支架技术在颅内复杂动脉瘤治疗中的应用

目的探讨支架在颅内复杂动脉瘤中的治疗技术及应用价值。方法回顾性分析应用支架技术辅助栓塞治疗的31例颅内动脉瘤患者（宽颈动脉瘤28例,梭形动脉瘤3例）的临床资料。术中将支架引至动脉瘤处释放支架覆盖动脉瘤颈,并结合弹簧圈栓塞术。结果 31例共置入支架32枚,其中Enterprise支架24枚,LEO支架5枚,Solitaire AB支架3枚。采用单纯支架置入技术2例,此2例微小动脉瘤术后见瘤腔内造影剂滞留。支架结合弹簧圈治疗29例,其中支架先释放技术7例,支架后释放技术22例,支架结合弹簧圈治疗组取得满意疗效。术后即刻栓塞结果按改良的Raymond分级：动脉瘤体完全栓塞20例（Ⅰ级）,瘤颈残留7例（Ⅱ级）,瘤体显影2例（Ⅲ级）。随访1～6个月未发生再出血及缺血并发症。结论支架辅助栓塞技术是治疗颅内动脉瘤安全有效的方法,可提高动脉瘤栓塞的致密程度,采用支架后释放技术使绝大多数颅内复杂动脉瘤的介入治疗成为可能。     

多层裸支架腔内隔绝动脉瘤的研究现状及存在问题

多层裸支架隔绝动脉瘤瘤腔的同时,能保持支架覆盖区域分支动脉的通畅,解决了覆膜支架不能保留支架覆盖区重要分支的问题。笔者就多层裸支架治疗动脉瘤的现状及其机制进行综述,并总结其存在的问题,为临床治疗提供依据。     

胆管狭窄内镜治疗的现状与评价

For the characteristics including minimal invasion,low incidence of complication and better postoperative prognosis,endoscopic therapy is widely accepted to be the first line therapy for most biliary s...     

感染性腹主动脉瘤的外科治疗及并发症分析

目的探讨感染性腹主动脉瘤的外科治疗策略,并对术后并发症进行分析。方法回顾性分析2009年11月—2012年12月血管外科收住入院并行外科干预的4例感染性腹主动脉瘤的临床资料。结果 4例均因发热并腰部或腹部疼痛入院,根据计算机断层X线血管造影(CTA)、血培养和白细胞升高等,确诊为感染性腹主动脉瘤。2例采用外科手术,2例采用腔内修复术。外科手术组1例术后发生多器官功能衰竭于术后4 d死亡,腔内修复组无围手术期死亡及并发症发生。3例存活者中位随访时间为15个月,其中1例腔内治疗15个月后因发生消化道大出血死亡。本组共死亡2例,病死率为50%。结论感染性腹主动脉瘤治疗方案尚不完善,腔内修复术近期疗效满意,为高危患者提供了一种相对安全、简便的术式选择,但需密切随访。今后还需进行更多的相关研究和长期随访以提高诊治水平。     

Endovascular treatment of acute basilar artery occlusion: Outcomes,influencing factors and imaging characteristics from the Tama-REgistry of acute thrombectomy (TREAT) study

ObjectiveThe effectiveness of mechanical thrombectomy (MT) for acute basilar artery occlusion (ABAO) remains unknown. We evaluated the feasibility, safety, and efficacy of endovascular treatment for ABAO.MethodsWe retrospectively investigated patients with ABAO who underwent MT using modern stent retrievers and an aspiration device between January 2015 and March 2019 at 12 comprehensive stroke centers. Functional outcomes and 90-day mortality rates were analyzed as primary outcomes. Factors influencing outcomes were analyzed as secondary outcomes. Relationships between outcome and affected area of infarction on arrival were also analyzed.ResultsSeventy-three patients were included. Good outcome (modified Rankin Scale (mRS) score 0–2) was achieved in 25/73 patients (34.2%) and the all-cause 90-day mortality rate was 23.3% (17/73). Successful recanalization (modified Thrombolysis In Cerebral Infarction grade 2b and 3) was achieved in 70/73 patients (95.9%). In univariate analyses, age, National Institutes of Health Stroke Scale score, and posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) differed significantly between good and poor functional outcome groups. Age and pc-ASPECTS were significantly associated with functional outcomes in the logistic regression model. Positive findings for the midbrain on diffusion-weighted imaging on pc-ASPECTS and brainstem score were significantly associated with poor outcomes.ConclusionMT with modern devices for ABAO resulted in highly successful recanalization and good outcomes. A positive finding for the midbrain on initial imaging might predict poor outcomes. Further studies are required to confirm our results.     

Retrievable stent thrombectomy in the treatment of acute ischemic stroke: Analysis of a revolutionizing treatment technique

