远端保护装置下颈动脉支架术预防卒中的安全性和有效性研究

目的探讨在远端保护装置下行颈动脉支架术对预防缺血性脑卒中的安全性、可行性以及中、远期临床效果。方法对2002-2005年住院的58例颈动脉狭窄超过70％的患者,在置入远端保护伞装置后行颈动脉支架置入术,术后行心脑血管专科及颈动脉超声检查随访。结果58例患者中57例成功置入远端保护伞装置,远端保护伞装置置入的成功率为98％;59处颈动脉狭窄病变共置入61枚支架,支架置入成功率100％。平均颈动脉狭窄程度由术前的（81．3±19．6）％减少到术后的（6．2±1．3）％。颈动脉狭窄处直径由术前（1．3±0．9）mm增加到（5．2±1．1）mm;平均住院2．5天;1例患者术中发生小卒中。平均随访时间（14±2）个月,随访期间,2例患者发生无症状性颈动脉狭窄;2例发生心肌梗死;1例发生小卒中;无大卒中及无死亡发生。结论远端保护伞装置置入及在其下进行的经皮颈动脉支架术成功率高、安全性好,能够有效减少近、远期卒中的发生。     

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。     

滤网保护装置在颈动脉和椎动脉狭窄支架置入术中的应用

目的 探讨滤网保护装置在血管内支架治疗颈动脉和椎动脉狭窄中的应用。方法 配合应用滤网保护装置，对颈动脉和椎动脉狭窄患者进行经皮血管内支架成形术36例次(其中颈动脉33例次，椎动脉起始部3例次)，对手术过程、治疗效果和病理学检查结果进行分析。结果全部病例成功应用滤网保护装置进行了支架置入术，手术相关并发症的发生率为O。血管狭窄率由支架前的81．4％下降至支架后的14．1％；病理学检查显示，27例患者保护装置的滤网内有斑块成分，占75％；保护装置捕捉到的有形成分包括纤维蛋白、斑块碎片(坏死组织、胆同醇碎片、钙化成分等)。结论 滤网保护装置可以捕捉到颈动脉和椎动脉狭窄支架成形术中碎解的斑块成分，降低术中栓塞性并发症的发生概率；目前临床治疗中应用的滤网保护装置可以选择性地应用于椎动脉起始部狭窄的支架成形术中；滤网保护装置应进一步向微型化发展，以适应更多部位的血管内支架成形术。     

单中心颈动脉狭窄患者支架植入术的远期疗效

目的 探讨颈动脉狭窄患者行支架植入术的安全性及近、远期疗效.方法 回顾性分析2005年1月至2010年12月在沈阳军区总医院住院的48例颈动脉狭窄患者资料,在远端脑保护装置下植入颈动脉支架,观察其围术期并发症及临床疗效.结果 48例颈动脉狭窄患者,男41例（85.4％）,年龄（66±6.8）岁,靶病变1处/例,病变长度（22.5±10.3）mm,狭窄程度88.5％±9.9％.手术成功率100％,植入颈动脉自膨式支架1枚/例,使用远端滤网保护装置1个/例,支架直径（7.3±2.4）mm,长度（36.0±5.5） mm.术后即刻残余狭窄程度5.6％±4.5％.术中11例（22.9％）出现心率减慢,于术中给予1 mg阿托品静脉注射,心率恢复至正常范围.2例（4.2％）出现一侧肢体活动障碍,经治疗24 h内好转,术后无严重并发症发生.随访（36.2±15.5）个月,随访率93.8％（45/48）,2例（4.4％）患者死亡,其中1例死于肺癌,1例死于缺血性脑卒中,4例（8.9％）患者仍有头晕发作,3例（6.7％）偶有肢体麻木,无严重脑缺血发作,无脑梗死、脑出血发生.术后6～12个月复查增强计算机断层扫描成像示无颈动脉、椎动脉及肾动脉支架内再狭窄.结论 在远端脑保护装置下行颈动脉支架植入术,是治疗颈动脉狭窄安全、有效的手段,手术成功率高,长期临床随访患者仍能从中获益.     

