颈动脉狭窄的血管内支架治疗

目的 总结颈内动脉狭窄血管内支架治疗的经验与并发症。方法 颈内动脉狭窄患者417例，全部患者行全脑血管造影及颈部超声检查。134例患者使用脑保护装置；283患者未使用保护装置，对其中202例(71．38％)进行预扩张，66例(23．32％)采取后扩张，3例未扩张。结果 417例患者术中，心率下降者105例(25．18％)；术中微栓子脱落5例，其中2例治疗后好转，2例留有一侧肢体运动障碍，术后颅内出血死亡1例。322例随诊，占77．22％，其中再狭窄15例，再狭窄发生率为3．6％。325例有临床症状的患者中，256例症状消失或好转，占78．77％；结论 采用正确的围手术期治疗及手术方法，颈内动脉狭窄的血管内支架治疗是安全的，应对术后脑血管过度灌注导致脑出血给予重视。     

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。     

自发性颈动脉内膜剥脱症的诊断与治疗

目的探讨自发性颈动脉内膜剥脱症（SCAD）的诊断与治疗方法。方法回顾性分析9例SCAD患者的临床诊断和治疗资料。结果血管超声检查显示颈动脉管腔狭窄或闭塞。脑血管造影显示闭塞病变近端呈＂火焰征＂,狭窄病变内见内膜片游离。1例患者双侧颈内动脉完全闭塞,6例患者单侧颈内动脉完全闭塞,接受抗血小板治疗;2例颈动脉不完全闭塞者接受血管内支架植入术,治疗均取得较满意效果。结论脑血管造影是诊断SCAD的金标准,血管内支架植入术是治疗SCAD的有效方法。     

颈内动脉旁路移植、内膜剥脱同期冠状动脉旁路移植术一例

患者　女 ,6 3岁。因不稳定型心绞痛加重 15天伴左侧心力衰竭入院。冠状动脉造影示左前降支中段闭塞 ,左回旋支开口处 85 %狭窄 ,右冠状动脉开口处 90 %狭窄。因心绞痛发作频繁 ,未行心室造影。二维超声心动图检查示室壁运动异常 ,经颅多普勒超声检查示颅内血管多发性狭窄 ,颈动脉超声检查示双颈内动脉严重狭窄。脑血管造影示右颈内动脉近段85 %局限性狭窄 ,左颈内动脉长段串珠样改变 ,最窄处达95 % (图 1)。图 1　脑血管造影示左颈内动脉长段串珠样改变　　手术方法 :先用大隐静脉行左颈总动脉、颈内动脉的旁路端侧吻合 ,右侧行颈内动脉内…     

血管内支架成形术治疗基底动脉狭窄

目的 探讨血管内支架成形术治疗基底动脉狭窄的近期疗效。方法 20例症状性基底动脉狭窄应用球囊膨胀支架行血管内成形术治疗。结果 12例基底动脉恢复正常管径，8例狭窄程度减小80％以上，无手术相关并发症。无短暂性脑缺血发作(Transient ischemic sttack，TIA)或卒中再发作。脑血管造影随访13例，均无血管再狭窄。结论 血管内支架成形术治疗基底动脉狭窄的近期疗效令人满意。     

血管内支架成形术治疗颅外颈动脉狭窄

目的　评价颅外颈动脉狭窄支架成形术的安全性及近期疗效。　方法　 2 0 0 0年 10月～ 2 0 0 2年 12月共收治颈动脉狭窄 16 4例 ,其中颅外分叉部颈内动脉狭窄 14 6例 ,单纯颅外段颈内动脉狭窄 13例 ,单纯颈总动脉狭窄 5例 ,采用自膨胀支架进行血管成形治疗。　结果　 16 4例支架植入均获得成功 ,血管狭窄程度从治疗前 (78 8± 13 6 ) %降低到 (10 2± 7 5 ) % ,围手术期无死亡及大卒中发生 ,1例出现短暂性脑缺血发作 (Transientischemicattack ,TIA) (0 6 % ) ,1例出现小卒中 (0 6 % )。14 5例获得随访 ,时间 3月～ 30月 (平均 8 9月 ) ,随访期间无TIA及卒中发生 ,无死亡。术后 6月数字减影脑血管造影随访 4 5例 ,再狭窄 1例 (2 2 % ) ,但无临床症状。　结论　血管内支架成形术是治疗颈动脉狭窄安全而有效的方法 ,短中期结果令人满意。     

