颈动脉支架置入术课件

*,*,*,*,*,*,*,*,*,*,颈动脉支架置入术,颈动脉支架置入术,SAPPHIRE,研究,CEA,高危患者保护装置下支架置入与血管成形试验 （,stenting and angioplasty with protection in patient at high rish for endarterectomy, SAPPHIRE,）,第一项在有症状或无症状颈动脉狭窄患者中比较,CAS,和,CEA,疗效的多中心随机对照研究,SAPPHIRE 研究CEA高危患者保护装置下支架置入与血管,介入器材,ANGIOGUARD,血栓保护装置,Cordis PRECISE,支架,介入器材ANGIOGUARD血栓保护装置Cordis PRE,入选病例被随机分入使用保护装置的支架介入术组,(n=159),和内膜切除术组,(n=151),对于风险过高的病人，由介入科医生、血管外科医生和神经科医生组成的医生小组共同决定进入注册组,CONSENSUS,一致同意,RANDOMIZED, PROSPECTIVE,随机，前瞻性,3,10 (12 month),Stenting,支架组,=15,9,/,CEA=151,STENT,REGISTRY,支架注册,40,7,SURGICAL,REFUSAL,外科拒绝,SURGICAL,REGISTRY,外科注册,7,INTERVENTIONAL,REFUSAL,介入拒绝,医生小组：神经科医生，外科医生，介入科医生,The SAPPHIRE Trial,入选病例被随机分入使用保护装置的支架介入术组(n=159)和,SAPPHIRE (high-risk patients) 30 days and 12 months results,SAPPHIRE (high-risk patients) 30 days and 12 month results,“Stented patients are now 12 months out from treatment, and their,MAE rate,continue to,be as good as, and in many ways better than, those for the surgically treated group.”,接受治疗12个月后，支架组病人不良事件的发生率相当于，甚至在很多方面，优于手术治疗组。,SAPPHIRE (high-risk patients),12 month Results: CAS vs. CEA,Overall MAE rate,总体主要不良事件发生率,11.9% vs. 19.9% :,difference,显著差异,p = 0.06,Death rate,死亡率6.9%,vs. 12.6%:, double number of patients died in the CEA arm,外科组死亡人数比支架组多一倍,Stroke rate,中风发生率 5.7%,vs. 7.3%:, 30% more patients experienced a stroke in the CEA arm,外科组至少发生一次中风的病人数比支架组多30%,Major Ipsilateral Stroke rate,主要同侧大中风发生率,0.0%,vs. 3.3%, was significant higher in CEA,外科组显著高于支架组，,p = 0.03,MI (Q or non Q) rate,心梗发生率2.5%,vs. 7.9%:,patients got 3 times more MI in the CEA arm,外科组发生心梗的病人数比支架组多三倍以上,Outcome of cranial nerve injury (30 days) 30,天内颅神经损伤的发生率,0.0%,vs. 5.3%:,was significant for CEA arm,外科组显著高于支架组，,p 0.01,12 month Results: CAS vs. CEA,结 论,结 论,ISC 2010,-CREST,ISC 2010 -CREST,CREST,设计,前瞻、多中心、随机对照试验，盲法判定,比较对于症状性和无症状性颈动脉狭窄患者是,CEA,还是,CAS,更好,每个中心团队包括神经科医生、介入医生、外科医生和研究协调员,9,CREST设计前瞻、多中心、随机对照试验，盲法判定9,患者分组和基本情况,CAS(n-1262),CEA(n=1240),年龄,69,69,女性,36,34,无症状性,47,47,高血压,86,86,糖尿病,30,30,血脂异常,82,85,目前吸烟,26,26,心血管病,40,43,平均收缩压,mmHg,142,141,70%,狭窄的例数,85,87,症状性狭窄发病天数,20,25,10,患者分组和基本情况CAS(n-1262)CEA(n=1240,主要终点,（,卒中、心梗、围手术期死亡加同侧卒中）,HR=1.11,95%CI 