3D DSA对颈动脉狭窄支架成形术的价值

目的　评价三维数字减影血管造影 (3DDSA)在颈动脉狭窄血管内治疗中的价值。方法　2 0 0 1年 7月至 2 0 0 4年 3月对 2 16例缺血性脑血管病行颈动脉 3DDSA重建 ,其中男 14 1例 ,女 75例。年龄为 4 2～ 89岁 ,平均为 6 5岁。对 2 16例缺血性脑血管病颈动脉的 3DDSA与 2DDSA图像进行比较 ,分析颈动脉的形状、狭窄的显示、血管内治疗的必要性、血管内治疗的工作角度及支架的选择。结果　与2DDSA相比 ,3DDSA能更清晰显示颈动脉狭窄的形状及程度 ,能提供最佳血管内治疗的工作角度 ,使用 3DDSA能正确决策支架的选择。结论　 3D重建DSA对颈动脉狭窄的评估有重要的作用 ,对常规DSA是一种有益的补充。它能非常清晰的显示颈动脉狭窄的形态、程度 ,准确判断血管内治疗的必要性 ,精确测量颈动脉的大小 ,这些对血管内治疗是非常重要的。     

三维数字减影血管造影影像在颈动脉狭窄血管内治疗中的价值

目的 评价三维数字减影血管造影(3D DSA)在颈动脉狭窄血管内治疗中的价值。方法 对138例缺血性脑血管病颈动脉的3D DSA与二维(2D)DSA图像进行比较，分析颈动脉的形状、狭窄的显示、血管内治疗的必要性、血管内治疗的工作角度及支架的选择。结果 与2D DSA相比，3D DSA能更清晰显示颈动脉狭窄的形状及程度，能提供最佳血管内治疗的工作角度，使用3D DSA能正确决策支架的选择。结论 3D DSA在颈动脉狭窄血管内治疗中具有重要的价值，能提供许多2D DSA不能提供的有价值信息，对常规DSA是一种有益的补充。     

大动脉炎血管内支架治疗

目的探讨应用血管内支架治疗大动脉炎所致血管狭窄或闭塞性病变的临床疗效。方法26例大动脉炎所致锁骨下动脉、颈动脉及肾动脉狭窄患者行血管内支架治疗。结果26例患者中25例成功地施行了1次血管内支架成形术,其中颈总动脉5例,锁骨下动脉3例,腹主动脉1例,肾动脉16例,共置入支架25次,病变血管均获得满意的开放或扩张。结论介入性血管内成形术可有效的治疗大动脉炎所致血管狭窄或闭塞性病变。     

Endovascular treatment of carotid stenosis]

PURPOSE: To evaluate the efficacy and risks of endovascular treatment of carotid stenosis by percutaneous angioplasty and stenting, and to point out the potential indications of this technique compared to surgery. MATERIAL AND METHODS: From June 1996 to May 2000 we performed 84 endovascular treatments of epiaortic vessels in 79 patients with age ranging from 42 to 80. Sixty-eight symptomatic carotid stenosis greater than 70% were treated in 63 patients: 28 (41%) were post-surgical restenosis of the carotid bifurcation after carotid endarterectomy and 40 (59%) were primitive carotid stenosis. In 14 cases (20%) there was occlusion of the contralateral internal carotid artery. All the procedures were performed in the angiographic suite, with local groin anesthesia and with femoral arterial approach. Angioplasty alone was done in 9 cases (13%) while stents were positioned in 59 cases (87%). The stenoses were pre-dilated in 57% of the procedures, and post-dilated in 61%. In 8 patients (12%) the endovascular treatment was performed during distal cerebral protection. During the follow-up period patients underwent echo-Doppler studies after 24 hours, at 6 and 12 months. RESULTS AND DISCUSSION: The stenotic tracts were successfully dilated in all the patients, with a residual stenosis less than 30% in 94% of cases. We didn't observe any complication in the 30 days post-operative period. One permanent neurological deficit (1.5 %) and 1 transient neurological deficit (1.5%) were observed in 2 patients within 1 hour after treatment. Other 2 patients complained a transient ortostatic hypotension. Combined major stroke and death rates was of 1,5% after 30 days post-operative follow-up. The presence of associated occlusion of the contralateral internal carotid and the presence of cardiological failure or pulmonary insufficiency has not influenced the outcome. No new clinical complication has been reported during the follow-up while the restenosis rate after the endovascular procedure is 1.5%. Our results with the endovascular treatment of the carotid stenosis appear not significantly different from those reported by the main surgical publications and trails about the carotid endarterectomy. In particular in our experience the complication rate is similar to surgery, probably due to our patient selection and to the evolution of the materials for endovascular therapy. CONCLUSIONS: Our experience points out an improvement of the efficacy and safety of the endovascular technique. We confirm the indication of the angioplasty and stenting in post-surgical restenosis and in patients with high surgical risk. Moreover we think that the endovascular treatment can be performed also in primitive carotid stenosis with acceptable complication risk.     

