椎动脉起始部狭窄血管内介入治疗中国专家共识（2024版）

椎动脉起始部狭窄血管内介入治疗中国专家共识(2024版)椎动脉起始部狭窄(vertebralarteryo(二)文献检索(三)推荐等级设置5个选项：(1)强推荐；(2)弱推荐；(3)无明确推荐意见；(4)弱不推荐；(5)强不推荐。通过统计投票结果中不同选项及组合的投票比例，将推荐等级分为I、Ⅱ、Ⅲ、IV级，具体代表意义见表1。I级(一致推荐或一致不推荐)投票100%一致，所有专家完全达成共识Ⅱ级(强推荐或强不推荐)投票75%~99%一致，绝大多数专家达成共识Ⅲ级(弱推荐或弱不推荐)投票50%~74%一致，多数专家达成共识，但少数专家存在分歧IV级(专家未达成一致性结论)(一)椎动脉的解剖结构椎动脉一般起自锁骨下动脉中段，向上经第6至第1颈椎的横突孔，再向后方穿过枕下三角，然后通过枕骨大孔进入颅内；双侧椎动脉汇合形成基底动脉。椎动脉在解剖学上分为四段，分别为颈段(V1段)、椎间段(V2段)、枕段(V3段)和颅内段(V4段)[5]。人群中约11%存在椎动脉发育不良，包括椎动脉纤细、椎动脉仅供血至小脑后下动脉、椎动脉缺如等[6-7,3]。研究表明，存在主要来自后交通动脉，其次为颈外动脉系统中枕动脉-咽升动脉之间的吻合、肋 为：轻度狭窄(狭窄率≤为49%)、中度狭窄(狭窄率为50%~69%)和重度狭窄 (狭窄率为70%~99%)。(一)临床表现(二)辅助检查(一)药物治疗聚集治疗3~6个月后改用单一抗血小板聚集治疗(推荐等级：Ⅱ级)。(2)合后6个月停用抗血小板聚集药(推荐等级：Ⅱ级)。(二)血运重建4.6年随访中年脑卒中风险为0.4%,高于无椎动脉狭窄人群(年脑卒中风险<0.等);(2)后交通动脉缺如或Willis环代偿不良；(3)前循环血管重度狭窄纯药物球囊扩张的VA0S患者术后再狭窄率为11.9%[50]。虽然与裸球囊相比，窄设计的支架，临床主要使用冠脉或外周支架等[38]。最常用的两种用于VAOS裂风险。研究报道表明，球囊扩张支架治疗VAOS再狭窄率为10%~67%,支架断裂率为4%~25%[52-54]。也有研究报道应用开环设计的颈动脉自膨胀支架治疗局部钙化明显、血管直径大或血管走行扭曲的VAOS,结果表明，对于椎动脉内径>4.5mm且锁骨下动脉直径<10mm的VAOS,开环颈动脉自膨胀支架置入手术成功率100%,术后3~34个月随访的血管再狭窄率为3.1%,且无支架断裂[55]。98%,30d神经功能预后良好率为80%;并发症发生率为9.1%,主要为动脉夹层病变且长度较短的支架为宜(推荐等级：Ⅱ级)。(2)桡动脉入路穿刺成功置管后，可给予血管舒张剂减少血管痉挛(推荐等级：Ⅱ级)。(3)支架植入术限，建议继续口服药物治疗，定期复查血管超声或CTA;若血流受限，建议行血管内介入治疗或外科手术治疗(推荐等级：Ⅱ级)。6.外科手术：VAOS的外科手术包括椎动脉内膜剥脱术、椎动脉转位术、椎动脉搭桥术、复合手术等。研究表明，外科手术对VAOS症状改善率高，血管长Ma等[73]、Choi等[74]分别报道了应用复合手术方法入治疗的同质化水平，从而为开展全国性VAOS治疗登记研究及多中心随机对照[1]SchneiderV,DirschingerR,WustrowI,etal.Endovasculartherapryorigin[J].Vasa,2020,49(3):205-213.DOI:10.1024/03culationregistry[J].ArchNeurol,1998,55(4):470-478.DOI:10.100[3]XingPF,ZhangYW,LiZF,etal.The"distayforthetreatmentofposteriorcirculationtandemocclusions:asingle-centreexperience[J].Neuroradiology,2020vedisease[J].ClinNeuroradiol,2019,29(3):435-443.DOI:10.1007/ritingGroup,BranchofVascularDiseasesandHyperteCare.Chineseexpertconsensusonthemanagementofsubclavian/extracranialvertebralarteryste[6]Valenzuela-FuenzalidaJJ,Rojas-Navlinicalimplications:asystematicreviewandMeta-analysence[J].SurgRadiolAnat,2024,46(7):963-975.DOI:10.1007/s00276-hypoplasia[J].JUltrasoundMed,2019,38(11):3037-30422/jum.15011.