颈内动脉起始部合并椎动脉起始部重度狭窄的外科治疗

Surgery for severe stenosis at the origins of the internal carotid and vertebral arteries

目的探讨颈内动脉起始部合并椎动脉起始部重度狭窄的外科治疗策略。方法回顾性分析106例颈内动脉起始部合并椎动脉起始部重度狭窄病人的临床资料,同时行椎动脉支架植入术（VAS）和颈动脉支架植入术（CAS）87例;先行支架植入术再行颈动脉内膜剥脱术（CEA）19例,其中先行VAS再行CEA 11例,先行VAS和CAS再行CEA 5例,先行双侧VAS再行CEA 3例。结果术后DSA复查均显示狭窄解除、管腔通畅,远端显影较术前明显好转。MRI灌注复查提示脑灌注较术前明显改善。围手术期出现小脑点状梗死5例,经常规内科治疗后好转出院。随访6~48个月,出现脑梗死3例,VAS术后再狭窄14例,CAS术后再狭窄5例,CEA术后未见再狭窄者。结论对颈内动脉起始部合并椎动脉起始部重度狭窄的病人,需灵活运用VAS、CAS及CEA术式,扬长避短,减少术后并发症。

Objective To investigate the surgical strategy for patients with severe stenosis at the origins of the internal carotid and vertebral arteries（OICVA）. Methods Clinical data of 106 patients with severe stenosis at OICVA were analyzed retrospectively.Eighty-seven patients were treated by one-stage operation of vertebral angioplasty and stenting（VAS） and carotid angioplasty and stenting（CAS）, and 19 patients were treated by two-stage operation of angioplasty and stenting followed by carotid endarterectomy（CEA）, including VAS followed by CEA in 11 patients, VAS and CAS followed by CEA in 5, and bilateral VAS followed by CEA in 3.Results Good artery morphology, smooth blood flow and improved cerebral perfusion were achieved in all the patients based on DSA and MRI perfusion reexamination after the operation. Petechial cerebellum infarction occurred in 5 patients during perioperative period,and all the patients recovered after conventional medical treatment. During a follow-up period of 6 to 48 months, cerebral infarction occurred in 3 patients, restenosis after VAS in 14 and restenosis after CAS in 5, while no patient underwent restenosis after CEA.Conclusion The surgical method of VAS, CAS and CEA can flexibly apply to severe stenosis at OICVA, and can reduce postoperative complication.