高危患者中症状性颈动脉狭窄的血管内支架治疗
Sir Ganga Ram Hospital, and St. Stephens’s Hospital, New Delhi. INDIA
【摘要】
背景：在症状性和非症状性颈动脉病中，颈动脉支架成形术应用越来越广泛。虽然北美症状性颈动脉内膜剥脱术试验(NASCET)显示，颈动脉内膜剥脱术比单纯药物治疗疗效更好，但在这组患者中排除了病情严重、血管成形术和有神经科危险因素的患者。由于外科手术在这些高危人群中手术期间的发病率和死亡率均高，故我们研究了支架血管成形术在这些高危人群中的安全性和有效性。支架术发生并发症的一个主要的危险就是脑栓塞，各种脑保护措施或过滤装置对预防这种并发症有一定效果，但这又会增加新的危险或增加费用。因此需要寻找一种既有效又不需要脑保护措施的颈动脉支架技术是必需的。
资料与方法：从1999年5月至2004年8月，我们对96例NASCET排除的症状性颈动脉病患者实施了颈动脉支架成形术。其中37例(37.5%)对侧完全闭塞。在这96例中，60例男性，36例女性，平均年龄52岁(40-84岁)。平均受损长度22±7.9mm，平均狭窄率85±8.0%(参考直径5.8±0.3mm)。所有这些颈动脉在治疗期间均未采取脑保护措施。支架用的有Precise自膨式支架(Cordis, Johnson&Johnson)、自膨式颈动脉支架(Boston Scientific Inc)、颈动脉窦支架(Optimed)和Prostar球囊膨胀支架[7/35(20%)采取了球囊预扩张]。术后对76例进行了6个月的随访，并进行了系列的彩超和临床双重评价。
, http://www.100md.com
结果：在进行基线处理后，颈动脉血管成形术总的成功率是95/96(99%)。6例(6.2%)在球囊打气时出现短暂的局灶抽搐，在球囊放气后就很快恢复了。这6例患者都有对侧颈内动脉完全闭塞。10例(10.4%)在球囊打气时有短暂的心动过缓，无需起搏即恢复了。1例(1%)术后8 h有轻微卒中，是由于高灌注损伤引起颅内小的出血。在手术后30天内没有1例死亡。2/76(2.6%)在随访期间有相同动脉供应区的TIA。
结论：对高危人群的颈动脉支架术与低温人群颈动脉内膜剥脱术的发病率和死亡率进行比较，颈动脉支架术是一项安全有效的方法，此类方法中没有必要进行脑保护。但是，尚需大样本随机试验进一步证实。
Stent Angioplasty of Symptomatic Carotid Stenoses in High risk Patients: Is Cerebral Protection Device necessary?
, 百拇医药
Shakir Husain
Honorary Consultant
NeuroEndoVascular Therapy Unit,Sir Ganga Ram Hospital, and St. Stephens’s Hospital, New Delhi. INDIA.
Background: Carotid angioplasty and stenting (CAS) is increasingly being used for the treatment of symptomatic and asymptomatic carotid artery disease. Although the North American Symptomatic Carotid Endarterectomy Trial (NASCET) has shown carotid endarterectomy (CEA) to be protective compared with medical therapy alone, its stringent eligibility criteria excluded patients with severe medical, angiographic, and neurological risk factors. We examined the safety and efficacy of stent angioplasty in this high-risk subset for which the perioperative morbidity and mortality of surgery are high. One of the major risks of complication is due to embolization of the clot during the procedure. Various cerebral protection or filter devices are available to prevent this complication. The use of additional devices sometimes adds new risk related to these devices and also increases the cost of the procedure. Technical essentials and therapeutic results of carotid stenting without cerebral protection are presented.
, 百拇医药
Materials and methods: From May 1999 and August 2004, CAS was performed in 96 symptomatic NASCET-ineligible patients. Thirty six (37.5%) patients had complete occlusion of contra-lateral carotid. There were 60 males and 36 female, mean age was 52 years (range 40 to 84 years). Mean lesion length was 22 ± 7.9 mm, and mean percent stenosis was 85 ± 8.0% (reference diameter 5.8 ± 0.3mm). All the carotids were treated without cerebral protection device. Stents used were Precise self expanding stent (Cordis, Johnson & Johnson), self expanding Carotid Wallstents (Boston Scientific Inc), Carotid Sinus Stent (Optimed) and Prostar Balloon expandable stent [predilation was performed in 7/35(20%)]. Follow-up consisted of serial duplex ultrasonography and clinical assessment in 76 patients at a median of 16 months.
, 百拇医药
Results: On an intention to treat basis, the overall technical success rate for carotid angioplasty was 95/96(99%). Six (6.2%) patients had transient focal seizure during balloon inflation, which reversed immediately, uneventfully following balloon deflation. All six patients had complete occlusion of opposite internal carotid artery. Ten patients (10.4%) had transient bradicardia during balloon inflation which did not require pacing. One patient (1%) had a minor stroke 8 hrs after the procedure due to hyperperfusion injury resulting in minimal intracerebral haemorrhage. None of the patient died in 30 days peri-procedure period. Two of 76 (2.6%) patients had TIA involving same arterial territory in follow-up period.