Apollo支架置入术治疗颈内动脉颅内段血管狭窄的疗效分析

目的探讨Apollo支架置入治疗颈内动脉颅内段血管狭窄的疗效。方法回顾性分析我院2013年9月至2015年9月经全脑血管造影检查证实狭窄程度70%的颅内段颈内动脉狭窄接受Apollo支架置入手术治疗的患者22例。临床随访采用NIHSS及mRS评分,并观察患者手术之后血管事件发生情况、症状性支架内再狭窄发生情况、狭窄血管与非狭窄血管供血区术前、术后相对达峰时间。结果 21例患者成功进行了支架置入术,手术成功率为95.45%(21/22)。术后30 d,发生同侧小卒中1例;术后1~6个月发生同侧小卒中1例;术后7~12个月发生同侧小卒中1例,术后1~2年发生对侧卒中1例,无致命性脑卒中事件或死亡事件。术后2年随访总血管事件发生率为22.73%(5/22)。发生症状性支架内再狭窄2例,再狭窄率为9.52%(2/21);手术成功患者狭窄血管供血区术前达峰时间(1.23±0.09)s、术后相对达峰时间(1.01±0.06)s,有统计学意义。手术前、手术1周、手术后30 d NIHSS评分分别为1.4±2.6、0.9±1.3、0.6±0.4,手术前、手术1周、手术后30 d mRS评分分别为1.3±1.1、0.7±1.0、0.4±1.1,与手术前比较,P0.05,有统计学意义。结论 Apollo支架置入治疗颅内动脉狭窄,围术期并发症发生率低,中远期随访症状性再狭窄发生率低,但其远期疗效尚需进一步探讨。     

Wingspan支架与冠脉支架在血管内支架成形术中的应用

目的 评价血管内支架成形术治疗颅内动脉狭窄的有效性和安全性. 方法 22例颅内动脉狭窄患者根据数字减影全脑血管造影(DSA)检查分为Wingspan组和冠脉球扩支架组,并给予血管内支架成形术治疗;比较两组手术成功率、术后动脉狭窄改善率及并发症发生率;随访半年,复查DSA. 结果 Wingspan组与冠脉支架组手术成功率分别为100％和90％,术后动脉狭窄改善率均＞70％,并发症发生率分别为16％和10％,两组间差异无统计学意义;Wingspan组与冠脉支架组手术时间分别为80分钟和102分钟,两者之间存在显著性差异.结论 血管内支架成形术可明显改善颅内动脉狭窄,降低脑血管事件的发生,安全有效.     

支架成形术治疗症状性脑供血动脉狭窄及其并发症分析

目的探讨应用颈动脉支架成形术治疗症状性脑供血动脉狭窄的安全性、临床疗效及其并发症的防治。方法对经彩色多普勒超声检查筛选,并经脑血管造影确诊的104例症状性脑供血动脉狭窄患者实施支架成形术治疗。分析围手术期及术后随访期相关并发症的发生情况。结果 1例术中出现严重血管痉挛,致手术失败,全组技术成功率99.04%(103/104)。术前平均狭窄率为82.23%,术后残余狭窄率均20.00%。术后1周内患者症状及神经功能缺损体征均有不同程度改善。24例术后3天发生心率减慢,其中20例出现血压下降;1例介入术后第9天脑出血死亡,1例术后10天靶病变部位急性血栓形成。随访2个月～3年,死亡2例,其中82例复查经颅多普勒(TCD)示血流速度正常,12例复查DSA未发现再狭窄、支架移位及缺血性脑卒中。结论颈动脉支架成形术是治疗症状性脑供血动脉狭窄较为安全、有效的方法,严格掌握适应证和熟练操作并规律服药可降低术中及术后风险。     

血管内支架成形术治疗肾动脉狭窄的临床研究

目的探讨血管内支架成形术治疗肾动脉狭窄的安全性及临床疗效。方法回顾性分析2008年8月~2015年9月我院行血管内支架置入术的85例肾动脉狭窄患者临床资料,观察其手术成功率、围手术期并发症发生率及临床疗效。结果 85例患者共成功植入85枚球扩式肾动脉支架,手术成功率100%。围手术期未发生动脉夹层、支架内血栓形成、急性肾功能衰竭等并发症。术后血压较术前呈逐渐下降趋势,服用降压药数减少,肾功能-血肌酐稳定。85例患者随访6个月~7年,平均(21.3±18.4)个月。随访期间发现肾动脉再狭窄8例(9.4%),均为无症状性狭窄。无责任血管相关的肾功能恶化。结论血管内支架成形术治疗肾动脉狭窄能解除血管狭窄,可有效改善血压,防止肾功能恶化,是一种安全有效的治疗方法。     

