血管内支架成形术治疗基底动脉狭窄

目的 探讨血管内支架成形术治疗基底动脉狭窄的近期疗效。方法 20例症状性基底动脉狭窄应用球囊膨胀支架行血管内成形术治疗。结果 12例基底动脉恢复正常管径，8例狭窄程度减小80％以上，无手术相关并发症。无短暂性脑缺血发作(Transient ischemic sttack，TIA)或卒中再发作。脑血管造影随访13例，均无血管再狭窄。结论 血管内支架成形术治疗基底动脉狭窄的近期疗效令人满意。     

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。     

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。     

支架成形术治疗颅内血管狭窄的安全性及短期疗效分析

目的　评价血管内支架成形术治疗颅内动脉狭窄的安全性及短期疗效。方法　对 4 6例患者 5 0处颅内动脉狭窄病变行血管内支架成形术 ,其中基底动脉狭窄 16处 ,椎动脉颅内段狭窄12处 ,颈内动脉颅内段狭窄 13处 ,大脑中动脉狭窄 9处。结果　 5 0处狭窄中有 4 9处成功地进行了支架成形术 (98% ) ,动脉狭窄程度从治疗前的 (72 4± 12 3) %降为 (10 6± 7 8) %。本组患者无手术死亡及缺血性脑卒中 ;4例出现和操作有关的并发症 ,其中 1例发生近端颅外段颈内动脉夹层 ,1例微导丝引起颅内出血 ,2例穿刺部位出现皮下血肿。 37例患者临床随访超过 6个月 (平均 8 5个月 ) ,无缺血性脑卒中发生。结论　血管内支架成形术治疗颅内动脉狭窄的成功率高 ,具有一定的安全性 ,但长期疗效有待于进一步随访     

药物涂层球囊在症状性颅内椎基底动脉狭窄中的初步应用

目的探讨药物涂层球囊(DCB)在治疗症状性颅内椎基底动脉狭窄中的安全性及近期效果。方法回顾性分析2018年9月至2019年12月北京医院神经外科收治的16例应用DCB治疗的症状性颅内椎基底动脉狭窄患者的临床资料。其中男性15例, 女性1例, 年龄(63.1±9.2)岁(范围:48～77岁)。分析患者介入治疗情况、治疗效果及并发症情况。结果 16例患者共有19处颅内椎基底动脉狭窄进行经皮腔内球囊成形术治疗, 患者术前狭窄程度为75%(20%)[M(QR)], 所有DCB均成功置入并实施扩张, 术后残余狭窄率为0(20%);围手术期1例患者出现穿支血管闭塞所致后循环卒中。术后平均影像随访时间5.5个月, 均无再狭窄发生, 平均临床随访时间6.3个月, 均无新发症状。结论对于症状性颅内椎基底动脉狭窄患者, DCB血管成形术相对安全, 近期疗效满意。     

脑血管

椎基底动脉延长扩张症（附4例报道）;颅内海绵状血管捆不同手术方式的回顾性分析;大脑浅静脉吻合静脉的显微解剖及临床应用;颈动脉狭窄支架成形术的长期疗效;颅外段颈动脉狭窄支架成形术安全性探讨;     

经皮血管内支架成形术治疗下肢动脉硬化性闭塞疾病

目的 评价经皮血管内支架成形术（PTAS）,治疗下肢动脉硬化闭塞症（LEAOD）临床效果和应用价值。方法127例LEAOD患者接受了PTAS治疗,制订治疗成功标准并疗效随访,对术前术后踝／肱指数（ABI）统计学分析。结果全组治疗成功率97．64%（124／127）,除3例LEAOD患者PTAS失败外,其余病例均成功,临床症状消失或好转,踝／肱指数（ABI）由0．37±0．15上升为0．87±0．18（P〈0．05）。随访3～60个月,53例髂动脉均血流通畅,临床症状无复发;45例股浅动脉中、上2／3段阻塞和29例股浅动脉下1／3段阻塞,PTAS后6、12、36、60个月的通畅率分别为97．78％、91．11％、84．44％、75．56％及89．66％、79．31％、72．41％、65．52％。结论经皮腔内血管成形术（PTA）和支架成形术（PTAS）治疗LEAOD,可使闭塞血管得到长期的有效开通,显著提高血流动力学指标,是安全有效的治疗方法。     

