症状性大脑中动脉狭窄的血管内干预治疗

目的 探讨经皮腔内血管成形术及血管成形支架置入术治疗症状性大脑中动脉狭窄的可行性、安全性及有效性.方法 回顾性分析39例患者经药物治疗无效、反复短暂性脑缺血发作(TIA)或有明显脑缺血症状的大脑中动脉狭窄,经皮腔内血管成形或支架置入术的治疗及术后随访结果.结果 39例大脑中动脉狭窄(左侧23例,右侧13例,双侧3例,合并颈动脉狭窄5例)患者经皮腔内血管成形术9例、血管成形支架置入术30例(术后残余狭窄程度均<10%)均获成功,术后给予抗血小板聚集治疗,临床脑缺血症状和体征明显改善.2例患者术中见对比剂外泄,但无明显临床症状,且恢复良好;1例在术后1 h出现意识变化、对侧肢体活动障碍,CT提示支架侧底节区脑出血,经手术治疗后患者遗留语言障碍及右侧肢体不全偏瘫.其余患者无并发症发生.临床随访5～60个月,仅1例在支架置入7个月后右上肢无力症状复发,但较前轻微.经颅多普勒复查26例,显示原病变侧大脑中动脉血流速度增快2例;行数字减影血管造影复查14例,2例支架内发生再狭窄,均行药物治疗观察.结论 经皮腔内血管成形术及血管成形支架置入术治疗大脑中动脉狭窄是可行、安全、有效的;大样本的长期疗效有待于进一步观察.     

Endovascular repair of symptomatic external carotid artery stenosis

The treatment of external carotid artery stenosis has been described with a variety of operative interventions. We present a patient who presented with amaurosis fugax and a critical left external carotid artery stenosis with known left internal carotid artery occlusion. We treated this stenosis with angioplasty and stenting rather than endarterectomy. Our patient did well and had no complications from the procedure. Endovascular repair of symptomatic external carotid artery stenosis provides an alternative treatment method to conventional endarterectomy for patients with high surgical risk.     

Acute carotid artery stenting in symptomatic high-grade cervical carotid artery stenosis

The safety and efficacy of emergency carotid artery stenting (CAS) for patients with acute ischemic stroke resulting from internal carotid artery stenosis are not established. In this retrospective study, we evaluated outcomes for CAS performed within 2 weeks of acute ischemic stroke for 16 patients treated between December 2009 and February 2014. Cases of internal carotid artery occlusion, internal carotid dissection, or intracranial major arterial trunk occlusion were excluded. Five patients were treated with CAS during the hyperacute phase (within 24 h of stroke onset), three in the advanced phase (within 24 h of stroke-in-evolution after admission), and eight in the acute phase (24 h to 2 weeks after onset). We evaluated modified Rankin scale (mRS) scores 90 days after CAS. For patients treated during the hyperacute phase without intravenous tissue-type plasminogen activator (IV-tPA), two had mRS scores of 2 and one had a score of 3. Two patients treated in the hyperacute phase with IV-tPA had scores of 5: one with symptomatic intracerebral hemorrhage and the other with acute brain swelling. For patients treated in the advanced phase, mRS scores were 1, 3, and 5; the patient with 5 had contralateral cerebral infarction. All patients treated in the acute phase had scores of 2 or lower. Patients treated with IV-tPA in advanced or acute phases had no severe post-CAS complications. CAS was effective and safe for treating ischemic stroke within 2 weeks of onset. However, IV-tPA treatment may be a risk factor for CAS treatment during the hyperacute phase.     

支架成形术治疗颅外椎动脉硬化狭窄

目的 评价血管内支架成形术治疗颅外椎动脉狭窄的安全性及有效性.方法 回顾性分析2006年4月至2010年3月施行血管内支架成形术治疗的24例颅外椎动脉狭窄病例.MoriA型21例,Mori B型3例.动脉狭窄率60%～95%,平均狭窄率79%±10%.结果 24例共置入球囊扩张式支架24枚.技术成功率100%.术后平均狭窄率下降至4%±6%.随访3～36个月,平均随访22个月.17例有症状病例中,术后15例症状消失.1例治疗部位再狭窄伴短暂性脑缺血发作.1例术前检查提示多发梗死伴随共济失调、发作性眩晕患者,术后症状无明显改善,但无进一步脑卒中发作.彩色多普勒超声复查显示:治疗部位狭窄率＞50%5例,再狭窄发生率20.8%.按Malek评分法评定,1分22例,2分1例,4分1例.结论 应用血管内支架成形术治疗颅外椎动脉狭窄是安全、有效的.通过技术改进可以在一定程度上降低再狭窄率.

