应用覆膜支架介入救治颈动脉破裂并假性动脉瘤

The application of covered stent in the rescue treatment of carotid blowout with pseudoaneurysm formation

目的探讨应用覆膜支架介入治疗颈动脉破裂并假性动脉瘤。方法4例肿瘤所致颈动脉破裂并假性动脉瘤形成的患者,均出现颈部或口腔危及生命的出血,采用Seldinger方法,选用自膨式聚四氟乙烯覆膜支架治疗。结果4例成功施行血管内介入治疗,其中颈总动脉中段1例,颈动脉球2例,颈总动脉远段1例。共置入覆膜支架6枚。术后假性动脉瘤腔被隔绝,颈动脉通畅,患者的临床症状明显改善,无神经功能障碍。1例患者11 d后支架下缘颈总动脉与原瘤腔相通,再次置入覆膜支架,2个月的随访无再出血。1例患者经钢圈栓塞、放置覆膜支架及裸支架瘤腔隔绝,但术后6周先前的支架下缘出现假性动脉瘤,经置入覆膜支架后出血停止。结论自膨式聚四氟乙烯覆膜支架治疗颈动脉破裂并假性动脉瘤是患者安全、有效的方法,特别是在救治伴有出血的颈部假性动脉瘤,支架的长期效果有待于进一步随访观察。

Objective To evaluate the result of covered stent for carotid blowout with pseudoaneurysm formation. Methods Four patients with carotid blowout accompanied by pseudoaneurysm formation due to head and neck malignancies, who presented with life-threatening massive neck or oral bleedings, were treated with selfexpanding polytetrafluoroethylene（PTFE）-covered nitinol stents through percutaneous transluminal approach, Results Covered stents were successfully performed in four patients, one in the mid portion of common carotid artery（CCA） , two in the carotid bulb, and one in the distal CCA, containing six stents altogether. After treatment, angiography showed successful occlusion of the pseudoaneurysm, patency of carotid artery lumen, and significant improvement of clinical symptoms without neurologic deficit. One patient with the mid portion blowout of CCA, showed extension of the previous pseudoaneurysm below the lower margin of the stent 11 days after the first stent placement, so that the second covered stent was placed with no recurrent hemorrhage on the two months follow-up. Another patient with pseudoaneurysm near the carotid bulb, showed angiographically the successful occlusion of the pseudoaneurysm after coil embolization and placement of covered stent and bare stent, but extension of pseudoaneurysm in lower margin of the previous stent was found six weeks after the procedure, an additional covered stent was deployed with stoppage of bleeding. Conclusions Self-expanding covered nitinol stenting is a safe and effective option for carotid blowout with pseudoaneurysm formation, especially for rescue treatment of life-threatening bleediug pseudoaneurysm of the carotid artery. Long-term follow-up and larger serises are required for further evaluation of the stent efficacy.