脾动脉瘤血管腔内治疗的临床疗效分析

目的探讨血管腔内治疗脾动脉瘤的安全性和有效性。方法回顾性分析2010年1月至2014年12月本科收治的48例脾动脉瘤患者的资料,腔内治疗方法:弹簧圈动脉瘤(14例)或载瘤动脉栓塞术(19例),覆膜支架隔绝术(2例),支架辅助弹簧圈瘤体内填塞(5例)和多层裸支架隔绝术(8例)。术后1、3、6、12个月采用CT血管造影检查随访,记录并评价围手术期和随访期的临床结果指标。结果本组病例瘤体均治疗成功,支架植入患者的脾动脉均通畅。围手术期无手术相关死亡,8例患者弹簧圈栓塞后出现栓塞后综合征,均于3~5天后缓解。随访时间23.9(3~59)个月,采用弹簧圈栓塞瘤体或载瘤动脉33例:4例患者发现有部分脾脏梗死,但无明显临床症状,2例患者因瘤体内再灌注接受再次手术;采用覆膜支架植入或裸支架辅助弹簧圈栓塞7例:动脉瘤隔绝或栓塞良好,无内漏,支架通畅;采用多层裸支架隔绝术8例:术后12个月6例(75%)患者瘤腔达到完全血栓化,分支动脉通畅。其余病例未出现严重并发症。随访期患者均未观察到动脉瘤增大、破裂或复发。结论血管腔内治疗脾动脉瘤安全,疗效显著。     

肾动脉瘤的血管腔内治疗

目的评价血管腔内治疗对于肾动脉瘤（RAA）的安全性及疗效。方法回顾性分析11例接受血管腔内治疗的RAA患者,治疗方法包括单纯以弹簧圈填塞动脉瘤腔（6例）、载瘤动脉栓塞术（3例）和覆膜支架隔绝术（2例）,并随访3～68个月。结果11例患者共发现13个RAA（右肾9个,左肾4个）,均为真性囊状动脉瘤,对其中11例（11个RAA）行血管腔内治疗。术后5例出现栓塞后综合征,其中4例发生部分肾梗死,肾功能无异常;未见其他严重并发症。随访未见动脉瘤内残腔及内瘘,未见动脉瘤破裂及复发。结论血管腔内治疗RAA安全、有效,成功率高。     

介入治疗内脏动脉瘤的远期疗效

目的观察介入治疗内脏动脉瘤(VAA)的远期疗效。方法回顾性分析30例接受介入治疗VAA患者(41个瘤灶),术后随访时间均12个月,观察治疗效果及并发症。结果对12个肾动脉瘤、8个脾动脉瘤行动脉瘤填塞术,其中5个脾动脉瘤、5个肾动脉瘤采用裸支架辅助填塞;对13个脾动脉瘤、1个肝动脉瘤行动脉瘤栓塞术;对4个肾动脉瘤行载瘤动脉支架植入术,其中3个采用多层裸支架植入术、1个采用覆膜支架植入术;对2个肾动脉瘤、1个腹腔干动脉瘤行保守治疗;均获得成功。1个脾动脉瘤栓塞术后出现部分脾梗死,1个左肾多发动脉瘤植入支架后瘤腔小部分显影。术后随访12～55个月,平均(23.44±12.48)个月,期间脾梗死者梗死面积未增大、未见脓肿形成,瘤腔部分显影病变显影面积未增大。30例患者中,1例因心力衰竭死亡,余均存活,无VAA复发及其他并发症。结论介入治疗VAA远期疗效较好,且安全性较高。     

