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1、颅内外动脉狭窄的介入治疗 实施与培训的体会,刘新峰 南京军区南京总医院神经科 南京大学神经病学研究所 http:/www.chinaneurology.org,What cannot be cured with medicaments is cured by knife, what knife cannot cure is cured with searing iron, and whatever this cannot cure must be considered incurable.Hippocrates (460-370 BC) 希波克拉底（约公元前460-370, 称医药之父）,Me
2、dicaments for Stroke,Anti-platelet agents (proved by EBM) Thrombolysis (proved by EBM) Anti-coagulation (limited efficacy) Neuroprotection (not proved by EBM)Herb medicine (not proved by EBM),Knives for Stroke treatment,Decompressive craniotomy (unacceptable complications)Carotid endarterectomy (lim
3、ited indications) EC/IC bypass surgery (it works, but does not help) Clamp the aneurysm (limited to SAH),Do we have a searing iron ? Stent,Why should Neurologists be trained with endovascular techniques?,The future of neurology will be focused in treatment Lessens learned from cardiology Endovascula
4、r techniques will become key issue in stroke treatment and prevention The special status of stroke management in China,血管神经病学:神经科新分支,How to train a Neuro-endovascular specialists (recommendations from academic societies),The American Neurosurgery Association (ANA) When to do it The American Heart As
5、sociation (AHA)How long to do it The American Academy of Neurology (AAN)How to insure maintenance of skills and knowledge The American Association of Cycle of Science in Medicine How to up-date,How to train a Neuro-endovascular specialists (our experiences at Jinling Hospital) 南京军区总医院神经内科如何进行神经介入的培训
6、,2 years of clinical work in stroke management with experience of diagnostic imaging 1 years of training on neuro-endovascular skills, at least finish 80 case of DSA before stenting 病人选择、标准化术前评诂、术中操作规程和标准化的术后跟踪随访,Contents of training,Procedure trainingpre-procedure evaluationIndication and contraind
7、icationrisk reducingmanagement of complicationspost-procedure managementfollow-up,Contents of training,Endovascular skill trainingAcupuncture Cerebrovascular angiographyCarotid angioplasty (balloon dilation)Carotid stent implantationAngioplasty and stenting in veterbrobasilar arteries,Pre-procedure
8、Evaluations,Auscultation & Stethoscope Carotid duplex ultrasonography Transcranial Doppler Computed tomographic angiography (64-tier-CTA) Magnetic resonance angiography (MRA) Carotid angiography (the gold standard),颈动脉支架术的适应症,American Heart Association GuidelinesAsymptomatic PatientsFor treatment of
9、 70% or greater stenosisPerioperative stroke/death must be less than 3%Symptomatic PatientsFor treatment of 50% or greater stenosisPerioperative stroke/death must be less than 6%No proven indications beyond these thresholds,颅内动脉狭窄支架术的建议适应症,症状性颅内动脉狭窄50%病例，通过药物治疗无效，应考虑行球囊血管成形术，同时实施或不实施支架置入术无症状性颅内动脉粥样硬
10、化性狭窄，首先应给予最合理的最佳药物预防，包括抗血小板聚集和/或他汀类药物。监测有无新的神经病学症状，间隔6-12月定期行无创性影像学检查（磁共振血管成像或CT血管成像），有必要的话再进行脑血管造影检查, 对于进展的患者再评诂介入治疗的可行性有必要继续评价和改进药物及介入治疗，以降低颅内动脉粥样硬化相关的卒中,Technical Tips for CAS our experience,Patient Selection,Medical comorbiditiesArterial access issuesAortic arch and carotid anatomy and pathology
11、Collateral Circulation,Difficult aortic arch,Arterial Tortuosity,Eccentric calcification with ulceration,Providing Information for Collateral Circulation,Catheter and Guidewire Maneuvers,Wipe all guidewires and catheters liberally with heparin-saline Do not withdraw guidewire too rapidly. This helps
12、 to avoid micro-bubbles Do not administer flush or contrast if the catheter is not backbleeding because this may introduce air Do not flush cerebral catheters with too much volume,Cs = Contrast without protection; Cc = contrast with protection F = filter deployment; B1 = pre-stent ballooning; S = st
13、ent deployment; B2 = poststent ballooning; R = retrieving of filter.,filter,Pre-Bo,stent,Post-Bo,contrast,Predilation and Postdilation,Longer (but slender) balloons are used to avoid “melon seeding” and the potential release of embolic debris. The balloon should be inflated only once and the inflati
14、on time varies depending on the lesion. During predilation, aspirating blood from sheath can reduce the particulate debris into blood stream. Shorter balloons are used for postdilation. Longer balloons may cause dissections in the distal internal carotid artery.,Stent Implantation,Type and size of s
15、tent should be chose with reference to artery pathology and anatomy characters.Residual stenosis no more than 30% is accepted, as stents continue to expand with time. If continued flow of contrast into an ulcer is seen, no attempt should be made to obliterate it by using larger balloons or higher pr
16、essure. Deploy stents across kinks only if they are isolated. Multiple kinks may be displaced distally and become more exaggerated.,Severe ICA Stenosis with pre-dilation,ICA起始部狭窄合并同侧颅内动脉瘤,双支架置入覆盖夹层动脉瘤: 张荣X-M-62y, 脑梗塞, RICA-C1,C2段有两处狭窄，近段夹层动脉瘤形成至C1近端80%狭窄,LICA起始部狭窄30%,多个串联狭窄的支架植入,MCA-M-1 stenting: Hu GH-M-54y,L-MCA-M1 Stenting: Wei xx-F-70y,L-MCA-M2 stenting: Chen BY-F-75y,Pre-stent,Post-stent,PCA stenting,VA stenting,Post-stenting,BA Stenting,BA stenosis: 评价血液动力学+球扩,
