经颅多普勒超声对大脑中动脉狭窄患者支架置入后的随访研究

目的通过经颅多普勒超声（TCD）评估大脑中动脉狭窄患者支架置入（MCAS）前、后的血流动力学变化及再狭窄的发生率,并分析其相关影响因素。方法前瞻性纳入2006年1月-2012年4月,因症状性大脑中动脉狭窄接受支架置入的患者共62例（62枚支架）。采用TCD检测支架置入术前、术后1周及3、6、12个月大脑中动脉狭窄段、狭窄远段和大脑前动脉、大脑后动脉的血流动力学参数,判断12个月时的再狭窄发生率。分析残余狭窄、支架类型及疾病危险因素对MCAS术后再狭窄的影响。结果①MCAS术前、术后1周MCA狭窄段的收缩期峰值流速（PSV）和平均流速（MFV）分别由（308±59）cm／s和（218±51）cm／s降至（159±54）cm／s和（102±39）cm／s,差异有统计学意义（P〈0．01）。@TCD术后1周残余狭窄的检出率为11．3％（7／62）,术后1年的再狭窄发生率为19．4％（12／62）。③经多因素Logistic回归分析,糖尿病（P=0．024,OR=7．048,95％CI：1．286～38．617）和残余狭窄（P=0．040,OR=8．995,95％CI：1．110～72．911）是支架置人后再狭窄的独立危险因素。④是否规律服用降脂类药物的患者,MCAS再狭窄发生率差异有统计学意义[7．4％（2／27）比36．4％（8／22）,P=0．032]。结论TCD可以作为客观评估MCAS前、后血流动力学改变以及远期疗效观察的重要手段。糖尿病和术后残余狭窄是再狭窄发生的独立危险因素。术后规律性服用降脂类药物,可以降低MCAS再狭窄的发生率。     

Assessment of flow changes in the circle of Willis after stenting for severe internal carotid artery stenosis.

PURPOSE: To assess flow velocities in the cerebral arteries after carotid artery stenting (CAS) in patients with unilateral versus bilateral lesions and analyze velocities in patients with neurological complications after CAS. METHODS: Ninety-two patients (68 men; mean age 63.2 +/- 8.4 years, range 44-82) with internal carotid artery (ICA) stenoses were divided according to unilateral (group I, n = 72) or bilateral (group II, n = 20) disease. Fifty age- and gender-matched patients without lesions in the extra- or intracranial arteries served as a control group. Transcranial color-coded Doppler ultrasound was performed prior to and within 24 hours after CAS in the test groups; systolic velocities were assessed ipsilateral (i) and contralateral (c) to the CAS site in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). RESULTS: Collateral flow via the anterior communicating artery (ACoA) was found in all group-II patients and 90% of group-I patients. After CAS, collateral flow through the ACoA ceased, and the velocity increased by 26% in the iMCA in group I compared to controls (p < 0.001). In group II, iMCA flow increased by 30% (p < 0.001) and flow via the ACoA (p < 0.001) increased, resulting in normalization of cMCA velocities (p = 0.928). In 89 (96.7%) subjects, CAS was uncomplicated. Hyperperfusion syndrome occurred in 2 (2.2%) patients, both with bilateral ICA stenoses; 1 (1.1%) transient ischemic attack was seen in a patient with unilateral disease. In the patients with hyperperfusion syndrome, the MCA velocities were 2.7- and 7.4-fold higher, respectively, versus before CAS and 2-fold higher than in controls. CONCLUSION: Uncomplicated CAS results in an iMCA velocity increase >25% compared to controls. MCA velocities in hyperperfusion syndrome were greatly increased versus before CAS and in controls.     