变异脾动脉瘤腔内治疗15例分析

目的 总结变异脾动脉瘤的腔内治疗经验。方法 回顾性分析2007年4月至2017年4月复旦大学附属中山医院血管外科收治的15例变异脾动脉瘤腔内治疗病人的临床资料,其中5例为A型变异脾动脉瘤,10例为B型变异脾动脉瘤。结果 15例病人中14例腔内治疗成功,操作结束后造影检查示瘤体不再显影;1例术中造影检查后考虑弹簧栓栓塞后移位至肠系膜上动脉风险大且病人动脉瘤直径较小,遂停止手术并随访观察。14例腔内治疗成功的病人中,1例行单纯瘤腔栓塞,5例行出瘤动脉及瘤腔栓塞,1例行入瘤动脉、瘤腔及出瘤动脉栓塞,1例行瘤腔栓塞及肠系膜上动脉覆膜支架置入,2例行出瘤动脉栓塞及肠系膜上动脉覆膜支架置入,4例行出瘤动脉、瘤腔栓塞及肠系膜上动脉覆膜支架置入。随访2～117个月,无失访或死亡病例,无肠道缺血坏死、症状性脾梗死、动脉瘤破裂等严重并发症发生。1例病人7年后再发腹痛,再次腔内治疗行瘤腔密集填塞,术后腹痛消失,密切随访。1例病人腔内治疗行出瘤动脉栓塞及肠系膜上动脉覆膜支架置入,术后第2年随访动脉造影检查示覆膜支架完全闭塞,Riolan弓显影,支架远端肠系膜上动脉灌注良好。结论 腔内治疗变异脾动脉瘤安全、有效。在腔内治疗过程中,除了对动脉瘤完成满意的血流隔绝,还应重视保护肠系膜上动脉。     

颅内动脉瘤弹簧圈栓塞治疗术中动脉瘤再破裂的防治

目的颅内动脉瘤在弹簧圈栓塞过程中发生破裂是最可怕的术中并发症之一，本文探讨处理、预防这一并发症的初步经验。方法2002年4月-2006年12月，共有153例患有颅内动脉瘤的患者在我院接受了可脱卸弹簧圈栓塞治疗，其中141例患者曾有过动脉瘤破裂引起蛛网膜下腔出血史。5例有动脉瘤破裂出血史的患者术中再次发生动脉瘤破裂。术中动脉瘤再破裂时，常规使用鱼精蛋白中和肝素，并设法用弹簧圈尽快填塞动脉瘤腔。微导丝引起动脉瘤破裂时，尽量保持微导丝不动，微导管尽快送到瘤腔中进行填塞治疗。若微导管引起破裂而微导管头端位于瘤壁外蛛网膜下腔时，微导管且勿退入瘤腔内，应将弹簧圈经微导管送入蛛网膜下腔一部分后，再将微导管头撤入瘤腔内，继续弹簧圈填塞。若弹簧圈引起破裂，要将弹簧圈完全或部分送出去，将破裂口堵住后，调整微导管头端位置继续弹簧圈填塞。结果在接受动脉瘤栓塞治疗的153例患者中，141例曾有过动脉瘤破裂引起蛛网膜下腔出血，治疗中5例发生了术中再破裂，占动脉瘤破裂引起蛛网膜下腔出血的3．5％，总发生率为3．3％。1例破裂由导丝引起，1例由微导管引起，1例由弹簧圈过度填塞引起，弹簧圈穿孔1例，其余1例由微导管和弹簧圈共同引起。2例死亡，死亡率占术中破裂的40％，占总例数的1．3％；1例患者出院时遗留有右下肢瘫痪，其余2例患者无残留神经系统并发症。结论动脉瘤栓塞术中动脉瘤的再破裂是一少见、威胁生命但又不可避免的事件。应该立即采取妥善措施以挽救患者生命、改善预后、降低可怕并发症的发生。如处理恰当，多数术中动脉瘤破裂的患者能够存活，无后遗症。     

NeuroformⅡ支架联合MatrixⅡ弹簧圈治疗颅内宽颈动脉瘤的初步经验

目的探讨NeuroformⅡ支架植入联合MatrixⅡ弹簧圈栓塞治疗颅内宽颈动脉瘤的疗效、技术要点、安全性及并发症防治。方法诊断为颅内宽颈动脉瘤的病人11例,其中大脑前动脉瘤2例,后交通动脉瘤4例,眼动脉瘤1例,大脑中动脉瘤2例,椎基底动脉瘤2例。7例先行NeuroformⅡ支架瘤颈成形,将微导管通过支架网眼置入动脉瘤内,填塞弹簧圈;4例先置入微导管于动脉瘤内,再释放支架后栓塞,术后3~6个月随访。结果所有病例栓塞操作均顺利完成,无手术并发症;其中致密填塞8例,部分致密填塞3例,术后病人均恢复良好,4例短期随访无再出血及血栓栓塞症状发生。结论NeuroformⅡ支架联合MatrixⅡ弹簧圈治疗颅内宽颈动脉瘤安全、有效。     

