大血管闭塞性急性缺血性卒中机械取栓治疗影像学评估的研究进展

大血管闭塞性急性缺血性卒中(LVO-AIS)患者行机械取栓治疗,血管再通成功率高且能带来显著获益。随着治疗时间窗的延长,合理的影像学评估对于患者行机械取栓治疗至关重要。不同的影像学方法在检查内容及提供的信息上各有优势,关键影像学信息有助于临床医师的治疗决策。本文将对LVO-AIS患者机械取栓影像学评估方法进行综述。     

急性缺血性卒中机械取栓术中隐藏动脉瘤破裂一例并文献复习

机械取栓术被越来越多地应用于大血管闭塞性急性缺血性卒中的治疗。隐藏动脉瘤破裂是急性缺血性卒中机械取栓术中较为少见的并发症之一。该文报道1例急性缺血性卒中机械取栓术中隐藏动脉瘤破裂的病例,结合文献分析了出现该术中并发症的原因及危险因素,并提出预防及处理该并发症的方法,以供临床医师参考。     

急性前循环大血管闭塞性卒中患者超时间窗机械取栓的治疗效果研究

目的 分析急性前循环大血管闭塞性卒中患者超时间窗机械取栓的治疗效果。方法 本研究为回顾性队列研究。选取2019年1月至2022年5月在南阳市中心医院住院治疗的急性前循环大血管闭塞性卒中患者93例，其发病至入院时间均>24 h，且影像学检查显示存在明显的缺血半暗带。根据患者是否接受机械取栓将其分为对照组（n=49）和取栓组（n=44）。对照组患者给予常规药物治疗和标准护理，取栓组患者在对照组基础上进行机械取栓。比较两组患者基线资料、影像学资料，记录取栓组患者手术相关情况。所有患者于术后90 d通过电话进行随访，主要结局指标为术后90 d改良Rankin量表（mRS）评分，次要结局指标为术后90 d预后良好（mRS评分为0～2分）、mRS评分为0～3分、死亡、脑梗死复发情况及症状性颅内出血（sICH）发生情况。结果 取栓组患者手术方式：单纯抽吸取栓5例（11%），支架取栓39例（89%）；手术相关并发症：动脉夹层2例（5%），新发部位栓塞3例（7%）；取栓次数为1(1)次；植入支架19例（43%）;mTICI分级：0～1级2例（5%）,2a级3例（7%）,2b级27例（61%）,3级...     

应用Solitaire AB支架机械取栓联合溶栓治疗颅内静脉窦血栓形成的疗效观察

目的 探讨应用Solitaire AB支架进行颅内静脉窦血栓机械取栓的安全性和有效性.方法 回顾性分析广东省人民医院2010年1月--2012年10月应用Solitaire AB支架对颅内静脉窦血栓机械取栓的16例患者的临床资料,并进行3个月至1年的随访.结果 ① 16例患者中男6例,女10例.单纯上矢状窦血栓4例,上矢状窦＋侧窦血栓4例,上矢状窦及皮质静脉血栓3例,横窦及乙状窦血栓2例,上矢状窦及直窦血栓2例,上矢状窦＋直窦及皮质静脉血栓1例.②应用Solitaire AB支架20枚,同时应用尿激酶30万~70万U进行接触性溶栓3例.16例患者术后症状均明显改善,入院时格拉斯哥昏迷量表评分：3分1例,12分1例,15分14例.出院时格拉斯哥预后量表评分5分15例,4分1例.无一例患者发生支架取栓相关并发症.③随访3个月至1年,其中通过电话随访2例,门诊随访3例,MRV随访8例,DSA随访3例,无一例复发.结论 应用Solitaire AB支架进行颅内静脉窦机械取栓可显著改善患者的临床症状,单中心的经验显示无明显并发症发生.     

Fograty球囊导管在自体动静脉瘘血栓取栓术中的应用效果观察

目的 观察用Fograty球囊导管行自体动静脉内瘘血栓取栓术的疗效.方法 用Fograty球囊导管行自体动静脉内瘘血栓取栓术58例.结果 患者自体动静脉内瘘血栓均被完全取出,开放血管后血流恢复.49例患者术后内瘘保持畅通至今.9例术后约1 a再次血栓形成,均再次取栓均成功,次日有5例再次形成,2例改行腹膜透析,3例行颈内静脉长期留置管.结论 Fograty球囊导管用于自体动静脉内瘘血栓取栓疗效满意.     