Three cases of successful stenting for radiation-induced carotid arterial stenosis

We report three cases of radiation-induced carotid arterial stenosis that underwent successful angioplasty with stenting. The patients had received radiation therapy for tongue or laryngeal cancers and developed minor completed strokes 6 to 14 years after irradiation. All patients had multiple and bilateral stenosis, measuring more than 50%, of the carotid arteries. The stenosis was located in the internal, external, and common carotid arteries. We performed percutaneous transluminal angioplasty with stenting. All interventions were successful and carotid stenosis decreased to less than 28%. No permanent complications occurred. During follow-up periods of up to 26 months, all of these cases were free from ischemic symptoms. Neither carotid angiography nor ultrasound sonography showed evidence of restenosis. The present results suggest the usefulness of angioplasty with stenting for radiation-induced carotid arterial stenosis.     

Bilateral carotid stenting for bilateral carotid artery stenosis improved vascular dementia

We report a case of bilateral internal carotid artery (ICA) stenosis treated with stenting. A 78-year-old man suffered from vascular dementia and left hemiparesis, and, by magnetic resonance angiogram (MRA), was diagnosed as having bilateral ICA stenosis. Cerebral angiogram showed severe, bilateral ICA stenosis (right; 88%, left; 93%) and xenon single photon emission tomography (SPECT) showed severely decreased cerebral blood flow (CBF) and cerebrovascular reactivity (CVR). We performed bilateral carotid angioplasty with self-expanding stents. Both CBF and CVR were improved bilaterally after the operation. The patient was discharged without neurological deficits. Carotid stenting may be an alternative treatment for severe ischemia caused by severe, bilateral ICA stenosis.     

Stent-supported coil embolization for carotid artery pseudoaneurysm as a complication of endovascular surgery--case report

A 57-year-old male presented with right amaurosis fugax and left transient ischemic attack caused by stenosis of the intracranial segment of the right internal carotid artery (ICA). Percutaneous transluminal angioplasty with stenting was successfully performed to dilate the stenosis. However, serial angiography revealed the development of a large pseudoaneurysm in the cervical ICA, probably as a result of carotid wall injury caused by the guiding catheter during the procedures. The patient underwent a second endovascular angioplasty. A Palmaz stent was placed across the aneurysm neck to stabilize the carotid wall. Guglielmi detachable coils were then inserted into the aneurysm cavity through the stent struts to successfully obliterate the aneurysm. Both the angiographical results and the patient's outcome were favorable. Stent-supported coil embolization is an effective and safe technique for medically refractory pseudoaneurysms, and may be a useful alternative to direct surgery.     

Carotid duplex velocity criteria revisited for the diagnosis of carotid in-stent restenosis

Carotid percutaneous transluminal angioplasty/stenting has become an accepted treatment modality for carotid artery stenosis in high-risk patients. There has been an ongoing debate regarding which duplex ultrasound (DUS) criteria to use to determine the rate of in-stent restenosis. This prospective study revisits DUS criteria for determining the rate of in-stent restenosis. In analyzing a subset of 12 patients (pilot study) who had both completion carotid angiography and DUS within 30 days, 10 patients with normal post-stenting carotid angiography (< 30% residual stenosis) had peak systolic velocities (PSVs) of the stented internal carotid artery (ICA) of < or = 155 cm/s and two patients with > or = 30% residual stenosis had internal carotid artery (ICA) PSVs of > 155 cm/s. Eighty-three patients who underwent carotid stenting as part of clinical trials were analyzed. All patients underwent post-stenting carotid DUS that was done at 1 month and every 6 months thereafter. PSVs and end-diastolic velocities of the ICA and common carotid artery were recorded. Patients with PSVs of the ICA of > 140 cm/s underwent carotid computed tomographic (CT) angiography. The perioperative stroke rate was 1.2%. When the old DUS velocity criteria for nonstented carotid arteries were applied, 54% of patients had > or = 30% restenosis (PSV of > 120 cm/s), but when our new proposed DUS velocity criteria for stented arteries were applied (PSV of > 155 cm/s), 33% had > or = 30% restenosis at a mean follow-up of 18 months (p = .007). The mean PSVs for patients with normal stented carotid arteries based on CT angiography, were 122 cm/s versus 243 cm/s for > or = 30% restenosis and 113 cm/s versus 230 cm/s for > or = 30% restenosis based on our new criteria. The mean PSVs of in-stent restenosis of 30 to < 50%, 50 to < 70%, and 70 to 99%, based on CT angiography, were 205 cm/s, 264 cm/s, and 435 cm/s, respectively. Receiver operating curve analysis demonstrated that an ICA PSV of > 155 cm/s was optimal for detecting > or = 30% in-stent restenosis, with a sensitivity of 100%, a specificity of 90%, a positive predictive value of 74%, and a negative predictive value of 100%. The currently used carotid DUS velocity criteria overestimated the incidence of in-stent restenosis. We propose new velocity criteria for the ICA PSV of > 155 cm/s to define > or = 30% in-stent restenosis.     

