劉新峰南京軍區(qū)南京總醫(yī)院神經(jīng)內(nèi)科,研究所,齊魯醫(yī)院,濟(jì)南動(dòng)脈介入指南

1、,腦動(dòng)脈硬化性狹窄的介入治療,--從指南到臨床--,劉新峰 Xinfeng Liu,南京軍區(qū)南京總醫(yī)院神經(jīng)內(nèi)科,南京大學(xué)神經(jīng)病學(xué)研究所,Department of Neurology, Jinling Hospital,Nanjing University School of Medicine,http://www.chinaneurology.orgEmail: xfliu2@yahoo.com.cn,,? 顱外段頸動(dòng)脈病變

2、? 顱外段椎動(dòng)脈病變? 顱內(nèi)動(dòng)脈病變,,顱外段頸動(dòng)脈病變,? CAS is indicated as an alternative to CEAfor symptomatic patients at average or lowrisk of complications associated withendovascular intervention when thediameter of the lumen

3、of the internalcarotid artery is reduced by >70% by,noninvasive imaging or >50% by catheterangiography,(Class I; Level of Evidence B),,,,男，64歲，高血壓， TIAs，記憶力下降1年。,無局灶性神經(jīng)系統(tǒng)體征。DSA提示LICA 99%狹,窄，支架置入后上述癥狀明顯緩解,,? Amon

4、g patients with symptomatic severestenosis (>70%) in whom the stenosis isdifficult to access surgically, medicalconditions are present that greatlyincrease the risk for surgery, or whenother specific circums

5、tances exist, such asradiationinduced stenosis or restenosisafter CEA, CAS may be considered,(Class IIb; Level of Evidence B).,CAS 適合于手術(shù)高危患者,男性，62,歲，發(fā)作性意識(shí)喪失伴左下肢無力1,月。既往有高血壓病史15年，鼻咽,癌病史11,年，曾予以,多次放療,,LICA、,LCCA分別

6、予以支架置入治療,,? CAS in the above setting is reasonable,when performed by operators with,established periprocedural morbidity andmortality rates of 4% to 6%, similar tothose observed in trials of CEA and CAS,(Class IIa; L

7、evel of Evidence B).,圍手術(shù)期的風(fēng)險(xiǎn)控制,,The evaluation of CAS in symptomatic patients:,EVA-3S, ICSS, SPACE, are outcome outliers,,優(yōu)化的藥物治療很重要,? Optimal medical therapy, which should,include antiplatelet therapy, statin,therapy, a

8、nd risk factor modification, isrecommended for all patients withcarotid artery stenosis and a TIA orstroke as outlined elsewhere in this,guideline (Class I; Level of Evidence B).(New recommendation),,左側(cè)頸內(nèi)動(dòng)脈（R-,ICA)閉

9、,塞，經(jīng)過優(yōu)化的藥物治療半,年后，,CTA復(fù)檢查顯示血,管再通,,Lxx,M-78y, RCCA近竇部閉塞,TIA發(fā)作3月,DSA示RCCA上段閉塞,實(shí)施RCCA再通和RICA支架術(shù),,,M-57y,反復(fù)左眼視物模糊,失語(yǔ),右肢體無力。造影示LICA閉塞，顱內(nèi)部分經(jīng)眼動(dòng)脈部分代償,優(yōu)化的藥物治療不能控制,7days post-stent,,,LICA完全閉塞，C6段以遠(yuǎn)經(jīng)眼動(dòng)脈少量代償（a）經(jīng)微導(dǎo)管證實(shí)，導(dǎo)絲通過

10、閉塞病變后，用小球囊擴(kuò)張，血管再通，但DSA可見L-ICA遠(yuǎn)端較多血栓（b）給予氯吡格雷＋阿托他汀和肝素抗凝治療7d后，再次介,Pro-,Post-stent 入，C5段支架治療（d）,,椎動(dòng)脈顱外段病變-優(yōu)化的藥物治療,? Optimal medical therapy, which should,include antiplatelet therapy, statin,therapy, and risk fac

11、tor modification, isrecommended for all patients withvertebral artery stenosis and a TIA orstroke as outlined elsewhere in this,guideline (Class I; Level of Evidence B).(New recommendation),,? Endovascular and surgic

12、al treatment of,patients with extracranial vertebral,stenosis may be considered when patientsare having symptoms despite optimalmedical treatment (including,antithrombotics, statins, and relevantrisk factor control) (

13、Class IIb; Level ofEvidence C),優(yōu)化的藥物治療不能控制癥狀,可考慮介入或手術(shù),,患者男性，59歲，突發(fā)意識(shí)障礙1月余。既往有高血壓病史7年。DSA,示：雙側(cè)椎動(dòng)脈起始部次全閉塞,,雙側(cè)椎動(dòng)脈起始部予以支架植入術(shù)。術(shù)后第二天患者意識(shí)狀況開,始好轉(zhuǎn),,半年后復(fù)查，患者生活完全自理，,DSA示：左側(cè)椎動(dòng)脈支架輕度再狹窄,,,后循環(huán)盜血TIA: M-62Y,主動(dòng)脈弓上造影顯示

