頸動(dòng)脈支架置入術(shù)

頸動(dòng)脈支架置入術(shù)整理課件SAPPHIRE研究CEA高危患者保護(hù)裝置下支架置入與血管成形試驗(yàn)〔stentingandangioplastywithprotectioninpatientathighrishforendarterectomy,SAPPHIRE〕第一項(xiàng)在有病癥或無病癥頸動(dòng)脈狹窄患者中比較CAS和CEA療效的多中心隨機(jī)對(duì)照研究整理課件介入器材ANGIOGUARD血栓保護(hù)裝置CordisPRECISE支架整理課件入選病例被隨機(jī)分入使用保護(hù)裝置的支架介入術(shù)組(n=159)和內(nèi)膜切除術(shù)組(n=151),對(duì)于風(fēng)險(xiǎn)過高的病人，由介入科醫(yī)生、血管外科醫(yī)生和神經(jīng)科醫(yī)生組成的醫(yī)生小組共同決定進(jìn)入注冊(cè)組CONSENSUS一致同意RANDOMIZED,PROSPECTIVE隨機(jī)，前瞻性310(12month)

Stenting支架組=159

/CEA=151STENTREGISTRY支架注冊(cè)407SURGICALREFUSAL外科拒絕SURGICALREGISTRY外科注冊(cè)7INTERVENTIONALREFUSAL介入拒絕醫(yī)生小組：神經(jīng)科醫(yī)生，外科醫(yī)生，介入科醫(yī)生

TheSAPPHIRETrial整理課件SAPPHIRE(high-riskpatients)

30daysand12monthsresultsSAPPHIRE(high-riskpatients)30daysand12monthresults“Stentedpatientsarenow12monthsoutfromtreatment,andtheirMAEratecontinueto

beasgoodas,andinmanywaysbetterthan,thoseforthesurgicallytreatedgroup.〞接受治療12個(gè)月后，支架組病人不良事件的發(fā)生率相當(dāng)于，甚至在很多方面，優(yōu)于手術(shù)治療組。整理課件12monthResults:

CASvs.CEAOverallMAErate總體主要不良事件發(fā)生率11.9%vs.19.9%:

~difference顯著差異,p=0.06Deathrate死亡率6.9%vs.12.6%:

~doublenumberofpatientsdiedintheCEAarm外科組死亡人數(shù)比支架組多一倍Strokerate中風(fēng)發(fā)生率5.7%vs.7.3%:

~30%morepatientsexperiencedastrokeintheCEAarm

外科組至少發(fā)生一次中風(fēng)的病人數(shù)比支架組多30%MajorIpsilateralStrokerate主要同側(cè)大中風(fēng)發(fā)生率0.0%vs.3.3%

~wassignificanthigherinCEA外科組顯著高于支架組，p=0.03MI(QornonQ)rate心梗發(fā)生率2.5%vs.7.9%:

~patientsgot>3timesmoreMIintheCEAarm

外科組發(fā)生心梗的病人數(shù)比支架組多三倍以上Outcomeofcranialnerveinjury(30days)30天內(nèi)顱神經(jīng)損傷的發(fā)生率

0.0%vs.5.3%:

~wassignificantforCEAarm外科組顯著高于支架組，p<0.01整理課件結(jié)論整理課件ISC2021-CREST整理課件CREST設(shè)計(jì)前瞻、多中心、隨機(jī)對(duì)照試驗(yàn)，盲法判定比較對(duì)于病癥性和無病癥性頸動(dòng)脈狹窄患者是CEA還是CAS更好每個(gè)中心團(tuán)隊(duì)包括神經(jīng)科醫(yī)生、介入醫(yī)生、外科醫(yī)生和研究協(xié)調(diào)員9整理課件患者分組和根本情況CAS(n-1262)CEA(n=1240)年齡6969女性％3634無癥狀性％4747高血壓％8686糖尿?。?030血脂異常％8285目前吸煙％2626心血管?。?043平均收縮壓mmHg142141≥70%狹窄的例數(shù)％8587癥狀性狹窄發(fā)病天數(shù)202510整理課件主要終點(diǎn)

〔卒中、心梗、圍手術(shù)期死亡加同側(cè)卒中〕HR=1.1195%CI0.81-1.51P=0.51整理課件整理課件主要終點(diǎn):圍手術(shù)期事件