Abstract：

Objectives To evaluate the safety and efficacy of endovascular angioplasty for extracranial vertebral artery ( VA ) stenosis caused by atherosclerosis. Methods We analyzed retrospectively data of the 24 patients with extracranial vertebral artery stenosis who had been placed endovascular angioplasty from April 2006 to March 2010. According to Mori classification, there were 21 type A and 3 type B among all cases.The artery stenosis rate was 60％ -95％ , the average was 79％ ± 10％. Results Twenty-four balloon mounted stents were placed, the successful rate was 100％. Postoperatively the stenosis rate decreased to 4％ ± 6％. Patients were followed up from 3 to 36 months, the average was 22 months. Symptomes disappeared in 15 out of 17 patients. Postoperative restenosis on the treatment site with transient brain ischemia occurred in one patient. The symptoms in another patient of multiple cerebral infarction with ataxia and episodic vertigo were not relieved, although the patient didn't suffer from apoplectic seizure after the intervention. Postoperative color Doppler ultrasound revealed an over 50％ residual stenosis in 5 patients. The postoperative restenosis rate was 20. 8％. According to Malek scoring, 22 patients were scored 1 point, 1 patient scored 2 and one scored 4. Conclusions Endovascular angioplasty with stent placement is a safe and effective treatment. The restenosis rate could be futher reduced by technology improvement.     

Individualized endovascular treatment of high-grade traumatic vertebral artery injury

Background

Traumatic vertebral artery injury (TVAI) is associated with craniocervical trauma that can lead to potentially fatal posterior circulation stroke. It presents a clinical challenge since it is hard to detect and there are no widely accepted guidelines on diagnosis and management. High-grade TVAI is more difficult to treat and no consensus has been reached yet.

Methods

We performed a single-center, long-term, therapeutic study involving 272 patients with craniocervical injury, eleven of which were diagnosed with high-grade TVAI. Individualized endovascular treatments were performed on these patients based upon the hemodynamic and morphological characteristics of the injured vertebral artery. Postoperative angiography was conducted at 2 weeks, 3 months and 6 months, and then annually after intervention.

Results

Ten vertebral pseudoaneurysms and one arteriovenous fistula (AVF) were confirmed by postoperative angiography. All the participants’ neurological deficit symptoms disappeared or were significantly alleviated gradually, and no new symptoms were found after endovascular treatment. Follow-up angiography of the patients with pseudoaneurysms showed a normally shaped vertebral artery with no stenosis or aneurysms; the angiographic result of the patient with the AVF presented successful embolization in the proximal vertebral artery fistula with no progression or new stenosis. Their modified Rankin Scale (mRS) scores were also satisfactory.

Conclusions

Application of individualized endovascular therapy in high-grade TVAI is safe, technically feasible and clinically effective, but there is no comparison between endovascular management and other management approaches because randomized trials cannot be carried out currently.     

Endovascular treatment of severe symptomatic stenosis of the internal carotid artery: early and late outcome.

