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【摘要】目的:探讨血管内支架成型术治疗颈动脉狭窄的临床效果、安全性及并发症。方法:对经过颈部血管超声筛选有颈动脉狭窄的66例患者,进一步行脑血管造影,然后根据血管狭窄情况,选择合适球囊预扩后,将自膨式支架送至预想的位置释放,覆盖狭窄部位,66例患者共治疗69支血管。结果:治疗狭窄动脉69支,狭窄程度均明显改善,狭窄程度由原来的(88.96±11.7)%下降至(2.49±2.78)%,狭窄血管最大血流速度从(198.58±21.6)cm/s下降至(76.65±3.53)cm/s,术后患者症状均明显改善。无死亡病例,10例发生短暂性低血压及心率下降,28例发生持续性低血压及心率下降,1例术中出现同侧大脑中动脉急性闭塞事件,紧急溶栓、碎栓后血管开通,无任何后遗症。随访1～32个月,颈动脉超声检查治疗血管无再狭窄。结论:只要适应证选择正确,围术期处理得当,血管内支架成型术治疗颈动脉狭窄,不仅临床效果好,而且安全性高,无严重并发症。
【关键词】颈动脉狭窄;血管内支架成型术;脑缺血发作
doi:10.3969/j.issn.1006-1959.2010.05.102文章编号:1006-1959(2010)-05-1135-03
Carotid stenosis is being a common cause of ischemic stroke,because of the unsatisfactory therapeutic effect of drugs,Carotid endarterectomy (Carotid endaterectomy,CEA) is the effective method to reduce stroke in patient of carotid artery stenosis.With the advances in technology,materials by endovascular stent angioplasty had replaced the CEA[1-2],From July 2006 to December 2009 in our hospital, endovascular stent angioplasty treatment of carotid artery stenosis were using,69 stenotic vessels of 66 patients were treated using 69 stents,the clinical results are reported as follows.
1.MATERIALS AND METHODS
1.1 Materials:39 cases were males,27 cases were female among the 66 cases,the years old were 44 to 82.27 patients with transient ischemic attack.21 cases showed non-fluent speech and the side of the limb weakness,13 patients had recurrent dizziness performance,11 patients had a bad heavy headache,8 cases of personality had changed,taciturn,reaction retardation.11 cases showed recurrent episodes of blurred vision.66 cases of patients had been prompted by transcranial Doppler and showed the conditons of cerebral vascular insufficiency,the neck vascular color Doppler ultrasound had prompted and showed carotid artery stenosis in all patients.47cases had multiple patches,9 patients with ulcers,66 cases had hemodynamic abnormalities,stenosis peak systolic velocity were (198.58±21.6)cm/s.33 cases had hypertension,30 patients had diabetes,17 patients had coronary heart disease.
1.2 The extent of stenosis of carotid artery.The whole group of cases were prompted by transcranial Doppler cerebral vascular and showed the insufficiency, the neck vascular color Doppler ultrasound had prompted and showed carotid artery stenosis and with plaquein in all patients,in which 9 patients had ulcers,66 cases had hemodynamic abnormalities,including narrow vascular peak systolic flow velocity increased significantly faster.The degree of stenosis were determined according to the result of angiography,and the method as follows:the degree of stenosis (%)=stenosis distal normal vessel diameter (mm)-stenosis vessel diameter (mm)/narrow distal normal vessel diameter (mm)×100%.The narrow length were from3 mm to 31mm in this group of cases,the average were (15±2.6)mm,degree of stenosis was from 50% to 99%,the average degree of stenosis (%) were (88.96±11.7)%.
1.3 Indications.The degree of symptomatic carotid artery stenosis ≥50%;he vascular stenosis can lead to the current symptoms of patients;here had not a new stroke within 6 weeks;o intracranial tumors or arteriovenous malformations in all patinets;The conditions of heart,lung and other important organs can be toleranced the endovascular stent angioplasty treatment in patients;no relief or symptoms of cerebral ischemia and repeated attack by the regular medical drugs,or medication contraindications.