血管内支架治疗鼻咽癌放疗后颈部血管狭窄2例并文献复习

目的探讨血管内支架置入术对于鼻咽癌放疗后的颈动脉狭窄的疗效。资料与方法对2例鼻咽癌患者放疗后出现严重狭窄的血管行球囊成形术及支架置入术并进行随访。结果2例患者中1例为男性,1例为女性,其中1例有双侧颈内动脉起始段严重狭窄,分期对2侧病变血管进行了血管内支架治疗;1例左颈内动脉起始段严重狭窄,右椎动脉起始段严重狭窄,同时对2处严重狭窄进行了血管内支架治疗;经过随访并未发现有支架内再狭窄。结论血管内支架置入术对于鼻咽癌放疗后颈部血管重度狭窄是一种有效的治疗手段。     

Behandlung der arteriosklerotischen Erkrankung der A. carotis

In order to find the most suitable therapy concept for patients with severe stenosis of the carotid bifurcation (>70%), knowledge on the currently available treatment methods is necessary. In addition to carotid endarterectomy, medication therapy and stent angioplasty are also available. The outcome after stent angioplasty must be considered under the aspects of rapid technical development and increasing experience. Results of studies are still only of limited value with respect to the development of protection systems, flexible guiding catheters, low profile and more visible stents and balloons as well as using thrombocyte aggregation.     

Carotid artery stenting: Rationale, technique, and current concepts

Carotid stenosis is a major risk factor for stroke. With the aging of the general population and the availability of non-invasive vascular imaging studies, the diagnosis of a carotid plaque is commonly made in medical practice. Asymptomatic and symptomatic carotid stenoses need to be considered separately because their natural history is different. Two large randomized controlled trials (RCTs) showed the effectiveness of carotid endarterectomy (CEA) in preventing ipsilateral ischemic events in patients with symptomatic severe stenosis. The benefit of surgery is much less for moderate stenosis and harmful in patients with stenosis less than 50%. Surgery has a marginal benefit in patients with asymptomatic stenosis. Improvements in medical treatment must be taken into consideration when interpreting the results of these previous trials which compared surgery against medical treatment available at the time the trials were conducted. Carotid artery stenting (CAS) might avoid the risks associated with surgery, including cranial nerve palsy, myocardial infarction, or pulmonary embolism. Therefore and additionally to well-established indications of CAS, this endovascular approach might be a valid alternative particularly in patients at high surgical risk. However, trials of endovascular treatment of carotid stenosis have failed to provide enough evidence to justify routine CAS as an alternative to CEA in patients suitable for surgery. More data from ongoing randomized trials of CEA versus CAS will be soon available. These results will help determining the role of CAS in the management of patients with carotid artery stenosis.     