老年颈动脉狭窄患者介入治疗的风险性分析

目的探讨老年颈动脉狭窄患者经皮血管内支架置入血管成形治疗术的方法及其风险。方法本组收集84例老年颈动脉狭窄患者经全脑数字减影血管造影检查诊断后,均采用经股动脉入路应用自膨式支架行经皮血管内支架置入术治疗。结果支架置入成功率98．8%(83/84),术后平均狭窄率由术前(77．0±15．3)%降至(8．2±8．7)%,临床脑缺血症状和体征明显改善。术后发生消化道出血1例,脑出血2例(1例治愈,1例死亡)。随访2个月～3年,无脑缺血再发,其中11例行数字减影血管造影复查,63例行多普勒超声复查,均无再狭窄发生。结论应用经皮血管内支架置入血管成形术治疗老年颈动脉狭窄具有简便、安全、有效的优点,老年患者围手术期须采取综合性措施以降低手术风险及防止手术并发症的发生。     

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.     

严重冠心病患者合并颈动脉重度狭窄应用AngioguardTM 远端保护装置行颈动脉支架术--附7例报告

目的评价远端保护装置(DPD)AngioguardTM血栓捕获导丝在严重冠心病多支病变患者颈动脉支架置入术(CAS)中应用的安全性和疗效.方法2002年8月至2003年7月,7例冠心病多支病变患者在冠状动脉造影同时行颈动脉造影提示存在严重颈动脉狭窄(＞75%),在于预冠状动脉病变前后行CAS治疗,术中均应用AngioguardTM DPD.7例患者均为男性,平均年龄(60.9±10.1)岁(46～72岁).4例有陈旧脑梗死史,1例有短暂性脑缺血发作史.结果2例患者于CAS前1周行经皮冠状动脉介入治疗(PCI),其余5例于CAS术后1～2周体外循环下行心脏冠状动脉旁路移植术(CABG)治疗.AngioguardTMDPD均顺利通过所有病变并回收,均成功置入支架,技术成功率100%.干预单侧颈动脉4例,其余3例同时干预双侧病变.3例双侧病变者于球囊扩张或支架释放过程中出现短暂窦缓、窦停,伴血压下降,经对症处理后恢复.围术期无新发脑血管意外及其他严重并发症.2例PCI和5例CABG治疗患者术后恢复良好,无神经系统并发症.结论在严重冠心病多支病变患者CAS中应用AngioguardTMDPD行远端保护是安全有效的.     

单中心颈动脉狭窄患者支架植入术的远期疗效

目的探讨颈动脉狭窄患者行支架植入术的安全性及近、远期疗效。方法回顾性分析2005年1月至2010年12月在沈阳军区总医院住院的48例颈动脉狭窄患者,在远端脑保护装置下植入颈动脉支架,观察其围术期并发症及临床疗效。结果48例颈动脉狭窄患者,年龄（66±6.8）岁,男41例（85.4%,41/48）,靶病变1处/例,病变长度（22.5±10.3）mm,狭窄程度88.5%±9.9%。手术成功率100%,植入颈动脉自膨式支架1枚/例,使用远端滤网保护装置1个/例,支架直径（7.3±2.4）mm,长度（36.0±5.5）mm,术后即刻残余狭窄程度5.6%±4.5%。术中11例（22.9%,11/48）出现心率减慢,于术中给予1 mg阿托品静脉注射,心率恢复至正常范围。2例（4.2%,2/48）出现一侧肢体活动障碍,经治疗24 h后好转,术后无严重并发症发生。随访（36.2±15.5）个月,随访率93.8%（45/48）,2例（4.4%,2/48）患者死亡,其中1例死于肺癌,1例死于缺血性脑卒中,4例（8.9%,4/48）患者仍有头晕发作,3例（6.7%,3/48）偶有肢体麻木,无严重脑缺血发作,无脑梗死、脑出血发生。术后6～12个月复查增强计算机断层扫描：无颈动脉、椎动脉及肾动脉支架内再狭窄。结论在远端脑保护装置下行颈动脉支架植入术是治疗颈动脉狭窄安全有效的手段,手术成功率高,长期临床随访患者仍能从中获益。     

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。     

脑保护装置下颈动脉狭窄支架成形术临床应用观察

目的观察脑保护装置下颈动脉狭窄支架成形术的有效性和安全性。方法颈动脉狭窄患者45例,在颈动脉狭窄支架成形术中使用脑保护装置,首先将脑保护装置(过滤伞)小心通过颈动脉狭窄部位放置于颈动脉狭窄的远端并释放,然后再行颈动脉狭窄支架成形术,观察手术期缺血性脑血管病事件及其他并发症的发生情况。结果 45例保护伞放置及支架成形术均成功,术后残余狭窄<20%。操作过程中未发生栓塞等并发症。结论脑保护装置能有效提高颈动脉狭窄支架成形术的安全性,可降低手术风险。     

Procedure-related complications and early neurological adverse events of unprotected and protected carotid stenting: temporal trends in a consecutive patient series.

