非急性症状性颈内动脉闭塞患者血管内再通治疗的可行性和安全性分析

Investigation on the feasibility and safety of endovascular recanalization in patients with non-acute symptomatic internal carotid artery occlusion

目的:回顾性分析非急性症状性颈内动脉闭塞(ICAO)患者血管内再通治疗的可行性、安全性和有效性。方法:收集症状性亚急性及慢性ICAO行血管内治疗患者59例,根据Hasan等的DSA图像分类法,分析手术的成功率、围手术期的并发症及90 d后的预后。结果:59例中48例成功再通,总体再通率81.36%。成功再通病例中A型21例(43.75%)、B型15例(31.25%)、C型9例(18.75%)、D型3例(6.25%);开通失败未再通11例,其中A型2例(18.8%)、B型1例(9.09%)、C型3例(27.27%)、D型5例(45.45%)。术中并发症包括癫痫发作1例(1.69%)、谵妄1例(1.69%)、血压升高3例(5.08%)、栓子移位并行支架取栓2例(3.39%)、动脉夹层2例(3.39%)。术后1周内并发症仅头痛1例(2.08%),无癫痫发作、脑出血、蛛网膜下腔出血。平均随访(57.22±23.88)月,失访12例,均为再通成功者;死亡3例,1例死于癌症,1例死于肺部感染,1例死于心脏病。再通组围手术期mRS 0~2分者与出院时及长期随访之间比较差异无统计学意义(χ^(2)=2.244,P>0.05),但2例术中栓子移位,1例症状加重,mRS由3分增至4分;随访结束mRS 0~2分者28例(77.78%)。再通组与再通失败组mRS 0~2分者比较,长期随访差异有统计学意义(χ^(2)=7.454,P<0.001),围手术期与出院时差异无统计学意义(P>0.05)。另外,再通组围手术期mRS评分值高于长期随访者(P<0.05),而未再通组围手术期mRS评分与长期随访者差异无统计学意义(P>0.05)。结论:非急性症状性ICAO在DSA图像分类下分层进行血管内再通治疗是安全可行的,尤其是A型、B型。但闭塞的时间、部位及性质决定手术的再通率,栓子移位是术中缺血性卒中发生的主要原因。

Objective:To retrospectively analyze the feasibility,safety and efficacy of endovascular recanalization in patients with non-acute symptomatic internal carotid artery occlusion(ICAO).Methods:Fifty-nine cases of symptomatic sub-acute and chronic ICAO undergone endovascular treatment were collected and analyzed.Then retrospective analysis was performed concerning the successful rate of surgery,perioperative complications and prognosis in 90 days following treatment in compliance with DSA image classification described by Hasan et al.Results:Recanalization was successful in 48 of the 59 patients,with an overall recanalization rate of 81.36%.Of the patients with successful recanalization,21(43.75%)were in type A,15(31.25%)in type B,9(18.75%)in type C,and 3(6.25%)in type D.Recanalization was not given in 11 cases of failure,in whom 2 were in type A(18.8%),1 in type B(9.09%),3 in type C(27.27%)and 5 in type D(45.45%).Intraoperative complications were associated with epileptic seizure in 1 case(1.69%),delirium in another 1(1.69%),elevated blood pressure in 3(5.08%),stent thrombectomy due to embolus displacement in 2(3.39%),and arterial dissection in 2(3.39%).Complications within one week after operation consisted of headache only in 1 case(2.08%),yet no seizure,cerebral or subarachnoid hemorrhage occurred.Fifty-nine patients were followed up for an average of(57.22±23.88)months,whereas 12 patients were lost to follow.There were 3 deaths during follow-up,in whom one died from cancer,one from a lung infection and another one from heart disease.There was no difference between the perioperative modified Rankin score(mRS,ranging from 0 to 2)and that at discharge as well as long-term follow-up in patients in the recanalization group(χ^(2)=2.244,P>0.05),yet intraoperative embolus displacement and worsened symptom occurred respectively in two and one,leading to increased mRS from 3 to 4.By the end of follow-up,mRS at 0-2 was seen in 28 patients(77.78%).The difference was significant in patients in successful recanalization and failed recanalization with mRS at 0-2 by long-term follow-up(χ^(2)=7.454,P<0.001),yet was insignificant in perioperative period and at discharge(P>0.05).In addition,the perioperative mRS in patients with successful recanalization was higher than that of long-term follow-up(P<0.05),whereas there was no significant difference between the perioperative mRS in patients of failed recanalization and long-term follow-up(P>0.05).Conclusion:Intravascular recanalization according DSA classified stratification is safe and feasible for symptomatic non-acute ICAO,especially for type A and type B.However,the time,lesion location and nature of occlusion will affect recanalization rate,and embolus displacement represents the major cause of intraoperative ischemic stroke.