Stentgeschützte Angioplastie der arteriosklerotischen Stenose der A. carotis interna

For symptomatic stenosis of the carotid artery the invasive options for treatment (by means of stent or operation) are superior to conservative medical treatment. Recent multi-center randomized controlled trials, which will be presented here, indicate that stenting in the treatment of symptomatic carotid stenosis is neither safer nor more effective than carotid endarterectomy. When carried out by an experienced interventionalist stent-assisted angioplasty (CAS) is an alternative to carotid endarterectomy. Subgroup-analysis indicates that for patients older than 70 years of age invasive techniques should be the method of choice. In the case of contralateral high-grade stenosis or occlusion, CAS is the method of choice. For patients treated by stenting, the periprocedural complication rate is not influenced by the use of protection systems. The present results on symptomatic carotid stenosis should not be transferred to the therapy of asymptomatic carotid stenosis. A 3-armed study (SPACE2) on the comparison of the best medical treatment with the invasive treatment modalities (CAS or CEA) is in preparation and will be started in 2 months.     

Successful staged endovascular treatment of a symptomatic cervical carotid bifurcation stenosis coupled with a coincidental unruptured cerebral aneurysm in the carotid distal segment

SUMMARY: A 69-year-old woman had a symptomatic cervical carotid stenosis coupled with a coincidental unruptured cerebral aneurysm in the carotid distal segment. She underwent endovascular coiling for the aneurysm and then carotid stent placement (CAS) 1 month later. Both lesions were treated successfully and neither complications nor strokes occurred after the procedures. Staged endovascular treatment of coiling and subsequent CAS may be safe for patients with a cervical carotid stenosis coupled with cerebral aneurysms.     

颈动脉复杂性狭窄的血管内支架治疗

目的　报道５ 例颈动脉复杂性狭窄的血管内支架治疗结果,旨在评价血管内支架治疗颈动脉复杂性狭窄的可行性及临床疗效。方法　５ 例具有症状性颈动脉狭窄患者行血管内支架置入术治疗。颈动脉狭窄的病因包括动脉粥样硬化（ｎ ＝ ３） 和放射治疗后纤维化狭窄（ｎ ＝ ２） 。Ｄｏｐｐｌｅｒ 超声波检查提示颈动脉狭窄,并经血管造影证实。本组病例使用自展式Ｗａｌｌｓｔｅｎｔ 型支架。术后随访４ ～２２ 个月。结果　颈动脉造影显示全部患者颈动脉狭窄程度均大于７５ ％ ;狭窄位于颈总动脉（ＣＣＡ）３ 例,颈内动脉（ＩＣＡ）２ 例;病变长度２０ ～６０ｍｍ 。全部患者颈动脉内支架置入成功。１ 例术中出现短暂性脑缺血（ＴＩＡ） ,无其它并发症发生。随访期间无神经病学后遗症和支架内血栓形成。Ｄｏｐｐｌｅｒ 超声波检查未发现血管内支架早期及迟发性再狭窄。结论　应用血管内支架治疗颈动脉复杂性狭窄具有技术可行性和安全性,具有满意的中期开通率。     

Endovascular stenting for carotid artery stenosis: preliminary experience using the shape-memory- alloy-recoverable-technology (SMART) stent

We describe our initial clinical experience using the newly available self-expanding, Nitinol, shape-memory-, alloy-recoverable-technology (SMART) stent in treating carotid artery occlusive disease. Five stents were used in four carotid arteries in four consecutive patients with carotid stenosis of at least 70%. Technical success (<20% residual stenosis) was achieved in all cases. No procedural complications specifically related to use of the SMART stent were encountered. All patients remained symptom-free, with no evidence of transient ischemic attacks or new strokes during an average follow-up period of 6 months. Excellent performance of the SMART stent for the endovascular treatment of carotid artery stenosis has been shown based on our early experience. Validation with greater numbers and longer-term follow-up is required. The specific technical characteristics, potential advantages, and disadvantages of this stent are discussed and compared with other currently used carotid artery stents.     

Endovascular Treatment of a Carotid Dissecting Pseudoaneurysm in a Patient with Ehlers-Danlos Syndrome Type IV with Fatal Outcome

We present a patient with Ehlers-Danlos syndrome type IV (EDS IV) with a carotid dissecting pseudoaneurysm causing severe carotid stenosis. This lesion was treated endovascularly. Unfortunately, the patient died of remote vascular catastrophes (intracranial hemorrhage and abdominal aortic rupture). This unique case illustrates the perils of endovascular treatment of EDS IV patients and the need for preoperative screening for concomitant lesions. It also shows that a dissecting pseudoaneurysm can feasibly be treated with a covered stent and that closure is effective using Angioseal in patients with EDS IV.     

