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动脉粥样硬化性颅内动脉狭窄的支架成形

动脉粥样硬化性颅内动脉狭窄的支架成形. 大纲. 颅内血管的特点 TIA 的病理生理 进展 治疗 有待探讨的问题. 颅内血管的特点. 血管与其相应供血区的关系 血管壁的结构 穿支的问题 血管走行特点. TIA 的病理生理. 大动脉狭窄型 栓塞型 腔隙型 混合型. 进展. 自然病程 药物治疗 WASID 支架治疗 首例 目前报道的小结. 进展. 第一例颅内动脉支架（ 1996 年 7 月）.

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动脉粥样硬化性颅内动脉狭窄的支架成形

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  1. 动脉粥样硬化性颅内动脉狭窄的支架成形

  2. 大纲 • 颅内血管的特点 • TIA的病理生理 • 进展 • 治疗 • 有待探讨的问题

  3. 颅内血管的特点 • 血管与其相应供血区的关系 • 血管壁的结构 • 穿支的问题 • 血管走行特点

  4. TIA的病理生理 • 大动脉狭窄型 • 栓塞型 • 腔隙型 • 混合型

  5. 进展 • 自然病程 • 药物治疗 • WASID • 支架治疗 • 首例 • 目前报道的小结

  6. 进展 • 第一例颅内动脉支架（1996年7月） Use of coronary Palmaz-Schatz stent in the percutaneous treatment of an intracranial carotid artery stenosisFeldman RL, Trigg L, Gaudier J, Galat J.Ocala Heart Institute, Florida, USA. A 69-yr-old man had chronic transient ischemia attacks due to severe stenosis of the intracranial portion of the right carotid artery. After failure of both antiplatelet and anticoagulant therapy, treatment was successful with percutaneous transluminal angioplasty and a coronary Palmaz-Schatz stent. Use of the stent led to a better angiographic result than angioplasty alone. The patient is asymptomatic 4 mo later. Cathet Cardiovasc Diagn. 1996 Jul;38(3):316-9

  7. 进展

  8. 进展 • SSYLVIA Trial • WINGSPAN Trial （prospective, multicenter study） • selfexpanding microstent • 45 patients with stenoses > 50% • ipsilateral stroke or death rate of 30-d 4.4% 6-m 7.1%

  9. 进展 • 多中心、随机对照研究

  10. 进展 • As technology and experience evolve, this procedure is becoming increasingly effective and safe for the treatment of intracranial atherosclerotic disease, and guidelines are being developed for its use. Hartmann M, et al. Curr Op Neurol. 2005;18:39–45. AJNR Am J Neuroradiol. 2005;26:2323–2327.

  11. 进展 • Within peri-procedure Stroke and death 8.3% • Annual stroke 3% - 5% Neurosurg Clin N Am. 2005;16:297–308. AJNR Am J Neuroradiol. 2005;26:525–530.

  12. 进展 • This procedure, however, remains hazardous with up to 50% of patients showing new, ipsilateral ischemic lesions on diffusion-weighted MR images. AJNR Am J Neuroradiol. 2005;26:385–389.

  13. 进展 • Intracranial angioplasty with or without stenting should be offered to symptomatic patients with intracranial stenoses who have failed medical therapy • Similar to revascularization for extracranial carotid artery stenosis, patient benefit from revascularization for symptomatic intracranial arterial stenosis is critically dependent on a low periprocedural stroke and death rate and should thus be performed by experienced neurointerventionists J Vasc Interv Radiol 2005; 16:1281–1285

  14. 进展 • Drug-eluting stents, although showing promise in coronary and canine vessels for the prevention of restenosis, are still not ready for human cerebral arteries because of differing histology and questions of drug neurotoxicity. Pelz D, Advances in Interventional Neuroradiology 2005. Stroke. 2006;37:309-311.)

