脑保护装置下的血管成形和支架置入术治疗颈动脉狭窄

目的探讨颈动脉狭窄患者颈动脉血管成形和支架置入术(CAS)中应用脑保护装置的有效性和安全性。方法颈动脉狭窄患者CAS治疗时,12例应用脑保护装置(滤网型),16例未使用脑保护装置。结果28例颈动脉狭窄患者成功释放31枚自膨式支架。未使用脑保护装置组球囊预扩1次(6·2%),无一例后扩;使用脑保护装置组球囊预扩4次(33·3%),后扩6次(50%)。CAS治疗中,7例(25·0%)患者出现短暂性心率减慢和低血压。回收的脑保护装置中2例(16·7%)肉眼可见组织碎片。使用脑保护装置组在围手术期和随访期无神经并发症;未使用脑保护装置组围手术期发生1例(6·3%)脑梗死,随访期发生1例(6·3%)脑梗死。结论脑保护装置的使用有助于减少颈动脉狭窄患者CAS治疗的神经并发症。     

脑保护装置下高龄重度颈动脉狭窄患者颈动脉支架成形术的有效性和安全性评价

目的评价脑保护装置下高龄重度颈动脉狭窄患者颈动脉支架成形术(CAS)的有效性及安全性。方法选择2009年1月—2012年1月在青岛大学医学院附属医院行CAS的高龄重度颈动脉狭窄患者37例,术中均应用脑保护装置,观察患者狭窄改善情况、围术期并发症发生情况、回收脑保护装置内脱落栓子情况,随访1年观察患者缺血性脑血管事件发生情况。结果 36例患者脑保护伞均一次性顺利通过狭窄段放置到位成功释放;术后残余狭窄率均30%,平均狭窄程度从(83.0±6.7)%降至(13.0±6.1)%;回收的脑保护装置中有26个发现脱落的组织碎片;围术期均未出现脑出血、症状性脑梗死、支架内血栓形成等严重并发症;37例患者随访1年,无短暂性脑缺血发作(TIA)、卒中、死亡发生。结论脑保护装置下对高龄重度颈动脉狭窄患者行CAS成功率和安全性较高。     

颈动脉支架成形术治疗颈动脉狭窄263例

目的：总结颈动脉狭窄支架成形术的经验，评价其疗效。方法：颈动脉狭窄患者263例，其中双侧颈动脉狭窄97例，对侧颈动脉闭塞23例，均使用自膨式支架进行预动脉支架成形术。在263根病变血管中置入支架265枚，其中84例使用了脑保护装置。结果：技术成功率98．9％?术后小卒中5例，颅内出血4例。围手术期神经源性病死率为1．14％，致残率为1．52％?对95例患者进行了随访(超过6个月)，其中2例发生再狭窄，1例死亡。结论：颈动脉支架成形术是治疗颈动脉狭窄相对安全、有效的方法，但这一结果还有待长期随访证实，其技术和应用材料也有待进一步研究和探讨。     

支架置入术治疗颈动脉狭窄

目的：总结血管内支架置人治疗颈动脉狭窄的安全性和疗效。方法：收治颈动脉狭窄患者16例，其中3例进行狭窄预扩，3例使用脑保护装置，共放置自膨式支架18枚。结果：18枚支架均成功置人，术中无严重并发症，1例(6．3％)术后第3天发生非处理血管供血区脑梗死。随访1～8个月，无新发短暂性脑缺血发作(TIA)和脑梗死，末次改良Rankha量表评分平均0．75(0～2)分，所有患者生活均自理。10例患者术后3个月颈动脉彩超复查，均未见再狭窄。结论：支架置人治疗颈动脉狭窄是一种比较安全和可能有效的方法，但亟需设计随机对照临床试验观察其长期疗效和不良反应。     

高危症状性颈动脉狭窄支架成形术的疗效分析

目的分析颈动脉支架成形术治疗高危症状性颈动脉狭窄的有效性和安全性。方法对20例高危症状性颈动脉狭窄患者进行颈动脉支架成形术治疗,其中男12例,女8例;年龄为62～76岁,平均69岁。其中短暂性脑缺血发作11例,脑梗死9例。对所有患者均行全脑血管造影,显示颈动脉狭窄率均〉70％,其中一侧颈动脉重度狭窄9例（2例为颈动脉剥脱术后再狭窄）;双侧颈动脉重度狭窄6例;一侧颈动脉闭塞,另--N重度狭窄5例（1例为鼻咽癌放疗术后）。对所有患者使用脑保护装置,并均采用预扩张,预扩张后均使用自膨式支架。结果技术成功率为100％,残余狭窄率均〈30％。所有患者术中均出现不同程度的短暂性心率、血压下降,1例患者出现了微栓子栓塞,无其他严重并发症;其余患者围手术期内无缺血性卒中发作。术后复查颈动脉超声见,显示狭窄明显改善。结论颈动脉支架治疗高危症状性颈动脉狭窄创伤小,围手术期并发症少,是安全、有效的。     