急性缺血性脑卒中桥接治疗与直接血管内机械取栓的研究进展

静脉溶栓是治疗急性缺血性脑卒中患者的重要手段,但因受限于较窄的治疗时间窗、低再通率等因素,部分患者并未获得显著的疗效。血管内机械取栓的出现不仅扩大了治疗时间窗,而且可以使患者获得更高的再通率。目前对桥接治疗(采取静脉溶栓后再进行血管内机械取栓)与直接血管内机械取栓的临床疗效及预后尚存争议,本文针对桥接治疗与直接取栓治疗的优势与局限、临床证据、随机对照试验等研究情况综述如下。     

颈内动脉夹层并颈内动脉/大脑中动脉串联闭塞致醒后脑梗死机械取栓术成功一例并文献复习

大动脉粥样硬化所致脑梗死较为常见,而颈内动脉夹层并颈内动脉/大脑中动脉串联闭塞所致醒后脑梗死较为少见,单纯内科治疗预后较差。本文报道了1例颈内动脉夹层并颈内动脉/大脑中动脉串联闭塞所致醒后脑梗死患者,成功行机械取栓术且预后良好。通过复习相关文献发现,颈内动脉夹层并颈内动脉/大脑中动脉串联闭塞行机械取栓术是安全、有效的,而取栓术后颅内血管再通及Willis环代偿良好的患者未行颈动脉夹层处支架成形术也许是安全可行的。     

急性缺血性卒中机械取栓治疗技术概述

随着精准的筛选和材料的改进，机械取栓已成为急性大血管闭塞卒中推荐等级最高的治疗方案。技术的命名是基于材料的发展，机械取栓材料主要包括取栓支架及抽吸导管。支架及抽吸导管单独或联合使用产生了眼花缭乱的技术命名。本文对急性缺血性卒中机械取栓治疗技术进行概述，并对我国人群发病更高的颅内动脉粥样硬化性大血管闭塞的取栓技术进行梳理。     

彩色多普勒血流显像和超声造影鉴别诊断门静脉良恶性栓子临床研究

正门静脉栓子是肝癌重要的生物学特性之一,常有癌栓和血栓两种。临床上,对于门静脉栓子鉴别的"金标准"是取门静脉内栓子行病理学检查,但是病理穿刺活检难度大且限制因素多,如凝血功能障碍者不能穿刺活检等,常以实验室和影像学检查以及随访观察等方法进行鉴别。彩色多普勒血流显像常用于发现门静脉栓子,确定栓子的存在,但仍难以鉴别栓子的良恶性质,而超声造影通过观察造影剂的填充特征,则有利于临床判断。我们对60例门静脉栓子患者采用彩色多普勒血流     

机械取栓治疗急性基底动脉闭塞患者预后的影响因素研究

背景急性基底动脉闭塞(ABAO)是缺血性脑卒中的一种,其起病急、预后差,因此如何根据相关指标判断预后情况显得极为重要。目的探讨机械取栓治疗ABAO患者预后的影响因素。方法选取2018年1月—2019年1月南阳市中心医院接受机械取栓治疗的ABAO患者53例,根据90 d改良Rankin量表(mRS)评分分为预后良好组(n=28)及预后不良组(n=25)。比较两组患者一般资料,发病至穿刺时间,手术时间,入院、治疗24 h、治疗30 d美国国立卫生研究院卒中量表(NIHSS)评分,血栓长度,血栓位置,血流再通分级,侧支循环分级,症状性颅内出血及死亡情况。ABAO患者的预后影响因素分析采用多因素Logistic回归分析。结果预后良好组患者手术时间、血栓长度短于预后不良组,入院、治疗24 h、治疗30 d NIHSS评分低于预后不良组,血流再通分级、侧支循环分级优于预后不良组,病死率低于预后不良组(P0.05)。行多因素Logistic回归分析结果显示,治疗24 h NIHSS评分[OR=22.294,95%CI(2.989,166.275)]和侧支循环分级[OR=0.010,95%CI(0.001,0.151)]是机械取栓治疗ABAO患者预后的影响因素(P0.05)。结论治疗24 h NIHSS评分、侧支循环分级是机械取栓治疗ABAO患者预后的影响因素。     

Instant dissolution of intracoronary thrombus by abciximab

Formation of intracoronary thrombus during percutaneous coronary intervention can lead to acute vessel closure and myocardial infarction if prompt action is not taken. Thrombus removal using mechanical thrombectomy is the common treatment approach. We report a rare case of thrombus formation immediately after guidewire advancement, causing acute myocardial ischemia. Intracoronary bolus of abciximab was given and this resulted in prompt dissolution of the thrombus. The procedure proceeded uneventfully and there was no myocardial damage. This is consistent with a recent report suggesting that intracoronary abciximab may be more beneficial than standard intravenous administration for patients undergoing emergency coronary intervention for acute coronary syndrome.     