PURPOSE: To report procedure-related complications and neurological adverse events of unprotected over-the-wire (OTW) and protected rapid exchange (RX) carotid artery stenting (CAS) in a single-center patient series during an 8-year period. METHODS: Between 1997 and 2004, 651 consecutive patients (445 men; median age 72 years, interquartile range 64-77) were enrolled in a registry database of carotid stent procedures; from 1997 to 2002, 471 patients underwent unprotected CAS using an OTW technique, while the other 180 patients were treated with protected CAS using RX monorail systems from 2003 to 2004. Technical success and complications (neurological, hemodynamic instability, and access site) up to 30 days post intervention were analyzed. RESULTS: Technical success improved from 95% with unprotected OTW CAS to 99% with protected RX CAS (p=0.025). Procedure-related complications occurred in 86 (18.3%) of 471 unprotected OTW CAS versus 18 (10.0%) of 180 protected RX CAS procedures (p=0.010). Transient ischemic attacks (3.2% versus 2.8%), minor stroke (1.7% versus 0.6%), and major stroke (2.1% versus 0.6%) showed a trend toward a difference between unprotected OTW and protected RX CAS (p=0.076); combined 30-day stroke/death rates were 3.8% for OTW versus 1.2% for RX CAS (p=0.073). During the 8-year period from 1997 to 2004, the annual rates of procedure-related complications (p=0.002), neurological events (p=0.040), and stroke and death (p=0.14) markedly decreased. CONCLUSIONS: Carotid stenting became substantially safer in the era of protected RX technology. In addition to a reduction in neurological complications, which may be due to cerebral protection devices, the improved technical success and reduced non-neurological procedure-related complications are likely due to recent technical advances unrelated to cerebral protection.     

Feasibility of carotid artery stenting in patients with angiographic string sign

Background : Treatment of angiographic string sign (SS) of the carotid artery with carotid endarterectomy or carotid artery stenting (CAS) has been associated with a high incidence of periprocedural neurological events. We describe our experience with CAS in a case series of symptomatic patients with severe carotid stenosis and angiographic SS. Methods : We performed a retrospective review from 1999 to 2009 using our cardiac cath laboratory database and identified nine patients with the angiographic SS who underwent CAS. All patients were referred for carotid angiography by a neurologist due to symptoms (stroke or transient ischemic attack (TIA)). All lesions were predilated and treated with self‐expanding stents. Distal protection devices were utilized (six patients) once they became available. Periprocedural outcomes and long‐term follow‐up was reviewed when available. Results : The average time from onset of symptoms to CAS was 45 days. All CAS procedures were technically and clinically successful without acute complications. One year follow‐up was available in eight patients. One patient had a possible TIA, and the remaining seven patients did not report any events (death, stroke, TIA or myocardial infarction). Carotid ultrasound evaluation at 12 months was available in six patients and showed no evidence of restenosis. Conclusions : In our experience, CAS in patients with severe symptomatic carotid stenosis and angiographic SS is feasible, with an acceptably low periprocedural complication rate. © 2010 Wiley‐Liss, Inc.     

Feasibility and efficacy of balloon-based neuroprotection during carotid artery stenting in a single-center setting

We sought to prospectively assess the feasibility and in-hospital efficacy of the PercuSurge GuardWire temporary balloon-occlusive system for neuroprotection during carotid angioplasty and stenting (CAS).Carotid angioplasty and stenting harbors a risk of distal embolization. Cerebral protection devices are currently under clinical investigation.Ninety-six consecutive patients with carotid bifurcation disease underwent a total of 102 CAS procedures with the intention to use the GuardWire for neuroprotection.GuardWire deployment was achieved in 99 procedures performed in 93 patients (97%). Device failure (n = 3) and severe neurologic responses to balloon occlusion of the targeted carotid artery (n = 2) accounted for five additional procedures that were essentially concluded without neuroprotection, for a total of 94 procedures completed as intended in 88 patients (92% procedural feasibility rate). Carotid angioplasty and stenting was performed successfully in 94 patients (100 procedures). There were no in-hospital deaths; but three patients (3.1%) sustained strokes, and two patients experienced transient ischemic attacks, for a total periprocedural complication rate of 5.2%. One major stroke occurred with the GuardWire in place, whereas two minor strokes were observed in patients in whom the device could not be deployed. Thus, successful neuroprotected CAS without major neurologic events was achieved in 87 patients (91%).The GuardWire temporary balloon-occlusive system is feasible as an adjunct to CAS in the majority of patients. It is associated with a 3.1% rate of major periprocedural neurologic complications. Adverse neurologic reactions to balloon occlusion may prohibit effective use of the system in about 2% of patients.     

