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1、Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,顱內(nèi)外動脈狹窄的,介入治療,實施與培訓(xùn)的體會,劉新峰,南京軍區(qū)南京總醫(yī)院神經(jīng)科,南京大學(xué)神經(jīng)病學(xué)研究所,:/,What cannot be cured with medicaments is cured by knife,what knife cannot cure is cured with searing iron,and whatever this can
2、not cure must be considered incurable.,Hippocrates(460-370 BC)希波克拉底約公元前460-370,稱醫(yī)藥之父,Medicaments for Stroke,Anti-platelet agents,(proved by EBM),Thrombolysis,(proved by EBM),Anti-coagulation,(limited efficacy),Neuroprotection,(not proved by EBM),Herb medicine,(not proved by EBM),Knives for Stroke tr
3、eatment,Decompressive,craniotomy,(unacceptable complications),Carotid,endarterectomy,(limited indications),EC/IC bypass surgery,(it works,but does not help),Clamp the aneurysm,(limited to SAH),Do we have a searing iron?,Stent,Why should Neurologists be trained with endovascular techniques?,The futur
4、e of neurology will be focused in treatment,Lessens learned from cardiology,Endovascular techniques will become key issue in stroke treatment and prevention,The special status of stroke management in China,血管神經(jīng)病學(xué),:,神經(jīng)科新分支,How to train a Neuro-endovascular specialists(recommendations from academic so
5、cieties),The American Neurosurgery Association(ANA),When to do it,The American Heart Association(AHA),How long to do it,The American Academy of Neurology(AAN),How to insure maintenance of skills and knowledge,The American Association of Cycle of Science in Medicine,How to up-date,How to train a Neur
6、o-endovascular specialists(our experiences at Jinling Hospital),南京軍區(qū)總醫(yī)院神經(jīng)內(nèi)科如何進行神經(jīng)介入的培訓(xùn),2 years of clinical work in stroke management,with experience of diagnostic imaging,1 years of training on,neuro,-endovascular skills,at least finish 80 case of DSA before,stenting,病人選擇、標準化術(shù)前評詁、術(shù)中操作規(guī)程和標準化的術(shù)后跟蹤隨訪,C
7、ontents of training,Procedure training,pre-procedure evaluation,Indication and contraindication,risk reducing,management of complications,post-procedure management,follow-up,Contents of training,Endovascular skill training,Acupuncture,Cerebrovascular angiography,Carotid angioplasty(balloon dilation)
8、,Carotid stent implantation,Angioplasty and stenting in veterbrobasilar arteries,Pre-procedure Evaluations,Auscultation&Stethoscope,Carotid duplex,ultrasonography,Transcranial,Doppler,Computed,tomographic,angiography,(64-tier-CTA),Magnetic resonance angiography(MRA),Carotid angiography(the gold stan
9、dard),頸動脈支架術(shù)的適應(yīng)癥,American Heart Association Guidelines,Asymptomatic Patients,For treatment of 70%or greater,stenosis,Perioperative,stroke/death must be less than 3%,Symptomatic Patients,For treatment of 50%or greater,stenosis,Perioperative,stroke/death must be less than 6%,No proven indications beyo
10、nd these thresholds,顱內(nèi)動脈狹窄支架術(shù)的建議適應(yīng)癥,病癥性顱內(nèi)動脈狹窄50%病例，通過藥物治療無效，應(yīng)考慮行球囊血管成形術(shù)，同時實施或不實施支架置入術(shù),無病癥性顱內(nèi)動脈粥樣硬化性狹窄，首先應(yīng)給予最合理的最正確藥物預(yù)防，包括抗血小板聚集和/或他汀類藥物。監(jiān)測有無新的神經(jīng)病學(xué)病癥，間隔6-12月定期行無創(chuàng)性影像學(xué)檢查磁共振血管成像或CT血管成像，有必要的話再進行腦血管造影檢查,對于進展的患者再評詁介入治療的可行性,有必要繼續(xù)評價和改進藥物及介入治療，以降低顱內(nèi)動脈粥樣硬化相關(guān)的卒中,Technical Tips for CAS,our experience,Patient Se
11、lection,Medical,comorbidities,Arterial access issues,Aortic arch and carotid anatomy and pathology,Collateral Circulation,Difficult aortic arch,Arterial Tortuosity,Eccentric calcification with ulceration,Providing Information for Collateral Circulation,Catheter and Guidewire Maneuvers,Wipe all,guide
12、wires,and catheters liberally with heparin-saline,Do not withdraw,guidewire,too rapidly.This helps to avoid micro-bubbles,Do not administer flush or contrast if the catheter is not,backbleeding,because this may introduce air,Do not flush cerebral catheters with too much volume,Cs,=Contrast,without p
13、rotection;,Cc,=contrast with protection,F,=filter deployment;,B1,=pre-stent ballooning;,S,=stent deployment;,B2,=poststent,ballooning;,R,=retrieving of filter.,filter,Pre-Bo,stent,Post-Bo,c,ontrast,Predilation and Postdilation,Longer(but slender)balloons are used to avoid“melon seeding and the poten
14、tial release of embolic debris.,The balloon should be inflated only once and the inflation time varies depending on the lesion.,During predilation,aspirating blood from sheath can reduce the particulate debris into blood stream.,Shorter balloons are used for postdilation.Longer balloons may cause di
15、ssections in the distal internal carotid artery.,Stent Implantation,Type and size of stent should be chose with reference to artery pathology and anatomy characters.,Residual,stenosis,no more than 30%is accepted,as stents continue to expand with time.,If continued flow of contrast into an ulcer is s
16、een,no attempt should be made to obliterate it by using larger balloons or higher pressure.,Deploy stents across kinks only if they are isolated.Multiple kinks may be displaced distally and become more exaggerated.,Severe ICA Stenosis with pre-dilation,ICA,起始部狹窄合并同側(cè)顱內(nèi)動脈瘤,雙支架置入覆蓋夾層動脈瘤:張榮X-M-62y,腦堵塞,RICA-C1,C2段有兩處狹窄，近段夾層動脈瘤形成至C1近端80%狹窄,LICA起始部狹窄30%,多個串聯(lián)狹窄的支架植入,MCA-M-1 stenting:Hu GH-M-54y,L-MCA-M1 Stenting:Wei xx-F-70y,L-MCA-M2 stenting:Chen BY-F-75y,Pre-stent,Post-stent,PCA stenting,VA stenting,P
顱內(nèi)外動脈狹窄的介入治療
