支架辅助弹簧圈栓塞颅内动脉瘤的并发症分析
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摘要
背景:支架辅助弹簧圈栓塞已成为治疗颅内复杂动脉瘤的重要技术,对于该技术的相关并发症以及防治策略尚缺少系统分析。目的:系统分析自膨式颅内专用支架辅助弹簧圈栓塞治疗颅内宽颈和梭形动脉瘤的围手术期和随访并发症,探讨该技术的安全性。方法:回顾性分析解放军沈阳军区总医院神经外科从2003年7月到2009年12月应用支架辅助弹簧圈栓塞治疗的232例颅内动脉瘤患者(239个动脉瘤)的临床资料及随访结果;针对治疗中出现的各种并发症,详细分析原因和总结处理经验。结果与结论:①接受治疗的239个动脉瘤中,2个动脉瘤因血管迂曲支架未能到位,1个动脉瘤支架释放后3个月复查造影动脉瘤消失,其余236个动脉瘤顺利完成支架辅助栓塞治疗,术中支架顺利到位,放置满意;②操作相关并发症包括:血栓形成(n=13)、动脉瘤术中破裂(n=8)、弹簧圈突出(n=5)、占位效应(n=3)、血管损伤(n=3)和支架移位(n=2);③操作相关致残率和死亡率分别为4.3%(10/232)和1.3%(3/232)。蛛网膜下腔出血所致的非操作相关并发症主要包括脑血管痉挛和脑积水,在129例急性期破裂动脉瘤患者中发生率分别为18.6%(24/129)和7.0%(9/129);④88.4%(205/232)患者预后满意(mRS 0-2分),术后无(再)出血发生;⑤155例患者(159个动脉瘤)接受脑血管造影随访,总体再通率为14.5%(23/159)。随访中无支架或弹簧圈移位发生。迟发性并发症包括支架内狭窄(n=2)和穿支血管闭塞(n=2);⑥结果表明,支架辅助弹簧圈栓塞治疗颅内宽颈动脉瘤疗效肯定,并发症发生率和再通率低。血栓形成是主要的操作相关致残、致死因素。支架对载瘤动脉的长期影响需进一步随访观察。
BACKGROUND: Stent-assisted coil embolization has become an important technique for the treatment of intracranial complex aneurysms. However, there is no systematic analysis of complications and prevention strategies related to this technique. OBJECTIVE: To systematically analyze the complications related to stent-assisted coil embolization of intracranial aneurysms during perioperative and follow-up periods and to assess the safety of this method. METHODS: A retrospective study of 232 consecutive patients with 239 wide-necked aneurysms who underwent stent-assisted coil embolization at the Department of Neurosurgery, General Hospital of Shenyang Military Command from July 2003 to December 2009 was performed. Angiographic results and clinical outcomes were evaluated. A variety of complications were analyzed. The technical feasibility of the procedure, procedure-related complications, angiographic results, clinical outcomes and follow-up angiography were evaluated. RESULTS AND CONCLUSION: Stenting was successful in the 236 of 239 aneurysms. Procedure-related complications included thomboembolism(n=13), intraprocedural rupture(n=8), coil protrusions(n=5), new mass effect(n=3), vessel injury(n=3), and stent dislodgement(n=2). Procedure-related morbidity and mortality was 4.3%(10/232) and 1.3%(3/232), respectively. Nonprocedural complications attributable to subarachnoid hemorrhage in 129 patients with acute ruptured aneurysms were symptomatic vasospasm(18.6%, 24/129) and shunt-dependent hydrocephalus(7.0%, 9/129). Favorable clinical outcomes(mRS 0-2) were observed in 88.3%(205/232) of the patients, and no rehemorrhage of treated aneurysms occurred. Follow-up angiography was obtained in 155 patients(159 treated aneurysms). The overall recanalization rate was 14.5%(23/159). No stenting or coiling displacement occurred during the follow-up. Delayed complications included in-stent stenosis(n=2) and penetrating artery occlusion(n=2). In conclusion, our study indicates that stent-assisted coil embolization of intracranial aneurysm is a safe technique with low morbidity and mortality rates. Thromboembolism is the main cause of procedure-related disability and death. Nevertheless, further long-term follow-up is necessary to determine the durability of these promising results.