远端保护装置用于重度颈动脉狭窄的介入治疗

目的分析远端保护装置应用于颈动脉狭窄支架成形术的安全性和有效性。方法对26例症状性颈动脉狭窄患者行血管内支架成形术时应用远端保护装置，首先将远端保护装置通过狭窄部位并在狭窄远端展开，然后行保护性颈动脉支架成形术，观察围手术期缺血性脑卒中的发生情况，并观察保护装置滤网内捕获的斑块组织碎片。结果26例患者行远端滤网保护下的颈动脉支架成形术均获成功，回收的保护装置中有14个（54％）发现滤网中有斑块碎片组织和血栓颗粒，无死亡及急性栓塞事件发生，但有3例患者在手术后1～6d经磁共振检查发现了新的无症状性脑梗死病灶，26例患者在出院后临床随访期内未发生严重脑缺血事件。结论颈动脉支架成形术是重度症状性颈动脉狭窄的微创治疗方法，术中常规使用远端保护装置可提高颈动脉支架成形术的安全性和有效性。     

颈动脉狭窄支架成形术疗效及并发症分析

目的探讨血管内支架成形术治疗颈动脉狭窄的临床疗效、安全性及并发症。方法选择经脑血管造影证实的颈动脉狭窄患者100例行血管内支架成形术,术中应用抗栓塞远端保护装置,球囊预扩张狭窄部位,释放颈动脉自膨支架。结果所有支架释放定位准确,残余狭窄〈30%,围手术期出现1例脑出血,1例急性血管形成。临床随访1例再发短暂性脑缺血发作,超声示支架远端再狭窄。结论应用脑保护装置进行血管内支架成形术是治疗颈动脉狭窄安全可行的方法 。     

远端保护装置下CAS治疗颈动脉狭窄的疗效及并发症分析

目的探讨在远端保护装置（保护装置）下采用血管内支架成形术（CAS）治疗颈动脉狭窄的疗效,分析其并发症发生情况。方法对47例颈动脉狭窄患者行颈动脉CAS时应用保护装置,先将保护装置通过狭窄部位并在狭窄远端展开,然后行保护性颈动脉CAS;并对手术过程、疗效及围术期并发症进行分析。结果术后颈动脉造影证实,残余狭窄率〈30%,术后第10天死亡1例;术后1 a均未发生TIA、再卒中及死亡。结论在保护装置下采用CAS治疗颈动脉狭窄安全有效;掌握其适应证及操作规范,可减少并发症发生。     

颈动脉支架成形术治疗老年重度颈内动脉狭窄患者的疗效观察

目的评价脑保护装置下老年重度颈动脉狭窄患者颈动脉支架成形术的有效性及安全性。方法选择年龄≥70岁的重度症状性颈动脉狭窄患者43例,均行颈动脉支架成形术,术中均应用脑保护装置,观察术后狭窄改善情况,围术期并发症的发生情况以及回收的脑保护装置内脱落栓子情况,对患者随访1年。结果在43例患者中,脑保护装置及颈动脉支架均放置到位,术后残余狭窄率均<30%,患者颈动脉平均狭窄程度从(82.8±6.5)%降低至(12.4±5.9)%,支架置入手术前后比较,差异有统计学意义(P<0.05)。回收的脑保护装置中,发现27个有脱落的组织碎片,患者术后缺血相关症状均有明显改善,围术期所有患者均未出现症状性脑卒中,无手术相关死亡事件发生,1年随访无缺血性脑血管事件发生,颈动脉超声复查未见支架内发生再狭窄。结论脑保护装置下,对老年重度颈内动脉狭窄患者行颈动脉支架成形术安全、有效。     

颅外颈动脉支架成形术后颈动脉狭窄的危险因素分析

目的探讨颈动脉支架形成术(CAS)治疗颈动脉狭窄的危险因素,并分析其有效性和安全性。方法回顾性分析采用CAS治疗颈动脉狭窄的110例病人资料,根据术后30 d内有无不良事件发生分为有不良事件组(24例)和无不良事件组(86例),比较两组病人临床资料、危险因素、术前美国国立卫生研究院卒中量表(NIHSS)评分、术前血管狭窄程度、狭窄部位等,预后结果采取多因素Logistic回归分析,全部CAS病例应用脑保护装置防止血栓脱落。结果 110例病人共植入支架115枚,脑保护装置全部回收,支架植入术成功率为100%。狭窄程度由术前中度、重度变为术后轻度、中度;围术期术后总体并发症24例(21.8%),30 d内不良事件7例(6.36%);随访3个月后,2例支架内再狭窄。两组年龄、高血压比较差异有统计学意义(P0.05);多因素Logistic回归分析显示高血压是CAS治疗颈动脉狭窄的危险因素。结论 CAS治疗颈动脉狭窄30 d内出现不良事件与高血压显著相关,颅外CAS可有效减轻病人颈动脉狭窄程度,且围术期是相对安全的。     

颈动脉狭窄的干预治疗:支架还是内膜剥脱?

