后交通动脉动脉瘤夹闭术中瘤夹的选择和应用

Selection and application of aneurysm clip in posterior communicating artery aneurysm clipping

目的探讨开颅夹闭后交通动脉动脉瘤(PCoAA)的手术中,动脉瘤夹的选择规律和使用方式。方法回顾性分析2007年1月—2011年6月,北京大学第一医院开颅手术夹闭的46例PCoAA患者的临床资料。根据动脉瘤颈与载瘤动脉的关系对动脉瘤进行分型,分析瘤颈的位置、术中动脉瘤夹的型号及放置方式等。术后对患者以门诊、电话、DSA进行随访4个月至4年。结果①将46例PCoAA分为颈内动脉、后交通动脉、分叉型3种类型。其中分叉型22例、颈内动脉型19例、后交通动脉型5例。动脉瘤的位置(按时钟模式的12个钟点方向)位于1个钟点的2例,跨2个钟点的34例,跨3个钟点的10例。②对37个动脉瘤选用弯型动脉瘤夹、6个选用直型、2个选用成角度跨血管型(90°)、1个选用枪型。瘤夹长度54.3%(25/46)的为6～7 mm,另有21.7%(10/46)的长度为5～7 mm。对后交通动脉型及分叉型动脉瘤夹放置均采用平行于血管方向,而对颈内动脉型动脉瘤,垂直血管放置瘤夹13例,平行于血管放置瘤夹6例。③术后随访显示,患者均无动脉瘤复发及破裂的临床表现。对12例行DSA随访,显示动脉瘤颈均夹闭完全,无动脉瘤残留。结论 PCoAA夹闭术中,确认动脉瘤颈的位置,辨别瘤周血管的解剖关系,对动脉瘤夹的选择和放置至关重要。首选弯型动脉瘤夹,能提高完全夹闭PCoAA的成功率。

Objective To investigate the selection and application of aneurysm clips for microsurgical clipping of posterior communicating artery aneurysms（PCoAA）.Methods The clinical data of 46 patients with PCoAA whom underwent microsurgical clipping in Peking University First Hospital from January 2007 to June 2011 were analyzed retrospectively.The aneurysms were classified according to the relationship between the aneurysm neck and its parent artery.The locations of aneurysm necks,the types of aneurysm clip and the placement of aneurysm clips were analyzed.The patients were followed up by outpatient department examination,telephone inquiry and DSA for 4 months to 4 years.Results ①The 46 patients with PCoAA were divided into 3 types according to the site of aneurysmal necks in parent artery：internal carotid artery（n=19）,PCoAA（n=5） proper,and bifurcation（n=22）.② The bent clip,straight clip,angled fenestrated clip,and bayonet-shaped clip were used in 37,6,2,and 1 patients,respectively.The clip length was 6-7 mm in 54.3% patients,and was 5-7 mm in 21.7% patients.In the PCoAA type and bifurcation type aneurysms,the clips were parallel to the direction of the vessels,whilein the internal carotid type aneurysms were placed vertically the clips to the internal carotid artery in 13 patient,and parallel to the direction of the vessels in 6 patients.③The postoperative follow-up showed that the patients did not have the clinical manifestations of aneurysm recurrence and rupture.Twelve patients were followed up with DSA,and it revealed that their aneurysm necks were occluded completely and no residual aneurysms seen.Conclusion In the PCoAA clipping,confirming the location of aneurysm necks and identifying the relationship between the aneurysm and its surrounding vessels are critical for selecting and placing aneurysm clips.The first choice of bent aneurysm clip may improve the success rate for complete occlusion of PCoAA.