Carotid artery stenting in octogenarians: results from the ALKK Carotid Artery Stent (CAS) Registry.

AIMS: We tried to determine the influence of age on complication rates of carotid artery stenting (CAS). METHODS AND RESULTS: Two thousand seven hundred eighty CAS procedures were included in the registry. Median age of the patients was 70.8 years, with a proportion of octogenarians of 11.2% and a significant increase between 1996 (5.9%) and 2005 (13.7%; P for trend = 0.002). In octogenarians, a symptomatic stenosis was a more frequent indication for CAS (60.7% vs. 48%, P < 0.001), the CAS procedure was aborted more frequently (6.9% vs. 2.2%; P < 0.001) and the duration of intervention was longer (Median 45 vs. 40 min; P = 0.008). Increasing age was associated with a significant increase in the in-hospital death or stroke rate (P for trend: 0.001). In-hospital death or stroke rate was also higher in octogenarians compared with younger patients (5.5 vs. 3.2%; P = 0.032, OR = 1.79; 95%CI: 1.04-3.06). Logistic regression analysis showed that age analysed as a continuous variable was a strong predictor of in-hospital death or stroke (P < 0.001), whereas octogenarians had only a trend towards a higher event rate (P = 0.062). CONCLUSION: CAS in octogenarians is performed in an increasing proportion of patients. In-hospital stroke or death rates increase significantly with older age; however, there was no excess complication rate in octogenarians.     

Safety of carotid artery stenting for symptomatic carotid artery disease: a meta-analysis.

AIMS: Clinical trials comparing carotid artery stenting (CAS) with carotid endarterectomy (CEA) for patients with symptomatic carotid artery disease have produced conflicting results. We performed a meta-analysis to systematically evaluate currently available data by comparing CAS with CEA in patients with symptomatic carotid artery disease. METHODS AND RESULTS: We searched MEDLINE, Embase, ISI Web of Knowledge, Current Contents, International Pharmaceutical Abstracts databases, the Cochrane Central Register of Controlled Trials, and scientific meeting abstracts up to 31 October 2006 and then calculated summary risk ratios (RRs) for mortality, stroke, disabling stroke, and death using random- and fixed-effect models. Data from five trials with 2122 patients were pooled. There was no difference in risk of 30-day mortality (summary RR 0.57, 95% CI 0.22-1.47, P = 0.25), stroke (summary RR 1.64, 95% CI 0.67-4.00, P = 0.34), disabling stroke (summary RR 1.67, 95% CI 0.50-5.62, P = 0.50), death and stroke (summary RR 1.54, 95% CI 0.81-2.92, P = 0.19), or death and disabling stroke (summary RR 1.19, 95% CI 0.57-2.51, P = 0.64) among patients randomized to CAS, compared with CEA. CONCLUSIONS: No significant differences could be identified between CAS and CEA in the treatment of patients with symptomatic carotid artery disease. Larger randomized controlled trials are warranted to compare the two strategies.     

降低颈动脉支架置入术后缺血性脑损伤措施的研究进展

颈动脉支架置入术(CAS)后缺血性脑损伤是认知功能下降及临床缺血事件的有效预测指标。目前,降低CAS术后缺血性脑损伤发生的措施包括选择合适的患者、控制危险因素以及应用抗血小板聚集及他汀类降脂药、神经保护药物和非药物神经保护措施、根据患者情况个体化选择合适的支架类型及栓塞保护装置等,对术者进行规范化培训也是降低手术并发症的重要措施之一。尽管如此,CAS术后缺血性脑损伤的发生率仍较高。因此,作者将该类治疗措施进行综述,以期降低CAS并发症的发生率。     

颅内侧枝循环开放程度与颈动脉支架置入术后短期预后的关系

目的探讨症状性颅外段颈动脉狭窄患者颅内血管侧枝循环开放程度对颈动脉支架置入术(CAS)后短期预后的影响。方法回顾性分析行CAS术的111例患者的脑血管造影资料,评估术前及术后脑血管侧枝循环的建立程度,以及对术后短期随访结果的影响。结果侧枝循环良好组为53例,侧枝循环差组为58例。侧枝循环良好组中,颈动脉严重狭窄、前交通动脉开放以及软脑膜动脉开放的比率明显高于侧枝循环差组,差异有统计学意义(P0.05),而糖尿病患者的比例明显低于侧枝循环差组(P0.05);CAS术后出现2例脑出血患者,均在侧枝循环良好组,所有患者随访1年,有3例患者再发脑梗死,均为侧枝循环差组病例。侧枝循环良好组术前及术后1年的NIHSS及mRS评分均明显低于侧枝循环差组。结论良好的侧枝循环可明显改善症状性颈动脉狭窄患者CAS术后的神经功能,可能是颈动脉支架置入术后发生脑梗死的保护因素。     

