颈内动脉颅外段严重迂曲伴重度狭窄支架成形术的临床分析

Clinical analysis of carotid angioplasty stenting for high-grade extracranial carotid artery stenosis combined with severe tortuosity

目的 探讨颈动脉颅外段严重迂曲伴重度狭窄支架成形术的手术疗效及安全性.方法 回顾性纳入2011年6月至2014年6月在中日友好医院神经内科收治的20例经脑血管造影诊断为颈内动脉颅外段重度狭窄且伴颈段血管严重迂曲者,其中症状性患者12例.所有患者不适合或不同意行颈动脉内膜剥脱术（CEA）而接受颈动脉支架成形术（CAS）治疗.分析手术技术成功率、围手术期并发症及症状缓解情况.同时,在4～40个月随访期内,观察有无受治侧颈动脉供血区短暂性脑缺血发作（TIA）、脑卒中与死亡事件及利用颈动脉超声或头颈CTA观察支架内有无斑块增生、再狭窄及支架变形或断裂发生.结果 （1）手术结果：手术技术成功率19/20,远端保护装置放置率18/20,其中1例支架及2例远端保护装置因血管形态异常而无法到位.颈内动脉迂曲分类中以折曲（65％）最多见.支架植入后狭窄明显改善,由术前平均狭窄率（82％±9％）下降到术后平均的狭窄率（7％±6％）.围手术期并发症5例,其中血管痉挛4例,1例伴颈动脉窦反应、1例伴术中TIA;同侧颈动脉供血区小卒中1例.所有并发症状于术后1周内消失,无支架相关的死亡及致残.（2）预后及随访结果：12例症状性患者出院时症状明显改善：由入院时平均NIHSS评分（4±4）分下降到出院时的（2±2）分.在平均19个月的随访期中,受治侧颈动脉供血区内发生小卒中1例、TIA 1例;支架内轻微斑块增生5例,无支架内再狭窄及支架变形或断裂.结论 颅外段颈动脉严重迂曲会影响介入材料使用而增加CAS的复杂性,但对于不同意或存在CEA禁忌的患者,CAS仍可能是一种相对安全、有效的替代治疗手段.

Objective To observe the feasibility and safety of carotid angioplasty stenting （CAS） for high-grade extracranial carotid artery stenosis combined with severe tortuosity.Methods Twenty patients diagnosed with high-grade extracranial carotid artery stenosis combined with severe tortuosity by cerebral angiography,who were in hospital in neurology department of China-Janpan friendship from June 2011 to June 2014.Twelve of these patients were symptomatic.All cases weren＇t suit for or disagreed with carotid endarterectomy （CEA） to accept CAS.We retrospectively discussed the rates of technical success,the perioperative complications and clinical improvement.During the follow-up for 4 to 40 months we observed the events of cured carotid artery territory stroke and death,and record the plaque hyperplasia in stent,in-stent restenosis,stent deformation or fracture by color doppler ultrasonography or craniocervical CT angiography.Results （1） The results of operation：the rate of technical success was 19/20 and the rate of the distal protection device placement was 18/20.One stent and 2 distal protection device were difficult to pass the tortuous access vessels.The kinking was the most common in circuity classification of internal carotid artery.The stenosis was significantly improved after stenting,and the mean degree of stenosis was reduced from （82% ±9%） before stenting to （7% ± 6%） after stenting.Although 5 patients were with perioperative complications,all symptoms disappeared within 1 weeks,and there was no stent related death and disability.There were 4 cases with vascular spasm,one of them was combined with carotid sinus reaction,and anther with transient ischemic attack （TIA） during operation.There was one with ipsilateral carotid territory minor stroke.（2） The results of prognosis and follow up：The clinical symptoms from 12 symptomatic patients were improved significantly on discharge,and the average NIHSS scores on admission were reduced from （4 ± 4） to （2 ± 2） on discharge.One patient experienced ipsilateral carotid territory minor stroke and another patient experienced ipsilateral carotid territory TIA during the follow-up for an average of 19 months,and there were 5 cases with mild plaque hyperplasia in stent and no in-stent restenosis,stent deformation or fracture.Conclusion The severe tortuosity of extracranial carotid artery may affect the using of intervention materials and increase the complexity of CAS,but for the patients who disagree with CEA or were with the contraindications to CEA,CAS may be still a relatively safe,effective and alternative treatment.