弹簧圈栓塞动脉瘤及载瘤动脉治疗出血性椎动脉夹层动脉瘤

目的探讨采用弹簧圈栓塞动脉瘤及载瘤动脉治疗出血性椎动脉夹层动脉瘤的疗效及并发症。方法收集经颅脑CT及全脑DSA确诊的椎动脉夹层动脉瘤破裂出血患者17例,采用弹簧圈栓塞动脉瘤及载瘤动脉,观察疗效及并发症。结果 17例动脉瘤及载瘤动脉均完全闭塞,无死亡病例。术后当天1例发生Wallenberg综合征,恢复良好;1例术后3个月出现脑积水,行侧脑室-腹腔分流术后遗留轻度残疾;随访2~36个月,无再出血病例。术后6个月12例接受DSA复查,动脉瘤完全不显影,载瘤动脉未发生再通。结论应用弹簧圈栓塞夹层动脉瘤及载瘤动脉治疗出血性椎动脉夹层动脉瘤疗效确切,具有一定应用价值。     

大脑中动脉分叉部动脉瘤的血管内治疗

目的总结大脑中动脉分叉部动脉瘤的诊断和血管内治疗方法。方法 2010年1月-2011年6月,收治32例大脑中动脉分叉部动脉瘤患者并行血管内治疗。男12例,女20例;年龄35～81岁,平均49.5岁。患者均有突发头痛病史,其中2例有意识障碍伴一侧肢体活动受限;22例有高血压病史。术前Hunt-Hess分级:Ⅰ级10例,Ⅱ级15例,Ⅲ级7例;Fisher分级:Ⅱ级24例,Ⅲ级8例。16例患者应用单微导管弹簧圈栓塞,7例应用双微导管弹簧圈栓塞,4例应用球囊辅助弹簧圈栓塞,4例应用单支架辅助弹簧圈栓塞,1例应用双支架辅助弹簧圈栓塞。结果术后即刻数字减影血管造影检查示,除2例单微导管弹簧圈栓塞者获近乎致密栓塞外,余均获致密栓塞。术中18例蛛网膜下腔广泛出血,行腰大池置管持续引流3～7 d;余14例有少量蛛网膜下腔出血,术后间断腰椎穿刺缓慢释放血性脑脊液。术后1周颅脑CT示蛛网膜下腔出血量明显减少。术后1 d,2例出现局部脑缺血,经尼莫同等药物抗血管痉挛治疗1周后缓解。32例均获随访,随访时间4～17个月。患者无动脉瘤破裂再出血,术后3例一侧肢体瘫痪,1例术后失语,余无并发症及后遗症发生。术后3、6个月及1年复查计算机断层摄影血管造影术示致密栓塞的动脉瘤未再通。结论选择合适的介入治疗方法,大脑中动脉分叉部动脉瘤的血管内治疗是安全、可靠的。     

颅内动脉瘤破裂出血后假性动脉瘤的血管内治疗时机与并发症防治

目的探讨颅内动脉瘤破裂出血后在其破口周围所形成的假性动脉瘤与真性动脉瘤（TAN-FAN）复合体的血管内栓塞时机及并发症防治方法。方法采用电解可脱性弹簧圈对58例TAN—FAN复合体进行血管内栓塞。结果58例TAN—FAN复合体中24例（41．4％）为出血后7天内进行栓塞，20例（34．5％）为出血后7天～2周内进行栓塞，14例（24．1％）为出血后2周～1个月内进行栓塞。58个动脉瘤均被成功栓塞，其中真性动脉瘤腔100％闭塞者46个，95％闭塞者9个，90％闭塞者3个；13例A型与31例B型假性动脉瘤腔均未行弹簧圈填塞，14例C型中11例仅用弹簧圈疏松填塞假性动脉瘤腔，另3例用3D-GDC仅栓塞真性动脉瘤腔部分。术中并发动脉瘤破裂1例；并发脑血管痉挛2例；并发脑梗死3例。1例复发者经二次补充GDC栓塞而治愈。其治疗结果根据Glasgow预后评分：Ⅰ级43例，Ⅱ级11例，Ⅲ级3例，全组死亡1例，死亡率1．7％。术后随访3～60个月均无再出血。结论对动脉瘤破裂后形成的TAN—FAN复合体应早期进行血管内栓塞；只有根据TAN—FAN复合体不同的类型采用不同的栓塞方法进行个体化治疗，并具有丰富的动脉瘤栓塞经验，才能最大限度的降低并发症。     