Transcervical approach for carotid artery stenting without flow reversal: A case report

Current treatment options for high-risk patients with severe carotid artery stenosis include transcarotid artery revascularization, transfemoral carotid artery stenting, and carotid endarterectomy. Transfemoral carotid artery stenting is associated with high perioperative stroke risk, and recent studies and trials have identified transcarotid artery revascularization as a new technique able to minimize the stroke risk associated with high-risk procedures. Moreover, the transcervical approach allows easy access to the carotid artery in cases with an anatomically tortuous aortic arch. Therefore, determining the optimal approach to achieve arterial access during carotid stenting is important for successful procedures and positive outcomes. We report a clinical case of ischemic stroke due to severe stenosis of the left internal carotid artery indicated for stent deployment. After transfemoral carotid artery stenting failure, the patient''s symptoms progressed from minor stroke to hemiplegia and Broca''s aphasia. The transcervical approach was used to perform transcarotid artery revascularization after several days. The procedure was both safe and prevented recurrent stroke occurrence. Although transfemoral access is the classic approach used for carotid stenting, the transcervical approach can be used as an alternative and safe choice in cases with complex vascular anatomy, such as the one described here.     

Reperfusion hemorrhage following superior mesenteric artery stenting

Percutaneous transluminal angioplasty and stent placement is now an established treatment option for chronic mesenteric ischemia and is associated with low mortality and morbidity rates. We present a case of reperfusion hemorrhage complicating endovascular repair of superior mesenteric artery stenosis. Although a recognized complication following repair of carotid stenosis, hemorrhage has not previously been reported following mesenteric endovascular reperfusion. We describe both spontaneous cessation of bleeding and treatment with coil embolization.     

High-Resolution CT and Angiographic Evaluation of NexStent Wall Adaptation

Carotid stenting is a minimally invasive treatment for extracranial carotid artery stenosis. Stent design may affect technical success and complications in a certain subgroup of patients. We examined the wall adaptability of a new closed-cell carotid stent (NexStent), which has a unique rolled sheet design. Forty-one patients had 42 carotid arteries treated with angioplasty and stenting for internal carotid artery stenosis. The mean patient age was 65 ± 10 years. All patients underwent high-resolution computed tomographic angiography after the stent implantation. Data analysis included pre- and postprocedural stenosis, procedure complications, plaque calcification, and stent apposition. We reviewed the angiographic and computed tomographic images for plaque coverage and stent expansion. All procedures were technically successful. Mean stenosis was reduced from 84 ± 8% before the procedure to 15.7 ± 7% after stenting. Two patients experienced transient ischemic attack; one patient had bradycardia and hypotension. Stent induced kinking was observed in one case. Good plaque coverage and proper overlapping of the rolled sheet was achieved in all cases. There was weak correlation between the residual stenosis and the amount of calcification. The stent provides adequate expansion and adaptation to the tapering anatomy of the bifurcation.     

Efficacy of treatment of severe carotid bifurcation stenosis by using self-expanding stents without deliberate use of angioplasty balloons