BACKGROUND: Stent-assisted coil embolization has become an important technique for the treatment of intracranial complex aneurysms. However, there is no systematic analysis of complications and prevention strategies related to this technique. OBJECTIVE: To systematically analyze the complications related to stent-assisted coil embolization of intracranial aneurysms during perioperative and follow-up periods and to assess the safety of this method. METHODS: A retrospective study of 232 consecutive patients with 239 wide-necked aneurysms who underwent stent-assisted coil embolization at the Department of Neurosurgery, General Hospital of Shenyang Military Command from July 2003 to December 2009 was performed. Angiographic results and clinical outcomes were evaluated. A variety of complications were analyzed. The technical feasibility of the procedure, procedure-related complications, angiographic results, clinical outcomes and follow-up angiography were evaluated. RESULTS AND CONCLUSION: Stenting was successful in the 236 of 239 aneurysms. Procedure-related complications included thomboembolism(n=13), intraprocedural rupture(n=8), coil protrusions(n=5), new mass effect(n=3), vessel injury(n=3), and stent dislodgement(n=2). Procedure-related morbidity and mortality was 4.3%(10/232) and 1.3%(3/232), respectively. Nonprocedural complications attributable to subarachnoid hemorrhage in 129 patients with acute ruptured aneurysms were symptomatic vasospasm(18.6%, 24/129) and shunt-dependent hydrocephalus(7.0%, 9/129). Favorable clinical outcomes(mRS 0-2) were observed in 88.3%(205/232) of the patients, and no rehemorrhage of treated aneurysms occurred. Follow-up angiography was obtained in 155 patients(159 treated aneurysms). The overall recanalization rate was 14.5%(23/159). No stenting or coiling displacement occurred during the follow-up. Delayed complications included in-stent stenosis(n=2) and penetrating artery occlusion(n=2). In conclusion, our study indicates that stent-assisted coil embolization of intracranial aneurysm is a safe technique with low morbidity and mortality rates. Thromboembolism is the main cause of procedure-related disability and death. Nevertheless, further long-term follow-up is necessary to determine the durability of these promising results.
引文
[1]吴中学.合理选择脑血管病的治疗方法[J].中华神经外科杂志,2006,22(8):453.
[2]Higashida RT,Smith W,Gress D,et al.Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery.Case report and review of the literature.J Neurosurg.1997;87(6):944-949.
[3]Wolstenholme J,Rivero-Arias O,Gray A,et al.Treatment pathways,resource use,and costs of endovascular coiling versus surgical clipping after a SAH.Stroke.2008;39(1):111-119.
[4]Yahia AM,Gordon V,Whapham J,et al.Complications of Neuroform stent in endovascular treatment of intracranial aneurysms.Neurocrit Care.2008;8(1):19-30.
[5]Qian Z,Feng X,Kang H,et al.Ruptured Wide-Necked Aneurysms:Is Stent-Assisted Coiling During Posthemorrhage Days 4-10 Safe and Efficient.World Neurosurg.2017;101:137-143.
[6]Lv X,Li Y,Jiang C,et al.Potential advantages and limitations of the Leo stent in endovascular treatment of complex cerebral aneurysms.Eur J Radiol.2011;79(2):317-322.
[7]张亮,吕明,李佑祥,等.支架辅助栓塞颅内宽颈动脉瘤手术相关出血性与缺血性并发症的危险因素分析[J].中国微侵袭神经外科杂志,2016,21(2):49-52.
[8]Liang G,Gao X,Li Z,et al.Neuroform stent-assisted coiling of intracranial aneurysms:a 5 year single-center experience and follow-up.Neurol Res.2010;32(7):721-727.
[9]Yahia AM,Latorre J,Gordon V,et al.Thromboembolic events associated with Neuroform stent in endovascular treatment of intracranial aneurysms.J Neuroimaging.2010;20(2):113-117.
[10]Murayama Y,Nien YL,Duckwiler G,et al.Guglielmi detachable coil embolization of cerebral aneurysms:11 years'experience.J Neurosurg.2003;98(5):959-966.
[11]Mericle RA,Lanzino G,Wakhloo AK,et al.Stenting and secondary coiling of intracranial internal carotid artery aneurysm:technical case report.Neurosurgery.1998;43(5):1229-1234.
[12]Park HK,Horowitz M,Jungreis C,et al.Periprocedural morbidity and mortality associated with endovascular treatment of intracranial aneurysms.AJNR Am J Neuroradiol.2005;26(3):506-514.