0.81-1.51,P=0.51,主要终点（卒中、心梗、围手术期死亡加同侧卒中）HR=1.1,颈动脉支架置入术课件,主要终点,:,围手术期事件,（,死亡、卒中、心梗）,HR=1.18,95%CI 0.82-1.68,P=0.38,主要终点:围手术期事件（死亡、卒中、心梗）HR=1.18,围手术期卒中,卒中,HR=1.79,95% CI 1.14-2.82,P=0.01,心梗,HR=1.35,95% CI 0.54-3.36,P=0.52,围手术期卒中卒中心梗,围手术期颅神经麻痹,HR=0.07,95% CI 0.02-0.18,P0.0001,围手术期颅神经麻痹HR=0.07,同侧卒中,HR=0.94,95% CI 0.50-1.76,P=0.85,同侧卒中HR=0.94,结论,CEA,和,CAS,有相同的净预后，尽管各自风险不同，但是,CAS,有较低的心梗发生，,CEA,有较低的卒中风险,年轻患者,CAS,获益多，年长患者,CEA,获益多,有经验的中心,CEA,和,CAS,显示更低的围手术期并发症，有更杰出的预后,未来，,CEA,和,CAS,是预防卒中有用的工具,结论CEA和CAS有相同的净预后，尽管各自风险不同，但是CA,适应症,无症状血管狭窄程度大于,70,，有症状,(TIA,或中风发作,),血管狭窄程度大于,50,狭窄程度小于,50,，但有溃疡性斑块形成,某些肌纤维发育不良者，大动脉炎稳定期有局,限性狭窄,放疗术后或内膜剥脱术后、支架术后再狭窄,由于颈部肿瘤压迫等受压而导致的狭窄,急性动脉溶栓后残余狭窄,适应症无症状血管狭窄程度大于70，有症状(TIA,禁忌症,3,个月内有颅内出血，,2,周内有新鲜脑梗塞,不能控制的高血压,对肝素、阿司匹林或其他抗血小板类药物有禁忌者,对造影剂过敏者,颈内动脉完全闭塞,伴有颅内动脉瘤，并且不能提前或同时处理者,在,30,天以后预计有其他部位外科手术者,2,周内曾发生心肌梗塞,有严重心、肝、肾疾病,禁忌症3个月内有颅内出血，2周内有新鲜脑梗塞,术前准备,术前,6,小时禁食水,术前,6,小时之内碘过敏试验,双侧腹股沟区备皮,术前,35,天口服抗血小板药物：氯吡咯雷,75mg+,阿司匹林,100mg,颈部血管超声，,TCD,评价,局部脑血流评价,(,核磁共振灌注、,PET,、,CT,灌注或,SPECT,其中一项或以上,),全脑血管造影或,CTA,、,MRA,术前准备术前6小时禁食水,颈动脉支架置入术课件,颈动脉支架置入术课件,颈动脉支架置入术课件,狭窄程度的评价,参照,NASCET,标准,狭窄率,% =,（,1 - A/B,）, 100,狭窄程度,轻度（,0%-29%,）,中度（,30%-69%,）,重度（,70%-99%,）,狭窄程度的评价 参照NASCET标准,操作方法,经股动脉采用,Seldinger,技术穿刺，一般放置,8F,导管鞘，导管鞘连接加压盐水持续滴注冲洗,肝素（,50100 U/kg),导引导管后面接,Y,阀或止血阀并与加压盐水连接，在,0.035”,泥鳅导丝小心导引下放在患侧颈总动脉，头端位置距离狭窄约,35cm,。过度迂曲的颈总动脉可以使用交换导丝将导引导管交换到位,通过导引导管造影测量狭窄长度和直径选择合适支架，并行患侧狭窄远端颅内动脉造影以备支架术后对照,操作方法经股动脉采用Seldinger技术穿刺，一般放置8F,操作方法,通过导引导管将保护装置小心穿过狭窄并将其释放在狭窄远端,45cm,位置，撤出保护装置外套。支架置入前静脉给予阿托品,0.5mg,以防心动过缓及低血压,置入支架，造影检查支架术后残余狭窄管径，酌情作支架内后扩,如果狭窄特别严重，或血管弯曲影响保护伞的安全通过，可选择合适的球囊行预扩,最后撤出保护装置，行颈部以及患侧颅内动脉造影与术前对比,Aguard Deploy Mov Pic.mpg,操作方法通过导引导管将保护装置小心穿过狭窄并将其释放在狭窄远,脑保护装置,脑保护装置,颈动脉支架置入术课件,脑保护装置,脑保护装置,支架类型,球扩式支架,Palmaz Stent,(Cordis),自膨式支架,Carotid Wallstent,(Boston