球囊辅助瘤颈重塑形栓塞治疗颅内宽颈动脉瘤

目的评价应用球囊辅助瘤颈重塑形栓塞治疗颅内宽颈动脉瘤的效果。方法 11例颅内宽颈动脉瘤(瘤颈≥4mm或瘤颈与瘤体比≥1/2)患者,采用球囊辅助瘤颈重塑形技术结合电解脱弹簧圈(GDC)进行栓塞治疗。术后随访0.5～1a。结果 11例宽颈动脉瘤均应用球囊辅助瘤颈重塑形技术或球囊保护对动脉瘤进行了成功栓塞。7例患者经临床随访行脑血管DSA或CTA复查,无动脉瘤复发。结论球囊辅助瘤颈重塑形栓塞颅内宽颈动脉瘤是一种安全、有效的方法。     

Nonoperative management of unruptured visceral artery aneurysms: treatment by transcatheter coil embolization

PURPOSE: To describe our experiences with the treatment of visceral artery aneurysms (VAA) by transcatheter coil embolization and to propose indications for treating VAA by this method. METHODS: We treated 22 patients with VAA by coil embolization; 9 had splenic-, 7 renal-, 4 pancreaticoduodenal arcade-, and 2 proper hepatic artery aneurysms. All nine splenic artery aneurysms patients presented with chronic hepatitis-C; four had hepatocellular carcinoma. Of the seven renal artery aneurysms patients, four were hypertensive and three had rheumatoid arthritis. Both pancreaticoduodenal arcade artery aneurysms patients manifested severe stenosis of the celiac axis. Our transcatheter coil embolization procedure includes coil embolization and coil-packing of the aneurysmal sac, preserving the native arterial circulation. RESULTS: Transcatheter coil embolization with aneurysm packing was technically successful in 16 (72.7%) of the 22 patients and the native arterial circulation was preserved. Postprocedure angiograms confirmed complete disappearance of the VAA. In four of the nine splenic artery aneurysm patients, the native arterial circulation was not preserved. In one renal artery aneurysm patient, stenosis at the aneurysmal neck necessitated placement of a stent before transcatheter coil embolization. Magnetic resonance angiographs obtained during the follow-up period (mean 27 months) demonstrated complete thrombosis of the VAA in all 22 patients. Infarction occurred in one splenic- and two renal artery aneurysms patients; the latter developed flank pain and fever after the procedure. CONCLUSIONS: Transcatheter coil embolization is an effective alternative treatment for patients with saccular and proximal VAA. In particular, the isolation technique using coil embolization is advantageous in splenic artery aneurysm patients.     

Mid-term outcome of intracranial aneurysms treated with HydroSoft coils compared to historical controls treated with bare platinum coils: a single-center experience

Background

HydroSoft (MicroVention, Aliso Viejo, CA), a hydrogel-platinum coil hybrid device, is one of various efforts to overcome recanalization of coiled intracranial aneurysms. The purpose of this study was to evaluate the efficacy and safety of the HydroSoft coils in patients with intracranial aneurysms, and to compare the 12-month outcomes with that of bare platinum coils.

Methods

Four-hundred one patients harboring 430 intracranial aneurysms underwent endovascular embolization with the HydroSoft coils. In the control group, 221 patients harboring 253 aneurysms underwent coil embolization with bare platinum coils. The authors compared the degree of occlusion of the aneurysms, packing attenuations, procedural-related complications, and 12-month follow-up results between the two groups.

Results

There were no significant differences of initial angiographic outcomes and procedure-related complications between the HydroSoft-coil group and the bare-coil group. Mean volumetric packing density of the HydroSoft-coil group was significantly higher than that of the bare platinum coil group (36.0?±?8.50 % versus 32.1?±?8.22 %, p?p?=?0.001, Fischer’s exact test). Multivariate Poisson regression revealed that coil embolization using the HydroSoft coil significantly reduces the retreatment rate of coiled aneurysms at 12-month follow-up (adjusted RR, 0.21; 95 % CI, 0.07-0.64; p?=?0.004).

