頸動(dòng)脈支架植入術(shù)中腦保護(hù)裝置的應(yīng)用研究
欒 波 荊全民 韓雅玲
沈陽(yáng)軍區(qū)總醫(yī)院心內(nèi)科 110016
目的 動(dòng)脈粥樣硬化性斑塊和附壁血栓脫落導(dǎo)致的腦梗死，是采用血管內(nèi)球囊擴(kuò)張和支架置入術(shù)治療頸動(dòng)脈和椎動(dòng)脈粥樣硬化性狹窄的主要并發(fā)癥，而治療中應(yīng)用腦保護(hù)裝置防止脫落的栓子進(jìn)入腦血管，可有效降低此類并發(fā)癥的發(fā)生。現(xiàn)將我院應(yīng)用腦保護(hù)裝置進(jìn)行頸動(dòng)脈狹窄血管內(nèi)擴(kuò)張和支架置入治療2例患者的初步結(jié)果報(bào)告如下。
方法 2例患者經(jīng)頸動(dòng)脈造影入選，分別為男性67歲，左頸內(nèi)動(dòng)脈95%偏心性狹窄；女性64歲，左頸內(nèi)動(dòng)脈70%偏心性狹窄伴左鎖骨下動(dòng)脈完全閉塞。2例患者臨床表現(xiàn)均有頭暈、頭昏，短暫性腦缺血發(fā)作，記憶力減退。2例患者均在頸動(dòng)脈病變處放置了支架。術(shù)中均應(yīng)用了腦保護(hù)裝置（angioguard）。治療方法：① 術(shù)前3天常規(guī)服用阿司匹林0.3 1次/d，氯吡格雷75mg 1次/d；② 均采用右股動(dòng)脈入路穿刺，肝素5000u抗凝后，行雙側(cè)頸動(dòng)脈造影；③ 選用Cordis公司生產(chǎn)的腦保護(hù)裝置，在對(duì)頸動(dòng)脈狹窄處球囊擴(kuò)張及支架釋放前張開(kāi)腦保護(hù)裝置，此時(shí)動(dòng)態(tài)觀察血管直徑變化，警惕血管痙攣；④ 根據(jù)造影結(jié)果，男性患者選用了Smart8.0mmX40mm支架，女性患者選用了Smart9.0mmX40mm支架；⑤ 手術(shù)結(jié)束前均復(fù)查頸動(dòng)脈造影，未發(fā)現(xiàn)血管內(nèi)膜撕裂及支架擴(kuò)張不良；⑥ 術(shù)后克塞40mg皮下注射 2次/日，共5天，阿司匹林0.3 1次/d，4周后改為0.1 1次/日，長(zhǎng)期服用，氯吡格雷75mg 1次/d，4周后停用。
結(jié)果 采用腦保護(hù)裝置成功地對(duì)2例患者2處血管狹窄進(jìn)行了支架植入術(shù)。術(shù)中及術(shù)后隨訪6月無(wú)粥樣斑塊或血栓脫落性腦栓塞發(fā)生。頭暈、頭昏癥狀消失，無(wú)短暫性腦缺血發(fā)作。
討論 頸動(dòng)脈和椎動(dòng)脈粥樣硬化性狹窄是腦缺血性卒中的重要原因之一。動(dòng)脈內(nèi)球囊擴(kuò)張和支架置入術(shù)，由于其具有療效肯定、創(chuàng)傷微小、適應(yīng)證寬、再狹窄（或復(fù)發(fā)）率低和可重復(fù)施行的優(yōu)勢(shì)，目前已成為治療頸動(dòng)脈和椎動(dòng)脈狹窄的主要方法之一。但是，血管內(nèi)擴(kuò)張和支架置入術(shù)的圍手術(shù)期永久性并發(fā)癥發(fā)生率和患者病死率共為4.2%-19.2%。其中主要原因是粥樣斑塊或附壁血栓的脫落性栓塞。腦保護(hù)裝置的應(yīng)用是目前解決上述問(wèn)題的主要方法。我院2例次的初步嘗試結(jié)果也顯示此方法效果良好，并且操作簡(jiǎn)單易行。腦保護(hù)裝置的使用，不僅可以明顯地降低手術(shù)并發(fā)癥和患者病死率，而且還可以提高動(dòng)脈狹窄的治療療效。應(yīng)用腦保護(hù)裝置主要應(yīng)注意的問(wèn)題是避免該裝置通過(guò)動(dòng)脈狹窄處時(shí)引起斑塊或血栓的脫落。
關(guān)鍵詞 頸動(dòng)脈支架置入 腦保護(hù)裝置
Practice and study of carotid artery stenting under brain protection
Luanbo,HAN Ya-Ling,JING Quan-Min， Department of Cardiology, Shenyang Command General Hospital， PLA， Shenyang 110016
[Abstract] Objective Cerebral infarction due to exfoliating atherosclerotic plaque and mural thrombus was the main complication when the stenosis of carotid artery and vertebral artery were treated by stenting. Whereas brain protection device can decrease effectively the rate of the camplication. This study reported our department performance of carotid artery stenting(CAS) under brain protection device. Analyse the application value of the angioguard in CAS. Materials and Method A 67-year-old man with continuous vertigo was found having left carotid artery stenosis 95 per cent by B-ultrasound and carotid artery angiography. Another 64-year-old woman with dizziness repeatedly , anamnesis decline and left radial pulse disappearing for 5 years was found left carotid artery eccentric stenosis 70 per cent and left subclavian artery occlusion completely.This tow patients accepted CAS under brain protection and Angioguard was used. While, the woman was performed balloon-angiography pre-stenting. Result Two procedures were successfully accomplished and blood resumed. A plaque was gained after operation in Angioguard in the man case. Most symptoms vanished. No cerebral embolism occurred due to angiography when follow-up after 6 months. Conclusion Brain protection can catch athroslerolic plaque and minimize the rate of complication when CAS.
[Key words] Carotid stenosis stent ballon；Brain protection
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