14、,左側(cè)鎖骨下動(dòng)脈閉塞，左側(cè)椎動(dòng)脈逆行顯影,,右側(cè)椎動(dòng)脈造影顯示LVA、LSCA逆行顯影，基底動(dòng)脈顯影欠佳,,LSCA起始段閉塞，予以Maverick3.5×20球囊擴(kuò)張，Acculink 9×30,,顱內(nèi)動(dòng)脈病變--藥物治療,? For patients with stroke or TIA due to 50%,to 99% stenosis of a major intracranialartery, as

15、pirin is recommended in,preference to warfarin (Class I;Level ofEvidence B). On the basis of the data ongeneral safety and efficacy, aspirin doses of50 mg to 325 mg of aspirin daily are,recommended (Class I; Level of

16、Evidence B).(New recommendation),,? For patients with stroke or TIA due to 50%,to 99% stenosis of a major intracranial,artery, long-term maintenance of BP <140/90mm Hg and total cholesterol level <200,mg/dL may b

17、e reasonable (Class IIb; Level ofEvidence B). (New recommendation),,藥物治療無效后可考慮在有條件的機(jī)構(gòu)進(jìn)行血管內(nèi)介入治療?,? For patients with stroke or TIA due to,50% to 99% stenosis of a major,intracranial artery, the usefulness ofangioplasty

18、 and/or stent placement is,unknown and is considered investigational(Class IIb; Level of Evidence C). (Newrecommendation),,M-61y, 雙枕葉梗死,基底動(dòng)脈下段狹窄,DSA提示基底動(dòng)脈下段重度狹窄,,由于狹窄病變部位剛好是,雙側(cè)AICA發(fā)出，僅行球擴(kuò),血管成形術(shù)以免穿支事件,,大腦中動(dòng)脈M1遠(yuǎn)端,嚴(yán)重狹

19、窄，置入,Wingspan支架,M-71y，高血壓，右側(cè),肢體輕偏癱,,大腦中動(dòng)脈狹窄置入球擴(kuò),支架,路徑較好,病變較平,直,選擇球擴(kuò)支架,F-60y，反復(fù)言語(yǔ)不清，,右側(cè)肢體無力,,,搭橋/介入??,? For patients with stroke or TIA due to,50% to 99% stenosis of a majorintracranial artery, EC-IC bypass,surgery is no

20、t recommended (Class III;Level of Evidence B). (Newrecommendation),,血管內(nèi)介入的指征,頸動(dòng)脈支架術(shù),? 無癥狀狹窄 > 70%? 有癥狀 > 50%,顱內(nèi)動(dòng)脈和椎動(dòng)脈顱外段成形/支架術(shù),? 癥狀性顱內(nèi)動(dòng)脈粥樣硬化性狹窄>70%，正規(guī)抗血小板，他汀強(qiáng)化及控制危險(xiǎn)因素和調(diào)整血壓的等治療無效, 經(jīng)過嚴(yán)格選擇病例后, 可考慮在有條件

21、的機(jī)構(gòu)進(jìn)行血管內(nèi)介入治療,? 無癥狀性顱內(nèi)動(dòng)脈粥樣硬化性狹窄目前不推薦,血管內(nèi)介入治療,,卒中血管介入的目標(biāo),? 使狹窄或閉塞血管恢復(fù)通暢,? 防止栓子脫落形成新的血管閉塞? 維持腦組織正常供血和灌注,? 促進(jìn)側(cè)支循環(huán)的形成（如支架后）? 延緩或阻止動(dòng)脈粥樣硬化的發(fā)展,? 關(guān)注血管、關(guān)注病因、關(guān)注策略、關(guān)注卒中,,卒中介入應(yīng)重點(diǎn)考慮的因素,?,病變性質(zhì)和狹窄程度,? 側(cè)枝循環(huán)? 血流動(dòng)力學(xué)

22、? 病變血管解剖特點(diǎn)? 共患疾病? 藥物干預(yù)的有效性? 急性缺血性卒中的超早期和早期介入—是一個(gè)正在關(guān)注的領(lǐng)域,,患者男性，76歲，突發(fā)意識(shí)喪失4小時(shí)。DSA顯示基底動(dòng)脈遠(yuǎn)端閉塞，予以IA-tPA 20mg后血管未通，再予以Maverick 2×20mm球囊成型后血管再通,,中國(guó)缺血性腦血管病介入診療指南建議,缺血性卒中急性期動(dòng)脈溶栓治療,? 動(dòng)脈溶栓治療應(yīng)當(dāng)在能夠快速開展血管造影和,有

