复合手术治疗症状性颅内动脉狭窄合并近端血管迂曲病变二例
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摘要
分析2例经药物治疗无效的症状性颅内动脉重度狭窄合并近端血管迂曲患者的影像学特点及手术治疗经过,探讨通过复合手术改善或创造介入路径,同期行远端狭窄介入治疗的效果。患者1为73岁女性,症状性左侧大脑中动脉重度狭窄合并左侧颈内动脉起始段严重迂曲,规范药物治疗无效,行颈动脉血运重建+大脑中动脉支架置入复合手术后症状缓解。12个月随访期间血流通畅,症状无复发。患者2为70岁男性,症状性基底动脉狭窄合并左侧椎动脉起始段迂曲、右侧椎动脉V4段生理性纤细,规范药物治疗后仍有反复后循环缺血发作,行左侧椎动脉暴露+直视下穿刺椎动脉基底动脉支架置入复合手术,术后症状消失。9个月随访期间血流通畅,症状无复发。结合文献复习认为,对于药物治疗无效、单纯介入治疗失败或难度较大的症状性颅内动脉狭窄合并近端血管严重迂曲的患者,复合手术可能是安全有效的治疗方式。
Patient 1 was a 73-year-old female who was diagnosed as symptomatic severe stenosis of left middle cerebral artery with left internal carotid artery tortuosity. Her symptoms persisted despite the optimal medical therapy. Reconstruction of the left internal carotid artery was successfully performed by truncating the redundant segment and following end-to-end anastomosis,then intracranial stent was deployed via a new available approach. Patient's symptoms alleviated after operation and never reoccured in 12-month follow-up. Patient 2 was a 70-year-old male who had basilar artery severe stenosis with left vertebral artery tortuosity and contralateral one slenderness. He suffered from recurrent posterior circulation ischemia even with optimal medical therapy. During the hybrid operation,the left vertebral artery was exposed and cut open so that an available approach for endovascular procedure was created. No recurrence of symptoms in followup after operation with for 9 months. Relevant literature was reviewed. We concluded that for treatment of symptomatic severe intracranial artery stenosis with proximal vascular tortuosity,hybrid operation can be safe and effective.
Patient 1 was a 73-year-old female who was diagnosed as symptomatic severe stenosis of left middle cerebral artery with left internal carotid artery tortuosity. Her symptoms persisted despite the optimal medical therapy. Reconstruction of the left internal carotid artery was successfully performed by truncating the redundant segment and following end-to-end anastomosis,then intracranial stent was deployed via a new available approach. Patient's symptoms alleviated after operation and never reoccured in 12-month follow-up. Patient 2 was a 70-year-old male who had basilar artery severe stenosis with left vertebral artery tortuosity and contralateral one slenderness. He suffered from recurrent posterior circulation ischemia even with optimal medical therapy. During the hybrid operation,the left vertebral artery was exposed and cut open so that an available approach for endovascular procedure was created. No recurrence of symptoms in followup after operation with for 9 months. Relevant literature was reviewed. We concluded that for treatment of symptomatic severe intracranial artery stenosis with proximal vascular tortuosity,hybrid operation can be safe and effective.
引文
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[10]中国卒中学会,中国卒中学会神经介入分会,中华预防医学会卒中预防与控制专业委员会介入学组.症状性颅内动脉粥样硬化性狭窄血管内治疗中国专家共识2018[J].中国卒中杂志,2018,13(6):594-604.
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[12]张利勇,张士刚,郝继恒,等.复合手术在颈动脉狭窄病变治疗中的初步应用[J].中国脑血管病杂志,2013,10(11):594-598.
[2] Wong LK. Global burden of intracranial atherosclerosis[J].Int J Stroke,2006,1(3):158-159.
[3] Wong KS,Huang YN,Gao S,et al. Intracranial stenosis in Chinese patients with acute stroke[J]. Neurology,1998,50(3):812-813.
[4] Gao P,Zhao Z,Wang D,et al. China angioplasty and stenting for symptomatic intracranial severe stenosis(CASSISS):a new,prospective,multicenter,randomized controlled trial in China[J]. Interv Neuroradiol,2015,21(2):196-204.
[5] Beigelman R,Izaguirre A,Robles M,et al. Kinking of carotid arteries is not a mechanism of cerebral ischemia:a functional evaluation by Doppler echography[J]. Int Angiol,2011,30(4):342-348.
[6] Matula C,Trattnig S,Tschabitscher M,et al. The course of the prevertebral segment of the vertebral artery:anatomy and clinical significance[J]. Surg Neurol,1997,48(2):125-131.
[7] Kernan WN,Ovbiagele B,Black HR,et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack:a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke,2014,45(7):2160-2236.
[8] Al Hasan M,Murugan R. Stenting versus aggressive medical therapy for intracranial arterial stenosis:more harm than good[J]. Crit Care,2012,16(3):310.
[9] Yu SC,Leung TW,Hung EH,et al. Angioplasty and stenting for intracranial atherosclerotic stenosis with nitinol stent:factors affecting technical success and patient safety[J]. Neurosurgery,2012,70(1 Suppl Operative):104-113.
[10]中国卒中学会,中国卒中学会神经介入分会,中华预防医学会卒中预防与控制专业委员会介入学组.症状性颅内动脉粥样硬化性狭窄血管内治疗中国专家共识2018[J].中国卒中杂志,2018,13(6):594-604.
[11]王亚冰,焦力群,谌燕飞,等.复合手术技术治疗复杂颈动脉狭窄和闭塞性疾病[J].中国现代神经疾病杂志,2014,14(2):93-98.
[12]张利勇,张士刚,郝继恒,等.复合手术在颈动脉狭窄病变治疗中的初步应用[J].中国脑血管病杂志,2013,10(11):594-598.