Solitaire支架半释放保护技术治疗急性颈内动脉串联闭塞患者的效果分析

目的探讨使用Solitaire支架半释放保护(SHARP)技术逆行处理串联闭塞的安全性和疗效。方法回顾性连续纳入2017年1月至2019年3月陆军特色医学中心神经内科接受血管内治疗的14例急性缺血性卒中颈内动脉串联闭塞患者的临床及影像学资料,且均使用SHARP技术。采用急性卒中Org 10172治疗试验(TOAST)病因分型:大动脉粥样硬化型、心源性栓塞型、小血管病变型、其他病因型和不明原因型。先将导引导管及中间导管挤过近端闭塞处进行颅内血管闭塞段支架取栓,然后使用SHARP技术,将SolitaireAB支架半释放至颈内动脉,起到类似于远端栓塞保护装置的作用,再将导管退至颈总动脉,经血管造影确认是否存在远端栓塞,同时根据造影评估结果选择近端取栓或支架置入。若造影显示前向血流无法维持或残余狭窄过重,则行颈动脉支架置入术。术后成功再通定义为脑梗死溶栓(TICI)分级达2b级或3级。术后即刻及术后(24±6)h复查头部平扫CT评估不良事件,包括术中并发症(血管痉挛、远端栓塞事件)、与SHARP技术相关并发症支架半释放后和(或)导引导管后退至颈内动脉狭窄近端时,经DSA证实出现了远端栓塞事件]、出血转化(出血性梗死Ⅰ型、出血性梗死Ⅱ型、脑实质出血Ⅰ型、脑实质出血Ⅱ型)、蛛网膜下腔出血、症状性颅内出血。术后7 d或出院时美国国立卫生研究院卒中量表(NIHSS)评分较入院时至少降低4分为神经功能改善。以90 d随访记录评价临床预后,以改良Rankin量表(mRS)评分≤2分为神经功能独立,mRS评分>2分为预后不良,其中6分为死亡。结果14例串联闭塞患者均为颈内动脉起始部闭塞,有8例合并颈内动脉终末闭塞(C7段闭塞),6例合并大脑中动脉M1段闭塞;病因分型以大动脉粥样硬化型9例,心源性栓塞型3例,动脉夹层2例。14例患者均成功再通,达TICI分级2b级或3级;穿刺至再通的平均时间为(63±6)min;4例患者再通后因前向血流无法维持而行颈内动脉支架置入术(大动脉粥样硬化型3例,动脉夹层1例)。未发生SHARP技术相关并发症(远端栓塞事件)。14例患者中,术后发生脑实质出血1例、出血性梗死3例、蛛网膜下腔出血1例,无症状性颅内出血。术后90 d随访,1例因神经功能恶化死亡,10例患者达神经功能独立(mRS评分≤2分),3例预后不良。结论对急性缺血性卒中串联闭塞患者使用SHARP技术逆行处理的初步分析显示,该技术可减少操作步骤,使手术时间缩短,一定程度上减少了急性期支架置入。但该项技术的安全性及有效性仍需进一步验证。

Effect analysis of Solitaire stent-retriever half-release protection technique in endovascular therapy for acute tandem occlusion of internal carotid artery

Objective To explore the safety and feasibility of retrograde treatment with Solitaire stent-retriever half-release protection(SHARP)technique in tandem occlusion.Methods From January 2017 to March 2019,clinical and imaging data of 14 patients with acute internal carotid artery(ICA)tandem occlusion and treated with SHARP technique in Army Medical Center were collected retrospectively.Stroke etiology was established as per the trial of Org 10172 in acute stroke treatment(TOAST)criteria:large-artery atherosclerosis,cardioembolism,small-vessel occlusion,stroke of other determined/undetermined etiology.Firstly,in these cases,the guiding catheter and the intermediate catheter were squeezed through the proximal occlusion for thrombectomy of intracranial vascular occlusion.Then using SHARP technique,the Solitaire AB was half-released into the ICA,which played a role similar to the distal embolic protection device.The catheter was retreated to the common carotid artery for angiography to evaluate distal embolism,and then proximal thrombectomy or stent implantation was determined according to angiography.Carotid artery stenting was performed if ante-flow was not maintained or residual stenosis was excessive.Successful recanalization was defined as the thrombolysis in cerebral infarction(TICI)grade 2b or 3.All patients were performed noncontrast CT immediately after the operation and(24±6)h after the operation to evaluate adverse events,including intraoperative complications(vasospasm,distal embolism),complications related to SHARP technology(distal embolization confirmed by DSA after half-release of stent and/or when the guided catheter retreated to proximal ICA stenosis),hemorrhagic transformation(hemorrhagic infarction typeⅠ,hemorrhagic infarction typeⅡ,parenchymal hemorrhage typeⅠand parenchymal hemorrhage typeⅡ),subarachnoid hemorrhage and symptomatic intracranial hemorrhage.Neurological function improvement was defined as the National Institutes of Health stroke scale(NIHSS)score at postoperative 7 d or at discharge was at least 4 points lower than that at admission.Clinical prognosis was evaluated by 90-day follow-up records.Independent neurological function was defined as modified Rankin scale(mRS)score≤2,and poor prognosis defined as mRS score>2,with death as mRS core of 6.Results All 14 patients had ICA initial segment occlusion,including 8 patients combined with ICA terminal occlusion(C7 segment occlusion)and 6 patients combined with M1 segment occlusion of middle cerebral artery.Large-artery atherosclerosis in 9 cases,cardioembolism in 3 cases and arterial dissection in 2 cases.All 14 patients were successfully recanalized and reached TICI grade 2b or 3.The average time from puncture to recanalization was(63±6)min.Four cases(3 cases of large-artery atherosclerosis and 1 case of arterial dissection)underwent ICA stent implantation due to the inability of maintaining ante-flow after recanalization.There was no complication related to SHARP technology(distal embolism).Among 14 patients,postoperative parenchymal hemorrhage occurred in 1 case,hemorrhagic infarction in 3 cases and subarachnoid hemorrhage in 1 case.None had symptomatic intracranial hemorrhage.90-day follow-up after operation showed 1 patient died due to neurological function deterioration;10 patients achieved independent neurological function(mRS score≤2);3 cases had poor prognosis.Conclusions The preliminary analysis of retrograde treatment with SHARP technique in acute ischemic stroke patients with tandem occlusion showed this technique can simplify operation steps,shorten operation time,and reduce acute stent implantation to a certain extent.However,the safety and effectiveness of this technology still need to be further verified.