Conclusion

Coil embolization using HydroSoft coils achieves higher volumetric packing density. Twelve-month follow-up data favors HydroSoft coils, with lower retreatment rates.     

Surgically treated aneurysms previously coiled: lessons learned

OBJECTIVE: Intravascular coil embolization of cerebral aneurysms has proved to be a safe and effective treatment in certain patient groups; however, this treatment is relatively new, and the long-term outcomes are unknown. One of the known complications is refilling of the aneurysm dome, which is seen in follow-up studies. This patient population poses unique technical difficulties for the neurosurgeon. We present a series of 18 patients who underwent surgery for residual aneurysms after coil remobilization. METHODS: During a 5-year period, we performed surgery in 18 patients who had previously undergone coil embolization for their aneurysms. Of these aneurysms, four were in the anterior communicating artery, five were in the posterior communicating artery, three were in the internal carotid artery, three were in the posteroinferior cerebellar artery, and three were in the middle cerebral artery. One patient presented with rupture, one presented with acute IIIrd cranial nerve palsy, and the rest of the aneurysms were found on routine follow-up angiograms. Fifteen aneurysms were clipped, and in three patients, they were wrapped because the clip could not be placed adequately. RESULTS: There were no major complications in any of the patients, and all had uneventful recoveries. The presence of coils in the aneurysm dome and/or neck made clipping and exposure of the aneurysm neck difficult, resulting in incomplete neck obliteration in three patients. CONCLUSION: Operative clipping after previous coil embolization in aneurysms poses a unique problem for neurosurgeons. With the increasing use of coil embolization, this patient population will undoubtedly increase. The neurosurgeon should be aware of the difficulties and pitfalls encountered in these patients.     

Multimodal endovascular treatment for traumatic carotid- cavernous fistula

bjective：To present our experience in treating traumatic carotid-cavernous fistula （TCCF） by multimodal endovascular treatment.Methods：The management of 28 patients with TCCF between January 2004 and October 2012 in our hospital was retrospectively analyzed.According to imaging charateristics,24 cases were categorized into Type Ⅰ,3 Type Ⅱ and 1 Type Ⅲ.Totally 30 endovascular treatments were performed：Type Ⅰ TCCFs were obliterated via transvenous approach （7/25）,or transarterial approach （18/25） including 6 by detachable balloon occlusion,6 by microcoil embolization,3 by Hyperglide balloon-assisted coil embolization and 3 by a combination of detachable balloon and coil embolization.Two patients were treated with closure of internal carotid artery （ICA）.Type Ⅱ TCCFs were treated with transvenous embolotherapy （2/3） or carotid artery compression therapy （1/3）.The Type Ⅲ patient underwent detachable balloon embolization.Results：Immediate postoperative angiography showed recovery in 26 cases.One recurrent TCCF was found 2 weeks after detachable balloon embolization,and then reobliterated by transarterial coils.Reexamination found balloon deflation and fistula recanalization in 1 patient one month after combination of detachable balloons and coil embolization,which was cured by a second treatment via transvenous approach.The immediate angiography revealed residual blood flow in 4 patients.Among them,2 patients with delayed symptoms at follow-up needed a second treatment,1 patient recovered after carotid artery compression therapy,and the remaining patient＇s symptoms disappeared on digital subtraction angiography at five-month follow-up.CT angiography revealed anterior communicating artery aneurysm in the patient who was treated with closure ofICA 4 years later.Conclusion：According to results of images,characteristics of the fistula and type of drainage,proper treatment approach and embolic material can maximally heal pathological changes,retain the ipsilateral ICA patency and reduce long-term complications.     