[13]Linzey JR,Griauzde J,Guan Z,et al.Stent-assisted coiling of cerebrovascular aneurysms:experience at a large tertiary care center with a focus on predictors of recurrence.JNeurointerv Surg.2016 Oct 3.[Epub ahead of print]
[14]Sekhon LH,Morgan MK,Sorby W,et al.Combined endovascular stent implantation and endosaccular coil placement for the treatment of a wide-necked vertebral artery aneurysm:technical case report.Neurosurgery.1998;43(2):380-383.
[15]Lubicz B,Collignon L,Raphaeli G,et al.Solitaire stent for endovascular treatment of intracranial aneurysms:immediate and mid-term results in 15 patients with 17 aneurysms.JNeuroradiol.2010;37(2):83-88.
[16]Fiorella D,Albuquerque FC,Woo H,et al.Neuroform In-stent Stenosis:Incidence,Natural History and Treatment Strategies.Neurosurgery.2006;59(1):34-42.
[17]Shin YS,Kim BM,Suh SH,et al.Wingspan stenting for intracranial atherosclerotic stenosis:clinical outcomes and risk factors for in-stent restenosis.Neurosurgery.2013;72(4):596-604.
[18]Biondi A,Janardhan V,Katz JM,et al.Neuroform stent-assisted coil embolization of wide-neck intracranial aneurysms:strategies in stent deployment and midterm follow-up.Neurosurgery.2007;61(3):460-468.
[19]Dos Santos Souza MP,Agid R,Willinsky RA,et al.Microstent-assisted coiling for wide-necked intracranial aneurysms.Can J Neurol Sci.2005;32(1):71-81.
[20]Park HK,Horowitz M,Jungreis C,et al.Periprocedural morbidity and mortality associated with endovascular treatment of intracranial aneurysms.AJNR Am J Neuroradiol.2005;26(3):506-514.
[21]Murayama Y,Malisch T,Guglielmi G,et al.Incidence of cerebral vasospasm after endovascular treatment of acutely ruptured aneurysms:report on 69 cases.J Neurosurg.1997;87(6):830-835.
[22]Gruber A,Ungersb?ck K,Reinprecht A,et al.Evaluation of cerebral vasospasm after early surgical and endovascular treatment of ruptured intracranial aneurysms.Neurosurgery.1998;42(2):258-267.
[23]Rabinstein AA,Pichelmann MA,Friedman JA,et al.Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage:a comparison between surgical repair and endovascular coil occlusion.J Neurosurg.2003;98(2):319-325.
[24]Mu SQ,Yang XJ,Li YX,et al.Endovascular treatment of wide-necked intracranial aneurysms using of"remodeling technique"with the Hyper Form balloon.Chin Med J(Engl).2008;121(8):725-729.
[25]梁晓东,王子亮,李天晓,等.支架辅助栓塞颅内未破裂动脉瘤三种抗血小板方案围手术期并发症发生率比较[J].中华放射学杂志,2016,5(7):531-536.
[26]Katsaridis V,Papagiannaki C,Violaris C.Embolization of acutely ruptured and unruptured wide-necked cerebral aneurysms using the neuroform2 stent without pretreatment with antiplatelets:a single center experience.AJNR Am JNeuroradiol.2006;27(5):1123-1128.
[2]Higashida RT,Smith W,Gress D,et al.Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery.Case report and review of the literature.J Neurosurg.1997;87(6):944-949.
[3]Wolstenholme J,Rivero-Arias O,Gray A,et al.Treatment pathways,resource use,and costs of endovascular coiling versus surgical clipping after a SAH.Stroke.2008;39(1):111-119.
[4]Yahia AM,Gordon V,Whapham J,et al.Complications of Neuroform stent in endovascular treatment of intracranial aneurysms.Neurocrit Care.2008;8(1):19-30.
[5]Qian Z,Feng X,Kang H,et al.Ruptured Wide-Necked Aneurysms:Is Stent-Assisted Coiling During Posthemorrhage Days 4-10 Safe and Efficient.World Neurosurg.2017;101:137-143.
[6]Lv X,Li Y,Jiang C,et al.Potential advantages and limitations of the Leo stent in endovascular treatment of complex cerebral aneurysms.Eur J Radiol.2011;79(2):317-322.
[7]张亮,吕明,李佑祥,等.支架辅助栓塞颅内宽颈动脉瘤手术相关出血性与缺血性并发症的危险因素分析[J].中国微侵袭神经外科杂志,2016,21(2):49-52.
