6颈动脉狭窄的血管内治疗2
■TreatmentModalities
治疗方式
Oncethedeterminationhasbeenmadetoperformacarotidrevascularizationprocedure,anindividual’svascularanatomy,includingtheaorticarch,shouldbestudiedtodeterminethepresenceofanatomicvariationsthatwouldmakeendovasculartreatmentmorefavorableorlessfavorable.Althoughmostcarotidlesionsareaccessibleforendarterectomythroughastandardanterioraccessapproach,certainanatomicfeaturesplaceapatientatunnecessaryriskwithendarterectomy.Forexample,ahighbifurcation(abovethesecondcervicalvertebra[C2])orexcessiveextensionoftheplaquedistaltothecarotidbifurcationplacesthepatientundergoinganendarterectomyatgreaterriskforhypoglossalnerveinjury,whereasalowbifurcationorextensionofthecarotidplaquemorethan3cmproximaltothecarotidbifurcationplacesthepatientundergoinganendarterectomyatgreaterriskforrecurrentlaryngealnerveinjury.23–25Additionally,patientswithpreviousirradiationorextensivesurgerytotheneckcanbeexpectedtohavehigherperioperativeriskwithendarterectomyduetodifficultywithneckdissection.Patientswithipsilateralproximalorintracranialstenosisinadditiontocarotidbifurcationstenosisarebesttreatedwithendovasculartechniques,becausealllesionsmaybetreatedasnecessaryandwithalowerriskofintraoperativeevents.25,26Medicalriskfactors,suchasrecentoractivemyocardialinfarctionandevolvingneurologicsymptoms,increaseperioperativeriskforcarotidendarterectomybutnotcarotidstenting.23,27,28
一旦确定了进行颈动脉血管重建术，应研究患者的血管解剖，包括主动脉弓，应确定存在的解剖变异是使使得血管内治疗有利或不利。虽然通过标准的前入路，大多数颈动脉病变均可经过动脉内膜切除术完成，但某些解剖学特征却使得颈动脉内膜切除术患者面临不必要的风险。例如,分叉位置较高（位于第二颈椎之上），或颈动脉分叉远端斑块过度扩张，使接受颈动脉内膜切除术患者舌下神经损伤风险较大，而低分叉或颈动脉斑块延伸超过3cm处的颈动脉内膜切除术患者，喉返神经损伤的风险更大[23–25]。此外，既往放疗或颈部广泛手术的患者，由于颈部解剖困难，围手术期颈动脉内膜切除术的风险更大。除颈动脉分叉处狭窄外，同侧近端或颅内狭窄的患者最好用血管内技术治疗，因为所有的病变均可治疗，术中不良事件的风险较低[25、26]。内科治疗的危险因素，如近期或活动性心肌梗死和进行性神经系统症状恶化，不增加CAS，而增加CEA围手术期的风险[23,27,28]。
■■Devices
设备
Onceapatientisdeemedacandidateforcarotidarterystenting,preparationforendovascularaccessisofutmostimportanceforasuccessfulresult.Foreachcase,stentsandembolicprotectiondevicesmustbeselected,aswellasotherdevicessuchasangioplastyballoons.Ancillarydevicesthatarealsousefulincludeintravascularultrasound(IVUS)andaspirationcatheters.Angiographicanatomyisofprincipalimportanceindeviceselection.Carefulselectionofdevicesisimportantforsuccessfulandsafeplacementofacarotidarterystentandisdetailedinthediscussionbelow.Foralldevicesusedduringcarotidarterystenting,arapid-exchangedeliverysystemisemployed,insteadofanoverthe-wiredesign,resultinginashortworkinglumenfacilitatingusageofstandardwirelengths,therebydecreasingtimebyavoidingprotractedwireandcatheterexchanges.29
一旦患者被认为适合可行颈动脉支架治疗，血管内治疗的准备工作对于结果至关重要。对于每一种情况，必须选择支架和栓塞保护装置，以及其他设备，如球囊血管成形术。辅助设备，包括血管内超声（IVUS）和抽吸导管。血管造影解剖在设备选择中非常重要。仔细选择设备对于成功和安全放置颈动脉支架很重要，并在下面的讨论中详细介绍。对于颈动脉支架置入术中使用的所有设备，使用快速交换传递系统，而不是通过导线设计，导致使用标准线的长度，建立血管内通道，从而减少回撤导丝和导管交换的时间[29]。
EmbolicProtectionDevices
栓塞保护装置
Embolicprotectiondecreasestheriskofembolicstrokeduringcarotidstenting30,31andhasbe海南白癜风医院白癜风治疗需要多少钱