23、神經(jīng)血管介入條件的醫(yī)療機(jī)構(gòu)開展（Ⅰ級(jí)推薦，C級(jí)證據(jù)）。,? 對(duì)不宜行靜脈溶栓的患者，動(dòng)脈溶栓是一個(gè)可,供選擇的方法（Ⅱ級(jí)推薦，C級(jí)證據(jù)）。,? 動(dòng)脈溶栓適合于6小時(shí)以內(nèi)經(jīng)過選擇的大動(dòng)脈閉塞引起的腦梗死患者（Ⅰ級(jí)推薦，B級(jí)證據(jù)）。? 對(duì)于發(fā)病6-24 h內(nèi)由后循環(huán)動(dòng)脈閉塞引起的嚴(yán)重,腦梗死患者，經(jīng)過嚴(yán)格評(píng)估和篩選可嘗試動(dòng)脈溶栓(III級(jí)推薦，C級(jí)證據(jù))。,? 動(dòng)脈溶栓藥物可選用rTPA或尿激酶（Ⅱ級(jí)推薦,，C級(jí)證據(jù)）。,,中國(guó)缺

24、血性腦血管病介入診療指南建議頸動(dòng)脈狹窄的血管內(nèi)介入治療,??????,對(duì)有癥狀的頸動(dòng)脈狹窄?50%的患者，無條件或不適合行CEA治療時(shí)，可考慮CAS治療（Ⅱ級(jí)推薦、B級(jí)證據(jù)）。對(duì)于大面積腦梗死患者實(shí)施血管干預(yù)治療時(shí),應(yīng)在2周后實(shí)施CEA或CAS治療,其他患者在無禁忌癥的情況下,可考慮2周內(nèi)實(shí)施CEA或CAS（Ⅱ級(jí)推薦、B級(jí)證據(jù)）.對(duì)于無癥狀的頸動(dòng)脈狹窄?70%患者，無條件或不適合

25、行CEA治療時(shí)，可考慮CAS治療（Ⅱ級(jí)推薦、C級(jí)證據(jù)）。行CAS治療的患者術(shù)前應(yīng)給予氯吡格雷和阿司匹林聯(lián)合治療，術(shù)后兩者聯(lián)用至少1個(gè)月（Ⅱ級(jí)推薦、C級(jí)證據(jù)）。其他二級(jí)預(yù)防的方法參見《中國(guó)缺血性腦卒中和短暫性腦缺血發(fā)作二級(jí)預(yù)防指南2010》CAS應(yīng)由能將圍手術(shù)期致殘和致死率控制在6%以下的手術(shù)者或機(jī)構(gòu)實(shí)施（Ⅱ級(jí)推薦、B級(jí)證據(jù)),,中國(guó)缺血性腦血管病介入診療指南建議顱外段椎動(dòng)脈狹窄的介入治療,???

26、???,癥狀性椎動(dòng)脈顱外段動(dòng)脈狹窄≥50%的患者，若藥物治療無效，可考慮血管內(nèi)介入治療（II級(jí)推薦，C級(jí)證據(jù)）。無癥狀性椎動(dòng)脈顱外段高度狹窄≥70%患者，若狹窄程度進(jìn)行性加重，可考慮血管內(nèi)介入治療（II級(jí)推薦，C級(jí)證據(jù)）。無癥狀性椎動(dòng)脈顱外段高度狹窄（≥70%）患者，若伴有對(duì)側(cè)椎動(dòng)脈先天發(fā)育不良或缺如，可考慮血管內(nèi)介入治療（II級(jí)推薦，C級(jí)證據(jù)）。癥狀性鎖骨下動(dòng)脈狹窄（≥50%）患者，若藥物治療無效

27、，可考慮血管內(nèi)治療（II級(jí)推薦，C級(jí)證據(jù)）。行椎動(dòng)脈和鎖骨下動(dòng)脈狹窄介入治療的患者，應(yīng)給予氯吡格雷和阿司匹林聯(lián)合治療，且術(shù)后兩者聯(lián)用至少維持1個(gè)月（Ⅱ級(jí)推薦）。椎動(dòng)脈和鎖骨下動(dòng)脈狹窄的介入治療，應(yīng)在能將圍手術(shù)期并發(fā)癥控制在較低水平的醫(yī)療機(jī)構(gòu)開展 （II級(jí)推薦）。,,中國(guó)缺血性腦血管病介入診療指南建議顱內(nèi)動(dòng)脈狹窄的血管內(nèi)治療,? 癥狀性顱內(nèi)動(dòng)脈狹窄患者宜首先采用藥物優(yōu),化的治療 (Ⅰ級(jí)推薦，A級(jí)證據(jù))，具體見《中國(guó)缺血性

28、腦卒中和短暫性腦缺血發(fā)作二級(jí)預(yù)防指南2010》。藥物治療無效后可考慮在有條件的機(jī)構(gòu)進(jìn)行血管內(nèi)介入治療（III級(jí)推薦，C級(jí)證據(jù)）。,? 無癥狀性顱內(nèi)動(dòng)脈粥樣硬化性狹窄目前不推,薦血管內(nèi)介入治療（I級(jí)推薦，A級(jí)證據(jù)）。,,顱內(nèi)血管的特殊性—介入治療時(shí)病,例選擇尤為重要,硬：缺乏中膜和外膜之間的外彈力層細(xì)：與同水平的冠脈比較，直徑2.5:4.5?。汗鼙谥挥型焦诿}的1/4-1/10,偏：內(nèi)中外膜的比例2:5:3，其他血管3:3