OBJECTIVES: To report a 6 year experience with carotid percutaneous transluminal angioplasty (CPTA) in a selected group of patients. MATERIAL AND METHOD: We retrospectively reviewed our experience after performing 54 CPTAs, with (n=18) or without (n=36) stent deployment, over a period of 6 years from 1993 to 1999. All patients, except one, suffered from focal hemispheric neurologic symptoms. During the same time period 284 patients underwent carotid endarterectomy. The selection of the 54 patients (16%) for CPTA was based on the carotid angiogram and the sole inclusion criterion for endovascular treatment was a short, concentric, and smooth stenosis of more than 70% without ulceration or severe calcification. All patients who had a patent internal carotid artery after the last control were invited for a clinical duplex examination and all duplex examinations were carried out by a single experienced observer. RESULTS: Early outcome (<30 days): CPTA was judged technically successful in 50 cases (93%). Ten patients (18%) experienced a neurological event in relation to the procedure and one patient (2%) suffered a major stroke. One stent occluded within 30 days. LATE OUTCOME: Forty-six patients (85%) entered the follow-up study after a median of 34 months (range 1-80 months). Six patients (13%) had recurrent symptoms. The colour-duplex examination (n=45) showed internal carotid artery occlusion in 2 patients (5%), and restenosis (>70%) in 10 patients (22%). We found no significant difference in the reoccurrence of neurological symptoms or the rate of restenosis between patients treated with and without stent (Log Rank 0.28, p=0,59). ICA was patent without restenosis in 60% after 48 months in patients treated with CPTA alone, and in 76% after 3 months in patients treated with a stent (N.S.). CONCLUSION: CPTA in a selected group of patients has a mortality and major stroke rate comparable to that of carotid endarterectomy. However, the risk of transient neurological events was high, as well as the incidence of restenosis (>70%) after 3 years. We still consider CPTA an experimental procedure. The indications for this treatment must be clarified if CPTA should be an alternative to surgery with a comparable neurological complication rate.     

Endovascular treatment of traumatic arterio-venous fistulas of the vertebral artery

Cervical vertebral artery fistulas are rare arteriovenous malformations between the vertebral artery and veins of the neighbourhood. The etiology of the fistulas may be traumatic or spontaneous. Management and the results in two patients with large arterio-venous fistulas of the cervical vertebral artery with severe deterioration of spinal function by using the detachable balloon technique are discussed. Complete angiographic and clinical cure was achieved in both patients and no complications related to the embolization procedure occured. The detachable balloon technique is an effective method for selective occlusion of the fistula. Good radiographic monitoring facilities are required to make endovascular procedures effective and safe.     

肾动脉狭窄的腔内治疗经验

目的探讨腔内治疗肾动脉狭窄的临床疗效及影响因素。方法2003年2月至2005年6月共收治19例肾动脉狭窄患者,分析其中行腔内治疗12例的临床资料。其中动脉硬化9例,多发性大动脉炎1例,纤维肌性发育不良2例。结果本组12例,均有严重高血压,1例肾功能异常。支架置入10例,技术成功率91．7％(11／12)。随访12例,随访时间3—15个月,随访平均6．5个月,患者血压从(172±26／98±15)降至(156±22／88±14)mmHg。高血压治愈2例,改善6例,未愈4例,高血压控制率为66．7％。术后肾功能无明显变化。无并发症和死亡病例。再狭窄1例,再狭窄率为8．3％。结论严格掌握手术适应证,腔内治疗肾动脉狭窄是安全、有效的。     

Increased endothelial cell apoptosis in symptomatic high-grade carotid artery stenosis: preliminary data.

OBJECTIVE: Endothelial cell (EC) apoptosis has been associated with thrombus formation on an eroded atherosclerotic plaque surface. Alongside plaque rupture, it may constitute another mechanism of plaque destabilisation. We investigated whether EC apoptosis also may be involved in plaque destabilisation in high-grade internal carotid artery (ICA) stenosis. METHODS: We compared the degree of EC apoptosis in carotid endarterectomy specimens from n=38 patients undergoing surgery for high-grade ICA stenosis (> or =70%; n=19 clinically asymptomatic; n=19 symptomatic). The total number of endothelial cells (ECs) and apoptotic cells were determined using CD31 immunohistochemistry and the TdT dUTP nick end-labeling (TUNEL) method respectively. RESULTS: Overall, EC apoptosis was a rare finding. The median percentage of apoptotic ECs was 0.0% (0.0-0.7%) in asymptomatic and 0.5% (0.0-7.3%) in symptomatic plaques (p=0.015, Mann-Whitney U test). No difference was observed between ruptured and unruptured plaque (0.0% [0.0-6.0%] vs 0.0% [0.0-5.7%]; p=0.446). CONCLUSIONS: Our results indicate that TUNEL-detected EC apoptosis is rare in carotid plaque from patients with >70% stenosis.     