1.4 Treatment.Aspirin 100mg a day,clopidogrel 75mg a day were taken before 5 days of surgery,conventional preparation were done before cerebral angiography,0.1g phenobarbital were injected before 30min of operation.Using local anesthesia,ECG monitoring,oxygen,atropine ready to prepare for surgery applications.2% lidocaine local infiltration anesthesia.Punctured the femoral artery using Seldinger technique,8F arterial sheath,3000IU heparin subcutaneously,added 2000IU heparin every 1hour to extend the operation time foc,using he technology of guide wire and catheter,placed the 8F guiding catheter near the narrow blood vessels,after angiography,measured the length of stenosis and diameter of blood vessels,and understand the brain flow of the anterior artery and the middle cerebral artery.In the road-map,placed the EV3"s SPIDERX distal protection device in proper place through the narrow area.If the degree of stenosis were bad,you need to pre-expand using different types of balloon to the narrowest part of the vessles.34 patients had pre-expansion and then,selected the appropriate EV3"s PROTEGERX self-expanding stent and acrossed the stricture site,and released the stent in desired location,then the stent covering the narrow area.The principles of choosing the stent were according to the both ends of vascular lesion diameter and lesion length,the diameter of stent must be mached to the narrow diameter of the proximal blood vessels in order to maintain a good adherent of.
1.5 Perioperative period.Monitoring of vital signs after the operation within 24 to 48hours,giving antihypertensive therapy to high blood pressure,Nitroglycerin 10mg+0.9% sodium chloride 50ml were injected with the micro-infusion pump,usually blood pressure must controled around 120/70mmHg,the principles of controling blood pressure were the basis ofblood pressure,reached the 2/3"s level of the basis of blood pressure,in order to prevent the original ischemic of brain tissue perfusion over the region because of the lower blood pressure,or leading to the brain hemorrhage because of over-reperfusion injury.The blood pressure and heart rate may be decrease in some patients after stenting because of stimulating to the carotid sinus baroreceptor,atropine can increas heart rate,dopamine can induce hypertension.In this group,10 cases had transient hypotension and heart rate decreased,28 cases had persistent hypotension and heart rate decreased.taking aspirin 100 mg a day,clopidogrel 75mg a day after operation for 3 months,stopping clopidogrel and taking aspirin 100 mg,1 times a day in all life.
1.6 Statistical Methods.The degree of vascular stenosis data statistical methods using mean±standard deviation (x±s),statistical analysis using statistical software SPSS11.0,(P
(Figure 1a):the left internal carotic artery had bad stenosis,and the degree of stenosis was98%.(Figure 1b):After EV3"s PROTEGERX self-expanding stent of 9mmX4cm,the stenosis vessele recovered normal.
3.DISCUSSION
Stroke is one of the three major diseases in China leading to human death,Ischemic stroke caused by carotid atherosclerosis accounted for 20% of all ischemic stroke,and had a poor prognosis.Traditional drug therapy of ischemic cerebrovascular disease had less effective,survival of 50~70% of the patients left hemiplegia,aphasia and other serious disability,and mposed a heavy burden on society and the family.With the development of minimally invasive technique,endovascular stent angioplasty treatment of carotid artery stenosis is a hot topic in recent years[3-4],it was the secondary prevention of stroke,and had a less trauma and a quick recovery.This group patients had good effect,the stenosis improved significantly immediately by cerebral angiography in operation.After operation,vascular ultrasound monitored the blood flow velocity returned to normal,the patient dizziness,seizures limb weakness,unresponsive and other cerebral ischemic symptoms improved significantly,recent follow-up data showed a good recovery and no severe complications.
