经皮血管内治疗症状性基底动脉粥样硬化性狭窄的探讨

目的 探讨经皮腔内血管成形支架置入术治疗症状性基底动脉粥样硬化性狭窄的可行性、安全性及有效性.方法 回顾性分析2003年8月至2009年12月,经皮腔内血管成形支架置入术治疗的40例基底动脉粥样硬化性狭窄患者的临床资料及术后随访结果 .其中男性33例,女性7例;年龄30～75岁,平均58岁.患者均为经药物治疗无效、反复短暂性脑缺血发作或有明显脑缺血症状.结果 40例经皮腔内血管成形支架置入术均获成功,术后平均狭窄率由术前的82%±14%降为14%±11%,术后继续给予抗血小板聚集治疗.38例患者临床脑缺血症状和体征明显改善,2例术后发生脑干缺血症状加重,经治疗后临床症状好转但遗留神经功能障碍.无出血性并发症发生.随访2个月～7年,经颅多普勒复查26例,显示基底动脉血流速度增快2例.行全脑数字减影血管造影复查6例,1例支架内发生再狭窄,因有临床症状而行二次血管成形支架置入术;1例基底动脉支架内闭塞但侧支循环良好,临床上无后循环缺血症状.结论 经皮腔内血管成形支架置入术治疗基底动脉粥样硬化性狭窄是可行、安全、有效的;大样本的长期疗效有待于进一步观察.     

Axillary-Axillary Artery Bypass for the Corretion of Subclavian Artery Occlusive Disease

Numerous procedures have been proposed for the correction of symptomatic subclavian artery occlusive disease, none of which have been uniformly accepted by vascular surgeons. During the past 21 months we have successfully treated six patients with symptomatic subclavian artery occlusive disease by the construction of an axillary-axillary artery bypass. There were three complications in this small series, a wound hematoma, a case of median nerve parasthesias, and a late graft thrombosis, possibly caused by external pressure on the graft. These complications have not caused any serious morbidity. All patients have been followed to the present time, all have experienced symptomatic improvement and none has developed any symptoms of donor arm ischemia. Axillary-axillary artery bypass is currently our procedure of choice for the correction of symptomatic subclavian artery occlusive disease because of its effectiveness, absence of serious morbidity and ease of performance.     

Surgical results of two cases of simultaneous surgery of carotid and coronary occlusive disease]

Two cases of symptomatic extracranial carotid artery stenosis associated with ischemic heart disease are reported. The first case was 72-year-old male, who was admitted because of transient ischemic attack due to the stenosis of left internal carotid artery. He had a history of myocardial infarction and coronary angiography revealed three vessel disease. The second case was 74-year-old female with diabetes mellitus. She was admitted because of cerebral infarction. The carotid angiography revealed critical stenosis of bilateral internal carotid arteries. Her coronary angiography revealed three vessel disease. Her chest symptom became unstable after her admission. In both cases, simultaneous carotid endarterectomy and coronary bypass grafting were performed with successful outcome. In the patients with symptomatic extracranial carotid occlusive disease associated with severe ischemic heart diseases, we advocate simultaneous operation both for carotid and coronary artery occlusive disease.     