Two successful cases of coronary artery bypass grafting followed by transluminal carotid angioplasty with stenting]

In coronary artery bypass grafting (CABG), carotid artery disease is an important factor that affects the incidence of perioperative stroke. The incidence of stroke following cardiac surgery is about 5 times higher in patients with carotid lesions than in patients without them. However, therapeutic strategies for those cases have not established in recent years. We report 2 successful cases of CABG following transluminal carotid angioplasty with stenting (TCAS) for concomitant coronary and carotid artery disease. The first case was a 71-year-old male who had left main trunk (LMT) and three-vessel coronary artery disease (CAD) and a 90% stenosis of the right internal carotid artery (ICA). One month after TCAS, triple CABG with cardiopulmonary bypass (CPB) was performed. The second case was a 75-year-old male who had LMT and single vessel CAD and a 99.9% stenosis of the lt. ICA. Considering his poor general conditions, combined strategy of off-pump CABG and PTCA was performed following TCAS. During and after cardiac surgery, they had no cerebral complications. Postoperative myocardial scintigraphy showed improved imaging in both cases. Preoperative TCAS is a safe and minimally invasive procedure for the patients with carotid artery stenosis who need CABG.     

Carotid artery stenting in a patient with right-sided aortic arch with an aberrant left subclavian artery

A right-sided aortic arch with an aberrant left subclavian artery is a rare anatomical variation. We report a case treated with carotid artery stenting (CAS) for a patient with a right-sided aortic arch with an aberrant left subclavian artery. A 72-year-old man presented right hemiparesis due to acute brain infarction. Neck CT angiography showed 70% stenosis in the left internal carotid artery (ICA). We diagnosed acute brain infarction as artery-to-artery embolism due to ICA stenosis and decided to perform carotid artery stenting (CAS) for symptomatic ICA stenosis. CT angiography to evaluate an access route to the lesion incidentally showed the right-sided aortic arch with an aberrant left subclavian artery. An intraoperative aortogram showed a right-sided aortic arch. The guiding catheter was carefully introduced up to the left common carotid artery. CAS was performed with a proximal balloon and distal filter protection. The stenotic area was restored, and the patient was discharged without suffering recurrent attacks. Although a right-sided aortic arch with an aberrant left subclavian artery is a very rare anatomical variation, it can be encountered in neuroendovascular treatment, and therefore knowledge of this anatomical variation is important.     

Improved cerebral perfusion after simultaneous stenting for tandem stenoses of the internal carotid artery--two case reports

Two patients with extracranial internal carotid artery (ICA) stenosis and tandem stenosis of the ipsilateral intracranial ICA were treated simultaneously by angioplasty with stenting. A 68-year-old man who presented with neovascular glaucoma had 90% stenosis of the right cervical ICA and 80% stenosis of the ipsilateral petrous ICA. A 74-year-old man who suffered from transient ischemic attack had 75% stenosis of the left cervical ICA and 90% stenosis of the ipsilateral cavernous ICA. Hemodynamic compromise was confirmed in both patients. Tandem stenting of both extracranial and intracranial ICA stenoses was performed simultaneously in both patients without complications. Poststenting angiography demonstrated excellent dilation of both lesions and normalization of cerebral perfusion. Simultaneous tandem stenting for extracranial ICA stenosis with intracranial tandem stenosis is less invasive than open surgery in high-risk patients with hemodynamic compromise, especially if the major lesion responsible for cerebral hypoperfusion is difficult to determine.     