10 cases had transient hypotension and heart rates decreased,28 cases had persistent hypotension and heart rates decreased among 66 cases of carotid artery stenting.The reasong may be carotid sinus baroreceptor stimulated by mechanical stimulation in stent placement or in the process of operation.Carotid sinus baroreceptor was in the carotid sinus vessel wall,it mainly felt the expansion of carotid sinus stimulation,catheter,guide wire in operationg may stimulate it (the longer operative time,right carotid sinus stimulation of the greater),stent continued stimulation after operation,all the reasons lead to hypotension and heart rate decreased[5-6].In this group there were 13 cases of stent diameter of optionswere greater than the normal carotid artery diameter of 1mm,the main reasong was that we did not plan to expand with balloon pre-or post-expansion,so used slightly larger stent,wanted to use the role of self-expandable stent in the artery to improve the carotid artery stenosis,ir can reduce the cost and shorten the surgery time and increases the adhesion of stent to the vessle,but increased the stimulation of carotid sinus,so the ratio of hypotension was relatively high.Our data also showed that a history of hypotension before surgery had a risk factor of persistent hypotension,it may be the basis of blood pressurewas low,plus stent stimulation,more likely to occur the continuous hypotension.This group of cases,elevated heart rate with atropine,increased blood pressure with dopamine,after those symptomatic treatment one week later,those sings returned to normal,no adverse effects occurred.
Another complication was cerebral embolism events in Carotid artery stenting.Cerebral embolism was a heavier endovascular stent complications,Mainly due to surgery inflated of balloon dilatation and stent stenosis to the wall of atherosclerotic plaque extrusion,for the different types of vascular thrombosis,the different clinical aphasia can occur,such as facial paralysis,memory loss,physical activity inconvenience.If this condition come place,early given thrombolysis,spasm,cerebral protection can significantly improve symptoms.In recent years,with the development of cerebral protection devices,it can significantly reduce the incidence of cerebral embolism.Wholev,etc.[7]reported that in 2003 registered in the global carotid artery stent study,6753 cases of cerebral protection devices were not used mortality was 5.29%,while the 4221 cases of cerebral protection device by using the case fatality rate was 2.23%.In this group,52 cases of the use of protective equipment did not occur cerebral embolism events in patients,17 who did not use the protective devices have 1 case of acute ipsilateral middle cerebral artery occlusion event,because it was local anesthesia,we detected patients vague language,limb paralysis surgery in the timely in operation,and timely to give guiding catheter,micro-catheter thrombolysis, micro-wire machine broken bolt and other comprehensive treatment,the occlusion of blood vessels opened,patients was good without any sequelae.Specifically case shown in (Figure 2).
(Figure 2a):the left middle cerebral artery occlusion beyond M2 segmen of the middle cerebral.(Figure 2b):micro-guide wire through the occluded segment division arrived in M3 segmen of the middle cerebral.
(Figure 2c):Micro-catheter through the occluded and reach the M3
segment,and M3senment was still vascular patency.(Figure 2d):the M2 segment beyond completely open after the role of micro-guide wire machine broken bolt and arterial injection of urokinase and papaverine.
Hemorrhagic stroke was the most serious complication to a vascular stent angioplasty,it was more common in patients with a high degree of stenosis.The responsibility vascular blood supply areas remain was in a low perfusion state,when other intracranial blood vessels were compensatory negative,the blood vessel was in poor self-regulatory function,after stening,the narrow vessles was improvement and influx of blood flow,resulting in a sudden increase in cerebral perfusion pressure caused by cerebral hemorrhage.This group did not happen cerebral hemorrhage complications,mainly because of effectively controlled blood pressure after the implant,controlling blood pressure normal range was 2/3 level of the patient"s pre-operarion blood pressure.It can be effectively prevent a sudden increase in perfusion pressure caused by cerebral hemorrhage.
Our experience was that the clinical effect of endovascular treatment of carotid artery stenosis was good,it could effectively alleviate the clinical symptoms.To ensure the operation was successful and reduced complications,it should note the following:The operator must be gentle,careful and accurate,and used flexible of guide wire technology,and placed guide catheter in the first end of the proximal stenosis;As much as possible reduced in the narrow blood vessels at the various operations,including catheters,guide wires,cerebral protection device and so on,in the case of stent through the narrow vessle,we need not pre-expansion with balloon;Please use the distal protection device as much as possible in operation;monitor the patients"blood pressure,and treat timely to symptom;long-term use of anti-platelet therapy is the key to prevent restenosis.
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