Acute ischemic stroke resulting from intracranial vessel occlusion is associated with high morbidity and mortality. The mainstays of therapy are fibrinolytics and mechanical thrombectomy in properly selected patients. A new Food and Drug Administration-approved technology to perform thrombectomy, retrievable stenting, may provide superior revascularization rates and improved patient outcomes. We analyzed the cumulative human experience reported for the Trevo Pro Retrieval System (Stryker, Kalamazoo, MI, USA) and the Solitaire FR Revascularization Device (ev3, Irvine, CA, USA) as the definitive treatment for acute ischemic stroke. A literature search was undertaken to identify studies using the retrievable stents published up to September 2012. Nineteen studies identified a total of 576 patients treated with either the Trevo (n = 221) or Solitaire (n = 355) devices. Pooled data analysis identified median baseline National Institutes of Health Stroke Scale scores of 18.5 ± 0.289 (standard error of the mean) and 17.9 ± 0.610, and time to recanalization of 53.9 ± 23.6 minutes and 59.0 ± 8.0 minutes for the Trevo and Solitaire groups, respectively. Recanalization was variably defined by individual studies, most commonly achieving at least a thrombolysis in cerebral infarction score of 2a–3 or a thrombolysis in myocardial infarction score of 2–3. Revascularization (83%, 82%), mortality (31%, 14%), hemorrhage (8%, 6%), device complications (5%, 6%), and good patient outcomes (51%, 47%) were found with the Trevo and Solitaire devices, respectively. Preliminary analysis reveals excellent clinical outcomes for retrievable stent technology. This may be attributable to both high rates of revascularization with a relatively short time to perfusion restoration.     

Accumetrics-based clopidogrel dosing in endovascular neurosurgery

Abstract

Introduction:

The role of the VerifyNow test to guide clopidogrel therapy in neurosurgical patients is still unclear. This study compared outcomes in patients undergoing neurointerventional procedures on either standard clopidogrel or tailored clopidogrel regimens.

Methods:

Adult patients undergoing neurointerventional procedures from 1 May 2002 to 31 December 2012 at the University of Illinois Hospital and Health Sciences System were included if they were receiving dual antiplatelet therapy (DAPT) for their procedure. Patients were categorised based on the use of VerifyNow to guide therapy. The primary endpoint was the incidence of thromboembolic complications within 6?months post procedure. Secondary endpoints included the incidence of haemorrhagic complications and death. P2Y₁₂ reaction units (PRU) were recorded when available and categorised based on relation to procedures and/or events.

Results:

A total of 228 patients were screened with 130 meeting inclusion criteria. Ninety patients were grouped into the standard therapy arm and 30 patients into the tailored therapy arm. There were no differences in the incidence of ischaemic complications (1.1 vs 2.5%, P?=?0.522), haemorrhagic complications (17.8 vs 15.0%, P?=?0.455) or death (3.0 vs 0%, P?=?0.552). Seventeen of 32 patients (53.1%) with PRUs were clopidogrel resistant defined as a PRU >180.

Discussion:

Use of the VerifyNow test to guide clopidogrel therapy in patients undergoing neurointerventional procedures did not result in a decrease in the incidence of thromboembolic complications compared to standard therapy. There was no difference in the incidence of haemorrhagic complications or death. Further studies are needed to evaluate the impact of tailored therapy using VerifyNow.     

Uncertainty assessment of imaging techniques for the 3D reconstruction of stent geometry

This paper presents a quantitative assessment of uncertainty for the 3D reconstruction of stents. This study investigates a CP stent (Numed, USA) used in congenital heart disease applications with a focus on the variance in measurements of stent geometry. The stent was mounted on a model of patient implantation site geometry, reconstructed from magnetic resonance images, and imaged using micro-computed tomography (CT), conventional CT, biplane fluoroscopy and optical stereo-photogrammetry. Image data were post-processed to retrieve the 3D stent geometry. Stent strut length, separation angle and cell asymmetry were derived and repeatability was assessed for each technique along with variation in relation to μCT data, assumed to represent the gold standard. The results demonstrate the performance of biplanar reconstruction methods is comparable with volumetric CT scans in evaluating 3D stent geometry. Uncertainty on the evaluation of strut length, separation angle and cell asymmetry using biplanar fluoroscopy is of the order ±0.2 mm, 3° and 0.03, respectively. These results support the use of biplanar fluoroscopy for in vivo measurement of 3D stent geometry and provide quantitative assessment of uncertainty in the measurement of geometric parameters.     

Flow-induced corrosion behavior of absorbable magnesium-based stents

The aim of this work was to study corrosion behavior of magnesium (Mg) alloys (MgZnCa plates and AZ31 stents) under varied fluid flow conditions representative of the vascular environment. Experiments revealed that fluid hydrodynamics, fluid flow velocity and shear stress play essential roles in the corrosion behavior of absorbable magnesium-based stent devices. Flow-induced shear stress (FISS) accelerates the overall corrosion (including localized, uniform, pitting and erosion corrosions) due to the increased mass transfer and mechanical force. FISS increased the average uniform corrosion rate, the localized corrosion coverage ratios and depths and the removal rate of corrosion products inside the corrosion pits. For MgZnCa plates, an increase of FISS results in an increased pitting factor but saturates at an FISS of ∼0.15 Pa. For AZ31 stents, the volume loss ratio (31%) at 0.056 Pa was nearly twice that (17%) at 0 Pa before and after corrosion. Flow direction has a significant impact on corrosion behavior as more severe pitting and erosion corrosion was observed on the back ends of the MgZnCa plates, and the corrosion product layer facing the flow direction peeled off from the AZ31 stent struts. This study demonstrates that flow-induced corrosion needs be understood so that Mg-based stents in vascular environments can be effectively designed.     

后循环缺血的名称演变及治疗进展

【摘要】 后循环缺血（posterior circulation ischemia,PCI）的概念逐渐被临床医师接受,其治疗亦越来越受到重视,但目前仍缺乏专门针对后循环缺血的大样本随机对照研究,除常规的药物治疗外,溶栓治疗与介入治疗可使后循环缺血患者明显受益,但手术治疗方面未见有更多研究报道。我们结合国内外文献,概述了后循环缺血名称的演变,总结了后循环缺血治疗的最新研究成果并做一简要综述。