Use of a new thrombus extraction catheter (the Pronto) in the treatment of acute myocardial infarction

The finding of an intracoronary thrombus at the time of coronary angiography is common in patients presenting with an acute coronary syndrome. Pharmacologic and mechanical treatment strategies have been developed and reported to facilitate the treatment of the thrombus along with a percutaneous coronary intervention. We report a case in which a Pronto thrombectomy catheter was utilized to facilitate thrombus removal prior to the placement of a coronary stent in a patient who developed postinfarct angina and pulmonary edema after successful thrombolytic therapy for a acute ST segment elevation myocardial infarction.     

Management of proximal deep vein thrombosis

Iliofemoral DVT constitutes approximately 20-25% of lower limb DVT and represents a specific subgroup of patients at highest risk for post-thrombotic syndrome (PTS). Anticoagulation alone has no significant thrombolytic activity and has not impact on PTS prevention. Early thrombus removal has reduced PTS in uncontrolled reports and reviews but major trials are awaited. The optimal timing for treatment appear to be thrombus <2 weeks old and, methods for thrombus removal include direct open or suction thrombectomy, catheter directed thrombolysis (CDT), with or without percutaneous mechanical thrombectomy (PMT) devices. Three principle types of PMT device are in use (rotational, rheolytic and ultrasound enhanced devices) and are combined with CDT in pharmocomechanical thrombolysis (PhMT) to enhance early thrombus removal. These devices have individual device specific attributes and side effects that are additional to the bleeding complications of thrombolysis. A number of additional interventions may be utilised to the improve results of CDT and PhMT. IVC filter deployment to reduce periprocedural PE, is supported by little evidence unless an indication for its use already exists. However, balloon venoplasty and vein stents undoubtedly vein patency after treatment. Early thrombus removal comes with additional upfront costs derived from devices, imaging and critical care bed usage. However, significant potential savings from reduction in PTS and rethrombosis rates may reduce overall societal costs. This review focuses on iliofemoral thrombosis, however, the less commonly encountered but clinically important subclavian vein thrombosis is also discussed.     

双支架并联取栓术治疗急性基底动脉闭塞初步研究

目的初步探讨双支架取栓治疗急性基底动脉闭塞患者的可行性、有效性及安全性。方法回顾性分析采用Solitaire FR双支架并联取栓术治疗血栓负荷重的急性基底动脉闭塞所致脑梗死5例患者,统计手术时间,评价取栓后即刻血流再灌注、24 h神经功能改善及术后90天随访mRS评分。结果 5例患者均通过双支架并联取栓术获得闭塞血管良好再通,改良脑梗死溶栓分级(mTICI)为2b-3级,其中完全再通4例(mTICI 3级)。无明显与操作相关并发症,术后24 h NIHSS评分较术前减少10分。术后90天随访,2例患者预后良好,2例残疾,1例患者死亡。结论使用Solitaire FR双支架并联取栓术治疗血栓负荷重的部分后循环急性脑梗死患者是安全有效的。     

Thrombectomy During Primary Angioplasty: Methods,Devices, and Clinical Trial Data

Distal embolization is a relatively common complication in primary angioplasty and is associated with poor perfusion and higher mortality. The aim of this article is to critically review literature on thrombectomy devices to prevent distal embolization in patients undergoing primary angioplasty. Several manual and mechanical devices have been proposed. Although negative data have been observed with mechanical devices, significant impact on mortality has been observed with routine use of manual thrombectomy devices, due to an improvement in myocardial perfusion and reduction in distal embolization. Therefore, routine adjunctive manual thrombectomy devices should be recommended in the setting of ST-segment elevation myocardial infarction, whereas the use of larger manual thrombectomy devices (7F) or mechanical devices may be considered in patients with large thrombotic burden to provide more guarantees for complete thrombus removal.     

Intracoronary thrombolytic therapy: A Treatment Option for Failed Mechanical Thrombectomy

The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have “failed” thrombectomy characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 66‐year‐old woman who was admitted to our institution with chest pain associated with inferior ST segment elevation. Coronary angiography showed a thrombotic occlusion of the right coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with intracoronary tenecteplase. Repeat coronary angiography 18 hr later revealed marked thrombus resolution with thrombolysis in myocardial infarction (TIMI) grade 3 anterograde flow and patency of the infarct‐related artery was maintained at 2‐month follow up. This case demonstrates the potential for intracoronary thrombolytic therapy as a treatment option for the management of patients following failed thrombectomy in PPCI. © 2011 Wiley Periodicals, Inc.     