Endovascular treatment of a symptomatic mycotic aneurysm of the peroneal artery

A 69-year-old man was referred to our facility owing to the sudden onset of a compression-like pain in the right leg, without limb-threatening acute ischemia. The duplex scan examination, followed by a selective leg angiography, showed the presence of a peroneal artery aneurysm. A?diagnosis of mycotic aneurysm was made on the basis of the patient's clinical condition, positive blood cultures, and the unusual location of the lesion. Endovascular repair was performed by using a coil embolization and covered stent release. The patient was discharged in good general condition with complete pain relief. In previously published data, only four cases of peroneal artery aneurysm with a mycotic etiology have been reported. In this case, the endovascular treatment was safe and resolutive.     

Endovascular stenting of symptomatic innominate artery stenosis under distal balloon protection of the internal carotid and vertebral artery for cerebral protection: a technical case report

The use of cerebral protection devices in endovascular treatment for innominate artery (IA) stenosis is not well established. We describe a novel technique for cerebral protection during endovascular stenting of symptomatic IA stenosis. An 82-year-old man presented with acutely scattered brain infarction by artery-to-artery embolism due to IA stenosis. Endovascular treatment for symptomatic IA stenosis was planned to prevent recurrent attacks. Endovascular stenting for IA stenosis via the right femoral artery approach was performed under simultaneous distal balloon protection of the right internal carotid artery (ICA) and vertebral artery (VA) via the right brachial artery approach. Successful treatment of symptomatic IA stenosis was achieved with no complications. The technique with simultaneous distal balloon protection of the ICA and VA provided excellent cerebral protection in stenting of IA stenosis.     

高危颈动脉狭窄患者的血管腔内治疗

目的探讨高危颈动脉狭窄患者血管腔内治疗的短期疗效和并发症预防。方法对41例高危颈动脉狭窄患者行颈动脉支架植入术,术前狭窄程度为75.0%～98.0%,狭窄长度1.3～3.6 cm,患者均合并一种或多种内科疾病。结果本组均采用脑保护伞及自膨式支架,操作均获得成功,术中颈动脉造影残余狭窄率≤30%。12例患者于术中出现一过性不同程度心率下降,1例患者支架释放后近端出现动脉夹层,1例患者在支架置入后出现失语及右侧肢体偏瘫,无脑出血,经保守治疗14天后症状缓解。随访33例患者,随访时间3～18个月。随访期间,1例死于恶性肿瘤,1例死于心肌梗死,2例出现支架内再狭窄,但无临床症状,其余患者支架无移位,支架内血流通畅,无脑缺血症状。结论对于高危患者,血管腔内治疗近期疗效较好,规范操作可减少并发症的发生。     

Endovascular repair of symptomatic sciatic artery aneurysm

Persistent sciatic artery (PSA) is a rare embrionary anomaly in which the internal iliac artery and the embryonic axial artery continue to provide the major blood supply to the lower limb after birth. Aneurysm formation occurs in as many as 46% of cases. We describe a percutaneous treatment of a complete PSA aneurysm in a high operative risk patient.     

Endovascular treatment of symptomatic moyamoya

Moyamoya is a rare though important source of neurological morbidity as a result of both ischemic and hemorrhagic sequelae. Although a litany of series detailing the endovascular management of cerebral ischemia is present in the literature, only a paucity of such reports exists for moyamoya. A systematic review of the literature was performed for patients with moyamoya managed with endovascular techniques in addition to the contribution of an additional case managed at our institution. We evaluated treatment approach (angioplasty and/or stent), complications, and both angiographic and clinical outcomes at last follow-up. Results from a total of 28 endovascular procedures were collected (11 stenting, 17 angioplasty alone). Procedural success, defined as a lack of both angiographic and clinical recurrence at follow-up, was achieved after seven procedures (25 %). This rate did not significantly differ between disease type (moyamoya disease vs moyamoya syndrome, p?=?1.0) and treatment approach (angioplasty alone vs stenting, p?=?1.0). The overall monthly angiographic and clinical recurrence rates were 9.3 and 8.0 %, respectively. Clinically devastating intracerebral hemorrhage was seen after two procedures (7 %), and in an additional three procedures, the treated vessel could not be effectively dilated (11 %). There is no evidence that angioplasty or stenting improves the natural history of moyamoya. Both are associated with significant rates of early angiographic and/or clinical recurrence of symptoms. Taken with the risk of procedural complications, the current limited data should advise against attempted endovascular treatment of moyamoya.