stent for symptomatic intracranial atherosclerotic stenosis

Objective To explore the safety and feasibility of multi-step pressure releasing balloon-expandable stent for symptomatic intracranial atherosclerotic stenosis.Methods A total of 405 patients(405 stenoses)who had symptomatic intracranial atherosclerotic stenosis(≥70%)confirmed by DSA were enrolled retrospectively in the Xingtai Third Hospital from January 2010 to December 2017.The patients received the treatment of balloon-expandable stent implantation.According to whether it had the collateral vessel and the angle of the vascular lesion by DSA,those 400 cases that were implanted balloon-expandable stent successfully were divided into the multi-step pressure releasing technique group(n=351)and the one-time pressure releasing technique group(n=49).The baseline data of the two groups were recorded and their ischemic events and lesion sites were compared to analyze the immediate successful operation(well stent coverage,residual stenosis less than 30%)rate,and the cumulative stoke events[hemorrhage,infarction,transient ischemic attacks(TIA)in the target vascular territory]in 30 days and 12 months after the procedure.Kaplan-Meier method was used to calculate the cumulative stoke incidence,and Log-rank method(χ^2 test)was used to make compare of the difference between the two groups.Results Four hundreds stents were successfully implanted(160 stents in the intracranial segment of the vertebral artery,108 stents in the middle cerebral artery,72 stents in the basilar artery,and 60 stents in the intracranial carotid artery).(1)There was no statistically significant difference on ischemic events(P>0.05),but there was significant difference on lesion sites between the two groups(χ^2=26.781,P<0.01).(2)The immediate achievement ratio of operation was 98.8%(400/405).Five cases failed because the stents could not arrive at the proper position.The time of the operation was 9 to 35 minutes with a mean(17±3)min;the multi-step pressure releasing technique group was(17±3)min,the one-time pressure releasing technique group was(17±3)min,there was no statistical significance on operation time between the two groups(P=0.063).The residual stenosis rate was 0 to 20%with a median 7(4,10)%after the procedure,which was statistically significant difference compared with the preoperative stenosis rate(Z=17.451,P<0.01).The residual stenosis rate in the multi-step pressure releasing technique group was 7(4,7)%,the one-time pressure releasing technique group was 8(5,10)%,there was statistically significant difference on the residual stenosis between the two groups(Z=1.983,P=0.047).(3)The poste operation rate of stroke events was 3%(12/400)within 30 days,including 2 cases of cerebral hemorrhage and 10 cases of cerebral infarctions(2 cases death).The rate of stroke events in the multi-step pressure releasing technique group was 2.0%(7 cases,1 cerebral hemorrhage,6 cerebral infarctions)and 10.2%(5 cases,1 cerebral hemorrhage,4 cerebral infarctions)in the one-time pressure releasing technique group,the rate of stroke events between the two groups within 30 days was statistically significant(χ^2=7.338,P=0.007).The rate of cumulative stroke events was 10.6%(38 cases)at 12-month follow-up,the multi-step pressure releasing technique group was 8.9%(29 cases),the one-time pressure releasing technique group was 18.9%(9 cases),the difference was statistically significant(P=0.027).Conclusion The treatment of symptomatic intracranial atherosclerotic stenosis with multi-step pressure releasing balloon-expandable stent is safe and feasible.