〔死亡、卒中、心?！矵R=1.1895%CI0.82-1.68P=0.38整理課件圍手術(shù)期卒中卒中HR=1.7995%CI1.14-2.82P=0.01心梗HR=1.3595%CI0.54-3.36P=0.52整理課件圍手術(shù)期顱神經(jīng)麻痹HR=0.0795%CI0.02-0.18P<0.0001整理課件同側(cè)卒中HR=0.9495%CI0.50-1.76P=0.85整理課件結(jié)論CEA和CAS有相同的凈預(yù)后，盡管各自風(fēng)險(xiǎn)不同，但是CAS有較低的心梗發(fā)生，CEA有較低的卒中風(fēng)險(xiǎn)年輕患者CAS獲益多，年長(zhǎng)患者CEA獲益多有經(jīng)驗(yàn)的中心CEA和CAS顯示更低的圍手術(shù)期并發(fā)癥，有更杰出的預(yù)后未來，CEA和CAS是預(yù)防卒中有用的工具整理課件適應(yīng)癥無病癥血管狹窄程度大于70％，有病癥(TIA或中風(fēng)發(fā)作)血管狹窄程度大于50％狹窄程度小于50％，但有潰瘍性斑塊形成某些肌纖維發(fā)育不良者，大動(dòng)脈炎穩(wěn)定期有局限性狹窄放療術(shù)后或內(nèi)膜剝脫術(shù)后、支架術(shù)后再狹窄由于頸部腫瘤壓迫等受壓而導(dǎo)致的狹窄急性動(dòng)脈溶栓后剩余狹窄整理課件禁忌癥3個(gè)月內(nèi)有顱內(nèi)出血，2周內(nèi)有新鮮腦堵塞不能控制的高血壓對(duì)肝素、阿司匹林或其他抗血小板類藥物有禁忌者對(duì)造影劑過敏者頸內(nèi)動(dòng)脈完全閉塞伴有顱內(nèi)動(dòng)脈瘤，并且不能提前或同時(shí)處理者在30天以后預(yù)計(jì)有其他部位外科手術(shù)者2周內(nèi)曾發(fā)生心肌堵塞有嚴(yán)重心、肝、腎疾病整理課件術(shù)前準(zhǔn)備術(shù)前6小時(shí)禁食水術(shù)前6小時(shí)之內(nèi)碘過敏試驗(yàn)雙側(cè)腹股溝區(qū)備皮術(shù)前3~5天口服抗血小板藥物：氯吡咯雷75mg+阿司匹林100mg頸部血管超聲，TCD評(píng)價(jià)局部腦血流評(píng)價(jià)(核磁共振灌注、PET、CT灌注或SPECT其中一項(xiàng)或以上)全腦血管造影或CTA、MRA整理課件整理課件整理課件整理課件狹窄程度的評(píng)價(jià)參照NASCET標(biāo)準(zhǔn)狹窄率%=〔1-A/B〕×100狹窄程度輕度〔0%-29%〕中度〔30%-69%〕重度〔70%-99%〕整理課件操作方法經(jīng)股動(dòng)脈采用Seldinger技術(shù)穿刺，一般放置8F導(dǎo)管鞘，導(dǎo)管鞘連接加壓鹽水持續(xù)滴注沖洗肝素〔50–100U/kg)導(dǎo)引導(dǎo)管后面接Y閥或止血閥并與加壓鹽水連接，在0.035〞泥鰍導(dǎo)絲小心導(dǎo)引下放在患側(cè)頸總動(dòng)脈，頭端位置距離狹窄約3~5cm。過度迂曲的頸總動(dòng)脈可以使用交換導(dǎo)絲將導(dǎo)引導(dǎo)管交換到位通過導(dǎo)引導(dǎo)管造影測(cè)量狹窄長(zhǎng)度和直徑選擇適宜支架，并行患側(cè)狹窄遠(yuǎn)端顱內(nèi)動(dòng)脈造影以備支架術(shù)后對(duì)照整理課件操作方法通過導(dǎo)引導(dǎo)管將保護(hù)裝置小心穿過狹窄并將其釋放在狹窄遠(yuǎn)端4~5cm位置，撤出保護(hù)裝置外套。支架置入前靜脈給予阿托品0.5mg以防心動(dòng)過緩及低血壓置入支架，造影檢查支架術(shù)后剩余狹窄管徑，酌情作支架內(nèi)后擴(kuò)如果狹窄特別嚴(yán)重，或血管彎曲影響保護(hù)傘的平安通過，可選擇適宜的球囊行預(yù)擴(kuò)最后撤出保護(hù)裝置，行頸部以及患側(cè)顱內(nèi)動(dòng)脈造影與術(shù)前比照AguardDeployMovPic.mpg整理課件

腦保護(hù)裝置整理課件整理課件腦保護(hù)裝置整理課件支架類型球擴(kuò)式支架PalmazStent(Cordis)自膨式支架CarotidWallstent(BostonScientific)PRECISE(Cordis)Protégé(ev3)Acculink(Abbott〕整理課件自膨式支架雕刻支架