Scientific),PRECISE,(Cordis),Protg,(ev3),Acculink,(Abbott,）,支架类型球扩式支架,自膨式支架,雕刻支架,编织支架,自膨式支架雕刻支架,编织支架,优点,支撑力更大,不易塌陷,柔韧性更强，表面光滑，易于球囊通过,网孔密集，限制斑块脱落,可重新定位、再次释放,编织支架优点,编织支架,不足,短缩、不易精确定位,拉伸颈动脉、上端扭曲、成角,凹凸不平处贴壁欠佳,编织支架不足,雕刻支架,优点,顺应性好，适应不同形状而不造成血管强直,贴壁性好，不易造成死腔,基本无缩短，定位和选择长度较精确,不足,后扩时有连接点断裂的风险,雕刻支架优点,支架选择,支架直径,(,完全张开,),必须至少比最大的目,标血管大,1,mm,目标血管：,CCA,支架长度：两端至少超过狭窄,0.5,1 cm,，,并覆盖“健康,”,动脉,如果颈动脉狭窄累及分叉处，则支架至少,要放,1,cm,在颈总动脉,支架选择支架直径 (完全张开) 必须至少比最大的目,支架选择,颈动脉迂曲不明显及狭窄边缘较光整时，选用,Wallstent,或雕刻支架均可,颈动脉迂曲较明显时，雕刻支架的柔顺性和贴壁性较好,高危斑块（软斑块）宜选用,Wallstent,如果必须处理颈外动脉病变，则只能选用,Wallstent,，以便在,Wallstent,的网眼中进行扩张,支架选择颈动脉迂曲不明显及狭窄边缘较光整时，选用Wallst,颈动脉支架置入术,颈动脉支架置入术,颈动脉支架置入术,颈动脉支架置入术,颈动脉支架置入术课件,颈动脉支架置入术课件,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Terumo guidewire,0.035”,100cm,Headhunter,5F Tempo,200cm,INTRODUCE GUIDEWIRE AND INTRODUCER SHEATH,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Terumo guidewire,0.035”,100cm,Headhunter,5F Tempo,200cm,INTRODUCE GUIDEWIRE AND INTRODUCER SHEATH,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,SELECTIVE CATHETHETERISATION OF ECA,Terumo guidewire,0.035”,100cm,Headhunter,5F Tempo,200cm,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Headhunter,5F Tempo,200cm,EXCHANGE,GUIDEWIRE,Terumo guidewire,0.035”,100cm,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Headhunter,5F Tempo,200cm,EXCHANGE,GUIDEWIRE,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Headhunter,5F Tempo,200cm,EXCHANGE,GUIDEWIRE,Amplatz Emerald,0.035”,260cm,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Amplatz Emerald,0.035”,260cm,EXCHANGE,INTRODUCER SHEATH,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Amplatz Emerald,0.035”,260cm,Brite Tip Sheath,7F,80cm,EXCHANGE,INTRODUCER SHEATH,External Carotid ArteryInterna,External Carotid Artery,Internal Carotid Artery,Common Carotid Artery,Brite Tip Sheath,7F,80cm,REMOVE,GUIDEWIRE,External Carotid ArteryInterna,Carotid Artery Disease :,Carotid Angioplasty - 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