Silverhawk斑块切除成形治疗严重膝下动脉硬化闭塞性病变

目的：探讨Silverhawk斑块切除成型治疗严重膝下动脉硬化闭塞性病变的安全性和有效性。 方法：回顾分析2年来治疗的9例该病患者临床与随访资料。其中男性3例,女性6例,平均年龄（64.0±9.1）岁,病程（28.9±25.9）个月;下肢间歇性跛行5例,静息痛1例,足趾溃疡1例,坏疽2例;6例病变位于胫腓干动脉,1例位于胫前动脉,2例位于胫后动脉;1例行单纯斑块切除,余8例患者均同时采用介入技术处理了流入道动脉病变。 结果：所有手术均获得成功。出院时所有患者再通血管保持通畅。跛行患者跛行距离均增至500 m以上,1例静息痛术后缓解,1例足趾溃疡面积缩小,2例坏疽呈干性无感染。患者术后踝肱比值（ABI）均较术前增加。所有患者得到随访,平均时间为（24.0±9.5）个月。1例患者术后23个月因心肌梗死死亡;1例患者间歇性跛行距离较术后最好时期有所减少,但仍优于术前;静息痛患者疼痛症状消失;溃疡患者伤口愈合;2例坏疽患者,1例仍保持干性状态,另1例其坏疽两趾脱落,创面愈合。 结论：Silverhawk斑块切除成型治疗严重膝下动脉硬化闭塞病变是一种安全有效的方法,是否能够成为一种常规的技术,还需要随机对照研究远期结果的验证。

     

Basilar artery occlusion after STA-SCA anastomosis; case report

A case of basilar artery occlusion after STA-SCA bypass surgery is reported. The patient was a 56 year old male and presented a TIA of vertigo and speech disturbance. The preoperative angiogram revealed severe stenosis of the basilar artery in its midportion between the bifurcation of AICA and that of SCA. After surgery, the patient's clinical course was uneventful, but the angiogram showed that the previous stenotic segment of the basilar artery had been occluded and the distal portion of the basilar artery and its branches were perfused through the widely-patent STA-SCA bypass. About 6 months after the operation, the patient developed a pontine infarction in the right paramedian region, which was confirmed on MRI. The angiogram revealed that the occlusion of the basilar artery extended further proximally to a point just distal to the bifurcation of AICA. So it was suspected that the perforating branches of the basilar artery to the pons were occluded with the extension of the thrombosis of the basilar artery. The hemodynamic changes associated with the EC-IC bypass was thought to be responsible for the occlusion of the previous stenotic lesion.     

Combined surgery and endovascular stenting for basilar artery stenosis refractory to balloon angioplasty: technical case report

Summary  The authors report a case of symptomatic basilar artery stenosis treated by stenting via the surgically exposed C1 vertebral artery. This case was initially treated by percutaneous transluminal angioplasty via a transfemoral route but resulted in unsatisfactory dilatation. Stenting via a transfemoral route also resulted in failure because of the coiling of the proximal vertebral artery. Direct puncture of the vertebral artery beyond the coiling portion was tried but a stent could not be delivered beyond the C2 vertebrae. Finally, the vertebral artery was surgically exposed between C1 and the occipital bone and a stent was introduced into the lesion from this portion under fluoroscopic control. The basilar artery was fully opened by stenting without new neurological deficits. Stenting of the basilar artery via a transfemoral route is not always possible even with newer generation stents if the vertebral artery has elongated tortuous curves. Combined surgery and endovascular stenting is one of the alternatives in such cases including our case.     

Combination of percutaneous balloon angioplasty and aggressive medical intervention improves symptomatic basilar artery stenosis with a tortuous access route: case report

The prognosis of symptomatic intracranial artery stenosis (SIAS) by medical treatment is poor. Percutaneous balloon angioplasty (PTA) or stenting is effective for SIAS. However, recently, aggressive medical intervention (AMI) has progressed and some drugs have been reported to improve stenosis or prevent the progression of stenosis. We describe a case where combination of PTA and the AMI improved symptomatic basilar artery stenosis with a tortuous access route. Case: A 78-year-old man was admitted to our hospital suffering from acute brain infarction due to severe basilar artery stenosis. The AMI including cilostazol, statin, and eicosapentaenoic acid failed to prevent recurrence of the brain infarction. We performed PTA and 45% of the residual stenosis remained. We continued the AMI and the stenosis improved to 30% after 3 months. Conclusion: PTA with minimal risk should be considered for SIAS resistant to AMI. Even if residual stenosis remains, continuation of AMI may prevent recurrence of a brain infarction. The strategy of a combination of PTA with minimal risk and AMI may result in a better prognosis for SIAS.     