Wingspan支架治疗颅内动脉粥样硬化狭窄:单中心并发症分析

目的 评价Wingspan支架治疗症状性颅内动脉粥样硬化狭窄的安全性,探讨并发症的相关因素.方法 收集2007年7月至2013年4月在我中心接受Wingspan支架成形术治疗的433例颅内动脉粥样硬化狭窄患者,所有患者病变狭窄程度≥70％且伴有狭窄病变相关的卒中或短暂性脑缺血发作.将本中心术者早期完成的100例病例做为经验积累阶段组,而近期完成的333例做为技术成熟阶段组.采用x2检验或Fisher精确检验对可能影响围手术期并发症的因素进行分析.结果 433例患者中429例成功实施支架成形术(99.1％),狭窄度由术前的(82.3±7.6)％改善为术后的(16.6±6.6)％;围手术期30 d内29例(6.7％)患者出现卒中或死亡,其中致死致残性卒中7例(1.6％);30 d内发生缺血性卒中21例(4.8％),出血性卒中8例(1.8％);基底动脉30 d内总的卒中率、缺血性卒中率、穿支卒中率明显高于其他部位(P＜0.01),而大脑中动脉30 d内出血性卒中发生率明显高于其他部位(3.6％比0.4％,P＜0.05);经验积累阶段组总的围手术期卒中率明显高于技术成熟阶段组(13.0％比4.8％,P＜0.01),但围手术期穿支卒中发生率在经验积累阶段与技术成熟阶段比较差异无统计学意义(3.0％比3.0％,P＞0.01).结论 颅内Wingspan支架成形术安全可行;基底动脉缺血并发症高于其他部位而大脑中动脉出血并发症高于其他部位;操作相关的并发症受术者经验的影响,但穿支并发症并不随术者手术经验的积累而减少.     

血管内支架成形术治疗脑供血动脉狭窄的研究

目的 探讨血管内支架成形术治疗脑供血动脉狭窄患者的近期疗效,并发症及安全性.方法 行血管内支架成形术治疗的19例脑供血动脉狭窄患者,其中颈内动脉起始段狭窄13例[5例表现为短暂性脑缺血发作(TIA),8例表现为脑梗死],椎动脉开口部狭窄6例,均表现为TIA.结果 19例患者支架全部成功置入,术前动脉狭窄程度平均为86%,术后残余狭窄程度平均为10%;明显增高的血流动力学恢复正常且持续保持;颈内动脉系统腩梗死患者NIHSS评分在术后明显改善.3例颈内动脉支架置入术患者出现一过性心率下降和血压下降,经药物治疗后均恢复正常.随访仅1例颈内动脉支架术后22周症状有所加重;1例椎动脉狭窄患者在术后19周出现1次TIA发作;其余患者术后随访6个月无症状复发.结论 血管内支架成形术是治疗脑供血动脉狭窄的一种安全、有效的治疗方法.     

经皮腔内血管成形术治疗糖尿病患者下肢动脉病变

目的评价经皮腔内血管成形术治疗糖尿病患者下肢缺血的疗效。方法回顾分析我科2008年5月～2012年3月经皮腔内血管成形术治疗2型糖尿病下肢缺血89例的l临床资料,记录其内科情况、股胭动脉TASC（泛大西洋协作组）Ⅱ分级、流出道评分、Rutherford分期以及术后30天并发症。随访计算一期通畅率（Kaplan—Meier）、分级情况、保肢率,观察其疗效。结果共89例108条患肢。年龄（70．5±8．6）岁。术前踝肱指数（ABI）中位数0．36（0～0．73）,术后1个月0．79（0．33～1．15,Z=-3．276,P=0．001）。术前胫腓动脉流出道评分中位数7．5分（3．5～10分）,术后即刻中位数6．0分（1．5～9分,Z=-2．948,P=0．003）。股胭及膝下胫腓动脉腔内血管成形术技术成功率分别为97．2％（105／108）和93．3％（98／105）。随访患者86例105条患肢。中位随访时间13个月（5～46个月）,随访期间死亡3例,均死于急性心肌梗死,随访率90．7％（78／86）。术后1年股胭动脉一期通畅率67．3％,胫腓动脉为56．3％,1年保肢率91．9％（34／37）,1年时症状缓解率83．3％（90／108）。结论经皮腔内血管成形术治疗糖尿病合并下肢动脉闭塞性病变症状缓解明显,有较高的保肢率,可以作为糖尿病合并下肢动脉闭塞性病变．特别是膝下病变治疗的首选．远期疗效有待讲一步观察．     