編織支架整理課件編織支架優(yōu)點(diǎn)支撐力更大,不易塌陷柔韌性更強(qiáng)，外表光滑，易于球囊通過網(wǎng)孔密集，限制斑塊脫落可重新定位、再次釋放整理課件編織支架缺乏短縮、不易精確定位拉伸頸動(dòng)脈、上端扭曲、成角凹凸不平處貼壁欠佳整理課件雕刻支架優(yōu)點(diǎn)順應(yīng)性好，適應(yīng)不同形狀而不造成血管強(qiáng)直貼壁性好，不易造成死腔根本無縮短，定位和選擇長(zhǎng)度較精確缺乏后擴(kuò)時(shí)有連接點(diǎn)斷裂的風(fēng)險(xiǎn)整理課件支架選擇支架直徑(完全張開)必須至少比最大的目標(biāo)血管大1mm目標(biāo)血管：CCA支架長(zhǎng)度：兩端至少超過狹窄0.5～1cm，并覆蓋“健康〞動(dòng)脈如果頸動(dòng)脈狹窄累及分叉處，那么支架至少要放1cm在頸總動(dòng)脈整理課件支架選擇頸動(dòng)脈迂曲不明顯及狹窄邊緣較光整時(shí)，選用Wallstent或雕刻支架均可頸動(dòng)脈迂曲較明顯時(shí)，雕刻支架的柔順性和貼壁性較好高危斑塊〔軟斑塊〕宜選用Wallstent如果必須處理頸外動(dòng)脈病變，那么只能選用Wallstent，以便在Wallstent的網(wǎng)眼中進(jìn)行擴(kuò)張整理課件頸動(dòng)脈支架置入術(shù)整理課件頸動(dòng)脈支架置入術(shù)整理課件整理課件整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArtery整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryTerumoguidewire0.035〞100cmHeadhunter5FTempo200cmINTRODUCEGUIDEWIREANDINTRODUCERSHEATH整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryTerumoguidewire0.035〞100cmHeadhunter5FTempo200cmINTRODUCEGUIDEWIREANDINTRODUCERSHEATH整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArterySELECTIVECATHETHETERISATIONOFECATerumoguidewire0.035〞100cmHeadhunter5FTempo200cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryHeadhunter5FTempo200cmEXCHANGEGUIDEWIRETerumoguidewire0.035〞100cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryHeadhunter5FTempo200cmEXCHANGEGUIDEWIRE整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryHeadhunter5FTempo200cmEXCHANGEGUIDEWIREAmplatzEmerald0.035〞260cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryAmplatzEmerald0.035〞260cmEXCHANGEINTRODUCERSHEATH整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryAmplatzEmerald0.035〞260cmBriteTipSheath7F80cmEXCHANGEINTRODUCERSHEATH整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cmREMOVEGUIDEWIRE整理課件CarotidArteryDisease:

CarotidAngioplasty-Procedure

HintsAtthisstage:NevercrossthelesionintheICA整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cmINTRODUCEPROTECTIONDEVICE整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryAngioguard0.014〞300cmBriteTipSheath7F80cmINTRODUCEPROTECTIONDEVICE整理課件AngioguardDevice:

DeliverySheathCoveringFilter整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cmCROSSLESIONWITHPROTECTIONDEVICEAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cmCROSSLESIONWITHPROTECTIONDEVICEAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryDEPLOYMENTPROTECTIONDEVICEBriteTipSheath7F80cmAngioguard0.014〞300cm整理課件AngioguardDevice:

FilterDeployed整理課件CarotidArteryDisease:

CarotidAngioplasty-Procedure

HintsHoldtheprotectiondevicealwaysinthescreen,NOTinsidethebrain(bleedings)整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArterySTENTDEPLOYMENT

SmartCarotidstent7-8mm30-40mmBriteTipSheath7F80cmAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cm

SmartCarotidstent7-8mm30-40mmSTENTDEPLOYMENTAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cm

SmartCarotidstent7-8mm30-40mmANGIOGRAPHICCONTROLAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cm

SmartCarotidstent7-8mm30-40mmANGIOGRAPHICCONTROLAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternal

CarotidArteryCommonCarotidArtery

Savvyballoon5-6mm30-40mmBriteTipSheath7F80cm

SmartCarotidstent7-8mm30-40mmPOSTDILATATIONAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cm

SmartCarotidstent7-8mm30-40mmPOSTDILATATIONAngioguard0.014〞300cm

Savvyballoon5-6mm30-40mm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cm

SmartCarotidstent7-8mm30-40mmANGIOGRAPHICCONTROLAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryBriteTipSheath7F80cm

SmartCarotidstent7-8mm30-40mmANGIOGRAPHICCONTROLAngioguard0.014〞300cm整理課件ExternalCarotidArteryInternalCarotidArteryCommonCarotidArteryRETRIEVALPROTECTIONDEVICEBriteTipSheath7F80cm

SmartCarotidstent7-8mm30-40mmAngioguard