双路途指导下血管内再通治疗颅内动脉非急性闭塞的单中心临床研究

doi:10.3969/j.issn.1673-5765.2022.03.007

摘要/Abstract

摘要：

目的通过回顾性单中心数据，探讨双路途指导下血管内再通治疗症状性颅内动脉非急性闭塞的安全性和可行性。

方法对2015年1月-2021年5月因症状性颅内动脉非急性闭塞于首都医科大学附属北京天坛医院神经介入中心住院治疗，双路途指导下完成血管内再通治疗的30例患者的临床资料进行回顾性分析。根据双路途采用的不同技术路径分为4型：Ⅰ型，椎动脉颅内段闭塞，对侧非优势椎动脉有前向血流，远端基底动脉显影，导引导管和造影导管分别置于双侧椎动脉；Ⅱ型，颈动脉颅内段闭塞，对侧颈内动脉通过前交通动脉代偿闭塞远端血管显影，导引导管和造影导管分别置于双侧颈内动脉；Ⅲ 型，基底动脉或椎动脉颅内段闭塞，一侧颈内动脉通过后交通动脉代偿椎基底动脉闭塞远端血管显影，导引导管和造影导管分别置于椎动脉和后交通动脉侧颈内动脉；Ⅳ型，颈内动脉颅内段闭塞，椎基底动脉通过后交通动脉代偿闭塞侧颈内动脉远端血管显影，导引导管和造影导管分别置于颈内动脉和椎动脉。主要观察指标包括再通成功率、术后30 d内并发症（主要包括缺血性卒中、出血性卒中、高灌注综合征、血管夹层等）发生率、30 d内卒中（包括出血性及缺血性卒中）发生率、手术相关死亡率、临床随访功能良好（mRS 0～1分）率和影像随访再狭窄/再闭塞发生率。

结果 30例患者再通成功率为93.3%（28/30）；术后30 d内并发症发生率为6.7%（2/30），其中1例为无症状性夹层，另1例为血管再通后高灌注出血；30 d内死亡发生率为3.3%（1/30）。中位临床随访时间34.00（20.48～105.54）个月，1例（3.6%，1/28）发生急性卒中后死亡，临床随访期间功能良好率与术前差异有统计学意义[75.0%（21/28） vs. 10.0%（3/30）；χ 2=25.205，P <0.001]；中位影像随访时间为17.92（8.00～92.13）个月，再狭窄率为21.1%（4/19）。

结论双路途指导下血管内再通治疗症状性颅内动脉非急性闭塞对于合理选择的患者是安全、可行的，双路途技术有利于提高再通成功率和降低手术操作风险。

文章导读： 本研究为前瞻性登记、回顾性分析研究，既往双路途技术开通颅内动脉非急性闭塞多以小样本病例报道为主，本研究可为后续颅内动脉非急性闭塞血管内治疗的多中心、前瞻性、对照研究探索技术操作规范及标准，并提供一定的数据支持。

关键词: 颅内动脉; 闭塞; 非急性期; 血管内再通; 双路途技术

Abstract:

Objective To explore the safety and feasibility of endovascular recanalization for symptomatic non-acute intracranial artery occlusion under the guidance of dual roadmap.

Methods This retrospective study included 30 patients who underwent endovascular recanalization for symptomatic non-acute artery occlusion under the guidance of dual roadmap at the Neurointervention Center of Beijing Tiantan Hospital from January 2015 to May 2021. The dualroadmap technical scheme included the following four types. Type Ⅰ: the dominant intracranial vertebral artery was occluded and the basilar artery could be visualized through the contralateral non-dominant vertebral artery. The guide catheter and angiography catheter were placed in bilateral vertebral arteries. Type Ⅱ: the intracranial carotid artery was occluded, and the distal vessels of the occluded segment could be visualized through anterior communicating artery. The guide catheter and angiography catheter were placed in the bilateral internal carotid arteries. Type Ⅲ: the basilar artery or intracranial vertebral artery were occluded, and the distal vessels of the occluded segment could be visualized through posterior communicating artery. The guide catheter and angiography catheter were placed in vertebral artery and internal carotid artery. Type Ⅳ: the intracranial carotid artery was occluded, and the distal vessels of the occluded segment could be visualized through posterior communicating artery. The guide catheter and angiography catheter were placed in internal carotid artery and vertebral artery. The main outcome included technical success rate, the rate of complications (ischemic stroke, hemorrhagic stroke, hyperperfusion syndrome and vascular dissection) within 30 days after the procedure, any stroke within 30 days (including ischemic and hemorrhagic stroke), surgical mortality, good functional prognosis (mRS 0-1) during follow-up, restenosis/ re-occlusion rate during imaging follow-up.