[8]Liang G,Gao X,Li Z,et al.Neuroform stent-assisted coiling of intracranial aneurysms:a 5 year single-center experience and follow-up.Neurol Res.2010;32(7):721-727.
[9]Yahia AM,Latorre J,Gordon V,et al.Thromboembolic events associated with Neuroform stent in endovascular treatment of intracranial aneurysms.J Neuroimaging.2010;20(2):113-117.
[10]Murayama Y,Nien YL,Duckwiler G,et al.Guglielmi detachable coil embolization of cerebral aneurysms:11 years'experience.J Neurosurg.2003;98(5):959-966.
[11]Mericle RA,Lanzino G,Wakhloo AK,et al.Stenting and secondary coiling of intracranial internal carotid artery aneurysm:technical case report.Neurosurgery.1998;43(5):1229-1234.
[12]Park HK,Horowitz M,Jungreis C,et al.Periprocedural morbidity and mortality associated with endovascular treatment of intracranial aneurysms.AJNR Am J Neuroradiol.2005;26(3):506-514.
[13]Linzey JR,Griauzde J,Guan Z,et al.Stent-assisted coiling of cerebrovascular aneurysms:experience at a large tertiary care center with a focus on predictors of recurrence.JNeurointerv Surg.2016 Oct 3.[Epub ahead of print]
[14]Sekhon LH,Morgan MK,Sorby W,et al.Combined endovascular stent implantation and endosaccular coil placement for the treatment of a wide-necked vertebral artery aneurysm:technical case report.Neurosurgery.1998;43(2):380-383.
[15]Lubicz B,Collignon L,Raphaeli G,et al.Solitaire stent for endovascular treatment of intracranial aneurysms:immediate and mid-term results in 15 patients with 17 aneurysms.JNeuroradiol.2010;37(2):83-88.
[16]Fiorella D,Albuquerque FC,Woo H,et al.Neuroform In-stent Stenosis:Incidence,Natural History and Treatment Strategies.Neurosurgery.2006;59(1):34-42.
[17]Shin YS,Kim BM,Suh SH,et al.Wingspan stenting for intracranial atherosclerotic stenosis:clinical outcomes and risk factors for in-stent restenosis.Neurosurgery.2013;72(4):596-604.
[18]Biondi A,Janardhan V,Katz JM,et al.Neuroform stent-assisted coil embolization of wide-neck intracranial aneurysms:strategies in stent deployment and midterm follow-up.Neurosurgery.2007;61(3):460-468.
[19]Dos Santos Souza MP,Agid R,Willinsky RA,et al.Microstent-assisted coiling for wide-necked intracranial aneurysms.Can J Neurol Sci.2005;32(1):71-81.
[20]Park HK,Horowitz M,Jungreis C,et al.Periprocedural morbidity and mortality associated with endovascular treatment of intracranial aneurysms.AJNR Am J Neuroradiol.2005;26(3):506-514.
[21]Murayama Y,Malisch T,Guglielmi G,et al.Incidence of cerebral vasospasm after endovascular treatment of acutely ruptured aneurysms:report on 69 cases.J Neurosurg.1997;87(6):830-835.
[22]Gruber A,Ungersb?ck K,Reinprecht A,et al.Evaluation of cerebral vasospasm after early surgical and endovascular treatment of ruptured intracranial aneurysms.Neurosurgery.1998;42(2):258-267.
[23]Rabinstein AA,Pichelmann MA,Friedman JA,et al.Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage:a comparison between surgical repair and endovascular coil occlusion.J Neurosurg.2003;98(2):319-325.
[24]Mu SQ,Yang XJ,Li YX,et al.Endovascular treatment of wide-necked intracranial aneurysms using of"remodeling technique"with the Hyper Form balloon.Chin Med J(Engl).2008;121(8):725-729.
[25]梁晓东,王子亮,李天晓,等.支架辅助栓塞颅内未破裂动脉瘤三种抗血小板方案围手术期并发症发生率比较[J].中华放射学杂志,2016,5(7):531-536.
[26]Katsaridis V,Papagiannaki C,Violaris C.Embolization of acutely ruptured and unruptured wide-necked cerebral aneurysms using the neuroform2 stent without pretreatment with antiplatelets:a single center experience.AJNR Am JNeuroradiol.2006;27(5):1123-1128.