MO.MA -- a new cerebral stroke protection system during carotid artery stenting

BACKGROUND: Carotid angioplasty and stenting (CAS) has been introduced as an alternative to carotid endarterectomy for the treatment of carotid atherosclerosis. Due to the risk of embolisation during CAS, the usage of cerebral protection devices is obligatory. AIM: To assess the safety and efficacy of the novel cerebral protection device -- the MO.MA system. METHODS: Twenty one patients selected for carotid stenting were included into the study. We estimated the deliverability of the device to the target site, procedural success rate and the incidence of adverse events. RESULTS: All performed procedures were successful without major cerebro-vascular complications during both 30-day and 6-month follow-up periods. CONCLUSIONS: The MO.MA system is safe and effective in preventing stroke during CAS.     

Carotid artery stenting with distal filter protection: single-center experience in high-surgical-risk patients

Carotid artery stenting (CAS) is an efficient alternative procedure for the treatment of high-surgical-risk patients with symptomatic and asymptomatic carotid stenosis. The use of cerebral protection systems might decrease procedural risk of stroke and death. We report our initial experience with protected carotid stenting in high-risk patients with severe carotid artery disease. From January 2006 until July 2008 we routinely performed CAS using a distal filter protection device in 65 consecutive high-surgical-risk patients with 72 high-grade carotid stenoses. Technical success rate was 97.2%. Neurologic periprocedural complications included two transient ischemic attacks and one major stroke. Three filter-related complications were managed without negative results to the patients. The overall in-hospital and 30-days MACE rate was 1.5%, 3.6% in symptomatic patients and 0% in asymptomatic patients. In our series of high-risk patients, CAS with the use of a distal filter protection system was safe and effective with a low incidence of periprocedural complications.     

Procedural outcome and midterm result of carotid stenting in high-risk patients

Carotid endarterectomy is the standard treatment for carotid stenosis, but carotid artery stenting has emerged as a potential alternative. Elective carotid artery stenting was performed in 42 patients aged 42 to 79 years (mean, 67.05 +/- 8.67 years) after ultrasonography, computed tomography, magnetic resonance angiography and a neurological evaluation. There was bilateral carotid stenosis in 23 patients (55%), with > 90% stenosis in 18 vessels. All patients had significant associated coronary lesions. An emboli protection device and self-expanding stents were used. One year later, the patients were evaluated by Doppler sonography and selective angiography. Technical success was achieved in all procedures. During follow-up, 1 (2.4%) patient died from myocardial infarction, 1 underwent coronary artery bypass and 14 (40%) had minor complaints including occasional dizziness. No other neurological events were noted. Restenosis was found in one case, but selective angiography ruled out a significant lesion. One patient suffered embolization, but recovered completely within 24 hours. In 7 (17%) patients with type C arch interruption and a tortuous carotid course, stenting was successful and they had no embolization or restenosis. Carotid artery stenting is recommended in high-risk patients.     

Carotid angioplasty with stenting in post-carotid endarterectomy restenosis

Recurrent stenosis post-carotid endarterectomy (CEA) is not a solitary or unusual phenomenon. Compared to the initial CEA, the reoperation is often more technically challenging and frequently results in local and neurological complications. Carotid artery angioplasty with stenting (CAS) is currently being investigated as an alternative to carotid endarterectomy. In our study, ninety-nine patients underwent CAS in 110 arteries. Procedural success was 99% (109/110). Our results show that CAS treatment in post-CEA restenosis, especially with improved technique and distal protection, is safe with a low neurological complication rate, without any "local" complications and without any cranial nerve palsies. This study suggests that the future primary mode of treatment of post-CEA restenosis might be carotid stenting rather than surgery.     