  15. 治疗 • 手术适应症 • TIAs or stroke attributed to intracranial stenoses of ≥ 50% diameter reduction • Evidences of atherosclerotic risk factors or dissection • Evidences of decreased perfusion distal to the stenosis

  16. 治疗 • 狭窄率的测量 AJNR Am J Neuroradiol 21:643–646, April 2000

  17. 治疗 • Determined by the following criteria • First choice：The diameter of the proximal part of the artery at its widest, nontortuous, normal segment was chosen

  18. 治疗 • Second choice：If the proximal artery was diseased (eg, middle cerebral artery origin stenosis), the diameter of the distal portion of the artery at its widest, parallel, non-tortuous normal segment was substituted

  19. 治疗 • Third choice：If the entire intracranial artery was diseased, the most distal, parallel, non-tortuous normal segment of the feeding artery was measured

  20. 治疗 • 技术成功标准 • Residual stenosis ≤ 30%

  21. 治疗 • 术前评估 • 临床 • 影像 • 脑实质 • 脑血管 • 脑灌注 • 术前准备 • 标准的颅内支架置入技术 • Reduce related procedural complications

  22. 治疗 • 术前评估 • 临床 • 病史: 现病史、既往史、过敏史 • 物理检查：神经系统、全身 • 实验室检查：病因、危险因素

  23. 治疗 • 术前评估 • 影像 • 脑实质 • 脑灌注 • 脑血管

  24. 治疗 • 脑实质 • 头颅CT • 头颅MRI

  25. 治疗 • 脑灌注 • 灌注CT • 磁共振的PWI • 氙CT • PET • SPECT

  26. 治疗 • 脑血管 • 超声检查 • CTA • CEMRA • 脑血管造影

  27. 治疗 • 造影分型 • Mori分型 • A型病变：同心性或适度偏心性狭窄，长度<5mm • B型病变：偏心性狭窄，长度5-10mm，或闭塞，但时间<3个月 • C型病变：狭窄长度>10mm，血管明显扭曲，或闭塞时间≥3个月 PTA时 A型 B型 C型 卒中率 8% 26% 87% 1年的再狭窄率 0 33% 87%

  28. 治疗 • LMA分型 • 部位（Location）分型 • 病变的形态学（Morphology）分型 • 径路（Access）分型

  29. A B C D 治疗 • 部位（Location）分型 • N型：非分叉处病变 • A型：分叉前病变 • B型：分叉后病变 • C型：跨分叉，但边支无狭窄 • D型：跨分叉，但边支有狭窄 • E型：边支开口狭窄 • F型：分叉前狭窄，并边支狭窄 A E F

  30. 治疗 • 病变的形态学（Morphology）分型 • A型：长度<5mm，同心或适度偏心性狭窄 • B型：长度5-10mm，偏心性、成角（ > 45°）或不规则狭窄，闭塞时间<3个月 • C型：长度>10mm，成角（ > 90°）狭窄，或狭窄周围有许多细小新生血管，闭塞时间≥3个月

  31. 治疗 • 径路（Access）分型 • Ⅰ型：适度迂曲，管壁光滑 • Ⅱ型：较严重的迂曲 • Ⅲ型：严重迂曲，管壁不光滑

  32. 治疗 • 术前准备 • 术前7天，口服阿司匹林 300mg，qd 氯吡格雷 75mg，qd • 术前2小时，静脉泵注尼膜同 • 对于次全闭塞的病变可给予抗凝治疗 • 心、肺功能的评价（全麻）

  33. 治疗 • 手术过程 • 全麻或局麻 • 入路的选择 • 上肢 • 下肢 • 术中肝素

  34. 治疗 • 手术过程 • 导引导管的置入 • 微导丝的放置 • 直接放置 • 交换技术 • 支架的置入 • 常规置入方法 • 特殊置入方法

  35. 治疗 • 颅内专用支架 • 国际 • Wingspan • 国内 • Apollo

  36. 治疗 • 术后的治疗和监护 • TCD的监测和术后评价 • 即刻神经功能的评价 • 即刻头颅CT • 术后抗凝、抗血小板 • 血压的调控 • 危险因素的治疗

  37. 有待探讨的问题 • PTA与支架的对照研究 • 药物与支架的随机、对照研究 • 颅内血管的定义 • 颅内血管病变性质的确定 • 最佳支架置入时机 • 药物洗脱支架的应用

  38. 谢 谢

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