颅内外动脉狭窄的介入治疗课件

Whatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.

Hippocrates(460-370BC)希波克拉底（约公元前460-370,称医药之父）Whatcannotbecuredwith1MedicamentsforStrokeAnti-plateletagents(provedbyEBM)Thrombolysis(provedbyEBM)Anti-coagulation(limitedefficacy)Neuroprotection(notprovedbyEBM)Herbmedicine(notprovedbyEBM)MedicamentsforStrokeAnti-pla2KnivesforStroketreatmentDecompressivecraniotomy(unacceptablecomplications)Carotidendarterectomy(limitedindications)

EC/ICbypasssurgery(itworks,butdoesnothelp)

Clamptheaneurysm(limitedtoSAH)KnivesforStroketreatmentDec3Dowehaveasearingiron?StentDowehaveasearingiron?St4WhyshouldNeurologistsbetrainedwithendovasculartechniques?ThefutureofneurologywillbefocusedintreatmentLessenslearnedfromcardiologyEndovasculartechniqueswillbecomekeyissueinstroketreatmentandpreventionThespecialstatusofstrokemanagementinChinaWhyshouldNeurologistsbetra5血管神经病学:神经科新分支血管神经病学:神经科新分支6HowtotrainaNeuro-endovascularspecialists(recommendationsfromacademicsocieties)TheAmericanNeurosurgeryAssociation(ANA) WhentodoitTheAmericanHeartAssociation(AHA) HowlongtodoitTheAmericanAcademyofNeurology(AAN) HowtoinsuremaintenanceofskillsandknowledgeTheAmericanAssociationofCycleofScienceinMedicine Howtoup-dateHowtotrainaNeuro-endovascu7Anti-coagulation(limitedefficacy)L-MCA-M2stenting:

ChenBY-F-75yAngioplastyandstentinginveterbrobasilararteries病人选择、标准化术前评诂、术中操作规程和标准化的术后跟踪随访ComputedtomographicangiographyThishelpstoavoidmicro-bubblesCarotidendarterectomy(limitedindications)Wingspan支架后(3.Typeandsizeofstentshouldbechosewithreferencetoarterypathologyandanatomycharacters.有必要继续评价和改进药物及介入治疗，以降低颅内动脉粥样硬化相关的卒中AsymptomaticPatientspre-procedureevaluationICA起始部狭窄合并同侧颅内动脉瘤Wingspan颅内专用支架:

MaoYQ-M-73yArterialaccessissues监测有无新的神经病学症状，间隔6-12月定期行无创性影像学检查（磁共振血管成像或CT血管成像），有必要的话再进行脑血管造影检查,对于进展的患者再评诂介入治疗的可行性Nomajorco-morbidityAorticarchandcarotidanatomyandpathologyArterialTortuosityContentsoftrainingHowtotrainaNeuro-endovascularspecialists(ourexperiencesatJinlingHospital)南京军区总医院神经内科如何进行神经介入的培训

2yearsofclinicalworkinstrokemanagementwithexperienceofdiagnosticimaging1yearsoftrainingonneuro-endovascularskills,atleastfinish80caseofDSAbeforestenting病人选择、标准化术前评诂、术中操作规程和标准化的术后跟踪随访Anti-coagulation(limitedeffi8ContentsoftrainingProceduretraining

pre-procedureevaluationIndicationandcontraindicationriskreducingmanagementofcomplicationspost-proceduremanagementfollow-upContentsoftrainingProcedure9ContentsoftrainingEndovascularskilltrainingAcupunctureCerebrovascularangiographyCarotidangioplasty(balloondilation)CarotidstentimplantationAngioplastyandstentinginveterbrobasilararteriesContentsoftrainingEndovascul10Pre-procedureEvaluations

Auscultation&StethoscopeCarotidduplexultrasonographyTranscranialDoppler

Computedtomographicangiography(64-tier-CTA)Magneticresonanceangiography(MRA)Carotidangiography(thegoldstandard)Pre-procedureEvaluationsAusc11颈动脉支架术的适应症AmericanHeartAssociationGuidelinesAsymptomaticPatientsFortreatmentof70%orgreaterstenosisPerioperativestroke/deathmustbelessthan3%SymptomaticPatientsFortreatmentof50%orgreaterstenosisPerioperativestroke/deathmustbelessthan6%Noprovenindicationsbeyondthesethresholds颈动脉支架术的适应症AmericanHeartAssoc12颅内动脉狭窄支架术的建议适应症症状性颅内动脉狭窄>50%病例，通过药物治疗无效，应考虑行球囊血管成形术，同时实施或不实施支架置入术无症状性颅内动脉粥样硬化性狭窄，首先应给予最合理的最佳药物预防，包括抗血小板聚集和/或他汀类药物。监测有无新的神经病学症状，间隔6-12月定期行无创性影像学检查（磁共振血管成像或CT血管成像），有必要的话再进行脑血管造影检查,对于进展的患者再评诂介入治疗的可行性有必要继续评价和改进药物及介入治疗，以降低颅内动脉粥样硬化相关的卒中颅内动脉狭窄支架术的建议适应症13TechnicalTipsforCAS

