椎动脉-颈总动脉转位术对不适合介入治疗的椎动脉V1段重度狭窄患者的疗效分析

Application of vertebral artery-common carotid artery transposition on patients for severe stenosis of V1 segment of vertebral artery unable to be treated by intervention

目的 探索椎动脉-颈总动脉(VA-CCA)转位术在不适合介入治疗的椎动脉V1段重度狭窄患者中的安全性及疗效。方法 回顾性连续纳入2019年4月至2022年6月经苏州大学附属第一医院神经外科治疗的不适宜介入治疗(血管异常致介入治疗困难、不能使用抗血小板聚集药物治疗、近期开放性手术、患者拒绝介入治疗)的12例椎动脉起始部V1段重度狭窄(狭窄率70%~99%)患者的病历资料,所有患者经头颈CT血管成像(CTA)+CT灌注成像(CTP)、头颈DSA、颈部经颅多普勒超声(TCD)证实存在V1段重度狭窄,且均采用VA-CCA转位术治疗。12例患者中男11例,女1例;年龄41~77岁,平均(58±10)岁。收集患者的临床资料,包括性别、年龄、临床表现(头晕、肢体乏力、发作性意识丧失、头痛、黑矇)、高血压病、糖尿病、消化性溃疡、吸烟、酗酒、入院时改良Rankin量表(mRS)评分、椎动脉起始部重度狭窄程度、术后3个月随访结果(TCD、mRS评分)。安全性事件指术后3个月新发卒中、再狭窄和死亡,有效性评价为术中、住院期间和术后3个月血管通畅情况及临床预后,以术后3个月mRS评分≤1分定义为预后良好。结果 12例患者手术均获得成功,术中及住院期间TCD均证实患侧椎动脉血流通畅,术后症状均有改善;仅1例患者术后出现声音嘶哑,考虑为喉返神经损伤,术后1周症状完全消失。12例患者随访时间3~40个月,术后3个月经TCD证实血管通畅,未出现围术期死亡、新发卒中、再狭窄事件;临床随访均获得良好预后。结论 对于不适合介入治疗的椎动脉V1段重度狭窄患者,或可考虑采用VA-CCA转位术。

Objective To explore the safety and effect of vertebral artery-common carotid artery transposition on patients for severe stenosis of V1 segment of vertebral artery that unable to be treated by intervention. Methods The clinical data of 12 patients with severe vertebral artery stenosis(diameter stenosis rate, 70%-99%)(Failure of interventional therapy for vascular malformation, inability to use antiplatelet aggregation drugs long-term, open surgery being required in the near future or patients being unwilling to undergo interventional therapy) who were treated by vertebral artery-common carotid artery(VA-CCA) transposition from April 2019 to June 2022 in Department of Neurosurgery, the First Affiliated Hospital of Soochow University were retrospectively analyzed. All patients were verified severe stenosis of V1 segment of vertebral artery by computed tomography angiography(CTA), computed tomography perfusion(CTP), digital subtraction angiography(DSA) and transcranial doppler(TCD) and underwent VA-CCA transposition. There were 11 males and 1 female, aging 41-77 years with an average age of(58±10) years. Clinical data of patients were collected, including sex, age, clinical manifestations(dizziness, limb weakness, paroxysmal loss of consciousness, headache and amaurosis), hypertension, diabetes mellitus, peptic ulcer, smoking, drinking, modified Rankin scale(mRS) on admission, the stenosis degree of vertebral artery origin and follow-up results at 3 months after operation(TCD, mRS score). Safety events referred to new onset of stroke, VA restenosis and death at 3-month follow-up. Effectiveness evaluation was based on vascular patency and clinical prognosis during surgery, hospitalization and 3-month follow-up. The mRS≤1 was defined as good prognosis. Results All 12 patients were performed VA-CCA transposition successfully. TCD confirmed the patency of the affected VA during the operation and hospitalization. Symptoms of all patients were improved after the surgery. Hoarseness occurred in 1 patient postoperatively, which was considered as recurrent laryngeal nerve injury, and the symptom finally disappeared 1 week after surgery. All 12 patients were followed up for 3-40 months. The vascular patency was confirmed by TCD 3 months after operation. No perioperative death, new onset of stroke and restenosis after VA-CCA transposition occurred. Good prognosis was obtained in all cases. Conclusion VA-CCA transposition may be considered for patients with severe stenosis of V1 segment of vertebral artery that unable to be treated by intervention.