抽吸取栓术与支架取栓术治疗前循环心源性脑栓塞患者的安全性和有效性分析

Safety and efficacy of a direct aspiration first-pass thrombectomy technology versus stent-retriever thrombectomy for patients with anterior circulation cardiogenic cerebral embolism

目的比较抽吸取栓术与支架取栓术治疗前循环心源性脑栓塞的安全性和有效性。方法回顾性连续纳入2019年1月至2021年12月江苏大学附属宜兴医院神经外科收治的急性前循环心源性脑栓塞患者88例,均存在前循环大血管闭塞,且急诊行经皮颅内动脉取栓术。根据取栓方式的不同,将88例患者分为抽吸取栓组(33例)和支架取栓组(55例)。记录两组患者的年龄、性别、危险因素(高血压病、糖尿病、高脂血症、冠心病)、栓塞病因(心房颤动、瓣膜病、心肌病及其他心脏病)、栓塞部位(颈内动脉、大脑中动脉M1段)、入院时美国国立卫生研究院卒中量表(NIHSS)评分、入院时Alberta卒中项目早期CT评分(ASPECTS)、入院时头部CT血管成像(CTA)侧支循环分级、入院时CTA血栓负荷评分、静脉溶栓情况、发病至股动脉穿刺时间、术前使用抗凝药(华法林、新型抗凝药利伐沙班)或抗血小板聚集药物(阿司匹林及氯吡格雷)情况、血栓逃逸、术后即刻改良脑梗死溶栓(mTICI)分级(mTICI分级2b~3级为闭塞血管成功再通)、有效性指标(一次血管再通率、一次血管再通时间、穿刺至血管再通时间、取栓次数)、安全性指标(症状性颅内出血、非症状性颅内出血)、术后90 d改良Rankin量表(mRS)评分(mRS评分≤2分为临床预后良好,6分为死亡),并进行组间比较。结果(1)两组年龄、性别、危险因素、栓塞病因、栓塞部位、入院时NIHSS评分、入院时ASPECTS、入院时CTA侧支循环分级、入院时CTA血栓负荷评分、静脉溶栓、发病至股动脉穿刺时间及术前长期使用抗凝药或抗血小板聚集药物的差异均无统计学意义(均P>0.05)。(2)抽吸取栓组一次血管再通率高于支架取栓组[60.6%(20/33)比21.8%(12/55),χ^(2)=13.41],一次血管再通时间及穿刺至血管再通时间均短于支架取栓组[30.0(21.0,35.0)min比42.5(31.0,65.0)min,Z=-2.419;33.0(25.0,56.0)min比80.0(60.0,112.5)min,Z=-5.560],取栓次数少于支架取栓组[1(1,2)次比2(2,3)次,Z=-3.983],组间差异均有统计学意义(均P<0.05);两组术后mTICI分级占比及血栓逃逸、补救措施、症状性颅内出血、非症状性颅内出血率的差异均无统计学意义(均P>0.05),术后90 d mRS评分≤2分占比的组间差异无统计学意义(P>0.05),两组患者病死率的差异无统计学意义(P>0.05)。结论抽吸取栓和支架取栓治疗前循环心源性栓塞的临床预后相似,抽吸取栓的效率略优于支架取栓。本研究结果有待进一步证实。

Objective To compare the safety and efficacy of a direct aspiration first-pass thrombectomy(ADAPT)technology and stent-retriever thrombectomy in patients with anterior circulation cardiogenic cerebral embolism(CCE).Methods The study retrospectively and continuously recruited 88 patients with anterior circulation CCE in the Department of Neurosurgery,Affiliated Yixing Hospital,Jiangsu University from January 2019 to December 2021.Emergency percutaneous intracranial artery embolectomy were performed for all patients.Patients were divided into ADAPT group(33 cases)and stent-retriever group(55 cases)according to surgical method.The age,sex,risk factors(hypertension,diabetes,hyperlipidemia,coronary heart disease),cause of embolism(atrial fibrillation,valvular disease,cardiomyopathy and other heart diseases),embolism location(internal carotid artery,M1 segment of middle cerebral artery),National Institute of Health Stroke Scale(NIHSS)score at admission,Alberta stroke program early CT score(ASPECTS)at admission,classfication of collateral status of computed tomography angiography(CTA)at admission,CTA clot burden score at admission,intravenous thrombolysis,time from onset to puncture,preoperative use of anticoagulants(Warfarin,new anticoagulant rivaroxaban)or antiplatelet aggregation drugs(Aspirin and clopidogrel),the rate of intraoperative thrombus escape,modified thrombolysis in cerebral infarction(mTICI)grade(successful recanalization was defined as mTICI grade 2b-3 at the end of procedure),effectiveness indicators(the percentage of first-pass effect,the time of one-time recanalization,the time of puncture to recanalization,number of passes),safety indicators(symptomatic intracranial hemorrhage,asymptomatic intracranial hemorrhage),and modified Rankin scale(mRS)score at 90 days after intervention(good prognosis was defined as 90-day mRS score≤2;death was defined as 90-day mRS 6).The above indexes were compared between two groups.Results(1)There were no significant differences between two groups in age,sex,risk factors,cause of embolism,embolism location,NIHSS score at admission,ASPECTS at admission,classification of collateral status of CTA at admission,CTA clot burden score at admission,the rate of intravenous thrombolysis,time from onset to puncture,and the rate of long-term use of anticoagulants or antiplatelet drugs before surgery(all P>0.05).(2)The percentage of first-pass effect of the ADAPT group was higher than that in the stent-retriever group(60.6%[20/33]vs.21.8%[12/55],χ^(2)=13.41).The time of one-time recanalization and the puncture to recanalization time of the ADAPT group were both shorter than that in the stent-retriever group(30.0[21.0,35.0]min vs.42.5[31.0,65.0]min,Z=-2.419;33.0[25.0,56.0]min vs.80.0[60.0,112.5]min,Z=-5.560).The number of passes of the ADAPT group was less than the stent-retriever group(1[1,2]times vs.2[2,3]times,Z=-3.983).The differences between two groups were all significant(all P<0.05).There were no significant differences between two groups in the rate of mTICI grade after intervention,the percentage of intraoperative thrombus escape,remedial therapy,symptomatic intracranial hemorrhage and asymptomatic intracranial hemorrhage(all P>0.05).The proportion of mRS score≤2 at 90 days after intervention and mortality had no significant difference(both P>0.05).Conclusions The stent-retriever thrombectomy and the ADAPT technology are similar in terms of clinical outcome in anterior circulation cardiogenic cerebral embolism.Compared to stent-retriever thrombectomy,the ADAPT technology has slightly better clinical efficacy.The results of this study should be confirmed further.