颈动脉支架置入术PPT课件.ppt

.,1,颈动脉支架置入术,.,2,SAPPHIRE研究,CEA高危患者保护装置下支架置入与血管成形试验（stentingandangioplastywithprotectioninpatientathighrishforendarterectomy,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,.,3,介入器材,ANGIOGUARD血栓保护装置,CordisPRECISE支架,.,4,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310(12month)Stenting支架组=159/CEA=151,STENTREGISTRY支架注册407,SURGICALREFUSAL外科拒绝,SURGICALREGISTRY外科注册7,INTERVENTIONALREFUSAL介入拒绝,医生小组：神经科医生，外科医生，介入科医生,TheSAPPHIRETrial,.,5,SAPPHIRE(high-riskpatients)30daysand12monthsresults,SAPPHIRE(high-riskpatients)30daysand12monthresults,“Stentedpatientsarenow12monthsoutfromtreatment,andtheirMAEratecontinuetobeasgoodas,andinmanywaysbetterthan,thoseforthesurgicallytreatedgroup.”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。,.,6,12monthResults:CASvs.CEA,OverallMAErate总体主要不良事件发生率11.9%vs.19.9%:difference显著差异,p=0.06Deathrate死亡率6.9%vs.12.6%:doublenumberofpatientsdiedintheCEAarm外科组死亡人数比支架组多一倍Strokerate中风发生率5.7%vs.7.3%:30%morepatientsexperiencedastrokeintheCEAarm外科组至少发生一次中风的病人数比支架组多30%MajorIpsilateralStrokerate主要同侧大中风发生率0.0%vs.3.3%wassignificanthigherinCEA外科组显著高于支架组，p=0.03MI(QornonQ)rate心梗发生率2.5%vs.7.9%:patientsgot3timesmoreMIintheCEAarm外科组发生心梗的病人数比支架组多三倍以上Outcomeofcranialnerveinjury(30days)30天内颅神经损伤的发生率0.0%vs.5.3%:wassignificantforCEAarm外科组显著高于支架组，p0.01,.,7,结论,.,8,ISC2010-CREST,.,9,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,.,10,患者分组和基本情况,10,.,11,主要终点（卒中、心梗、围手术期死亡加同侧卒中）,HR=1.1195%CI0.81-1.51P=0.51,.,12,.,13,主要终点:围手术期事件（死亡、卒中、心梗）,HR=1.1895%CI0.82-1.68P=0.38,.,14,围手术期卒中,卒中HR=1.7995%CI1.14-2.82P=0.01,心梗HR=1.3595%CI0.54-3.36P=0.52,.,15,围手术期颅神经麻痹,HR=0.0795%CI0.02-0.18P0.0001,.,16,同侧卒中,HR=0.9495%CI0.50-1.76P=0.85,.,17,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,.,18,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,.,19,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,.,20,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,.,21,.,22,.,23,.,24,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%）,.,25,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（50100U/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,.,26,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AguardDeployMovPic.mpg,.,27,脑保护装置,.,28,.,29,脑保护装置,.,30,支架类型,球扩式支架PalmazStent(Cordis)自膨式支架CarotidWallstent(BostonScientific)PRECISE(Cordis)Protg(ev3)Acculink(Abbott）,.,31,自膨式支架,雕刻支架编织支架,.,32,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,.,33,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,.,34,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,.,35,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1mm目标血管：CCA支架长度：两端至少超过狭窄0.51cm，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1cm在颈总动脉,.,36,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,.,37,颈动脉支架置入术,.,38,颈动脉支架置入术,.,39,.,40,.,41,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,.,42,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,Terumoguidewire0.035”100cm,Headhunter5FTempo200cm,INTRODUCEGUIDEWIREANDINTRODUCERSHEATH,.,43,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,Terumoguidewire0.035”100cm,Headhunter5FTempo200cm,INTRODUCEGUIDEWIREANDINTRODUCERSHEATH,.,44,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,SELECTIVECATHETHETERISATIONOFECA,Terumoguidewire0.035”100cm,Headhunter5FTempo200cm,.,45,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,Headhunter5FTempo200cm,EXCHANGEGUIDEWIRE,Terumoguidewire0.035”100cm,.,46,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,Headhunter5FTempo200cm,EXCHANGEGUIDEWIRE,.,47,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,Headhunter5FTempo200cm,EXCHANGEGUIDEWIRE,AmplatzEmerald0.035”260cm,.,48,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,AmplatzEmerald0.035”260cm,EXCHANGEINTRODUCERSHEATH,.,49,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,AmplatzEmerald0.035”260cm,BriteTipSheath7F80cm,EXCHANGEINTRODUCERSHEATH,.,50,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,REMOVEGUIDEWIRE,.,51,CarotidArteryDisease:CarotidAngioplasty-ProcedureHints,Atthisstage:NevercrossthelesionintheICA,.,52,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,INTRODUCEPROTECTIONDEVICE,.,53,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,Angioguard0.014”300cm,BriteTipSheath7F80cm,INTRODUCEPROTECTIONDEVICE,.,54,AngioguardDevice:DeliverySheathCoveringFilter,.,55,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,CROSSLESIONWITHPROTECTIONDEVICE,Angioguard0.014”300cm,.,56,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,CROSSLESIONWITHPROTECTIONDEVICE,Angioguard0.014”300cm,.,57,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,DEPLOYMENTPROTECTIONDEVICE,BriteTipSheath7F80cm,Angioguard0.014”300cm,.,58,AngioguardDevice:FilterDeployed,.,59,CarotidArteryDisease:CarotidAngioplasty-ProcedureHints,Holdtheprotectiondevicealwaysinthescreen,NOTinsidethebrain(bleedings),.,60,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,STENTDEPLOYMENT,SmartCarotidstent7-8mm30-40mm,BriteTipSheath7F80cm,Angioguard0.014”300cm,.,61,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,SmartCarotidstent7-8mm30-40mm,STENTDEPLOYMENT,Angioguard0.014”300cm,.,62,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,SmartCarotidstent7-8mm30-40mm,ANGIOGRAPHICCONTROL,Angioguard0.014”300cm,.,63,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,SmartCarotidstent7-8mm30-40mm,ANGIOGRAPHICCONTROL,Angioguard0.014”300cm,.,64,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,Savvyballoon5-6mm30-40mm,BriteTipSheath7F80cm,SmartCarotidstent7-8mm30-40mm,POSTDILATATION,Angioguard0.014”300cm,.,65,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,SmartCarotidstent7-8mm30-40mm,POSTDILATATION,Angioguard0.014”300cm,Savvyballoon5-6mm30-40mm,.,66,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,SmartCarotidstent7-8mm30-40mm,ANGIOGRAPHICCONTROL,Angioguard0.014”300cm,.,67,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,BriteTipSheath7F80cm,SmartCarotidstent7-8mm30-40mm,ANGIOGRAPHICCONTROL,Angioguard0.014”300cm,.,68,ExternalCarotidArtery,InternalCarotidArtery,CommonCarotidArtery,RETRIEVALPROTECTIONDEVICE,BriteTipSheath7F80cm,SmartCarotidstent7-8mm30-40mm,Angioguard0.014”300cm,.,69,Ext