BACKGROUND AND PURPOSE: One of the limitations of carotid artery angioplasty is the potential for embolic stroke. Our purpose was to assess whether the force of a self-expanding stent alone is usually sufficient to dilate severely stenotic atherosclerotic plaques without the deliberate use of an angioplasty balloon. If so, the procedural stroke risk might be reduced. METHODS: Over a 30-month period, 21 consecutive patients were prospectively identified with severe symptomatic carotid artery stenosis (>70% NASCET [North American Symptomatic Carotid Endarterectomy Trial]) and relative indications for endovascular treatment. All underwent treatment with the aim of deploying a self-expanding stent across the stenosis without the use of angioplasty balloons or distal protection devices. RESULTS: Stent deployment was successful in 20/21 patients. In one patient, the stent could not be deployed without balloon predilatation and a stroke occurred. In the other 20 patients, angiography before and immediately after stent deployment showed a reduction in the mean stenosis from 83% to 49%. A second periprocedural stroke occurred as a result of early stent thrombosis at 4 days in a patient who stopped Acetylsalicylic acid while undergoing bowel preparation for colon surgery. He made a good recovery. Average duration of follow-up imaging was 19 months (range, 1-44 months). During the follow-up period there were four deaths, all unrelated to the carotid disease, and no major strokes. At 5-11 months, the average residual stenosis was 21%, which remained stable in 16 of the 18 patients studied between 12 and 44 months (average, 24 months). At last follow-up, in these 16 the mean peak systolic velocity was 123 cm/s (range, 60-238 cm/s) and the mean internal-to-common carotid ratio was 1.8. The other two patients were long-term failures of the "stent-only" approach. In one patient, a heavily calcified plaque prevented stent expansion and the artery occluded at 18 months with a minor stroke. In the second patient, a recurrent stenosis developed at 16 months with one episode of transient ischemic attack. CONCLUSION: Deployment of a self-expanding stent alone resulted in a favorable and more gradual reduction of severe symptomatic carotid stenosis. Improvements in stent profile and chronic outward force may widen the indications for simple stent placement without the use of balloons or adjunctive protection devices.     

Establishing an endovascular carotid stent program

FDA approval of carotid stent and distal protection devices has transformed carotid artery stenting (CAS) from an investigational procedure to a practical application. Recent approval by the Center for Medicare Services (CMS) has ensured that CAS will be a part of everyday practice throughout the country. To establish a competitive endovascular carotid stent program, one needs to develop an effective strategy. The key to success is substance and service. A high-quality clinical program with excellent communication between the patient and referring physician is essential. You must first get access to the patient by establishing a clinical practice. As a radiologist, you have the advantage of gaining access by identifying appropriate patients through noninvasive vascular labs, CTA, and MRA. An algorithm-driven evaluation and treatment protocol with good pre- and postoperative care, along with a quality assurance program, will ensure that your carotid stent program has substance and delivers optimal service. With good planning, you will have a firm clinical foundation for treatment of carotid artery stenosis in your community. Putting all of the ingredients together will ensure a successful carotid endovascular program.     

颈动脉支架成形术治疗颈动脉粥样硬化性狭窄

目的：总结血管内支架治疗颈动脉粥样硬化性狭窄的临床体会，探讨该技术的适应证、并发症防治及初步疗效。材料和方法：55例颈动脉狭窄患者(2000年10月至2001年12月，40例有反复的短暂性脑缺血发作或脑梗死，1例小脑出血，14例无明显症状)在球囊扩张后安装自膨胀血管内支架，其中33例还应用不可脱卸球囊进行支架内再扩张。结果：53例支架定位准确，2例释放支架时支架向近端移位。31例患者狭窄完全消失，20例狭窄程度减少90％以上，4例减少70％，术中1例发生短暂脑缺血性发作，1例发生脑梗死。临床随访1－15个月(平均6．1个月)，仅1例术后2个月发作TIA　1次。颈动脉超声随访42例，DSA随访15例患者颈动脉均无再狭窄发生(6－12月)。结论：血管内支架成形术是治疗颈动脉狭窄的安全而有效方法，长期疗效有待于进一步观察。     

Ostial common carotid artery occlusion and balloon-mounted stenting: Implication of embolic protection device in tandem lesion

Ostial common carotid artery (CCA) stenosis is rare, compared to extracranial internal carotid artery bifurcation lesions. In cases of a tandem lesion, the proximal lesion usually involves the extracranial internal carotid artery, and the ostial CCA is rarely implicated. A 69-year-old woman who underwent 3 months of antiplatelet therapy for asymptomatic, right ostial, severely calcified CCA stenosis presented with sudden onset left hemiparesis. Radiographic examination revealed an ostial CCA-intracranial artery tandem lesion. After intracranial revascularization using a clot retrieval stent, we performed the endovascular treatment with a balloon-mounted stent using an embolic protection device. This procedure may be superior to others because it is possible to achieve early intracranial revascularization and prevent distal embolism during the complete treatment of proximal lesions.