经颈滤伞保护下颈动脉支架成形术的单中心经验

A single-center experience of transcervical carotid artery stenting with embolic filter protection

目的总结采用经颈滤伞保护下颈动脉支架成形术(TC-CAS)治疗颅外颈动脉狭窄的经验。方法本研究为回顾性纵向研究。分析2020年12月至2023年9月温州医科大学附属第一医院血管外科应用TC-CAS治疗31例(32条颈动脉)颈动脉狭窄患者的临床资料。32条颈动脉病变均为颈内动脉起始段狭窄,其中重度狭窄25条,中度狭窄7条。31例患者中,CT血管造影示Ⅲ型弓10例,牛角弓2例,主动脉弓溃疡1例,重度钙化4例,混合斑块6例,颈总动脉迂曲7例,主髂动脉闭塞1例。观察和评估手术成功率、术后30 d短暂性脑缺血发作(TIA)/卒中发生率、术后3 d内磁共振弥散加权成像(DW-MRI)检测到的新发脑缺血灶发生率以及外科并发症情况。结果32条狭窄的颈动脉均经过TC-CAS成功开通(其中1例双侧颈动脉狭窄采取分期手术),残余狭窄程度均≤20%,手术成功率为100%。23例患者术后行DW-MRI,发现脑部新缺血灶4例(17.4%),其中3例无症状,1例出现小卒中,表现为短暂的意识淡漠,围术期卒中发生率为3.1%(1/32)。此外,2例患者术后早期出现创口血肿,经清创处理后成功治愈。所有患者均获得随访,术后中位随访时间为7.5(4.0,14.0)个月,随访期间无TIA或卒中发生。结论TC-CAS治疗颈动脉狭窄,有利于降低CAS中导管接触主动脉弓斑块导致脑卒中的风险和避免对侧栓塞性卒中的发生,可考虑用于符合CAS适应证且存在通路解剖高风险因素的患者。

ObjectiveTo summarize the experience in adopting transcervical carotid artery stenting(TC-CAS)for the treatment of extracranial carotid artery stenosis under the protection of embolic filter devices.MethodsThis study was a retrospective cohort.A retrospective analysis of clinical data was conducted for 31 patients(32 carotid arteries)with confirmed carotid artery stenosis who underwent TC-CAS in Department of Vascular Surgery of the First Affiliated Hospital of Wenzhou Medical university between December 2020 and September 2023.Among the 32 arteries with carotid artery lesions,all were stenotic at the origin of the internal carotid artery,including 25 severe and 7 moderate stenoses.Among the 31 patients,there were 10 cases of TypeⅢarch shown on CT angiography,2 cases of bovine arch,1 case of aortic arch ulceration,4 cases of severe calcification,6 cases of mixed plaques,7 cases of the carotid artery tortuosity,and 1 case of common iliac artery occlusion.The effectiveness assessment included procedural success rate,while safety assessment included the incidence of transient ischemic attack(TIA)/stroke within 30 days,the occurrence rate of new cerebral ischemic lesions detected by diffusion weighted magnetic resonance imaging(DW-MRI)within 72 hours after procedure,and local complications.ResultsAll 32 stenotic carotid arteries were successfully opened with TC-CAS(with one case undergoing staged surgery bilaterally),with a residual stenosis of≤20%and a 100%procedural success rate.DW-MRI was performed in 23 patients after surgery,and new cerebral ischemic lesions were found in 4 cases(17.4%),of which 3 were asymptomatic,and 1 exhibited minor stroke manifested as transient loss of consciousness.The incidence of periprocedural stroke rate was 3.1%(1/32).In addition,two patients developed wound hematomas in the early postoperative period,which were successfully treated after debridement.The median follow-up time after surgery was 7.5(4,14)months,during which no TIA or strokes occurred.ConclusionThe TC-CAS treatment for carotid artery stenosis is beneficial in reducing the risk of cerebral infarction caused by catheter contact with aortic arch plaques during carotid artery stent placement.It also helps prevent the occurrence of contralateral embolic strokes.It is particularly suitable for patients who meet the indications for carotid artery stent placement but present with anatomical high-risk factors for carotid cannulation.