【摘要】 背景:后循环动脉管径细、行程长、生理弯曲多、分支多,血管内支架置入治疗相当困难。目的:分析后循环动脉解剖特征与支架置入过程中并发症发生的相互性。设计、时间及地点:回顾性分析,病例来自2004-11/2008-02郧阳医学院附属人民医院神经内科。对象:选择郧阳医学院附属人民医院神经内科住院患者25例,27个后循环动脉狭窄性病变,男13例,女12例,年龄50～76岁;其中锁骨下动脉盗血综合征4例,V1段、V2段、V4段以及基底动脉中下段狭窄分别为1例、1例、14例、2例,基底动脉尖综合征3例,大脑后动脉P1段狭窄2例,狭窄程度均大于70%。Mori分型均为A型和B型。锁骨下选用自膨式支架,其他选用球扩式支架。方法:颅外段支架置入均在局部麻醉下,颅内段于气管插管全麻下进行。若行锁骨下动脉狭窄支架置入成形术,将8F导引导管上至左侧锁骨下动脉开口处或者右侧头臂干。若经椎动脉起始部或V2段支架置入,就将6F导引导管上至锁骨下动脉起始部。若行椎动脉颅内段、基底动脉、大脑中动脉P1段支架置入或球囊扩张术,就将6F导引导管上至第二颈椎高度,甚至更高。导引导管到位后在路途下将支架输送到狭窄部位,造影确认支架到位准确后释放支架,撤下输送系统,再造影,观察支架覆盖狭窄的情况及狭窄解除的程度。主要观察指标:支架覆盖狭窄性病变的情况、狭窄解除的程度,支架移位、病变部位的血管破裂及支架内长血栓的情况,通过体检、CT或MRI检查支架置入后脑梗死的发生。结果:27处病变中,26处为支架置入,1处为单纯球囊扩张术,成功率达96%。锁骨下动脉起点到椎动脉开口之间的距离短,尤其右侧,导引导管固定困难,支架容易移位;椎动脉V3段相对固定、弯曲大,限制了能通过支架的长度;基底动脉分支多,支架置入或球囊扩张后容易发生分支闭塞;基底动脉尖为5分支结构易破裂出血或分支闭塞,应该作为置入治疗的禁忌证。置入并发症包括支架移位1例、基底动脉穿通支闭塞性梗死1例、血管破裂出血2例。其他患者支架置入顺利,无置入期并发症发生,恢复良好。结论:置入过程中并发症的发生与后循环动脉解剖特点密切相关。更多还原

【Abstract】 BACKGROUND:It is difficult to implant stent in poterior circulation due to small diameter,tortuosity access and various branches. OBJECTIVE:To study the correlation between anatomical characteristics and intraprocedural complications after posterior circulation stent implantation. DESIGN,TIME AND SETTING:A retrospective analysis,25 consecutive patients with 27 lesions in posterior circulation underwent angioplasty at the Department of Neurology,Renmin Hospital of Yunyang Medical College between November 2004 and February 2008. PARTICIPANTS:Twenty-five consecutive patients with 27 lesions in posterior circulation underwent angioplasty were collected,including 13 male and 12 female,aged 50-76 years. Digital substract angiography revealed severe stenosis which the degree of stenosis was defined as >70% in subclavian artery (n=4),V1 vertebral artery segment (n=1),V2 vertebral artery segment (n=1),V4 vertebral artery segment (n=14),top of basilar artery (n=3),and P1 PCA segment (n=2). All of the lesion morphological features belonged to type A and type B. Self-expanding stents were employed for subclavian artery and balloon expandable stents were used for other stenoses. METHODS:Patients with extracranial lesions were administered local anesthesia with intracranial lesions general endotracheal anesthesia. When subclavian artery stenosis was treated with stent angioplasty,8F guiding catheter was placed at the origin in left subclavian artery or right brachiocephalic trunk. When stent angioplasty was performed at the origin or V2 segment,6F guiding catheter should placed at the origin of subclavian artery. 6F guiding catheter should placed at the epistropheus height or more when stent angioplasty or baloon angioplasty was underwent at the intracranial section of vertebral artery,basilar artery,or P1 segment of middle cerebral artery. Stent should transport to stenosis lesions,released under guidance of catheter followed by angiography. A second angiography was performed after withdraw conveying system to observe the coverage of stent on stenosis lesions and release of stenosis. MAIN OUTCOME MEASURES:The coverage of stent on stenosis lesions,release of stenosis,shifting of stent,angiorrhexis and in-stent thrombus. The occurrence of cerebral infarction after stent implantation was examined by physical,CT or MRI examination. RESULTS:Of the 27 procedures performed,26 were stent implantation and 1 was baloon angioplasty,the technical success was 96%. Right subclavian artery intervention tended to be more difficult than its left-side counterpart,which is related to fluoroscopic visualization and the tendency for stenoses to develop in the very short segment between its origin and the take-off of the right vertebral artery. The V3 vertebral artery segment was relatively fixation and its tortuosity bends was abrupt and unable movement. The length of the stents passed the segment was restricted. The branches of basilar artery were easily occluded after angioplasty or stenting because its branches were too much. The top of basilar artery was typical 5 branches structure which easily vascular rupture and vascular occlusion. Therefore,interventional treatment of the top of basilar artery should be contraindicated. Intraprocedural complications occurred in 4 patients,1 for stent displacement,1 for branches occlusion at top of basilar artery,2 for subarachnoid haemorrhage. CONCLUSION:Occurrence of complications is closely correlated to the anatomical characteristics of posterior circulation.更多还原