不符合NASCET纳入标准的高危有症状颈动脉狭窄患者的颈动脉成形支架置入术治疗

目的 探讨支架置入术治疗不符合NASCET纳入标准的高危有症状颈动脉狭窄患者的有效性和安全性.方法 对20例不符合NASCET纳入标准的高危有症状颈动脉狭窄患者进行颈动脉支架置入术治疗,其中男性12例,女性8例,年龄62～76岁(平均69岁),短暂性脑缺血发作11例,脑梗死9例.所有患者数字减影血管造影显示颈动脉狭窄程度＞70%(NA-SCET标准),其中-侧颈动脉重度狭窄9例(2例为内膜切除术后再狭窄),双侧颈动脉重度狭窄6例,一侧颈动脉闭塞伴对侧重度狭窄5例(1例为鼻咽癌放疗术后).所有患者均使用栓子保护装置,均采用预扩张和自膨式支架.结果 手术成功率100%,残余狭窄率均＜30%.所有患者术中均出现不同程度的一过性心率和血压下降,1例患者并发微栓子栓塞.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狭窄显著改善.术后1个月和3个月随访均未发现同侧缺血性卒中和冠状动脉缺血事件.结论 颈动脉支架置入术创伤小、围手术期并发症少,治疗外科手术高危的有症状颈动脉狭窄是安全和有效的.     

经桡动脉行颈动脉狭窄支架成形术的疗效分析

目的 探讨经桡动脉入路行颈动脉狭窄支架成形术的适应证和优势。方法 经桡动脉入路在颈内动脉岩部放置阻塞球囊，对38例颈动脉粥样硬化性狭窄患者行支架置人术。其中有症状者29例，无症状者9例。术前均行颈动脉数字减影血管造影（DSA）、脑实质血管DSA、颈动脉多普勒超声及头部MRI等检查。结果 术后患者均复查颈动脉DSA和脑实质血管DSA，显示脑部供血均有明显改善，其患侧颈内动脉、皮质下血管显影时问较术前提前0．3～0．8S，颅内血管血流经过时间缩短0．4～0．7s。短暂性脑缺血发作（TIA）症状消失。全组无手术死亡病例，无并发症。随访3～15个月，无再狭窄患者。结论 当经股动脉入路为相对禁忌时，经桡动脉入路是颈动脉狭窄支架成形术值得选择的一种入路。     

滤网保护系统在颈动脉支架置入术中应用的早期经验(附4例报告)

目的　评估在颈动脉支架植入术 (carotidarterystenting,CAS)中应用滤网保护系统 (An gioguardXP)的可行性和安全性。方法　从 2 0 0 2年 6月到 7月 ,共对 4名男性患者的 4个病变进行了滤网系统 (AngioguardXP ,Cordis)保护下的CAS ,入选条件为颈动脉靶病变狭窄≥ 70 % ,且无CAS及滤网放置禁忌证。手术前后按现标准服药及常规处理 ,CAS及滤网放置和回收均按照标准方法进行 ,采用镍钛合金的自膨式支架 (Smart,Cordis) ,技术成功包括血管造影和装置使用成功。所有病人在术前和术后 2 4h均接受神经内科医生的NIHSS评分 ,完整地评估神经专科的情况。对术后所有病人进行心脑血管事件及死亡等临床终点的随访。结果　患者平均年龄为 (5 9± 4)岁 ,除 1例曾有一过性脑缺血发作外 ,其余均无脑卒中史 ;各有 1例分别患有糖尿病及高血压病 ;1例有心肌梗死病史并在CAS前 1周行冠状动脉介入治疗。靶病变平均狭窄程度为 (82± 6 ) % ,其中左颈内动脉 (leftinternalcarotid ,LICA)及右颈内动脉 (rightinternalcarotid ,RICA)病变各有 2个。分别对以上 4个病变成功置入了 4枚自膨式支架及放置回收了 4个滤网保护系统 ,技术成功率为 10 0 % ;无围术期的心脑血管事件发生。在回收的 4个滤网中均发现 6～ 10个直径为 30 0～     

