压力导丝在颈动脉支架成形术中的应用

Application of pressure wire in carotid artery stenting

研究背景目前对于颈动脉狭窄临界性病变尚缺乏相应的治疗标准,颈动脉支架成形术需要更加直观的参考标准,本研究旨在探讨压力导丝用于颈动脉支架成形术的可能性,以及压力阶差对颈动脉支架成形术适应证选择的指导作用。方法选择2012年5-10月施行颈动脉狭窄支架成形术治疗的患者共32例,分别于手术前后根据颈动脉彩色超声、CT灌注成像及术中支架植入前后颈动脉血管内压力阶差变化,评价颅内血流代偿情况。结果术前颈动脉超声检查显示32例患者颈动脉狭窄率均≥70%或接近闭塞,狭窄血管收缩期峰值流速为184～718cm/s;术中全脑血管造影狭窄率达50%～70%者7例、>70%～90%者16例、>90%者9例,颈动脉超声与脑血管造影符合率约为84.38%(27/32)。术中颈动脉压力阶差获取率为100%,术前压力阶差为10～92mmHg、平均(41.45±25.50)mmHg,术后为0～15mmHg、平均(3.44±3.47)mmHg。根据全脑血管造影检查,颅内血供代偿良好者4例、不良者28例。结论压力导丝可以安全有效的获得颈动脉狭窄两端的压力阶差,对于缺乏颅内代偿的颈动脉狭窄患者,随着狭窄程度的加重,在一定范围内其颈动脉压力阶差亦随之增加。因此对于压力阶差较低的颈动脉狭窄患者施行支架成形术治疗时需综合考虑。

Background Nowadays, critical carotid stenosis lacks appropriate treatment standards, and carotid artery stenting （CAS） needs more direct guidance. This study aims to investigate the possibility of applying pressure wire in CAS, and the guidance of pressure gradients in choosing indications of CAS. Methods From May 2012 to October 2012, 32 consecutive cases with carotid stenosis undergoing CAS were enrolled. Preoperative and postoperative carotid ultrasound and CT perfusion imaging were performed, and intraoperative measurements of endovascular pressure gradients before and after stent implantation were recorded to evaluate intracranial circulation compensation. Results Preoperative carotid ultrasound showed the rate of stenosis in 32 cases was ≥70% or nearly total occlusion. Doppler measurement of peak systolic velocity （PSV） of the stenosed vessel ranged 184-718 cm/s. Digital subtraction angiography （DSA） examination showed the stenosis rates were 50%-70% in 7 cases, 70%-90% in 16 and 〉 90% in 9. The coincidence rate of carotid ultrasound and DSA was 84.38% （27/32）, and the acquisition rate of intraoperative carotid pressure gradients was 100%. Pressure gradients before stent implantation were 10-92 mm Hg, with an average of （41.45 ±25.50） mm Hg, and pressure gradients after stent implantation were 0-15 mm Hg, with an average of （3.44 ± 3.47） mm Hg. DSA revealed 4 cases with good intracranial circulation compensation and 28 cases with poor intraerania] circulation compensation. Conclusion Pressure wire can be safely and effectively used in CAS to acquire pressure gradients between the two ends of stenosis segment. For carotid artery stenosis patients lacking of intracranial circulation compensation, pressure gradients become higher as stenosis rate increases within a certain range. Therefore, CAS for stenosis with lower pressure gradients should be reconsidered.