Enlargement and rupture of distal basilar artery aneurysm after iatrogenic carotid occlusion

A case of angiographic enlargement and fatal rupture of a previously asymptomatic distal basilar aneurysm in a 12-year-old girl is reported. She had been treated by carotid sacrifice for a giant intracavernous carotid aneurysm. After superficial temporal-middle cerebral artery bypass, this patient underwent a trapping procedure and decompression of her symptomatic giant aneurysm. Despite postoperative patency of her bypass graft, the involved middle cerebral circulation was irrigated substantially by retrograde flow through her posterior communicating artery. An incidental distal basilar aneurysm involving the origin of her superior cerebellar arteries, posterior cerebral arteries, and multiple perforators was treated by a wrapping procedure. Eleven days after carotid ligation, she suffered a fatal subarachnoid hemorrhage from her basilar aneurysm. This catastrophe was undoubtedly produced by our failure to consider the additional hemodynamic stress placed upon the distal basilar artery by carotid sacrifice and may have been preventable by a more aggressive attack on this previously asymptomatic lesion.     

球囊扩张Apollo支架植入术治疗症状性基底动脉狭窄

目的观察球囊扩张支架植入术治疗症状性基底动脉狭窄的疗效及安全性。方法应用Apollo支架治疗18例症状性基底动脉严重狭窄（〉70%）患者,术后平均随访11个月,以改良Rankin量表（mRS）评分为基础评价治疗效果。结果对所有患者均成功植入支架,16例患者临床症状得到不同程度改善;18例中,14例mRS评分≤2分,4例mRS评分〉2分。结论球囊扩张支架植入术治疗症状性基底动脉狭窄安全、有效。     

Therapeutic basilar artery occlusion for management of medically refractory basilar artery stenosis: case report

OBJECTIVE AND IMPORTANCE: To describe a novel therapeutic approach (endovascular basilar artery occlusion) to a notoriously difficult-to-manage clinical condition (actively symptomatic high-grade basilar artery stenosis) on the basis of assessment of the patient-specific mechanism of disease. CLINICAL PRESENTATION: An 81-year-old woman presented with recurrent episodes of brainstem ischemia refractory to aggressive medical therapy. Cerebral angiography revealed a high-grade proximal basilar artery stenosis. On the basis of clinical presentation and angiographic findings, the pathogenesis of this complex of symptoms was thought to be embolic rather than hemodynamic. INTERVENTION: Endovascular coil occlusion of the basilar artery was used, with excellent outcome (cessation of ischemic symptoms and independent level of functioning at 1 yr). CONCLUSION: Successful endovascular management of intracranial occlusive disease requires understanding of the mechanism responsible for the patient's symptoms.     

A case of cerevical canal stenosis accompanied with congenital cervical fusion and extracranial occlusion of vertebral artery--a clinical and embryological study (author's transl)

A case of cervical canal stenosis accompanied by congenital cervical fusion and extracerebral occlusive disease of the verebral artery was reported. A 39-year-old male was admitted to our hospital on June 5, 1976, because of his shoulder strain, motor weakness and numbness of his left hand, and gait disturbance for a couple of months. Neurological examination disclosed spastic paraparesis with positive pyramidal signs in the four extremities which was greater on the left side, and the superficial and deep sensations were diminished below C-4 dermatomes bilaterally. Spinal tap revealed crystal clear fluid under an initial pressure equivalent to 120 mm of water with a protein content of 20 mg/dl. Plain X-P and laminogram of the cervical spine showed congenital fusion of C 2-3, cervical canal stenosis and cervical spondylosis. Posterior spurring of C 3-4 was demonstrated only on the laminogram. Myelogram showed incomplete myelographic block at the site of C 3-4-5. The left retrograde brachial angiogram disclosed occlusion of the vertebral artery at the site of C3-4. where the proxymal vertebral artery anastomosed with the well developed muscular branch of the vertebral artery, taking a tortuous course at the leve of the transverse foramen of the atlas, and were opacified the distal vertebral artery and basilar artery. Each collateral flow extending from the deep cervical artery and ascending cervical artery anastomosed with the proxymal and distal portion of the occluded vertebral artery. In spite of conservative treatment for two weeks, the cord compression syndromes rather deteriorated. Posterior decompression, that is, C 2-7 laminectomy and C 3-4 partial facetectomy were performed for relieving the symptoms. The postoperative course was uneventfull and there was progressive improvement of the sensory, motor and gait disturbance. The relationship betwen the cervical canal stenosis and cervical spondylosis and their clinco-radiological problem were discussed. The close embryological relationship was very suggestive of the pathogenesis between the cervical bony lesion and congenital cervical fusion and the occlusive vascular lesion of the vertebral artery.     