老年脑缺血患者颅内外动脉支架成形术后再狭窄分布研究

目的 探讨老年脑缺血患者支架成形术后发生支架内再狭窄分布及相关因素. 方法 158例老年脑缺血患者于我科行颅内外动脉支架治疗,留置颅内外支架172枚.在围术期利用血栓弹力图(TEG)系统评价患者血小板功能被抑制情况,并随之调整抗血小板药物使用.150例患者进行全脑血管造影(DSA)随访,8例门诊行CT血管造影(CTA)随访,随访期平均8.3个月. 结果 支架内再狭窄(IRS)11处(6.4％),10处为椎动脉起始部,1处为颈总动脉分叉部.椎动脉起始部支架成形术后再狭窄率为23.8％,皆为非优势供血侧椎动脉起始部,非优势供血侧椎动脉起始部支架成形术后支架内再狭窄发生率为66.7％. 结论 椎动脉起始部较其他部位支架成形术后更易发生支架内再狭窄,而且非优势供血侧比优势供血侧更易发生支架内再狭窄.     

Effects of carotid artery stenting on cognitive impairment in patients with severe symptomatic carotid artery stenosis

The effect of carotid artery stenting and medication on improvement of cognitive function in patients with severe symptomatic carotid artery stenosis is unknown. To investigate the effect of stenting compared with medication alone for severe carotid atherosclerotic stenosis on cognitive impairment. Patients with carotid stenosis and cognitive impairment were prospectively randomly divided into 2 groups of stenting or medication alone. Cognitive function was evaluated with the Montreal cognitive assessment (MoCA), Mini-Mental State Examination, and Barthel Index of Activities of Daily Living (BI). Continuous data in normal distribution were tested with the t-test but with the Mann-Whitney U test if not in normal distribution. Categorical data were presented as frequency and percentages and tested with the Fisher exact test. A P value < .05 was regarded as statistical significant. Carotid artery stenting was successfully performed in all patients (100%) in the stenting group. Compared with before treatment, the Mini-Mental State Examination, MoCA and BI scores at 6 months in the medication alone group and at 1, 3, and 6 months in the stenting group were significantly (P < .005) improved. The stenting group had significantly (P < .05) better scores than the medication alone group at the same time. At 6-month follow-up, the visuospatial/executive functions (3.69 ± 1.42 vs 2.42 ± 1.23), attention (5.24 ± 1.52 vs 3.63 ± 1.47), and language (2.64 ± 0.71 vs 1.96 ± 0.69) were significantly (P < .05) improved in the stenting group compared with the medication alone group. Carotid artery stenting may significantly improve cognitive impairment and neurological function compared with medication alone in patients with severe carotid atherosclerotic stenosis concurrent with cognitive impairment.     

颈动脉血管成形术和颈动脉内膜切除术治疗颈动脉狭窄近期疗效的Meta分析

目的评价颈动脉血管成形术和颈动脉内膜切除术治疗颈动脉狭窄的近期临床疗效和安全性。方法电子检索中国学术期刊网全文数据库(1996—2006年)、MEDLINE(1996—2006年)和Cochrane图书馆(2006年12月前已发表的文献和已注册但未发表的临床试验),并与研究者取得联系获得更多的相关研究资料。纳入比较颈动脉血管成形术和内膜切除术治疗颈动脉狭窄的随机对照试验,比较两种治疗方法术后30d内卒中发生率和卒中与死亡的联合发生率。以卒中发生率作为疗效评价指标,以卒中和死亡的联合发生率作为安全性评价指标。2名评价员独立检索和提取资料,对纳入试验的方法学质量进行评价,数据采用RevMan4.2.10版软件进行统计分析。结果在术后30d内的卒中发生率方面,共纳入7项临床试验的2747例患者,其中颈动脉血管成形术组1381例,颈动脉内膜切除术组1366例。在术后30d的卒中和死亡的联合发生率方面,纳入8项临床试验,共2966例患者,其中颈动脉血管成形术组1488例,颈动脉内膜切除术组1478例。Meta分析结果显示,在术后30d内的卒中发生率方面,颈动脉血管成形术略高于颈动脉内膜切除术(OR:1.44;95%CI:1.05~1.97,Z=2.28,P=0.02);在术后30d内卒中和死亡的联合发生率方面,颈动脉血管成形术与颈动脉内膜切除术间差异无统计学意义(OR:1.50;95%CI:0.89~2.52,Z=1.51,P=0.13)。结论现有临床研究资料显示,在目前的技术条件下,颈动脉血管成形术在治疗颈动脉狭窄的近期疗效方面未显示优于内膜切除术;而在治疗的安全性方面,两者间差异无统计学意义。     

Cerebral microemboli and neurocognitive change after carotid artery stenting with different embolic protection devices

Objectives

Proximal cerebral protection devices have been developed as an alternative to filter protection devices for reducing neurological complications during carotid artery stenting (CAS). The aim of the present study was to evaluate the frequency of silent cerebral embolism after CAS using different cerebral embolic protection devices and the impact of silent cerebral embolism on neurocognitive function.