, 百拇医药
Conclusion: Carotid arterial stent placement in a high-risk population has morbidity and mortality rates comparable to those of carotid endarterectomy in a lower risk population. CAS is a safe and viable alternative in such group of patients. Cerebral protection device use probably may not be necessary. However, this issue needs to be addressed in a large randomized trial., 百拇医药
【摘要】
背景：在症状性和非症状性颈动脉病中，颈动脉支架成形术应用越来越广泛。虽然北美症状性颈动脉内膜剥脱术试验(NASCET)显示，颈动脉内膜剥脱术比单纯药物治疗疗效更好，但在这组患者中排除了病情严重、血管成形术和有神经科危险因素的患者。由于外科手术在这些高危人群中手术期间的发病率和死亡率均高，故我们研究了支架血管成形术在这些高危人群中的安全性和有效性。支架术发生并发症的一个主要的危险就是脑栓塞，各种脑保护措施或过滤装置对预防这种并发症有一定效果，但这又会增加新的危险或增加费用。因此需要寻找一种既有效又不需要脑保护措施的颈动脉支架技术是必需的。
资料与方法：从1999年5月至2004年8月，我们对96例NASCET排除的症状性颈动脉病患者实施了颈动脉支架成形术。其中37例(37.5%)对侧完全闭塞。在这96例中，60例男性，36例女性，平均年龄52岁(40-84岁)。平均受损长度22±7.9mm，平均狭窄率85±8.0%(参考直径5.8±0.3mm)。所有这些颈动脉在治疗期间均未采取脑保护措施。支架用的有Precise自膨式支架(Cordis, Johnson&Johnson)、自膨式颈动脉支架(Boston Scientific Inc)、颈动脉窦支架(Optimed)和Prostar球囊膨胀支架[7/35(20%)采取了球囊预扩张]。术后对76例进行了6个月的随访，并进行了系列的彩超和临床双重评价。
, http://www.100md.com
结果：在进行基线处理后，颈动脉血管成形术总的成功率是95/96(99%)。6例(6.2%)在球囊打气时出现短暂的局灶抽搐，在球囊放气后就很快恢复了。这6例患者都有对侧颈内动脉完全闭塞。10例(10.4%)在球囊打气时有短暂的心动过缓，无需起搏即恢复了。1例(1%)术后8 h有轻微卒中，是由于高灌注损伤引起颅内小的出血。在手术后30天内没有1例死亡。2/76(2.6%)在随访期间有相同动脉供应区的TIA。
结论：对高危人群的颈动脉支架术与低温人群颈动脉内膜剥脱术的发病率和死亡率进行比较，颈动脉支架术是一项安全有效的方法，此类方法中没有必要进行脑保护。但是，尚需大样本随机试验进一步证实。
Stent Angioplasty of Symptomatic Carotid Stenoses in High risk Patients: Is Cerebral Protection Device necessary?
, 百拇医药
Shakir Husain
Honorary Consultant
NeuroEndoVascular Therapy Unit,Sir Ganga Ram Hospital, and St. Stephens’s Hospital, New Delhi. INDIA.
Background: Carotid angioplasty and stenting (CAS) is increasingly being used for the treatment of symptomatic and asymptomatic carotid artery disease. Although the North American Symptomatic Carotid Endarterectomy Trial (NASCET) has shown carotid endarterectomy (CEA) to be protective compared with medical therapy alone, its stringent eligibility criteria excluded patients with severe medical, angiographic, and neurological risk factors. We examined the safety and efficacy of stent angioplasty in this high-risk subset for which the perioperative morbidity and mortality of surgery are high. One of the major risks of complication is due to embolization of the clot during the procedure. Various cerebral protection or filter devices are available to prevent this complication. The use of additional devices sometimes adds new risk related to these devices and also increases the cost of the procedure. Technical essentials and therapeutic results of carotid stenting without cerebral protection are presented.
, 百拇医药
Materials and methods: From May 1999 and August 2004, CAS was performed in 96 symptomatic NASCET-ineligible patients. Thirty six (37.5%) patients had complete occlusion of contra-lateral carotid. There were 60 males and 36 female, mean age was 52 years (range 40 to 84 years). Mean lesion length was 22 ± 7.9 mm, and mean percent stenosis was 85 ± 8.0% (reference diameter 5.8 ± 0.3mm). All the carotids were treated without cerebral protection device. Stents used were Precise self expanding stent (Cordis, Johnson & Johnson), self expanding Carotid Wallstents (Boston Scientific Inc), Carotid Sinus Stent (Optimed) and Prostar Balloon expandable stent [predilation was performed in 7/35(20%)]. Follow-up consisted of serial duplex ultrasonography and clinical assessment in 76 patients at a median of 16 months.
, 百拇医药
Results: On an intention to treat basis, the overall technical success rate for carotid angioplasty was 95/96(99%). Six (6.2%) patients had transient focal seizure during balloon inflation, which reversed immediately, uneventfully following balloon deflation. All six patients had complete occlusion of opposite internal carotid artery. Ten patients (10.4%) had transient bradicardia during balloon inflation which did not require pacing. One patient (1%) had a minor stroke 8 hrs after the procedure due to hyperperfusion injury resulting in minimal intracerebral haemorrhage. None of the patient died in 30 days peri-procedure period. Two of 76 (2.6%) patients had TIA involving same arterial territory in follow-up period.
, 百拇医药
Conclusion: Carotid arterial stent placement in a high-risk population has morbidity and mortality rates comparable to those of carotid endarterectomy in a lower risk population. CAS is a safe and viable alternative in such group of patients. Cerebral protection device use probably may not be necessary. However, this issue needs to be addressed in a large randomized trial., 百拇医药