[8]VilimasA,GaigalaiteV,UrbonasM,etal.AssociationofveMedicina(Kaunas),2022,58(9):1189.DOI:10.3390/medicina58091189.ischemicstroke[J].Medicine(Baltimore),2021,100(38):e2[10]DharmasarojaPA,UransilpN,PiyabhanP.Fetaloriginofposteriorcerebralarteryrelatischemicstroke[J].JClin6/j.jocn.2019.07.006.60/112137-20210325-00743.BianY,MiaoY,WangKYocclusion[J].NatlMedJChina,2021,10160/112137-20210325-00743.[12]BurleVS,PanjwaniAnosis:anarrativereview[J].Cure59/cureus.28068.[13]MadonisSM,JeovascDis,2021,65:55-59.DOI:10.1016/j.pcad.2021.02.006.[14]PaikJJ,LubinG,Gromattorsindermatomyositis:asystematicRheumatol,2023,41(2):348-358.DOI:10.55563/clinexprheu[15]GoetzLH,SchorkNJ.Personalizedmedicine:motivation,challenges,andprogress[J].FertilSteril,2018,109(6):952-963.DOI:10.10[16]RadakD,BabicS,SagicD,etal.Endovasculartreatment0(1):92-97.DOI:10.1016/j.jvs.2014.01.023.[17]JenkinsJS,StewartM.Endovasculartreatmentystenosis[J].ProgCardiovascDis,2017,59(6):619-625.DOI:10[18]DrazykAM,MarkusHS.Recentadvancesintomaticvertebralarterystenosis[J].CurrOpinNeurol,2018,31(1):1-7.DOI:10.1097/WC0.0000000000000515.[19]ZhangJ,XingY,CuiL.Duplexultrasonognofextracranialvertebralartery:aitalsubtractionangiography[J].FrontNeurol,2022,13:814972.DOystRev,2022,5(5):CD013692.DOI:10.1002/14651858.CD013692.pub2.ofatherosclerosis:currentviewandfuinmodificationtreatment[J].I:10.1007/s12471-017-0959-2.[22]NaylorAR,RiccoJB,deBorstery(ESVS)[J].EurJVascEndovascmentofvertebralarteryorigins[J].JNeuroimaging,2020,30(1):449.DOI:10.1111/jon.12674.anceimagingrevealshiddenetiologiesofsymptomaticvertebralarteriallesions[J].JStrok10.1016/j.jstrokecerebrovasdis.2013.02.021. uraloptimization[J].TrendsCardiovascMed,565-575.DOI:10.3969/j.issn.1673-5765.2013.07.012.ExpertConsensusGrouponStatinDrugsfrthepreventionandtreatmentofischemicstroke/transientischemicattack[J].ChinJStroke,203604437596643097851527missionStrokePreventionandContro015)./upload/file/20160718(2016年修订版)[J].中国循环杂志，2016,31(10):937-950.DOI:10.3969/j.issn.1000-3614.2016.10.001.JointCommitteeforRevisionofChineseGuidelinesforPreventidelinesfortheprevChineseadults(Revisedin2016)[J].ChinJCircul,2016,31(用专家共识[J].中国卒中杂志，2019,14(10):1034-1044.DOI:10.3969/j. issn.1673-5765.2019.10.013.ChinesonalNeuroradiologySocietyofChineseStrokenicalapplicationoftsn.1673-5765.2019.10.013.tithromboticsinneurointerventionalprocedures:Guidelineupdate[J]. 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