Results The technical success rate was 93.3% (28/30), the complications rate within 30 days was 6.7% (2/30), and any death within 30 days is 3.3% (1/30). The clinical follow-up time was 34.00 (IQR: 20.48-105.54) months, one patient (3.6%) died from acute stroke during the follow-up, and the rate of good functional prognosis during the follow-up was higher than that before procedure [75.0% (21/28) vs .10.0% (3/30); χ 2=25.205, P <0.001]; the imaging follow-up time was 17.92 (IQR: 8.00-92.13) months, and the restenosis rate was 21.1% (4/19).

Conclusions Endovascular recanalization for symptomatic non-acute intracranial artery occlusion under the guidance of dual roadmap is safe and feasible, which can reduce the risk of operation and improve the successful recanalization rate.

Key words: Intracranial artery; Occlusion; Non-acute; Endovascular recanalization; Dual roadmap

韩建佳, 高原, 高峰. 双路途指导下血管内再通治疗颅内动脉非急性闭塞的单中心临床研究[J]. 中国卒中杂志, 2022, 17(03): 258-264.

HAN Jianjia, GAO Yuan, GAO Feng. Clinical Observation of Endovascular Recanalization for Symptomatic Non-Acute Intracranial Artery Occlusion under Dual Roadmap Guidance[J]. Chinese Journal of Stroke, 2022, 17(03): 258-264.

参考文献

[1] YAMAUCHI H，HIGASHI T，KAGAWA S，et al. Chronic hemodynamic compromise and cerebral ischemic event s in asymptomatic or remote symptomatic largeartery intracranial occlusive disease[J]. AJNR Am J Neuroradiol，2013，34（9）：1704-1710.
[2] SHIN H S，RYU C W，KO H C，et al. Clinical manifestations of isolated chronic middle cerebral artery occlusion in relation to angiographic features[J/OL]. World Neurosurg，2017，108：303-309[2021-10-06]. https://doi.org/10.1016/j.wneu.2017.09.003.
[3] WANG Y J，ZHAO X Q，LIU L P，et al．Prevalence and outcomes of symptomatic intracranial large artery stenoses and occlusions in China：the Chinese intracranial atherosclerosis（CICAS）study[J]. Stroke，2014，45（3）：663-669.
[4] GAO F，GUO X，SUN X，et al. Dual-roadmap guidance for endovascular recanalization of medically refractory non-acute intracranial arterial occlusions：consecutive multicenter series and technical review[J]. J Neurointerv Surg，2021，13（10）：889-893.
[5] MARSHALL R S，FESTA J R，CHEUNG Y K，et al. Randomized evaluation of carotid occlusion and neurocognition（RECON）trial：main results[J]. Neurology，2014，82（9）：744-751.
[6] LIN M S，CHIU M J，WU Y W，et al. Neurocognitive improvement after carotid artery stenting in patients with chronic internal carotid artery occlusion and cerebral ischemia[J]. Stroke，2011，42（10）：2850-2854.
[7] HE Y K，BAI W X，LI T X，et al. Perioperative complications of recanalization and stenting for symptomatic nonacute vertebrobasilar artery occlusion[J]. Ann Vasc Surg，2014，28（2）：386-393.
[8] MA N，MO D P，GAO F，et al. Endovascular recanalization for chronic symptomatic middle cerebral artery total occlusion[J/OL]. J Neurointerv Surg，2013，5（3）：e15[2021-10-06]. http：//dx.doi.org/10.1136/neurintsurg-2012-010304.

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