Staged stent-assisted angioplasty for symptomatic intracranial vertebrobasilar artery stenosis

OBJECT: Medically refractory symptomatic vertebrobasilar atherosclerotic disease has a poor prognosis. Studies have shown that longer (> or = 10 mm), eccentric, high-grade (> 70%) stenoses portend increased procedure-related morbidity. The authors reviewed their experience to determine whether a staged procedure consisting of angioplasty followed by delayed (> or = 1 month later) repeated angioplasty and stent placement reduces the morbidity associated with endovascular treatment of symptomatic basilar and/or intracranial vertebral artery (VA) stenoses. METHODS: The authors retrospectively reviewed the medical records in a consecutive series of eight patients who underwent planned stent-assisted angioplasty for medically refractory, symptomatic atherosclerotic disease of the intracranial posterior circulation between February 1999 and January 2002. Staged stent-assisted angioplasty was planned for these patients because the extent and degree of stenosis of the VA and/or basilar artery (BA) lesion portended an excessive procedure-related risk. The degree of stenosis, recent onset of symptoms (unstable plaque), vessel tortuosity, and lesion length and morphological feaures were contributing factors in determining procedure-related risk. Patient records were analyzed for location and degree of stenosis, preprocedural regimen of antiplatelet and/or anticoagulation agents, devices used, procedure-related complications, and clinical and radiographic outcomes. Among the patients in whom staged stent-assisted angioplasty was planned, vessel dissection, which necessitated immediate stent placement, occurred during passage of the balloon in one of them. In a second patient, the stent could not be maneuvered through the tortuous VA. In a third patient, the VA and BAs remained widely patent after angioplasty alone, and therefore stent placement was not required. Significant complications among the eight patients included transient aphasia and hemiparesis in one and a groin hematoma that necessitated surgical intervention in another; there was no permanent neurological morbidity. The mean stenosis before treatment was 78%, which fell to 54% after angioplasty, and the mean residual stenosis after stent placement was 30%. At the last follow-up examination, none of the treated patients had further symptoms attributable to the treated stenosis. CONCLUSIONS: The novel combination of initial angioplasty followed by delayed endoluminal stent placement may reduce the neurological morbidity associated with endovascular treatment of long, high-grade stenotic lesions. Attempting to cross high-grade stenoses with higher-profile devices such as stents may result in an embolic shower. Furthermore, neointimal proliferation and scar formation after angioplasty result in a thickened fibrous layer, which may be protective during delayed stent deployment. Larger-scale studies involving multiple centers are needed to elucidate further the lesion morphological characteristics and patient population most likely to benefit from staged procedures.     

Transluminal stent-assisted angiplasty of the intracranial vertebrobasilar system for medically refractory, posterior circulation ischemia: early results

OBJECTIVE: Symptomatic vertebrobasilar artery stenosis portends a poor prognosis, even with medical therapy. Surgical intervention is associated with considerable morbidity, and percutaneous angioplasty alone has demonstrated mixed results, with significant complications. Recent advances in stent technology have allowed for a novel treatment of symptomatic, medically refractory, vertebrobasilar artery stenosis. We report on a series of patients with medically refractory, posterior circulation stenosis who were treated with transluminal angioplasty and stenting at two medical centers in the United States. METHODS: A retrospective analysis of data for 11 consecutive patients with symptomatic, medically refractory, intracranial, vertebral or basilar artery stenosis was performed. All patients were treated with percutaneous transluminal angioplasty and stenting. Short-term clinical and angiographic follow-up data were obtained. RESULTS: Among 11 patients who were treated with stent-assisted angioplasty of the basilar or vertebral arteries, there were three periprocedural deaths and one delayed death after a pontine stroke. Other complications included a second pontine infarction, with subsequent residual diplopia. The remaining seven patients (64%) experienced symptom resolution and have resumed their preprocedural activities of daily living. Angiographic follow-up examinations demonstrated good patency of the stented lesions for five of seven survivors (71%); one patient exhibited minimal intrastent intimal hyperplasia, and another patient developed new stenosis proximal to the stent and also developed an aneurysm within the stented portion of the basilar artery. The last patient exhibited 40% narrowing of the treated portion of the vessel lumen. CONCLUSION: Recent advances in stent technology allow negotiation of the proximal posterior circulation vasculature. Although the treatment of vertebrobasilar artery stenosis with angioplasty and stenting is promising, long-term angiographic and clinical follow-up monitoring of a larger patient population is needed.     