症状性椎基底动脉狭窄经皮腔内支架成形的初步研究

目的探讨经皮腔内支架成形治疗椎基底动脉狭窄的临床疗效及适应证。方法2004年4月-2006年12月共收治22例患者：优势侧椎动脉狭窄4例；双侧椎动脉狭窄3例；一侧椎动脉狭窄、对侧椎动脉闭塞8例；单纯基底动脉狭窄5例；优势或“孤立”椎动脉狭窄合并基底动脉串联病变2例。治疗的24处病变：椎动脉开口8例，V4段椎动脉9例，基底动脉7例；Mori A型病变16例，B型病变8例。结果22例患者技术成功率95％，术前平均狭窄率为78．3％，术后残余狭窄率平均15％（P〈0．01）。除1例基底动脉支架成形致血管破裂出血死亡，余病例在围手术期内未发生严重并发症。17例患者随访1～24个月（平均13．5个月），Malek评分为1分者12例，2分者4例，3分者1例。结论症状性椎基动脉狭窄支架成形术疗效确切，但手术的难度和风险仍较大，临床就其适应证和长期疗效需要进一步积累经验。     

症状性颈内动脉闭塞的术前评估及手术治疗

目的:探讨症状性颈内动脉(ICA)闭塞患者手术治疗的效果和术前评价方法。方法:选择海南省人民医院血管外科2010年1月—2016年3月手术治疗的11例ICA闭塞的患者,2例行颈动脉内膜剥脱术(CEA),9例行CEA加取栓术。术前均行头颈联合CTA和颈部血管彩超,部分患者行脑CT灌注成像、经颅彩色多普勒超声以及脑血管造影等检查,观察患者围术期与长期疗效。结果:所有患者ICA闭塞均为单侧,其中4例对侧ICA有50%的狭窄。闭塞主要位于ICA起始端,8例闭塞段延至颅底,闭塞长度16~85 mm。术前颈动脉彩超均在可在颅底探及ICA血流。10例手术再通成功,1例失败。术后10例脑缺血症状明显改善,其中3例出现过度灌注综合征。随访期,1例患者ICA在术后3个月闭塞。1例在术后18个月死亡。结论:手术治疗ICA闭塞具有满意安全的围手术期效果和较好的中远期效果。术前精确的评估是手术成功的关键。     

Dissecting aneurysms of the main trunk of the superior mesenteric artery.

We treated four symptomatic patients who were admitted with a spontaneous and isolated dissecting aneurysm of the superior mesenteric artery. All four patients underwent operation. The superior mesenteric artery was repaired by means of either a bypass graft in two cases or an endoaneurysmorraphy in the latter two cases. Complete symptomatic relief with no postoperative complications was achieved in every case. The arterial repairs remained patent, and the patients remained free of symptoms, with follow-up ranging from 6 to 47 months. The available literature on this unusual lesion is reviewed.     