颈动脉狭窄是卒中的常见原因.颈动脉血管成形和支架正成为颈动脉内膜剥脱术后治疗颈动脉狭窄的一种有效方法.两种方法孰优孰劣是近来争论的焦点,现通过比较近来对颈动脉内膜剥脱术和颈动脉血管成形和支架术对比的试验研究,认为未来几年是评价两种方法的重要时期.     

Carotid Endarterectomy with Contralateral Carotid Occlusion: Is Shunting Necessary?

Background Controversy exists about the effect of contralateral carotid stenosis on the perioperative risks of carotid endarterectomy (CEA). Despite increased perioperative risk, the long-term outcome is improved in patients who undergo ipsilateral CEA with significant contralateral carotid stenosis. Traditionally, this involved shunting the ipsilateral carotid artery during the procedure. It was believed that this minimized the risk for cerebral ischemia. We believe selective shunting can be employed while still avoiding cerebral ischemia. This requires a reliable method of monitoring for ischemia. Intraoperative EEG monitoring has been proven to be a reliable method for monitoring for ischemic changes during a case.Methods A standard operative technique involving continuous EEG monitoring was used. We reviewed the records of carotid endarterectomies in the past 3 years. We present a series of 8 cases of CEA with contralateral occlusion in which shunting was selective based on EEG.Results Of eight patients, seven (87.5%) tolerated the procedure without EEG changes and thus did not requiring intraluminal shunting. There were no long-term complications in our series of patients.Conclusion We found that intraluminal carotid shunting during CEA with contralateral occlusion is not mandatory but neuroprotection methods need to be added to the operative procedure to ensure safety.     

Ischemic Stroke Caused by Carotid Stump at the Common Carotid Artery

An 84-year-old man developed motor aphasia and right hemiparesis on postoperative day 1 after orchiectomy for suspected malignant lymphoma. He had a history of thoracic endovascular aortic repair for aortic aneurysm using a bypass graft from the right subclavian artery to the left common carotid artery (CCA); however, the graft had become occluded six months later. Brain magnetic resonance imaging revealed acute cerebral infarctions in the left frontal lobe. Carotid ultrasonography revealed a stump at the left CCA, just below the bifurcation, formed by the occluded graft with an oscillating thrombus. This case was rare in that a CCA stump was identified as the embolic source of ischemic stroke.     

Carotid Endarterectomy: Current Concepts and Practice Patterns

Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.     

颈动脉狭窄的血管内治疗

颈动脉内膜切除术(CEA)是公认的预防有症状或无症状重度颈动脉狭窄患者卒中的标准治疗方法。近年来,包括球囊扩张术和支架成形术在内的颈动脉血管内治疗在临床上得到广泛应用,无论是单中心研究还是世界范围的多中心研究均显示出良好的治疗效果,尤其是在CEA高危患者中,栓子保护装置下的颈动脉支架成形术效果更佳。越来越多的证据表明,血管内治疗可能成为CEA之后治疗颈动脉粥样硬化性狭窄的又一重要方法。     

解除颈动脉狭窄对认知功能的影响

解除颈动脉狭窄对认知功能的影响日益引起重视,颈动脉内膜切除术和颈动脉支架置入术均可改善认知功能.解除颈动脉狭窄后认知障碍改善可能与脑血流灌注增加、白质病变减轻以及无症状腔隙性梗死发生率降低有关.     

颈动脉支架成形术治疗颈动脉狭窄263例

目的 :总结颈动脉狭窄支架成形术的经验 ,评价其疗效。方法 :颈动脉狭窄患者 2 6 3例 ,其中双侧颈动脉狭窄 97例 ,对侧颈动脉闭塞 2 3例 ,均使用自膨式支架进行颈动脉支架成形术。在 2 6 3根病变血管中置入支架 2 6 5枚 ,其中 84例使用了脑保护装置。结果 :技术成功率 98 9%。术后小卒中 5例 ,颅内出血 4例。围手术期神经源性病死率为 1 14 % ,致残率为 1 5 2 %。对 95例患者进行了随访(超过 6个月 ) ,其中 2例发生再狭窄 ,1例死亡。结论 :颈动脉支架成形术是治疗颈动脉狭窄相对安全、有效的方法 ,但这一结果还有待长期随访证实 ,其技术和应用材料也有待进一步研究和探讨。     

Comparative Review of the Treatment Methodologies of Carotid Stenosis

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.