Stent-assisted angioplasty of intracranial vertebrobasilar atherosclerosis: an initial experience

OBJECT: Patients with intracranial vertebrobasilar artery (VBA) atherosclerotic occlusive disease have few therapeutic options. Unfortunately, VBA transient ischemic attacks (TIAs) herald a lethal or devastating event within 5 years in 25 to 30% of patients. The authors report their initial experience with eight patients in whom medically refractory TIAs secondary to intracranial posterior circulation atherosclerotic occlusive lesions were treated with stent-assisted angioplasty. METHODS: Eight patients (six men), ranging in age from 43 to 77 years, experienced signs and symptoms of VBA insufficiency despite combination therapy with warfarin and antiplatelet agents. Angiographic studies revealed severe distal vertebral (four patients), proximal basilar (one patient), or proximal and midbasilar stenoses (three patients). Aspirin and clopidogrel were administered for 3 days before primary angioplasty and stent placement, and this regimen was maintained by the patients on discharge. Patients underwent heparinization during the procedure and were given a bolus and 12-hour infusion of abciximab. A neurologist specializing in stroke evaluated all patients before and after the procedure. The VBAs in all patients were successfully revascularized with 7 to 28% residual stenosis. Six patients experienced no neurological complications. One patient died the evening of the procedure due to a massive subarachnoid hemorrhage. Two patients had groin hematomas, one developed congestive heart failure, and one had transient encephalopathy. All surviving patients are asymptomatic up to 8 months postoperatively. CONCLUSIONS: Although primary intracranial VBA angioplasty with stent insertion is technically feasible, complications associated with the procedure can be life threatening. As experience is gained with this procedure, it may be offered routinely as an alternative therapy to patients with medically refractory posterior circulation occlusive disease that may develop into catastrophic VBA insufficiency.     

支架成形术治疗症状性脑供血动脉狭窄及其并发症分析

目的探讨应用颈动脉支架成形术治疗症状性脑供血动脉狭窄的安全性、临床疗效及其并发症的防治。方法对经彩色多普勒超声检查筛选,并经脑血管造影确诊的104例症状性脑供血动脉狭窄患者实施支架成形术治疗。分析围手术期及术后随访期相关并发症的发生情况。结果 1例术中出现严重血管痉挛,致手术失败,全组技术成功率99.04%(103/104)。术前平均狭窄率为82.23%,术后残余狭窄率均20.00%。术后1周内患者症状及神经功能缺损体征均有不同程度改善。24例术后3天发生心率减慢,其中20例出现血压下降;1例介入术后第9天脑出血死亡,1例术后10天靶病变部位急性血栓形成。随访2个月～3年,死亡2例,其中82例复查经颅多普勒(TCD)示血流速度正常,12例复查DSA未发现再狭窄、支架移位及缺血性脑卒中。结论颈动脉支架成形术是治疗症状性脑供血动脉狭窄较为安全、有效的方法,严格掌握适应证和熟练操作并规律服药可降低术中及术后风险。     

Angioplasty for intracranial symptomatic vertebrobasilar ischemia

OBJECTIVE: Although anterior circulation disease has both medical and surgical treatment options, management of vertebrobasilar disease has predominantly had only medical options. Some patients remain symptomatic despite medical treatment, and angioplasty has been demonstrated to relieve critical stenoses. However, the elative safety and effectiveness of medical and surgical treatments is not clearly known. This report reviews the clinical characteristics, indications, and procedural risks of intracranial angioplasty in a series of patients with symptomatic posterior circulation ischemia. METHODS: All patients undergoing angioplasty for critical intracranial vertebral or basilar artery stenosis at the University of California at San Francisco Medical Center between June 1986 and July 1999 were included in a retrospective record review. Clinical features and procedural complications were recorded. RESULTS: Angioplasty was performed on 25 vessel lesions in 25 patients in whom medical therapy had failed. The patients ranged in age from 50 to 87 years. Of the 25 stenoses, 10 were intracranial vertebral, 9 vertebrobasilar junction, and 6 basilar in location. Angioplasty was effective in reducing the degree of stenosis by more than 40% in all 25 vessels. The overall risk of stroke or death was 28%, and the risk of disabling stroke or death was 16%. CONCLUSION: Intracranial posterior circulation angioplasty is effective in the reduction of stenosis and can be performed with relative safety. Angioplasty can be considered as a treatment option in patients with recurrent ischemic symptoms despite medical therapy.     