Vascular recanalizing techniques in the hind brain circulation

Percutaneous transluminal angioplasty (PTA) was performed in 45 patients with a manifest subclavian steal syndrome. Thirty-five of those patients were subjected to follow up examinations over a period of 6 to 18 months. Five patients suffered from severe restenosis and were treated again. Two thirds of the patients benefited from the treatment. PTA of the proximal vertebral artery was performed in 15 patients with bilateral occlusive lesions of the extracranial vertebral arteries. In 13 of these cases the neurological and the vascular states of the patients were regularly reexamined, 8 showed a marked improvement. During the 2 to 25 month observation period (average 15 months post-PTA) reocclusion was observed in only two cases. These showed no recurrent neurological sequelae. Forty-three consecutive patients with acute vertebro-basilar or basilar occlusion received intraarterial fibrinolytic therapy with streptokinase or urokinase. Twenty-three of these had presented severe deficits at the beginning of therapy (e.g. complete tetraplegia, comatous state for more than 6 hours). None of this group survived. By contrast the 20 other patients in this group presented with incomplete fluctuating or progressive motor deficits. None was comatous for more than 6 hours. Fourteen patients (33% in this group) survived. Local intraarterial fibrinolytic therapy is the only therapy successful in the treatment of progressive stroke from vertebro-basilar thrombosis.     

对吻式支架治疗复杂长段主髂动脉闭塞

目的评价对吻式支架治疗复杂长段主髂动脉闭塞(AIOD)的可行性及疗效。方法对20例复杂长段主髂动脉闭塞患者,拟采用经肱动脉途径顺行开通闭塞段血管后,于腹主动脉下段及双侧髂动脉置入对吻式支架进行治疗。记录术中及术后并发症情况、术后踝肱指数(ABI)及Rutherford分级。随访观察术后6、12、24个月支架通畅率。结果 20例中,对18例成功置入对吻式支架,对另2例仅行腹主动脉及单侧髂动脉开通。术中1例斑块脱落导致腘动脉栓塞的患者,经溶栓及抗凝治疗后好转。术中开通髂动脉时,2例发生小动脉夹层,置入支架后夹层消失。术后3例穿刺处血肿的患者经对症治疗后血肿均自行吸收。术后1个月患者左、右侧ABI及Rutherford分级均与术前差异有统计学意义(P均0.05)。1例术后6个月发生支架再狭窄、2例分别术后12个月和24个月发生支架闭塞,对其均成功进行靶血管再通。1例患者术后17个月死于心肌梗死。术后6、12和24个月一期通畅率分别为(94.44±5.40)%、(88.89±7.40)%和(81.50±9.80)%。结论以对吻式支架治疗复杂长段主髂动脉闭塞近、中期疗效较好,且并发症相对较少。     

Two cases of "steal VBI" with stenosis of the internal carotid artery

Although previous reports have suggested "steal VBI" due to occlusive carotid artery diseases, there have been no reports that clearly define "steal VBI" from the viewpoint of cerebral hemodynamics. The authors presented two cases with "steal VBI" due to severe stenosis of the internal carotid artery. Both patients had well-developed collateral circulation through the ipsilateral posterior communicating artery. Although no occlusive lesion was found in the vertebrobasilar system, blood flow studies revealed impaired hemodynamics in the contralateral occipital lobe, which fact correlated with their neurological deficit, visual field disturbance. Carotid stenting markedly corrected the stenotic lesions, leading to neurological improvement. Follow-up blood studies showed normalization of hemodynamics in the contralateral occipital lobe. The findings strongly suggest that carotid surgery or stenting can improve cerebral hemodynamics in the carotid systems, resolving "steal VBI" due to developed collaterals from the posterior to the anterior circulation.     