Carotid artery stenting in octogenarians using a proximal endovascular occlusion cerebral protection device: A multicenter registry

Background : Carotid stenting (CAS) has been proposed as an alternative to carotid endoarterectomy also in elderly patients with discrepant results. However, the use of proximal neuroprotection devices have not been evaluated in octogenarians. Purpose : The aim of this multicenter prospective registry was to demonstrate that CAS in octogenarians is safe and effective if performed in high‐volume centers by experienced operators. Methods : From July 2005 to May 2009, a total of 198 octogenarians patients, in three different institutions, were included in this registry. All patients underwent CAS using proximal endovascular occlusion device (Mo.Ma. device Invatec, Roncadelle, Italy). An independent neurologist evaluated all patients. The primary endpoint was death and stroke rate at 30 days. Results : 198 octogenarians (135 men; mean age: 83.2 years) were included in the registry. 39.4% of the patients were symptomatic. Procedural success was 100%. In‐hospital complications: Two minor and two major strokes (2.02%) occurred. No device‐related complications and no serious access site complication were noted. Between discharge and 30‐day follow‐up, one patient died due to a cardiac arrest. The overall 30‐day combined stroke/death rate was 2.52%, resulting in 1.61% event incidence in asymptomatic and 3.9% in symptomatic patients (P = ns). Logistic regression did not identify independent predictor of neurological events, except in the female gender. Conclusion : This multicenter prospective registry shows that CAS performed with proximal flow blockage is safe and feasible also in octogenarians. Thirty days death/stroke rates are similar to those of the overall population and within the International guidelines. © 2010 Wiley‐Liss, Inc.     

Outcomes following extracranial carotid artery stenting in high-risk patients

BACKGROUND: Carotid artery angioplasty and stenting has become a viable alternative to carotid endarterectomy (CEA), especially for patients considered at high risk for post-operative complications. This study investigated the feasibility, safety and long-term outcome of carotid artery stenting (CAS) in high-risk patients. METHODS: From July 1995 to November 2000, sixty-two consecutive patients considered to be at high risk for post-operative complications of CEA were followed prospectively after undergoing extracranial CAS procedures. RESULTS: Sixty-two patients [37 men (60%) and 25 women (40%)] underwent a total of 69 CAS procedures. The mean age was 67 +/- 9 years (range, 32-89 years). Comorbid conditions included hypertension in 95% and severe coronary artery disease in 58%. Sixteen patients (26%) had a previous ipsilateral CEA, twenty-one percent had a history of neck radiation and 32% had a history of significant contralateral carotid artery disease. Fifty-two patients (84%) were symptomatic. All 69 CAS procedures were technically successful. The major post-operative complications were two minor strokes (2.8%), one major stroke (1.4%) and one fatal major stroke (1.4%). The mean length of follow-up was 17 months (range, 4 months to 5.6 years). Two patients (2.8%) have suffered ipsilateral neurologic events following CAS. Long-term follow-up revealed restenosis at 6 months in 4 patients (5.7%). CONCLUSIONS: Carotid artery angioplasty and stenting is safe and feasible. This procedure produces satisfactory outcomes in patients who are at high risk for post-operative complications of CEA.     

Mid‐term outcomes of carotid artery stenting in patients with angiographic string sign

Objectives : To report on early and mid‐term outcomes of carotid artery stenting (CAS) in patients with angiographic string sign (SS). Background : Little is known about the prognosis of patients with carotid SS treated by CAS. Methods : We retrospectively evaluated early and mid‐term outcomes, together with ultrasound findings, in patients with SS treated by CAS at our institution. Results : Of 308 CAS procedures, SS was diagnosed in 6.2% (19 patients, 58% symptomatic). Carotid stent implantation was successful in 18 patients (success rate 95%). There were no peri‐procedural adverse events. One patient suffered from a transient ischemic attack during hospitalization and died of pneumonia. All remaining patients completed a 30‐day follow‐up, and no complications were reported (asymptomatic restenosis was diagnosed in 1 patient and successfully redilated). Six patients died of causes unrelated to CAS (pneumonia, decompensated heart failure, and contralateral stroke) before completing a 6‐month follow‐up. However, these patients presented with more pronounced, unfavorable clinical and angiographic characteristics compared to the rest of the patients. Conclusions : We suggest that CAS might be performed with acceptable procedural risk in patients presenting with SS, which is unsuitable for surgery. However, patients' clinical and angiographic characteristics must be carefully evaluated when considering interventional therapy, regardless of the favorable procedural outcomes. © 2011 Wiley Periodicals, Inc.