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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）,M
2、edicaments 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 (
3、limited 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 Endovasc
4、ular 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
5、 Association (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
6、介入的培训,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 training pre-procedure evaluation Indication and co
7、ntraindication risk reducing management of complications post-procedure management follow-up,Contents of training,Endovascular skill training Acupuncture Cerebrovascular angiography Carotid angioplasty (balloon dilation) Carotid stent implantation Angioplasty and stenting in veterbrobasilar arteries
8、,Pre-procedure 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 Guidelines Asymptomatic Patients
9、 For treatment of 70% or greater stenosis Perioperative stroke/death must be less than 3% Symptomatic Patients For treatment of 50% or greater stenosis Perioperative 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
10、实施或不实施支架置入术 无症状性颅内动脉粥样硬化性狭窄，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 comorbidities Arterial access issues Aortic arch and car
11、otid anatomy and pathology 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 guidew
12、ire too rapidly. This helps 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 = p
13、re-stent ballooning; S = stent 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 inflate
14、d only once and the inflation 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 Impl
15、antation,Type and size of stent 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
16、larger balloons or higher pressure. 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
17、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,Wingspan颅内专用支架: Mao YQ-M-73y,Gateway(2.5/9mm)预扩,Wingspan支架后(3.5/9mm),RICA-C6段85%狭窄,Wingspan stenting:
18、 Zhou BY-F-71y,R-ICA-C7段70%狭窄,Gateway球囊(2.5/9mm)预扩,Wingspan支架后(3.5/15mm),Wingspan for MCA-M2,Further Messages,Get trained Its not as easy as it looks Learning curve 80 cases Start with easy cases Unilateral stenosis No major co-morbidity Ensure high standard of post-procedure care ICU Transient hypotension/hypertension,欢迎参会! 谢谢参与!,http:/,