Clinical outcome of standard extracranial-intracranial bypass surgery in patients with symptomatic atherosclerotic occlusion of the internal carotid artery

Summary Objective. In this retrospective study we wanted to determine the role of cerebral revascularization in patients with symptomatic occlusive cerebrovascular disease. Special emphasis was put on subsequent cerebrovascular events, benefit in neurological functioning and bypass patency, as evaluated during the follow-up period.Methods. A total of 73 superficial temporal artery to the middle cerebral artery bypasses were performed on 67 patients from 1986–2000. All patients exhibited a symptomatic occlusion of the internal carotid artery verified by angiography. All patients in our group were refractory to medical treatment. 65 patients (69 bypasses) with a mean age of 61 years (range: 38–79 years) were followed up over an average time of 44 months (range: 1.5–150 months).Results. The peri-operative morbidity rate was 3% with no mortality. 55 patients (85%) had no further cerebrovascular events after surgery, and only 7 (11%) patients experienced another cerebrovascular event. 57 (88%) patients showed an improvement of symptoms after surgery and only 1 patient fared worse during the follow-up peroid due to a stroke he suffered two years after bypass surgery. 90% of all bypasses remained patent during the follow-up.Conclusions. Although bypass surgery for occlusive cerebrovascular disease is still controversial, our retrospective study suggests both an improvement of symptoms and signs and a risk-reduction for future cerebrovascular events after surgery.     

Improved cerebral perfusion after stenting of a petrous carotid stenosis: technical case report.

OBJECTIVE AND IMPORTANCE: Atherosclerotic occlusive disease of the intracranial vasculature is associated with increased risk of systemic vascular occlusive disease and stroke. Therapeutic options have included anticoagulation therapy, antiplatelet therapy, or, in a limited number of patients, extracranial-intracranial vascular bypass procedures. We report a patient who had improved cerebral perfusion with silent watershed zone infarctions after endovascular stenting of a severe petrous segment carotid stenosis. CLINICAL PRESENTATION: A 73-year-old man with severe coronary artery disease and unstable angina was referred for treatment of a 90% right petrous carotid artery stenosis before coronary artery bypass grafting. A brain single-photon emission computed tomographic scan using 99mTc-bicisate revealed diminished perfusion throughout the right internal carotid artery territory, particularly in posterior watershed zones. TECHNIQUE: The patient underwent transfemoral placement of a 7-French introducer sheath, followed by a 7-French guide catheter. Urokinase (225,000 U) was infused through a microcatheter placed proximal to the lesion. No changes were noted in lesion morphology after this infusion. A microguidewire was navigated across the lesion. Subsequent balloon angioplasty with a coronary artery balloon was performed twice, followed by placement of a 4- x 12-mm coronary stent. CONCLUSION: Selective internal carotid artery angiography after stenting revealed markedly improved flow. A brain 99mTc-bicisate single-photon emission computed tomographic scan performed within 24 hours of stent placement, revealed significantly improved perfusion within the right internal carotid artery territory. Two perfusion voids suggestive of embolic stroke were noted; both were clinically silent. The patient had uncomplicated coronary artery bypass grafting 72 hours later. Five months postoperatively, he remains at home, living independently and with intact neurological function. Intracranial stenting for severe atherosclerotic stenosis is technically possible. However, its ultimate clinical role remains to be determined.     

A case of carotid occlusive disease treated with stenting for recurrence of stenosis: strategy on intolerance to temporary occlusion

Carotid artery stenting has emerged as an acceptable treatment alternative in patient with occlusive carotid bifurcation disease. High-risk surgical candidates have a lower rate of morbidity after carotid artery stenting with distal embolic protection. Among distal protection devices, a Guardwire balloon occlusion is the most frequently employed in Japan. A 79-year-old male who had severe stenosis at the origin of left carotid artery was treated with stenting under Guardwire balloon protection. He was intolerant to carotid artery occlusion and endovascular procedures were performed under intravenous anesthesia or general anesthesia. In addition, he suffered recurrent stenosis seven months after the first procedure and 16 months after second procedure, and underwent repeated intervention. It was considered that the long tortuous lesion was a cause of the recurrent stenosis.