ourexperienceTechnicalTipsforCAS

ourexp14PatientSelection

MedicalcomorbiditiesArterialaccessissuesAorticarchandcarotidanatomyandpathologyCollateralCirculationPatientSelectionMedicalcomo15DifficultaorticarchDifficultaorticarch16ArterialTortuosityArterialTortuosity17EccentriccalcificationwithulcerationEccentriccalcificationwithu18CarotidduplexultrasonographyLearningcurve~80casesProvidingInformationforCollateralCirculationAngioplastyandstentinginveterbrobasilararteriesAngioplastyandstentinginveterbrobasilararteriesWingspan支架后(3.WhyshouldNeurologistsbetrainedwithendovasculartechniques?withexperienceofdiagnosticimagingWhatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.Carotidendarterectomy(limitedindications)Nomajorco-morbidity监测有无新的神经病学症状，间隔6-12月定期行无创性影像学检查（磁共振血管成像或CT血管成像），有必要的话再进行脑血管造影检查,对于进展的患者再评诂介入治疗的可行性Typeandsizeofstentshouldbechosewithreferencetoarterypathologyandanatomycharacters.NoprovenindicationsbeyondthesethresholdsAsymptomaticPatientsWhatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.MedicalcomorbiditiesTheAmericanHeartAssociation(AHA)CollateralCirculationwithexperienceofdiagnosticimagingWingspan支架后(3.ProvidingInformationforCollateralCirculationCarotidduplexultrasonography19CatheterandGuidewireManeuversWipeallguidewiresandcathetersliberallywithheparin-salineDonotwithdrawguidewiretoorapidly.Thishelpstoavoidmicro-bubblesDonotadministerflushorcontrastifthecatheterisnotbackbleedingbecausethismayintroduceairDonotflushcerebralcatheterswithtoomuchvolumeCatheterandGuidewireManeuve20Cs=Contrastwithoutprotection;Cc=contrastwithprotectionF=filterdeployment;B1=pre-stentballooning;S=stentdeployment;B2=poststentballooning;R=retrievingoffilter.Cs=Contrast21filterPre-BostentPost-BocontrastfilterPre-BostentPost-Bocontra22PredilationandPostdilationLonger(butslender)balloonsareusedtoavoid“melonseeding”andthepotentialreleaseofembolicdebris.Theballoonshouldbeinflatedonlyonceandtheinflationtimevariesdependingonthelesion.Duringpredilation,aspiratingbloodfromsheathcanreducetheparticulatedebrisintobloodstream.Shorterballoonsareusedforpostdilation.Longerballoonsmaycausedissectionsinthedistalinternalcarotidartery.PredilationandPostdilationLo23StentImplantationTypeandsizeofstentshouldbechosewithreferencetoarterypathologyandanatomycharacters.Residualstenosisnomorethan30%isaccepted,asstentscontinuetoexpandwithtime.Ifcontinuedflowofcontrastintoanulcerisseen,noattemptshouldbemadetoobliterateitbyusinglargerballoonsorhigherpressure.Deploystentsacrosskinksonlyiftheyareisolated.Multiplekinksmaybedisplaceddistallyandbecomemoreexaggerated.StentImplantationTypeandsiz24SevereICAStenosiswithpre-dilationSevereICAStenosiswithpre-d25ICA起始部狭窄合并同侧颅内动脉瘤ICA起始部狭窄合并同侧颅内动脉瘤26双支架置入覆盖夹层动脉瘤:张荣X-M-62y,脑梗塞,RICA-C1,C2段有两处狭窄，近段夹层动脉瘤形成至C1近端80%狭窄,LICA起始部狭窄30%双支架置入覆盖夹层动脉瘤:张荣X-M-62y,脑梗塞,27多个串联狭窄的支架植入多个串联狭窄的支架植入28L-MCA-M2stenting:

ChenBY-F-75y病人选择、标准化术前评诂、术中操作规程和标准化的术后跟踪随访ContentsoftrainingArterialTortuosityPatientSelection颅内动脉狭窄支架术的建议适应症Longerballoonsmaycausedissectionsinthedistalinternalcarotidartery.TranscranialDopplerDowehaveasearingiron?StentWhatcannotbecuredwithmedicamentsiscuredbyknife,whatknifecannotcureiscuredwithsearingiron,andwhateverthiscannotcuremustbeconsideredincurable.Clamptheaneurysm(limitedtoSAH)CollateralCirculation双支架置入覆盖夹层动脉瘤:张荣X-M-62y,脑梗塞,RICA-C1,C2段有两处狭窄，近段夹层动脉瘤形成至C1近端80%狭窄,LICA起始部狭窄30%AngioplastyandstentinginveterbrobasilararteriesDecompressivecraniotomy(unacceptablecomplications)withexperienceofdiagnosticimagingHowlongtodoitAsymptomaticPatientsIndicationandcontraindicationIndicationandcontraindication症状性颅内动脉狭窄>50%病例，通过药物治疗无效，应考虑行球囊血管成形术，同时实施或不实施支架置入术EccentriccalcificationwithulcerationArterialTortuosity2yearsofclinicalworkinstrokemanagementContentsoftrainingDowehaveasearingiron?StentAsymptomaticPatientsTranscranialDopplerL-MCA-M2stenting:

ChenBY-F-75yballooning;PCAstentingDifficultaorticarchDonotflushcerebralcatheterswithtoomuchvolumeMedicamentsforStrokeIt’snotaseasyasitlookspre-procedureevaluationIfcontinuedflowofcontrastintoanulcerisseen,noattemptshouldbemadetoobliterateitbyusinglargerballoonsorhigherpressure.AsymptomaticPatientsLongerballoonsmaycausedissectionsinthedistalinternalcarotidartery.ComputedtomographicangiographyThespecialstatusofstrokemanagementinChinaWingspan支架后(3.MCA-M-1stenting:HuGH-M-54yL-MCA-M2stenting:

ChenBY-F-729L-MCA-M1Stenting:Weixx-F-70yL-MCA-M1Stenting:Weixx-F-7030L-MCA-M2stenting:

ChenBY-F-75yPre-stentPost-stentL-MCA-M2stenting:

ChenBY-F-731PCAstentingPCAstenting32VAstentingVAstenting33Post-stentingBAStentingPost-stentingBAStenting34BAstenosis:评价血液动力学+球扩BAstenosis:评价血液动力学+球扩35Wingspan颅内专用支架:

MaoYQ-M-73yGateway(2.5/9mm)预扩

Wingspan支架后(3.5/9mm)

RICA-C6段85%狭窄Wingspan颅内专用支架:

MaoYQ-M-73yGa36Wingspanstenting:ZhouBY-F-71yR-ICA-C7段70%狭窄Gateway球囊(2.5/9mm)预扩

Wingspan支架后(3.5/15mm)Wingspanstenting:ZhouBY-F-737WingspanforMCA-M2WingspanforMCA-M238FurtherMessagesGettrainedIt’snotaseasyasitlooksLearningcurve~80casesStartwitheasycasesUnilateralstenosisNomajorco-morbidityEnsurehighstandardofpost-procedurecareICUTransienthypotension/hypertensionFurtherMessagesGettrained39欢迎参会!谢谢参与!

欢迎参会!谢谢参与!40KnivesforStroketreatmentDecompressivecraniotomy(unacceptablecomplications)Carotidendarterectomy(limitedindications)

EC/ICbypasssurgery(itworks,butdoesnothelp)

Clamptheaneurysm(limitedtoSAH)KnivesforStroketreatmentDec41Dowehaveasearingiron?StentDowehaveasearingiron?St42血管神经病学:神经科新分支血管神经病学:神经科新分支43Wingspan支架后(3.Clamptheaneurysm(limitedtoSAH)Wingspan颅内专用支架:

MaoYQ-M-73yEndovascularskilltrainingNeuroprotection(notprovedbyEBM)Theballoonshouldbeinflatedonlyonceandtheinflationtimevariesdependingonthelesion.Clamptheaneurysm(limitedtoSAH)Howtoup-dateRICA-C6段85%狭窄AngioplastyandstentinginveterbrobasilararteriesContentsoftrainingAnti-plateletagents(provedbyEBM)ContentsoftrainingPCAstentingR=retrievingoffilter.Herbmedicine(notprovedbyEBM)DifficultaorticarchAmericanHeartAssociationGuidelinesLonger(butslender)balloonsareusedtoavoid“melonseeding”andthepotentialreleaseofembolicdebris.HowtotrainaNeuro-endovascularspecialists(ourexperiencesatJinlingHospital)南京军区总医院神经内科如何进行神经介入的培训Shorterballoonsareusedforpostdilation.有必要继续评价和改进药物及介入治疗，以降低颅内动脉粥样硬化相关的卒中PatientSelection

Medicalcomorbidities