Reoperative carotid surgery

Fourteen patients underwent carotid reoperation for symptomatic recurrent carotid stenosis after previous ipsilateral carotid endarterectomy. Eight of these patients presented with focal transient ischemic attacks, two with strokes, and four with vertebrobasilar insufficiency. Recurrent symptoms in eight patients were similar to those prompting the initial carotid endarterectomy. Symptoms recurred early after previous carotid endarterectomy in 2 patients and late in 12 patients. Eleven patients underwent repeat endarterectomy and carotid patch angioplasty, two patients underwent patch angioplasty alone, and one patient underwent carotid artery replacement with a vein graft. Persistent or recurrent focal symptoms referable to the reoperated carotid artery were not present during follow-up (mean 27.4 months, range 4 to 79 months). Vertebrobasilar symptoms were relieved by carotid reoperation in each patient. Although the natural history of asymptomatic postoperative carotid restenosis is unknown, reluctance to reoperate on symptomatic patients is unwarranted, since carotid reoperation can be performed safely with the expectation that recurrent focal and nonfocal vertebrobasilar symptoms will be relieved.     

Frequency and management of recurrent stenosis after carotid artery stent implantation

OBJECT: To determine the rate of hemodynamically significant recurrent carotid artery (CA) stenosis after stent-assisted angioplasty for CA occlusive disease, the authors analyzed Doppler ultrasonography data that had been prospectively collected between October 1998 and September 2002 for CA stent trials. METHODS: Patients included in the study participated in at least 6 months of follow-up review with serial Doppler studies or were found to have elevated in-stent velocities (> 300 cm/second) on postprocedure Doppler ultrasonograms. Hemodynamically significant (> or = 80%) recurrent stenosis was identified using the following Doppler criteria: peak in-stent systolic velocity at least 330 cm/second, peak in-stent diastolic velocity at least 130 cm/second, and peak internal carotid artery/common carotid artery velocity ratio at least 3.8. Follow-up studies were obtained at approximate fixed intervals of 1 day, 1 month, 6 months, and yearly. Angiography was performed in the event of recurrent symptoms, evidence of hemodynamically significant stenosis on Doppler ultrasonography, or both. Treatment was repeated because of symptoms, angiographic evidence of severe (> or = 80%) recurrent stenosis, or both of these. Stents were implanted in 142 vessels in 138 patients (all but five patients were considered high-risk surgical candidates and 25 patients were lost to follow-up review). For the remaining 112 patients (117 vessels), the mean duration of Doppler ultrasonography follow up was 16.42+/-10.58 months (range 4-54 months). Using one or more Doppler criteria, severe (> or = 80%) in-stent stenosis was detected in six patients (5%). Eight patients underwent repeated angiography. Six patients (three with symptoms) required repeated intervention (in four patients angioplasty alone; in one patient conventional angioplasty plus Cutting Balloon angioplasty; and in one patient stent-assisted angioplasty). CONCLUSIONS: In a subset of primarily high-risk surgical candidates treated with stent-assisted angioplasty, the rates of hemodynamically significant restenosis were comparable to surgical restenosis rates cited in previously published works. Treatment for recurrent stenosis incurred no instance of periprocedure neurological morbidity.     

The correction of cerebrovascular insufficiency by transluminal dilatation: a preliminary report

Transluminal angioplasty is being extensively utilized to dilate arteriosclerotic lesions. However, this technique has not been widely used for the treatment of cerebrovascular insufficiency. This report describes the application of transluminal angioplasty to relieve cerebral ischemia secondary to extracranial arterial stenosis. A total of 10 patients presented with symptoms of vertebrobasilar insufficiency. Bilateral upper extremity pressures were measured prior to the performance of arteriography on all patients. Significant stenoses were found in the subclavian artery (9) and in the innominate artery (1). Dilating catheters were passed retrograde through surgically exposed brachial and common carotid arteries. Transluminal angioplasty under fluoroscopic control was attempted. Anatomic correction of all lesions was achieved without hemorrhagic or embolic complications. The mean increase in brachial systolic pressure was 38.2 mm Hg postdilatation. Initial symptomatic relief was total in seven patients, partial in two, and absent in one. It is believed that associated small vessel brain stem disease accounted for the less than total relief of symptoms of these three patients. Average follow-up for all patients was 13 months with one recurrent subclavian artery stenosis occurring at three months postangioplasty. Preliminary results suggest that some patients with cerebral ischemia secondary to extracranial arterial stenosis can be treated safely by transluminal angioplasty.