Methods

One hundred consecutive patients who underwent CAS were enrolled. The patients were randomized to either proximal balloon occlusion or filter protection. Neurocognitive tests were performed before and six months after CAS. Cerebral embolisms were evaluated with diffusion-weighted magnetic resonance imaging (DW-MRI).

Results

The number and volume of new ischemic lesions found with DW-MRI were higher in the filter protection group than in the proximal balloon occlusion group. According to our definition, nine (21%) patients in the balloon occlusion group and 16 (36%) patients in the filter protection group showed neurocognitive decline, and ten (23%) patients in the balloon occlusion group and four (9%) patients in the filter protection group showed neurocognitive improvement (NS). Regarding the group of patients with new cerebral ischemic lesions on DW-MRI, neurocognitive decline occurred in 14 (31%) of 45 patients with DW-MRI lesions and 11 (26%) of 43 patients without DW-MRI lesions (NS).

Conclusion

Neurocognitive outcome after CAS is unpredictable; both neurocognitive decline and improvement can occur. In this study, the proximal balloon occlusion system significantly decreased cerebral microemboli during CAS compared to filter protection. Cerebral microembolism was not found to be associated with neurocognitive decline.     

经桡动脉途径行颈动脉支架置入术

目的 探讨经桡动脉途径行颈动脉支架治疗的可行性及安全性.方法 2011年2月至2011年12月邵逸夫医院心内科行颈动脉造影明确颈动脉狭窄≥70％患者12例通过桡动脉途径行颈动脉支架置入术.探讨手术成功率和并发症情况.结果 经桡动脉途径行颈动脉支架12例,左侧颈内动脉6例,右侧颈内动脉6例,均成功置入.平均手术时间(45 ± 11) min.1例术中出现TIA,2小时后恢复,2例术中出现血压、心率下降,予对症处理后,立即恢复,无桡动脉闭塞及前臂血肿等并发症.结论 经桡动脉途径行颈动脉支架治疗初步证明是安全可行的.     

颈动脉支架置入术颈动脉窦反应的危险因素:回顾病例系列研究

目的 探讨颈内动脉支架置入术(carotid artery stenting,CAS)时颈动脉窦反应(carotid sinus reaction,CSR)的危险因素.方法 回顾性收集36例行颈内动脉颅外段支架置入术的患者资料资料,并按是否发生CSR分为CSR组和无CSR组.采用单变量和多变量logistic回归分析术中发生CSR的危险因素.结果 36例患者中25例发生CSR(单纯低血压7例,单纯心动过缓4例,两者共存14例).CSR组年龄≥75岁(64.00％对27.27％;x2=2.384,P=0.028)、颈内动脉狭窄程度70％～99％(76.00％对36.36％;x2=4.430,P=0.035)、有症状狭窄(72.00％对36.36％;x2=4.082,P=0.043)、钙化斑块(76.00％对36.36％;x2 =4.430,P=0.035)、狭窄距分叉处距离≤10 mm(72.00％对27.27％;x2 =5.029,P=0.025)和球囊后扩(64.00％对18.18％;x2 =44.483,P=0.000)的患者构成比显著性高于无CSR组.多变量logistic回归显示,年龄≥75岁[优势比(odds ratio,OR) 1.520,95％可信区间(confidence interval,CI)1.376 ～4.369;P=0.034]、狭窄距分叉处距离≤10 mm(OR 2.432,95％ CI2.423 ～3.421;P=0.041)和球囊后扩(OR 3.631,95％ CI1.764～4.738;P=0.003)是CAS术中发生CSR的独立危险因素.结论 CSR是CAS术中的一种常见表现,高龄、狭窄距颈动脉分叉处距离≤10mm和球囊后扩是发生CSR的独立危险因素.     