Rheolytic thrombectomy with AngioJet catheter during transluminal coronary revascularization in patients with acute myocardial infarction

BACKGROUND: Although balloon angioplasty and stenting are effective in the treatment of acute myocardial infarction (M1), reduced coronary flow and distal embolization frequently complicate interventions when thrombus is present. Adjunctive treatment with mechanical thrombectomy devices was suggested to reduce these complications. METHODS: We evaluated immediate angiographic, in-hospital and 30-day follow-up clinical outcomes of 185 patients with acute MI and angiographically evident thrombus who were treated with AngioJet rheolytic thrombectomy followed by immediate definitive treatment. RESULTS: Procedural success (residual diameter stenosis <50% and thrombolysis in myocardial infarction [TIMI] flow >2 after final treatment) was 97%. Rheolytic thrombectomy success was achieved in 7% of patients. Subsequent definitive treatment included stenting in 67% and balloon angioplasty alone in 26% of patients. Final TIMI 3 flow was achieved in 89%. AngioJet treatment resulted in mean thrombus area reduction from 69.6 mm(2) at baseline to 17.3 mm(2) post-thrombectomy (p<0.001). Procedural complications included distal embolization (7.6%) and perforation (1.1%). Clinical success (procedure success without major in-hospital cardiac events) rate was 88%, in-hospital mortality - 7.0%. There were no further major adverse events during 30-day follow-up. CONCLUSION: Rheolytic thrombectomy can be performed safely and effectively in patients with acute MI, allowing for immediate definitive treatment of thrombus-containing lesions.     

Percutaneous rotational thrombectomy reduces acute reocclusion in an animal model of acute coronary thrombosis

This study was designed to compare acute reocclusion rates after treatment of acute coronary thrombosis with a percutaneous thrombectomy device or standard balloon angioplasty. Our group has previously reported on the rationale and development of a mechanical device for the treatment of intra-arterial thrombosis. This device removes fibrin from thrombus, allowing for dissolution of the cellular elements of the thrombus. Theoretically, thrombus removal (as opposed to displacement) might result in a lower rate of acute rethrombosis. The present study utilizes the device percutaneously in the coronary arteries of closed chest swine and compares recanalization and reocclusion rates with standard balloon angioplasty. Twenty-six animals with total thrombotic coronary occlusions were treated; 13 with each device. Reocclusion rates with the thrombectomy device were significantly reduced at 60 min and 120 min after recanalization (p < 0.02), and the mean time to reocclusion was prolonged by 45 min (p = 0.07). Technical problems included poor handling characteristics in early prototypes and stress fractures secondary to improper use. Changes in catheter design and operator protocols have largely eliminated these problems. We conclude that this study demonstrates the feasibility of percutaneous mechanical thrombectomy in the coronary arteries and that reocclusion rates after recanalization of thrombotic occlusions compare favorably to standard angioplasty. © 1993 Wiiey-Liss, Inc.     

Manual thrombosuction in patients with acute myocardial infarction receiving primary coronary interventions--two case reports

Acute myocardial infarction (AMI) can be caused by a ruptured plaque with sudden thrombosis occlusion or an embolization formation. Previous investigations have described the use of thrombolytic therapy, balloon angioplasty plus stenting, and various mechanical thrombectomy devices to treat patients with AMI with intracoronary thrombus, but all of these methods have certain limitations. The authors report 2 cases of AMI, 1 caused by ruptured plaque and the other caused by embolization, with large thrombus formation and total occlusion of the infarct-related artery. Manual thrombosuction with the Export catheter proved effective and safe for treating these 2 patients and achieved final thrombolysis in myocardial infarction (TIMI) III flow with good myocardial brushing.     

Arch thrombus formation in an apparently normal aorta as a source for recurrent peripheral embolization

A floating thrombus in an apparently normal aortic arch is a rare and often neglected source for systemic embolic events. When no other underlying pathology for systemic embolization can be found, transesophageal echo (TEE) and magnetic resonance imaging (MRI) are the diagnostic methods of choice and should be performed in order to detect thrombus formations in the thoracic aorta. We report a case in which a floating thrombus in the aortic arch was the source of emboli into both femoral arteries. Successful bilateral thrombectomy was performed. To prevent repeat embolization, we performed surgery under deep hypothermic circulatory arrest with removal of the thrombus and plication of the aortic wall at the site of thrombus adhesion.