Packing Technique for Endovascular Coil Embolisation of Peripheral Arterial Pseudo-aneurysms with Preservation of the Parent Artery: Safety,Efficacy and Outcomes

ObjectivesTo evaluate the endovascular treatment of pseudo-aneurysms (PAs) with super-selective coil embolisation using the 3D packing technique.DesignRetrospective study of consecutive patients in one academic centre.MaterialsFrom 2002 to 2009, 16 patients (mean age 51.6 years, range 24–82) underwent PA sac packing with coils. Four patients were asymptomatic, nine had PA rupture, and three had other symptoms. Lesion location was as follows: splenic artery (8), carotid artery (2), hepatic artery (2), superior mesenteric artery (1), cystic artery (1), uterine artery (1), and hypogastric artery (1).MethodsThe sac was packed with 0.018-inch controlled-detachable microcoils, preserving the parent artery. Magnetic resonance angiography was done within 6 months, at 12 months then yearly.ResultsTechnical success rate was 100%. Complete definitive PA exclusion was achieved with a single procedure in 15 (93.8%) patients. One patient with a secondary bleeding arterio-digestive fistula underwent successful surgery. No major complications or late recanalisations occurred during follow-up (mean, 24.7 months; range 6–49).ConclusionsCoil PA embolisation by 3D sac packing is safe and effective and may induce less morbidity than complete parent vessel occlusion, stent placement, or open surgery. This procedure should be used whenever possible, as it preserves parent artery patency.     

Pipeline flow diversion with adjunctive coil embolization for internal carotid artery aneurysms following an intradural component: results in 46 consecutive aneurysms from a Japanese single-center experience

In the treatment of an intracranial aneurysm with the flow diverter, the combined use of coil embolization can help promote subsequent progressive thrombosis within the aneurysm sac and reduce the risk of delayed aneurysm rupture. This study retrospectively reviewed outcomes of patients who had undergone the Pipeline Embolization Device (PED) with adjunctive coil embolization (PED/coil) at a single center to determine its safety and efficiency. Patients with internal carotid artery aneurysms following an intradural component were selected for PED/coil between 2015 and 2020. All patients were premedicated with dual antiplatelet therapy of aspirin plus clopidogrel or prasugrel. A minimal number of PEDs were deployed, with coils inserted using a stent-jail technique, avoiding dense packing. A total of 46 aneurysms (43 patients; median dome size, 11.6 mm; median neck width, 6.3 mm) were treated with PED/coil. The median volume embolization ratio was 14.8%. The degree of angiographic filling at the 6-month and latest angiography showed complete occlusion in 60.5% (26/43) and 70.5% (31/44), respectively. Small (<?10 mm) aneurysms achieved a higher complete occlusion rate in the early period; a lower cumulative incidence of aneurysm occlusion was observed in large and giant (≥?10 mm) aneurysms (P?=?.024). The median clinical follow-up was 22 months, and no aneurysm ruptures occurred. Favorable clinical outcomes were achieved, with permanent neurological morbidity of 4.7% and no mortality. PED/coil demonstrated a high angiographic occlusion rate at an early stage. Loosely packed coils are sufficient to obliterate aneurysms effectively.

     

介入栓塞术在头颈部肿瘤放疗后出血中的应用

目的评价介入栓塞术用于治疗头颈部肿瘤放疗后出血的可行性及安全性。方法收集20例因头颈部肿瘤放疗后大出血患者,对所有患者介入栓塞治疗,观察介入栓塞术的疗效及并发症。结果 20例患者共接受介入栓塞治疗21次;4例患者出血责任血管为颈内动脉,采用弹簧圈栓塞颈内动脉载瘤段,15例患者责任血管为上颌动脉分支,采用明胶海绵或聚乙烯醇(PVA)颗粒栓塞;1例患者为右侧甲状腺下动脉分支假性动脉瘤,采用PVA颗粒及弹簧圈栓塞。对所有患者治疗均有效,随访期内均未出现严重并发症。结论介入栓塞术治疗头颈部肿瘤放疗后出血有效、安全。     

Balloon-assisted coil placement in wide-necked cerebral aneurysms: preliminary clinical experience

Endovascular treatment of wide-necked cerebral aneurysms with Guglielmi detachable coils (GDCs) has been limited due to coil protrusion into the artery. Seven patients with wide-necked cerebral aneurysms were treated with GDCs with temporary balloon inflation for mechanical protection during coil placement. Transarterial embolization of the aneurysm with GDCs had failed due to coil protrusion into the parent artery. The use of simultaneous temporary balloon protection achieved more dense intra-aneurysmal coil packing, especially in the neck, without compromising the parent artery.