经颅多普勒超声检测颈内动脉颅外段支架置入术后脑血流动力学的改变

目的 评价经颅多普勒超声（TCD）在检测双侧颈内动脉病变患者支架置入术后脑血流动力学变化中的价值.方法 选择经DSA证实的双侧颈内动脉颅外段（ICAe）重度狭窄（8例）或一侧重度狭窄、另一侧闭塞（10例）患者,共18例.应用TCD榆测支架置入前、后颅内、外动脉血流动力学参数的变化.结果 ①TCD对ICAe闭塞诊断的敏感性为100%（10/10）,对狭窄或闭塞诊断的特异性为96%（25/26）,总体符合率为97%（35/36）.②术前ICAe狭窄段收缩期峰值流速（PSV）为（241 ±55）cm/s,术后1、3、6、12、24个月分别为（59 ±15）、（58±12）、（59 ±15）、（61 ±14）、（64 ±16）cm/s,与术前比较,差异均有统计学意义（P〈0.01）,而术后各阶段比较,差异尤统计学意义.③术后支架侧大脑中动脉（MCA）的PSV较术前升高[（59 ±14）、（120±24）cm/s,P=0.000],血管搏动指数（PI）明显改善（0.64 ±0.15,1.05 ±0.19;P=0.000）.术后闭塞侧MCA的PSV亦有所升高[（48 ±17）、（70 ±16）cm/s,P=0.005],而PI值的变化不明显（P=0.379）.④术前有2例前交通动脉（AcoA）开放,双侧颈动脉置入支架后,AcoA关闭;术后有11例AcoA开放,其中10例为一侧闭塞,另一侧狭窄的患者,1例为双侧重度狭窄而仪一侧置人支架的患者.术前后交通动脉（PcoA）开放24支（10例为双侧同时开放,4例为单侧开放）,术后18支PcoA关闭（6例为双侧同时期,6例为单侧关闭）.结论 TCD可用于双侧ICAe病变患者术前、术中、术后颅内外血流动力学变化的评估.     

Covered versus bare self-expanding stents for endovascular treatment of carotid artery stenosis: a stopped randomized trial.

PURPOSE: To investigate whether filter-protected carotid artery stenting (CAS) using a covered self-expanding stent reduces the risk of cerebral embolization. METHODS: Fourteen asymptomatic patients (13 men; median age 77 years, IQR 73-83) were enrolled in a randomized pilot trial comparing the rates of cerebral microembolism during and after filter-protected CAS using either a self-expanding covered (n=8) or a bare (n=6) carotid stent. Transcranial Doppler (TCD) monitoring was done during and for 90 minutes after the procedure. Diffusion-weighted magnetic resonance imaging (DW-MRI) was performed before and 24 hours after CAS. Patients were followed for 6 months for neurological events and occurrence of restenosis. RESULTS: A significant reduction in ipsilateral microembolic signals by TCD was observed with the covered (median 1, IQR 0-4) versus the bare stent (median 6, IQR 3-8; p=0.043). Comparison of the preprocedural and 24-hour postprocedural DW-MRI images showed no new ipsilateral lesions but 1 new lesion in the contralateral hemisphere in the covered stent group, resulting in an overall 7% (95% CI 0%-20%) rate of new ischemic lesions. No neurological complications occurred up to 6 months. Restenosis (>70%) occurred in 3 (38%) of 8 patients with the covered versus none of the bare stents (p=0.21). The trial was stopped when the third restenosis of a covered stent was detected. CONCLUSION: Self-expanding covered stents potentially reduce the risk of cerebral microembolism during and after carotid stenting. However, the problem of in-stent restenosis has to be resolved before these devices can be considered for further investigation.     

Evaluation of cerebral circulation in patients with significant carotid artery stenosis

BACKGROUND: A significant proportion of ischaemic stroke episodes are caused by atherosclerotic lesions in extracranial arteries. Assessment of haemodynamical profile of cerebral arteries in both symptomatic and asymptomatic patients with carotid artery stenosis is of clinical importance. AIM: To assess haemodynamic changes in cerebral arteries in patients with significant internal carotid artery (ICA) stenosis. METHOD: Patients (n=109) were divided into the following groups: group I (GI) - 42 subjects (64.6+/-9.0 years) with asymptomatic ICA stenosis > or =70%; and group II (GII) - 67 subjects (63.4+/-7.1 years) after stroke. The control group consisted of 30 patients (60.3+/-8.9 years) without significant stenoses of extracranial arteries on USG and angiography. In all cases ultrasonographic evaluation of flow velocities and directions in cerebral arteries within the circle of Willis and collateral flow was performed. RESULTS: The severity of ICA stenosis did not differ significantly between GI and GII. Patients in GI had flow velocity in the middle cerebral artery (MCA) increased by 15.7% and by 40.8% in the anterior cerebral artery (ACA) contralateral to the ICA stenosis (p<0.001 and p<0.001), whereas in GII no significant changes in flow velocity in these arteries were observed in comparison with the control group. Patients in the groups I and II had lower flow velocities in MCA ipsilateral to the ICA stenosis, however values for GII patients were significantly lower than in GI patients (p<0.001). The presence of collateral circulation through the anterior and posterior communicating arteries (ACoA and PCoA) was similar in GI and GII; however, the flow velocities in the ipsilateral MCA and ACA were significantly higher in asymptomatic patients (GI). The frequency of active collateral circulation through both ACoA and PCoA increased along with the increase of ICA stenosis severity (p=0.003; p<0.001). CONCLUSIONS: Collateral flow in the circle of Willis in subjects with ICA stenosis occurs equally often in symptomatic and asymptomatic patients; however, it is more efficient in patients without symptoms. The rate of development of collateral circulation depends on ICA stenosis severity. The important role in maintaining collaterals within the circle of Willis is played by ACoA, although in some patients MCA may also be supplied by PCoA.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉粥样硬化性狭窄患者支架置人术围手术期并发症的防治探讨

