顱內(nèi)外動脈狹窄的介入治療課件

Whatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.

Hippocrates(460-370BC)希波克拉底（約公元前460-370,稱醫(yī)藥之父）Whatcannotbecuredwith1MedicamentsforStrokeAnti-plateletagents(provedbyEBM)Thrombolysis(provedbyEBM)Anti-coagulation(limitedefficacy)Neuroprotection(notprovedbyEBM)Herbmedicine(notprovedbyEBM)MedicamentsforStrokeAnti-pla2KnivesforStroketreatmentDecompressivecraniotomy(unacceptablecomplications)Carotidendarterectomy(limitedindications)

EC/ICbypasssurgery(itworks,butdoesnothelp)

Clamptheaneurysm(limitedtoSAH)KnivesforStroketreatmentDec3Dowehaveasearingiron?StentDowehaveasearingiron?St4WhyshouldNeurologistsbetrainedwithendovasculartechniques?ThefutureofneurologywillbefocusedintreatmentLessenslearnedfromcardiologyEndovasculartechniqueswillbecomekeyissueinstroketreatmentandpreventionThespecialstatusofstrokemanagementinChinaWhyshouldNeurologistsbetra5血管神經(jīng)病學(xué):神經(jīng)科新分支血管神經(jīng)病學(xué):神經(jīng)科新分支6HowtotrainaNeuro-endovascularspecialists(recommendationsfromacademicsocieties)TheAmericanNeurosurgeryAssociation(ANA) WhentodoitTheAmericanHeartAssociation(AHA) HowlongtodoitTheAmericanAcademyofNeurology(AAN) HowtoinsuremaintenanceofskillsandknowledgeTheAmericanAssociationofCycleofScienceinMedicine Howtoup-dateHowtotrainaNeuro-endovascu7Anti-coagulation(limitedefficacy)L-MCA-M2stenting:

ChenBY-F-75yAngioplastyandstentinginveterbrobasilararteries病人選擇、標(biāo)準(zhǔn)化術(shù)前評詁、術(shù)中操作規(guī)程和標(biāo)準(zhǔn)化的術(shù)后跟蹤隨訪ComputedtomographicangiographyThishelpstoavoidmicro-bubblesCarotidendarterectomy(limitedindications)Wingspan支架后(3.Typeandsizeofstentshouldbechosewithreferencetoarterypathologyandanatomycharacters.有必要繼續(xù)評價和改進藥物及介入治療，以降低顱內(nèi)動脈粥樣硬化相關(guān)的卒中AsymptomaticPatientspre-procedureevaluationICA起始部狹窄合并同側(cè)顱內(nèi)動脈瘤Wingspan顱內(nèi)專用支架:

MaoYQ-M-73yArterialaccessissues監(jiān)測有無新的神經(jīng)病學(xué)癥狀，間隔6-12月定期行無創(chuàng)性影像學(xué)檢查（磁共振血管成像或CT血管成像），有必要的話再進行腦血管造影檢查,對于進展的患者再評詁介入治療的可行性Nomajorco-morbidityAorticarchandcarotidanatomyandpathologyArterialTortuosityContentsoftrainingHowtotrainaNeuro-endovascularspecialists(ourexperiencesatJinlingHospital)南京軍區(qū)總醫(yī)院神經(jīng)內(nèi)科如何進行神經(jīng)介入的培訓(xùn)

2yearsofclinicalworkinstrokemanagementwithexperienceofdiagnosticimaging1yearsoftrainingonneuro-endovascularskills,atleastfinish80caseofDSAbeforestenting病人選擇、標(biāo)準(zhǔn)化術(shù)前評詁、術(shù)中操作規(guī)程和標(biāo)準(zhǔn)化的術(shù)后跟蹤隨訪Anti-coagulation(limitedeffi8ContentsoftrainingProceduretraining

pre-procedureevaluationIndicationandcontraindicationriskreducingmanagementofcomplicationspost-proceduremanagementfollow-upContentsoftrainingProcedure9ContentsoftrainingEndovascularskilltrainingAcupunctureCerebrovascularangiographyCarotidangioplasty(balloondilation)CarotidstentimplantationAngioplastyandstentinginveterbrobasilararteriesContentsoftrainingEndovascul10Pre-procedureEvaluations

