颈动脉及颅内动脉狭窄的血管内支架治疗体会李慎茂北京市脑血管病中心首都医科大学宣武医院首都医科大学脑血管病研究所E-mail:shenmao@china.com颈动脉狭窄治疗简介颈动脉狭窄治疗简介-1-1•动脉硬化动脉硬化–血流动力学因素血流动力学因素•颈动脉分叉部颈动脉分叉部•末梢梗塞末梢梗塞–斑块斑块&&血栓脱落血栓脱落•1954Eastcott1954Eastcott等颈动脉内膜切除术等颈动脉内膜切除术(CarotidEndaterectomy,(CarotidEndaterectomy,CE)CE)•1980Mullan1980Mullan和和KerberKerber颈动脉经皮腔内血管成形术颈动脉经皮腔内血管成形术(Perc(Percutaneoustransluminalangioplasty;PTA)utaneoustransluminalangioplasty;PTA)•19861986批准:颈动脉经皮腔内血管成形术合并支架植入批准:颈动脉经皮腔内血管成形术合并支架植入(P(PercutaneousTransluminalAngioplastyandStenting;PTAS)ercutaneousTransluminalAngioplastyandStenting;PTAS)–Dotter1969Dotter1969年就用不锈钢支架进行了实验年就用不锈钢支架进行了实验–19891989~~19901990年年MathiasMathias首先使用了首先使用了WallstentWallstent支架行颈动脉置入术支架行颈动脉置入术TheronTheron首先使用首先使用StrekerStreker支架支架19931993年年DiethrichDiethrich首次使用首次使用PalmazPalmaz支架行颈动脉支架成形术支架行颈动脉支架成形术颈动脉狭窄治疗简介颈动脉狭窄治疗简介-2-2•1996Theron1996Theron运用三腔同轴球囊导管保护系统运用三腔同轴球囊导管保护系统•2001-20022001-2002::Cordis;BostonCordis;Boston相继推出脑保护装置相继推出脑保护装置颈动脉狭窄治疗简介颈动脉狭窄治疗简介-3-3ConfidentialInformation:OnlyfordistributiontotheEVA3ScommitteeSAPPHIRESAPPHIRESx>50%DS,Asx>80%DS,>1co-morbiditySx>50%DS,Asx>80%DS,>1co-morbidityN=723N=723Neurologist,Surgeon,Neurologist,Surgeon,IntervetionalistIntervetionalistSurgicalrefusalSurgicalrefusalConsensusConsensusInterventionalrefusalInterventionalrefusalCSregistryCSregistryRandomizationRandomizationCEregistryCEregistryN=406N=406N=7N=7CSCSCECEN=159N=159N=151N=151SAPPHIRESAPPHIRECSCEPDeath0.6%2.0%0.36Stroke3.8%5.3%0.59MI(Q/non-Q)2.6%7.3%0.07Death/stroke/MI5.8%12.6%<0.05TIA3.8%2.0%0.5Majorbleeding8.3%10.6%0.56Cranialnerveinjury0.0%5.3%<0.0130-30-dayrandomizationdatadayrandomizationdataSAPPHIRESAPPHIRECS(N=159)CE(N=151)PDeath(%)11(6.9)19(12.6)0.12Stroke9(5.7)11(7.3)0.65Majoripsi.05(3.3)0.03Majornon-ipsi.1(0.6)1(0.7)1Minoripsi.6(3.8)3(2.0)0.5Minornon-ipsi.3(1.9)3(2.0)1MI4(2.5)12(7.9)0.04QMI02(1.3)0.24Non-QMI4(2.5)10(6.6)0.1MAEw/onon-neurodeath>30D9(5.7)19(12.6)<0.05Cranialn.palsy07(4.6)<0.011-1-yearrandomizationdatayearrandomizationdataCatheterCardiovascInterv.2003Oct;60(2):259-66.Updatedreviewoftheglobalcarotidarterystentregistry.WholeyMH,Al-MubarekN,WholeyMH.DepartmentofCardiovascularandInterventionalRadiology,UniversityofTexasHealthScienceCenteratSanAntonio,SanAntonio,Texas78284,USA.wholey@uthscsa.edu•新增≥500,000/年卒中患者;2,000,000留有不同程度的残疾•卒中与心脏病,肿瘤并列3大死因•致死率1.5‰(脑卒中患者1年内死亡率25%)•颈动脉的因素20-30%•CEA(50年代);NASCET/ACAS证实CEA↓卒中•CAS成为一种CEA的替代治疗•CAS是有效的,安全的结论11243患者12392血管1149双侧病变技术成功率98.9%(残余狭窄<30%)共放12732个支架并发症(手术-术后30天;以血管数计算)TIA……………………………….381例3.07%小卒中………………………………265例2.14%大卒中………………………………149例1.20%死亡手术相关……………………………79例0.64%手术无关…………………………….95例0.77%卒中+手术相关死亡………………..3.98%总卒中+死亡率…………………………………4.75%以总人数计算总卒中+死亡率………………5.23%随访超声随访1-6个月...