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。     

Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels

BACKGROUND: Carotid endarterectomy (CEA) is the standard of care for patients with high-grade carotid artery stenosis who are acceptable surgical candidates. Focal occlusive lesions of the origin of aortic arch vessels can be effectively and safely treated with balloon angioplasty and primary stenting. The purpose of this study was to retrospectively review results of carotid endarterectomy for high-grade carotid bifurcation stenosis combined with intraoperative retrograde transluminal angioplasty and primary stenting of a hemodynamically significant stenosis at the origin of a proximal ipsilateral aortic arch vessel. METHODS: Between October 1994 and August 1998, 592 patients underwent CEA. Six patients were found to have hemodynamically significant tandem lesions affecting one of the aortic arch vessels and the ipsilateral ICA for an overall incidence of 1%. Age ranged from 63 to 78 years (mean 74.7). Four of 6 (67%) patients had asymptomatic lesions, and 2 of 6 (33%) had symptoms of cerebral ischemia. Five patients had tandem lesions affecting the proximal left common carotid artery and the left ICA. One patient had a tandem lesion affecting the innominate artery and the right ICA. Carotid duplex imaging and arch and cerebral arteriography was performed in all six patients. Arteriography confirmed high-grade stenoses in both the ICA and ipsilateral proximal aortic arch vessel. The range of stenoses in the ICA was 70 to 95% (mean 80.8%) measured arteriographically. The range of stenoses at the origin of the aortic arch vessels was 75-90% (mean 79.2%). All six patients underwent combined retrograde transluminal balloon angioplasty and primary stenting of the ipsilateral CCA or innominate artery with temporary occlusion of the ICA for cerebral protection. The endovascular procedure was then followed with standard surgical endarterectomy using an inline shunt. RESULTS: All six procedures were successfully completed. There were no periprocedural strokes or other morbidities. Follow-up ranged from 6 to 43 months (mean 23.6) and showed no evidence of recurrent stenosis by carotid duplex imaging. No TIAs or strokes related to the surgically corrected lesions were noted during the follow-up period. One patient suffered a right hemispheric stroke secondary to a high-grade right carotid stenosis which occurred two months after her procedure surgically correcting tandem lesions on the opposite side. CONCLUSIONS: Carotid endarterectomy with balloon angioplasty and primary stenting of an ipsilateral hemodynamically significant aortic arch trunk vessel stenosis can be safely and successfully accomplished and avoids the need for an intra/extrathoracic bypass procedure.     

Duplex Ultrasound Verified by Angiography in Patients with Severe Primary and Restenosis of Internal Carotid Artery

There are very limited data in the literature about the reliability of duplex ultrasound (DU) verified by angiography in patients with restenosis of the internal carotid artery (ICA) after carotid surgery compared with primary carotid artery stenosis patients. Our objective was to compare the reliability of DU verified by conventional angiography in the diagnosis of severe primary stenosis versus restenosis of ICA. One hundred thirty-four patients (238 arteries) were examined by both DU and angiography. Severe stenosis (>70%) was found in 47 primary stenotic arteries and in 70 restenotic arteries. Accuracy, specificity, sensitivity, positive predictive value (PPV), and negative predictive value were obtained for basic DU criteria after verification of ultrasound data by angiography. The best accuracy for detection of >70% stenosis by end diastolic velocity was found for the velocity of 70 cm/sec or more in both groups, but accuracy for the restenosis group was significantly higher (96.9% vs. 89.8%, p = 0.025). Additionally, specificity (p = 0.01) and PPV (p = 0.01) were significantly higher in the restenosis group. The best accuracy for detection of >70% stenosis by peak systolic velocity was found for the velocity of 220 cm/sec or more for restenoses and 200 cm/sec or more for primary stenoses. The accuracy of the ultrasound was significantly higher in the restenosis group (94.6% vs. 87%, p = 0.04), as were specificity (p = 0.01) and PPV (p = 0.02). The diagnosis of severe restenosis by DU is reliable and can be used for decision making regarding surgery or stenting without angiography. In patients with Doppler parameters pointing to borderline moderate/severe primary carotid stenosis and technically complicated cases, angiography in addition to sonography before surgery is recommended.