CT灌注成像对颈动脉狭窄支架置人后脑血流动力学的评价

目的使用CT灌注成像（CTP）评价颈动脉支架置人术后脑血流灌注的变化。方法前瞻性纳入31例颈动脉中、重度狭窄患者,将其分为3组：无症状组,7例;脑梗死组,11例;TIA组,13例。均经DSA确诊单侧颈内动脉中、重度狭窄（无症状组一侧狭窄率〉70％,另一侧狭窄率〈30％,脑梗死、TIA组患侧狭窄率均〉50％）。对全部患者行颈动脉支架置入术,共置入支架33枚。对所有患者均于术前及术后7d,行脑CTP检查。分别比较3组术前、术后7d的相对脑血流量（rCBF）,相对脑血容量（rCBV）,相对平均通过时间（rMTF）及相对达峰时间（rTFP）。结果①同组术前、术后比较：无症状组术后胛P（1．01±0．02）缩短,其余灌注指标变化不显著;TIA组的rTrP（1．10±0．06）、rMTT（1．06±0．04）较术前缩短,rCBF（0．96±0．02）增加;脑梗死组的rTFP（1．11±0．05）、rMTT（1．06±0．04）较术前缩短,rCBF（0．96±0．02）增加。均P〈0．05;rCBV均无明显变化。②3组比较：术前3组rTTP、rMTF、rCBF的差异有统计学意义,均P〈0．05;3组rCBV差异无统计学意义。术后3组肿P比较,差异有统计学意义（P〈0．05）,3组rMTT、rCBF、rCBV差异无统计学意义。结论CTP可以相对准确地反映颈动脉狭窄患者支架成形术前后的脑血流动力学状况,可成为头颈部动脉狭窄支架置入术后脑血流动力学改变的无创性评价方法。rTTP是评价早期缺血以及侧支循环代偿能力非常敏感的指标。     

颈动脉支架置入后脑过度灌注综合征

脑过度灌注综合征(cerebral hyperperfusion syndrome,CHS)是颈动脉狭窄患者支架置入术后的并发症之一.虽然其发生率较低,但有可能导致患者严重残疾或死亡.充分认识和理解CHS及其相关危险因素,有助于其预防和治疗.     

经皮颈动脉支架置入术的临床应用及效果

目的评价经皮颈动脉支架置入术对预防缺血性脑卒中的临床效果。方法对30例患者(共32个严重颈动脉狭窄病变)行经皮颈动脉支架置入术,包括男性26例,女性4例,年龄>56岁,其中13例曾患有脑卒中或反复一过性脑缺血;部分患者有高血压、糖尿病及心肌梗死病史。均在术前行颈动脉超声检查及颈动脉及其颅内段血管造影,将支架置入并覆盖颈动脉病变,部分采用远端脑保护装置;在术后均做心脑血管专科及颈动脉超声检查随访。结果选择性颈动脉造影示32个靶病变均有>70%的狭窄,共置入自膨式支架32个,球囊扩张式支架1个,支架置入成功率为97%;使用远端滤网保护装置21例,使用成功率为95%,在回收的滤网中均发现脱落碎片;4例患者在颈动脉支架置入术后顺利完成外科冠状动脉搭桥术;2例患者在术中分别出现靶病变对侧颅内出血和术后急性肺水肿,3d后死亡。在临床随访观察期间,患者均无脑卒中发生,颈动脉超声检查未发现支架置入段再狭窄。结论经皮颈动脉支架置入术是预防缺血性脑卒中的安全有效方法,也是综合治疗缺血性心脑疾病的新方法。远端保护装置的应用是防止术中脑卒中并发症的必要措施。     

支架置入治疗颈动脉狭窄发生重度低血流动力学状态的危险因素分析

目的分析颈动脉支架置入术(CAS)治疗颈动脉狭窄后发生重度低血流动力学(HD)状态的危险因素。方法回顾性分析85例接受CAS手术的患者,其中男70例,女15例。按照是否发生重度HD(血压≤90/60 mm Hg或心率≤50次/min)状态分为重度HD组18例和非重度HD组67例,观察相关因素对重度HD的影响,并应用多因素Logistic回归分析确定重度HD的独立危险因素。结果多因素Logistic回归分析显示,颈动脉彩色多普勒血流显像(CDFI)高回声斑块(OR=6.219,95%CI:1.163~33.266;P=0.033)、最狭窄处距颈动脉分叉处距离1 cm(OR=8.360,95%CI:1.372~50.930;P=0.021)、基础收缩压120 mm Hg(OR=6.384,95%CI:1.217~33.486;P=0.028)、扩张球囊直径≥5 mm(OR=8.028,95%CI:1.462~44.091;P=0.017)为CAS术后发生重度HD状态的独立危险因素。结论 CDFI高回声斑块、最狭窄处距颈动脉分叉处距离1 cm、基础收缩压120 mm Hg、扩张球囊直径≥5 mm为CAS术后发生重度HD状态的独立危险因素。