颈动脉支架植入术中脑保护装置的应用研究

栾  波  荆全民  韩雅玲

沈阳军区总医院心内科 110016

目的 动脉粥样硬化性斑块和附壁血栓脱落导致的脑梗死，是采用血管内球囊扩张和支架置入术治疗颈动脉和椎动脉粥样硬化性狭窄的主要并发症，而治疗中应用脑保护装置防止脱落的栓子进入脑血管，可有效降低此类并发症的发生。现将我院应用脑保护装置进行颈动脉狭窄血管内扩张和支架置入治疗2例患者的初步结果报告如下。

方法  2例患者经颈动脉造影入选，分别为男性67岁，左颈内动脉95%偏心性狭窄；女性64岁，左颈内动脉70%偏心性狭窄伴左锁骨下动脉完全闭塞。2例患者临床表现均有头晕、头昏，短暂性脑缺血发作，记忆力减退。2例患者均在颈动脉病变处放置了支架。术中均应用了脑保护装置（angioguard）。治疗方法：① 术前3天常规服用阿司匹林0.3 1次/d，氯吡格雷75mg 1次/d；② 均采用右股动脉入路穿刺，肝素5000u抗凝后，行双侧颈动脉造影；③ 选用Cordis公司生产的脑保护装置，在对颈动脉狭窄处球囊扩张及支架释放前张开脑保护装置，此时动态观察血管直径变化，警惕血管痉挛；④ 根据造影结果，男性患者选用了Smart8.0mmX40mm支架，女性患者选用了Smart9.0mmX40mm支架；⑤ 手术结束前均复查颈动脉造影，未发现血管内膜撕裂及支架扩张不良；⑥ 术后克塞40mg皮下注射 2次/日，共5天，阿司匹林0.3 1次/d，4周后改为0.1 1次/日，长期服用，氯吡格雷75mg 1次/d，4周后停用。

结果  采用脑保护装置成功地对2例患者2处血管狭窄进行了支架植入术。术中及术后随访6月无粥样斑块或血栓脱落性脑栓塞发生。头晕、头昏症状消失，无短暂性脑缺血发作。

讨论  颈动脉和椎动脉粥样硬化性狭窄是脑缺血性卒中的重要原因之一。动脉内球囊扩张和支架置入术，由于其具有疗效肯定、创伤微小、适应证宽、再狭窄（或复发）率低和可重复施行的优势，目前已成为治疗颈动脉和椎动脉狭窄的主要方法之一。但是，血管内扩张和支架置入术的围手术期永久性并发症发生率和患者病死率共为4.2%-19.2%。其中主要原因是粥样斑块或附壁血栓的脱落性栓塞。脑保护装置的应用是目前解决上述问题的主要方法。我院2例次的初步尝试结果也显示此方法效果良好，并且操作简单易行。脑保护装置的使用，不仅可以明显地降低手术并发症和患者病死率，而且还可以提高动脉狭窄的治疗疗效。应用脑保护装置主要应注意的问题是避免该装置通过动脉狭窄处时引起斑块或血栓的脱落。

关键词  颈动脉支架置入  脑保护装置

Practice and study of carotid artery stenting under brain protection

Luanbo,HAN Ya-Ling,JING Quan-Min， Department of Cardiology, Shenyang  Command General Hospital， PLA， Shenyang  110016

 [Abstract] Objective  Cerebral infarction due to exfoliating atherosclerotic plaque and mural thrombus was the main complication when the stenosis of carotid artery and vertebral artery were treated by stenting. Whereas brain protection device can decrease effectively the rate of the camplication. This study reported our department performance of carotid artery stenting(CAS) under brain protection device. Analyse  the application value of the angioguard in CAS. Materials and Method  A 67-year-old man with continuous vertigo was found having left carotid artery stenosis 95 per cent by B-ultrasound and carotid artery angiography. Another 64-year-old woman with dizziness repeatedly , anamnesis decline and left radial pulse disappearing for 5 years was found left carotid artery eccentric stenosis 70 per cent and left subclavian artery occlusion completely.This tow patients accepted CAS under brain protection and Angioguard was used. While, the woman was performed balloon-angiography pre-stenting. Result Two procedures were successfully accomplished and blood resumed. A plaque was gained after operation in Angioguard in the man case. Most symptoms vanished. No cerebral embolism occurred due to angiography when follow-up after 6 months. Conclusion Brain protection can catch athroslerolic plaque and minimize the rate of complication when CAS.

[Key words]  Carotid stenosis stent ballon；Brain protection