应用Willis覆膜支架治疗脑池段动脉瘤的临床对照研究和长期随访结果

Application of Willis covered stent in the treatment of aneurysms located in the cisternal segment of the internal carotid artery:a pilot comparative study with long-term follow-up results

目的复杂性颈内动脉脑池段动脉瘤(ICA-CSA)治疗难度很高。本研究通过与弹簧圈填塞治疗疗效比较,探讨Willis覆膜支架治疗ICA-CSA的可行性。方法19枚和17枚ICA-CSA分别使用Willis覆膜支架植入(A组)和弹簧圈(B组)填塞治疗。即刻和随访血管造影评价动脉瘤复发,内漏和载瘤动脉狭窄情况。Kaplan-Meier生存分析曲线比较两组治疗动脉瘤的无复发率和载瘤动脉无再狭窄率。结果A组中,13枚ICA-CSA植入支架,即刻造影完全闭塞,有5枚ICA-CSA存在少量内漏;B组中,7枚ICA-CSA弹簧圈填塞即刻达到完全和次完全闭塞,8枚达到大部填塞,2枚部分填塞。在两组中各发生1例急性血栓形成,1例弹簧圈填塞后发生再出血。A组随访造影显示16枚ICA-CSA完全闭塞,2支载瘤动脉有轻度狭窄。Kaplan-Meier曲线分析表明术后18个月两组病例中分别有93.3%和50%动脉瘤治疗后无复发,分别有87.5%和100%载瘤动脉无狭窄。临床症状随访研究表明A组和B组病例中神经症状完全恢复分别为9例和9例,明显改善分别为3例和5例,无改变分别为2例和2例,恶化进展分别为1例和0例。结论应用Willis覆膜支架植入治疗复杂性ICA-CSA是一种可行的血管内治疗方法,但是对于载瘤动脉极其弯曲和重要侧支覆盖风险的情况下,覆膜支架技术不能作为第一选择。

Objective Complicated aneurysms located in the cisternal segment of the internal carotid artery（ICA-CSA） present unique therapeutic difficulties.This study is to discuss the feasibility of the Willis stent-graft in treating complicated ICA-CSA by comparing its effect with that of coiling therapy.Methods Willis covered stents were employed in 19 complicated ICA-CSAs（group A）,while coils were used in 17 complicated ICA-CSAs（group B）.Follow-up angiography was performed to investigate aneurysm recurrence,endoleak and parent artery（PA） stenosis.Kaplan-Meier curves were constructed to compare the recurrence-free and PA stenosis-free rate in both groups.Results Total exclusion was immediately achieved in 13 ICA-CSAs and minor endoleaks presented in 5 cases in group A.Total or near-total occlusion was achieved in 7 ICA-CSAs,subtotal occlusion in 8 and partial occlusion in 2 cases in group B after coiling.Acute thrombosis occurred in 1 patient in either group and re-hemorrhage happened in 1 patient after coiling.Follow-up angiography in group A revealed that 16 ICA-CSAs were completely isolated,with two parent arteries showing mild in-stent stenosis.Eighteen months after the procedure,Kaplan-Meier analysis showed that the recurrence-free rate was 93.3% and 50%,while the stenosis-free rate of parent artery was 87.5% and 100% in group A and in Group B,respectively.In group A and group Bthe clinical neurological symptoms were fully recovered in 9 and 9,obviously improved in 3 and 5,unchanged in 2 and 2,and aggravated in one and 0 patients,respectively.Conclusion The implantation of Willis stent-graft is a feasible endovascular therapy for complicated ICA-CSAs.When the parent artery is very tortuous or when the risk that a main collateral branch may be wrongly covered and occluded is present,the implantation of Willis covered stent can not be taken as the treatment of first choice.