顱內(nèi)外動(dòng)脈狹窄的介入治療

顱內(nèi)外動(dòng)脈狹窄的介入治療—

實(shí)施與培訓(xùn)的體會劉新峰南京軍區(qū)南京總醫(yī)院神經(jīng)科南京大學(xué)神經(jīng)病學(xué)研究所http://Whatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.

Hippocrates(460-370BC)希波克拉底（約公元前460-370,稱醫(yī)藥之父）MedicamentsforStrokeAnti-plateletagents(provedbyEBM)Thrombolysis

(provedbyEBM)Anti-coagulation(limitedefficacy)Neuroprotection

(notprovedbyEBM)Herbmedicine(notprovedbyEBM)KnivesforStroketreatmentDecompressivecraniotomy(unacceptablecomplications)Carotidendarterectomy

(limitedindications)

EC/ICbypasssurgery(itworks,butdoesnothelp)

Clamptheaneurysm(limitedtoSAH)Dowehaveasearingiron?StentWhyshouldNeurologistsbetrainedwithendovasculartechniques?ThefutureofneurologywillbefocusedintreatmentLessenslearnedfromcardiologyEndovasculartechniqueswillbecomekeyissueinstroketreatmentandpreventionThespecialstatusofstrokemanagementinChina血管神經(jīng)病學(xué):神經(jīng)科新分支HowtotrainaNeuro-endovascularspecialists(recommendationsfromacademicsocieties)TheAmericanNeurosurgeryAssociation(ANA) WhentodoitTheAmericanHeartAssociation(AHA) HowlongtodoitTheAmericanAcademyofNeurology(AAN) HowtoinsuremaintenanceofskillsandknowledgeTheAmericanAssociationofCycleofScienceinMedicine Howtoup-dateHowtotrainaNeuro-endovascularspecialists(ourexperiencesatJinlingHospital)南京軍區(qū)總醫(yī)院神經(jīng)內(nèi)科如何進(jìn)行神經(jīng)介入的培訓(xùn)ContentsoftrainingProceduretraining

pre-procedureevaluationIndicationandcontraindicationriskreducingmanagementofcomplicationspost-proceduremanagementfollow-upContentsoftrainingEndovascularskilltrainingAcupunctureCerebrovascularangiographyCarotidangioplasty(balloondilation)CarotidstentimplantationAngioplastyandstentinginveterbrobasilararteriesPre-procedureEvaluations

Auscultation&StethoscopeCarotidduplexultrasonography

TranscranialDoppler

Computedtomographicangiography(64-tier-CTA)Magneticresonanceangiography(MRA)Carotidangiography(thegoldstandard)AmericanHeartAssociationGuidelinesAsymptomaticPatientsFortreatmentof70%orgreaterstenosis

Perioperativestroke/deathmustbelessthan3%SymptomaticPatientsFortreatmentof50%orgreaterstenosis

Perioperativestroke/deathmustbelessthan6%NoprovenindicationsbeyondthesethresholdsTechnicalTipsforCAS

ourexperiencePatientSelection

MedicalcomorbiditiesArterialaccessissuesAorticarchandcarotidanatomyandpathologyCollateralCirculationDifficultaorticarchArterialTortuosityEccentriccalcificationwithulcerationProvidingInformationforCollateralCirculationCatheterandGuidewireManeuversWipeallguidewiresandcathetersliberallywithheparin-salineDonotwithdrawguidewiretoorapidly.Thishelpstoavoidmicro-bubblesDonotadministerflushorcontrastifthecatheterisnotbackbleedingbecausethismayintroduceairDonotflushcerebralcatheterswithtoomuchvolumeCs=Contrastwithoutprotection;Cc=contrastwithprotectionF=filterdeployment;B1=pre-stentballooning;S=stentdeployment;B2=poststentballooning;R=retrievingoffilter.filterPre-BostentPost-BocontrastPredilationandPostdilationLonger(butslender)balloonsareusedtoavoid“melonseeding”andthepotentialreleaseofembolicdebris.Theballoonshouldbeinflatedonlyonceandtheinflationtimevariesdependingonthelesion.Duringpredilation,aspiratingbloodfromsheathcanreducetheparticulatedebrisintobloodstream.Shorterballoonsareusedforpostdilation.Longerballoonsmaycausedissectionsinthedistalinternalcarotidartery.StentImplantationTypeandsizeofstentshouldbechosewithreferencetoarterypathologyandanatomycharacters.Residualstenosisnomorethan30%isaccepted,asstentscontinuetoexpandwithtime.Ifcontinuedflowofcontrastintoanulcerisseen,noattemptshouldbemadetoobliterateitbyusinglargerballoonsorhigherpressure.Deploystentsacrosskinksonlyiftheyareisolated.Multiplekinksmaybedisplaceddistallyandbecomemoreexaggerated.SevereICAStenosiswithpre-dilationICA起始部狹窄合并同側(cè)顱內(nèi)動(dòng)脈瘤雙支架置入覆蓋夾層動(dòng)脈瘤:張榮X-M-62y,腦梗塞,RICA-C1,C2段有兩處狹窄，近段夾層動(dòng)脈瘤形成至C1近端80%狹窄,LICA起始部狹窄30%多個(gè)串聯(lián)狹窄的支架植入MCA-M-1stenting:HuGH-M-54yL-MCA-M1Stenting:Weixx-F-70yL-MCA-M2stenting:

ChenBY-F-75yPre-stentPost-stentPCAstentingVAstentingPost-stentingBAStentingBAstenosis:評價(jià)血液動(dòng)力學(xué)+球擴(kuò)Wingspan顱內(nèi)專用支架:

MaoYQ-M-73yGateway(2.5/9mm)預(yù)擴(kuò)

Wingspan支架后(3.5/9mm)

RICA-C6段85%狹窄Wingspanstenting:ZhouBY-F-71yR-ICA-C7段70%狹窄Gateway球囊(2.5/9mm)預(yù)擴(kuò)

Wingspan支架后(3.5/15mm)WingspanforMCA-M2FurtherMessagesGettra