Auscultation&StethoscopeCarotidduplexultrasonographyTranscranialDoppler

Computedtomographicangiography(64-tier-CTA)Magneticresonanceangiography(MRA)Carotidangiography(thegoldstandard)Pre-procedureEvaluationsAusc11頸動脈支架術(shù)的適應(yīng)癥AmericanHeartAssociationGuidelinesAsymptomaticPatientsFortreatmentof70%orgreaterstenosisPerioperativestroke/deathmustbelessthan3%SymptomaticPatientsFortreatmentof50%orgreaterstenosisPerioperativestroke/deathmustbelessthan6%Noprovenindicationsbeyondthesethresholds頸動脈支架術(shù)的適應(yīng)癥AmericanHeartAssoc12顱內(nèi)動脈狹窄支架術(shù)的建議適應(yīng)癥癥狀性顱內(nèi)動脈狹窄>50%病例，通過藥物治療無效，應(yīng)考慮行球囊血管成形術(shù)，同時實施或不實施支架置入術(shù)無癥狀性顱內(nèi)動脈粥樣硬化性狹窄，首先應(yīng)給予最合理的最佳藥物預(yù)防，包括抗血小板聚集和/或他汀類藥物。監(jiān)測有無新的神經(jīng)病學(xué)癥狀，間隔6-12月定期行無創(chuàng)性影像學(xué)檢查（磁共振血管成像或CT血管成像），有必要的話再進行腦血管造影檢查,對于進展的患者再評詁介入治療的可行性有必要繼續(xù)評價和改進藥物及介入治療，以降低顱內(nèi)動脈粥樣硬化相關(guān)的卒中顱內(nèi)動脈狹窄支架術(shù)的建議適應(yīng)癥13TechnicalTipsforCAS

ourexperienceTechnicalTipsforCAS

ourexp14PatientSelection

MedicalcomorbiditiesArterialaccessissuesAorticarchandcarotidanatomyandpathologyCollateralCirculationPatientSelectionMedicalcomo15DifficultaorticarchDifficultaorticarch16ArterialTortuosityArterialTortuosity17EccentriccalcificationwithulcerationEccentriccalcificationwithu18CarotidduplexultrasonographyLearningcurve~80casesProvidingInformationforCollateralCirculationAngioplastyandstentinginveterbrobasilararteriesAngioplastyandstentinginveterbrobasilararteriesWingspan支架后(3.WhyshouldNeurologistsbetrainedwithendovasculartechniques?withexperienceofdiagnosticimagingWhatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.Carotidendarterectomy(limitedindications)Nomajorco-morbidity監(jiān)測有無新的神經(jīng)病學(xué)癥狀，間隔6-12月定期行無創(chuàng)性影像學(xué)檢查（磁共振血管成像或CT血管成像），有必要的話再進行腦血管造影檢查,對于進展的患者再評詁介入治療的可行性Typeandsizeofstentshouldbechosewithreferencetoarterypathologyandanatomycharacters.NoprovenindicationsbeyondthesethresholdsAsymptomaticPatientsWhatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.MedicalcomorbiditiesTheAmericanHeartAssociation(AHA)CollateralCirculationwithexperienceofdiagnosticimagingWingspan支架后(3.ProvidingInformationforCollateralCirculationCarotidduplexultrasonography19CatheterandGuidewireManeuversWipeallguidewiresandcathetersliberallywithheparin-salineDonotwithdrawguidewiretoorapidly.Thishelpstoavoidmicro-bubblesDonotadministerflushorcontrastifthecatheterisnotbackbleedingbecausethismayintroduceairDonotflushcerebralcatheterswithtoomuchvolumeCatheterandGuidewireManeuve20Cs=Contrastwithoutprotection;Cc=contrastwithprotectionF=filterdeployment;B1=pre-stentballooning;S=stentdeployment;B2=poststentballooning;R=retrievingoffilter.Cs=Contrast21filterPre-BostentPost-BocontrastfilterPre-BostentPost-Bocontra22PredilationandPostdilationLonger(butslender)balloonsareusedtoavoid“melonseeding”andthepotentialreleaseofembolicdebris.Theballoonshouldbeinflatedonlyonceandtheinflationtimevariesdependingonthelesion.Duringpredilation,aspiratingbloodfromsheathcanreducetheparticulatedebrisintobloodstream.Shorterballoonsareusedforpostdilation.Longerballoonsmaycausedissectionsinthedistalinternalcarotidartery.PredilationandPostdilationLo23StentImplantationTypeandsizeofstentshouldbechosewithreferencetoarterypathologyandanatomycharacters.Residualstenosisnomorethan30%isaccepted,asstentscontinuetoexpandwithtime.Ifcontinuedflowofcontrastintoanulcerisseen,noattemptshouldbemadetoobliterateitbyusinglargerballoonsorhigherpressure.Deploystentsacrosskinksonlyiftheyareisolated.Multiplekinksmaybedisplaceddistallyandbecomemoreexaggerated.StentImplantationTypeandsiz24SevereICAStenosiswithpre-dilationSevereICAStenosiswithpre-d25ICA起始部狹窄合并同側(cè)顱內(nèi)動脈瘤ICA起始部狹窄合并同側(cè)顱內(nèi)動脈瘤26雙支架置入覆蓋夾層動脈瘤:張榮X-M-62y,腦梗塞,RICA-C1,C2段有兩處狹窄，近段夾層動脈瘤形成至C1近端80%狹窄,LICA起始部狹窄30%雙支架置入覆蓋夾層動脈瘤:張榮X-M-62y,腦梗塞,27多個串聯(lián)狹窄的支架植入多個串聯(lián)狹窄的支架植入28L-MCA-M2stenting:

ChenBY-F-75y病人選擇、標(biāo)準(zhǔn)化術(shù)前評詁、術(shù)中操作規(guī)程和標(biāo)準(zhǔn)化的術(shù)后跟蹤隨訪ContentsoftrainingArterialTortuosityPatientSelection顱內(nèi)動脈狹窄支架術(shù)的建議適應(yīng)癥Longerballoonsmaycausedissectionsinthedistalinternalcarotidartery.TranscranialDopplerDowehaveasearingiron?StentWhatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.Clamptheaneurysm(limitedtoSAH)CollateralCirculation雙支架置入覆蓋夾層動脈瘤:張榮X-M-62y,腦梗塞,RICA-C1,C2段有兩處狹窄，近段夾層動脈瘤形成至C1近端80%狹窄,LICA起始部狹窄30%AngioplastyandstentinginveterbrobasilararteriesDecompressivecraniotomy(unacceptablecomplications)withexperienceofdiagnosticimagingHowlongtodoitAsymptomaticPatientsIndicationandcontraindicationIndicationandcontraindication癥狀性顱內(nèi)動脈狹窄>50%病例，通過藥物治療無效，應(yīng)考慮行球囊血管成形術(shù)，同時實施或不實施支架置入術(shù)EccentriccalcificationwithulcerationArterialTortuosity2yearsofclinicalworkinstrokemanagementContentsoftrainingDowehaveasearingiron?StentAsymptomaticPatientsTranscranialDopplerL-MCA-M2stenting:

ChenBY-F-75yballooning;PCAstentingDifficultaorticarchDonotflushcerebralcatheterswithtoomuchvolumeMedicamentsforStrokeIt’snotaseasyasitlookspre-procedureevaluationIfcontinuedflowofcontrastintoanulcerisseen,noattemptshouldbemadetoobliterateitbyusinglargerballoonsorhigherpressure.AsymptomaticPatientsLongerballoonsmaycausedissectionsinthedistalinternalcarotidartery.ComputedtomographicangiographyThespecialstatusofstrokemanagementinChinaWingspan支架后(3.MCA-M-1stenting:HuGH-M-54yL-MCA-M2stenting:

ChenBY-F-729L-MCA-M1Stenting:Weixx-F-70yL-MCA-M1Stenting:Weixx-F-7030L-MCA-M2stenting:

ChenBY-F-75yPre-stentPost-stentL-MCA-M2stenting:

ChenBY-F-731PCAstentingPCAstenting32VAstentingVAstenting33Post-stentingBAStentingPost-stentingBAStenting34BAstenosis:評價血液動力學(xué)+球擴BAstenosis:評價血液動力學(xué)+球擴35Wingspan顱內(nèi)專用支架:

MaoYQ-M-73yGateway(2.5/9mm)預(yù)擴

Wingspan支架后(3.5/9mm)

RICA-C6段85%狹窄Wingspan顱內(nèi)專用支架:

MaoYQ-M-73yGa36Wingspanstenting:ZhouBY-F-71yR-ICA-C7段70%狹窄Gateway球囊(2.5/9mm)預(yù)擴

Wingspan支架后(3.5/15mm)Wingspanstenting:ZhouBY-F-737WingspanforMCA-M2WingspanforMCA-M238FurtherMessagesGettrainedIt’snotaseasyasitlooksLearningcurve~80casesStartwitheasycasesUnilateralstenosisNomajorco-morbidityEnsurehighstandardofpost-procedurecareICUTransienthypotension/hypertensionFurtherMessagesGettrained39歡迎參會!謝謝參與!

歡迎參會!謝謝參與!40KnivesforStroketreatmentDecompressivecraniotomy(unacceptablecomplications)Carotidendarterectomy(limitedindications)

EC/ICbypasssurgery(itworks,butdoesnothelp)

Clamptheaneurysm(limitedtoSAH)KnivesforStroketreatmentDec41Dowehaveasearingiron?StentDowehaveasearingiron?St42血管神經(jīng)病學(xué):神經(jīng)科新分支血管神經(jīng)病學(xué):神經(jīng)科新分支43Wingspan支架后(3.Clamptheaneurysm(limitedtoSAH)Wingspan顱內(nèi)專用支架:

MaoYQ-M-73yEndovascularskilltrainingNeuroprotection(notprovedbyEBM)Theballoonshouldbeinflatedonlyonceandtheinflationtimevariesdependingonthelesion.Clamptheaneurysm(limitedtoSAH)Howtoup-dateRICA-C6段85%狹窄AngioplastyandstentinginveterbrobasilararteriesContentsoftrainingAnti-plateletagents(provedbyEBM)ContentsoftrainingPCAstentingR=retrievingoffilter.Herbmedicine(notprovedbyEBM)DifficultaorticarchAmericanHeartAssociationGuidelinesLonger(butslender)balloonsareusedtoavoid“melonseeding”andthepotentialreleaseofembolicdebris.HowtotrainaNeuro-endovascularspecialists(ourexperiencesatJinlingHospital)南京軍區(qū)總醫(yī)院神經(jīng)內(nèi)科如何進行神經(jīng)介入的培訓(xùn)Shorterballoonsareusedforpostdilation.有必要繼續(xù)評價和改進藥物及介入治療，以降低顱內(nèi)動脈粥樣硬化相關(guān)的卒中PatientSelection

Medicalcomorbidities