目的探讨颈动脉支架置入术(CAS)治疗颈动脉粥样硬化性狭窄患者围手术期并发症防治的初步经验。方法回顾性分析413例动脉粥样硬化性颈动脉狭窄患者经全脑血管数字减影血管造影术诊断后,均采用自膨式支架经股动脉入路行CAS治疗,术中及术后严密监控血压、心率、意识等生命体征,并采取综合措施防止并发症的发生。结果 413例患者中,CAS成功412例(99.8%)。CAS前狭窄率70%～95%,CAS后残余狭窄率为0～20%,患者脑缺血症状及体征均有明显改善。脑出血5例,治愈2例,死亡3例;CAS后3 d发生支架内血栓形成1例,经溶栓治疗后血管再通;支架内再狭窄2例,均行二次CAS治疗;消化道出血1例,对症治疗痊愈;股动脉穿刺处假性动脉瘤5例,经超声波引导定点压迫痊愈2例,瘤腔内注射凝血酶治愈3例;临时起搏器电极造成心室壁穿孔引起心包填塞1例,经紧急开胸手术修补治愈;低血压导致心内膜下心肌梗死2例,经适当升压症状缓解。结论 CAS微创安全有效,围手术期应采取综合措施预防CAS后并发症的发生,以确保疗效。     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

颈动脉内膜切除术和支架置入术后再狭窄的诊断和治疗

作为一种经典的血管重建方式,颈动脉内膜切除术(carotid endarterectomy,CEA)已被广泛用于颅外颈动脉重度狭窄的治疗.近年来,颈动脉支架置入术(carotid artery stenting,CAS)已有逐步取代CEA的趋势.大量临床研究发现,除围手术期并发症外,CEA和CAS后颈动脉再狭窄对患者的预后也具有重要影响.文章就CEA和CAS术后再狭窄的诊断和治疗研究现状做了综述.     

经颅多普勒超声对颈动脉内膜切除术中选择性分流的评价

目的 采用经颅多普勒(transcranial Doppler,TCD)评价选择性分流在颈动脉内膜切除术(carotid endarterectomy,CEA)中的实施效果.方法 采用TCD对169例接受CEA治疗的颈动脉狭窄患者行术中双侧大脑中动脉(middle cerebral artery,MCA)脑血流连续监测.根据是否实施分流术,将患者分类为分流组(n=32)和未分流组(n=137).记录术前侧支循环开放途径,比较麻醉后、颈动脉夹闭前后、分流前后以及颈动脉开放后双侧MCA的收缩期峰值血流速度(peak systolic velocity,PSV)、平均血流速度(mean velocity,MV)、血管搏动指数(pulsatility index,PI)和MV变化率.结果 颈动脉夹闭前分流组与未分流组MV分别为(34.73±13.54)cm/s和(35.32±13.18)cm/s,无显著差异(P=0.825).颈动脉夹闭后分流组MV较未分流组显著降低(P=0.000),MCAMV下降率平均为69.34%±20.93%,较未分流组显著降低(P=0.000).分流后MCA MV显著提高,平均提高(35.68±16.69)cm/s(P=0.000).结论 TCD可客观评价分流前后的脑血流动力学改变.     

症状性大脑中动脉狭窄患者支架置入术后再狭窄影响因素的分析

目的 探讨症状性大脑中动脉（MCA）狭窄患者支架置入术后再狭窄的影响因素。方法 回顾性分析113例症状性MCA狭窄并且行支架置入术患者的临床资料，以TCD、DSA随访支架置入后的再狭窄率。狭窄率判定标准参照北美症状性颈动脉内膜切除试验的方法，术后MCA狭窄率〉50％为再狭窄。按MCA狭窄长度分为〈5mm、5～10mm、〉10mm；按置入支架类型分为裸支架与药物支架。分析MCA狭窄长度、置入支架种类及危险因素与再狭窄的相关性。对有、无相关危险因素再狭窄率的差异显著性采用卡方检验。结果 113例患者有161处狭窄，置入支架129枚。术前MCA平均狭窄率为（80．8±8．8）％，术后即刻平均狭窄率为（3．7±8．2）％。随访89例患者（78．8％），平均随访时间为（28．7±16．4）个月（3个月至5年）。TCD随访63例；随访26例。16例（16／89，17．9％）出现〉50％的再狭窄，其中病变长度〈5mm者再狭窄4例（4／39。10．2％），5～10mm者11例（11／47，23．4％），〉10mm1例（1／3）。置入裸支架后再狭窄15例（15／80，18．8％），置入药物洗脱支架再狭窄1例（1／9）。16例再狭窄患者伴糖尿病11例、高血压10例、高脂血症6例、糖尿病＋高血压4例、吸烟9例、饮酒5例及冠心病2例。有、无相关危险因素的再狭窄率差异无统计学意义，P均〉0．05。结论 术后再狭窄原因可能与支架类型有关，不除外与糖尿病有关。其他影响因素尚待进一步研究。     

超声监测在颈动脉内膜切除术围手术期的应用

目的探讨彩色多普勒超声（CDFI）与经颅多普勒超声（TCD）的联合应用,在颈动脉内膜切除术（CEA）中的临床价值。方法 CEA前采用CDFI和TCD评价186例患者颈动脉的狭窄程度及颅内侧支循环开放情况,将其结果与DSA对照。术中应用TCD对双侧大脑中动脉（MCA）在CEA不同阶段的血流动力学变化进行动态监测,指导转流管的使用。术后即刻行TCD和CDFI检查,评估手术前后术侧颈动脉的内径变化及颅内外血流动力学参数的变化。结果①186例患者CDFI检出狭窄程度与DSA完全一致的为178例,与DSA对照,CDFI判断颈动脉中、重度狭窄的符合率为95.7%。②术中CDFI和TCD监测的186例患者中,167例侧支循环建立良好,无需放置转流管,其余19例颈动脉压迫试验显示代偿不完全。③术后即刻复查CDFI、TCD,186例患者经CEA后狭窄均得到解除,管径明显增宽,狭窄处残余内径由（1.5±0.4）mm增至（5.9±0.7）mm,差异有统计学意义,P〈0.01;颈动脉狭窄处收缩期峰值流速（PSV）及患侧MCA的舒张期末血流速度（PSV）、血管搏动指数（PI）恢复正常。颈动脉狭窄处血流速度由术前（547±51）cm/s降至（89±28）cm/s（P〈0.01）;患侧MCA的PSV由术前（58±14）cm/s升至（80±5）cm/s（P〈0.01）;患侧MCA的PI由术前的0.56±0.11升至0.92±0.13（P〈0.01）,脑部血液供应得到明显改善。结论CDFI和TCD在CEA术前筛查、术中监测及术后评估中,提供了可靠的客观依据,在CEA围手术期有很重要的临床应用价值。     

应用经颅多普勒超声指导颈动脉内膜切除术中脑血流的调节

目的探讨颈动脉内膜切除术中，经颅多普勒超声（TCD）对血压与脑血流调节指导作用。方法回顾性分析颈动脉重度狭窄患者52例，在全身麻醉下行颈动脉内膜切除术，术中应用TCD监测大脑中动脉（MCA）血流参数，根据脑血流参数的变化调控血压，并决定术中是否应用临时转流管。应用临时转流管（转流组）16例，未用36例（非转流组）。结果①52例患者术后，完全恢复且无脑缺血发作50例，因过度灌注脑出血死亡2例。②颈动脉阻断前，转流组、非转流组平均动脉压（MAP）为（111±9）、（97±15）mmHg，两组比较差异有统计学意义，P〈0．01；MCA平均血流速度（MCA Vm）为（40±12）、（39±13）cm／s，差异无统计学意义。③阻断后，转流组、非转流组MAP为（118±8）、（106±9）mmHg，较阻断前差异均有统计学意义（P〈0．01）；MCA Vm为（14±8）、（33±16）cm／s，较阻断前均下降，平均血流速度变化率为（66±6）％、（15±5）％，P〈0．01。④转流组转流中，MAP（110±13）mmHg，接近阻断前水平；MCA Vm为（44±15）cm／s，MCA Vm较阻断前提高（10±2）％。⑤开放后两组MAP为（90±12）、（93±11）mmHg；MCA Vm为（55±19）、（54±23），较阻断前提高，平均血流速度变化率为（36±3）％、（37±4）％。差异均有统计学意义，P〈0．05。⑤术中转流组、非转流组呼气末二氧化碳分压为（31．0±2．5）、（31．8±2．2）mmHg，差异无统计学意义。结论颈动脉内膜切除术中应用TCD监测，可评价脑血流灌注情况，指导血压的调控及术中转流管的选择。