Cerebrovascular intervention is a small stent that reaches the skull through a long “channel” in the femoral artery, propping up the narrowed lumen of the vessel to improve blood supply to the brain and prevent strokes. This inspiring and miraculous technique is the latest technology for stroke prevention – cerebrovascular intervention, which has been hailed by the international medical community as “a major step forward in the prevention and treatment of stroke”. In the past 10 years, due to further research on cerebrovascular anatomy, the development of electronic computer technology, imaging technology, angiography technology, catheters, embolic materials and non-ionic contrast agents, the scope of research is widening, the research methods are changing day by day, and the therapeutic effects are becoming more and more perfect. Interventional treatment methods for cerebrovascular disease mainly include
Whole brain angiography
Indications
1, intracranial and extracranial vascular lesions. Such as hemorrhagic or occlusive cerebrovascular lesions.
2, spontaneous intracerebral hematoma or subarachnoid hemorrhage (SAH) etiology examination.
3.For blood-rich tumors of the head and face, preoperative understanding of the blood supply condition.
4.To observe the relationship between blood supply and adjacent blood vessels of intracranial occupying lesions and the characterization of certain tumors.
5.Review after treatment of head, face and intracranial vascular diseases.
Contraindications
1.Iodine allergy (after desensitization treatment, or use of iodine-free contrast agent).
2.Persons with serious bleeding tendency or bleeding disorders.
3) Severe cardiac, hepatic or renal insufficiency. 4) Advanced brain herniation and brainstem failure.
Preoperative preparation
1, routine preoperative examination: including blood, urine routine, bleeding and clotting time, liver and kidney function, electrocardiogram and chest X-ray.
2, 8h preoperative diet, special circumstances, such as emergency can be shortened at the discretion of the anesthesiologist.
3.Iodine allergy test: 1ml of contrast agent to be used for imaging, intravenous push. The test should be negative if there are no signs of allergy such as panic, shortness of breath, urticaria and bulbar conjunctival congestion, and if the blood pressure pulsation is less than 10~20mmHg before and after the injection. If the iodine allergy test is positive and it is necessary to perform imaging, hormone therapy should be performed 3 d before the operation and non-ionic iodine aqueous contrast preparation should be used as much as possible.
4.Bilateral inguinal and perineal area skin preparation: Patients with long operation time should have indwelling catheter.
5.Inject intramuscular phenobarbital 30min before operation.
6.Continuous intravenous administration of calcium antagonist 24h before surgery, if appropriate.
7.Apparatus preparation: 1 angiography bag, 2 pressure bags, 500ml×4 bags of soft packing isotonic saline, 1 Y-shaped valve, 2 tee connectors, 1 cerebral angiography catheter (5F or 4F, choose different shape of angiography catheter for tortuous vessels as appropriate), 1 catheter sheath (5F, 6F), 1 short guidewire of 750px and 1 long guidewire of 4000px each. High-pressure syringe and connecting tube, 100-200 ml of contrast medium. Puncture needle (16G or 18G for adults, 18G or 20G for children).
Operation method and procedure
1.Transfemoral artery puncture operation steps
(1) Routinely disinfect the inguinal and perineal areas bilaterally to expose the groin on both sides.
(2) Connect at least 2 sets of intra-arterial continuous drippers (1 of which is connected to the catheter target, and the other one is spare or connected to the Y-valve guidewire). Connect a high-pressure syringe and aspirate the contrast medium. All connections should be free of air bubbles. Flush the contrast tube with heparin saline.
(3) The puncture site is chosen 1.5~50px below the inguinal ligament where the pulsation of the femoral artery is most evident, and is anesthetized by local infiltration, with the needle angle of 30~45 degrees to the skin.
(4) After successful puncture, the vascular sheath is placed with the aid of a short guidewire. Continuous titration is regulated with a drop count of 15-30 drops/min.
(5) Systemic heparinization, control activated partial thromboplastin time (APTT) >120s or activated clotting time (ACT) >250s. The method of heparinization can be referred to the following: the first dose of 2/3mg per kg body weight is given intravenously, then half amount after 1h, and 1/4 amount after 2h, then additional half amount of the previous dose every 1h, and if reduced to 10mg, every 1h Give 10mg every 1h.
(6) Perform whole brain angiography under fluoroscopy, including bilateral internal and external carotid arteries and bilateral vertebral arteries. If necessary, bilateral thyrocervical trunk and cribriocervical trunk angiograms should be performed. In case of tortuous vessels, a guidewire can be used to assist when the catheter is not in place.
(7) In elderly patients, each trunk artery should be contrasted from the bottom up, and if necessary, the aortic arch should be contrasted with a pigtail catheter.
(8) Neutralize sodium heparin with fisetin (1~1,5mg can counteract 1mg of sodium heparin) after the end of contrast.
2.Postoperative treatment
(1) Compress and apply pressure to the puncture site, lie in bed for 24h, and keep the lower limb on the punctured side straight.
(2) Monitor the dorsalis pedis artery pulsation of the punctured limb for 1 time/0,5h.
(3) Give antibiotics and hormones appropriately.
(1) Interventional treatment of ischemic cerebrovascular disease Ischemic stroke accounts for more than 70% of all strokes, and atherosclerotic stenosis of intracranial arteries is an important cause of ischemic stroke and transient ischemic attack in Chinese people. Studies have shown that for patients with severe cerebral artery stenosis with a stenosis rate of more than 70%, pharmacological treatment is ineffective; surgical treatment is highly invasive and has a high complication rate. Cerebral artery stenting is a minimally invasive treatment method, and this group of patients with severe cerebral artery stenosis can benefit significantly from stenting.
I. Endovascular arterial thrombolysis Endovascular thrombolysis includes regional intra-arterial thrombolysis, early super-selective intra-arterial contact thrombolysis, and venous sinus contact thrombolysis. Regional intra-arterial thrombolysis is performed by injecting thrombolytic agent into the large vessel where the lesion is located with a catheter. The dose of thrombolytic agent used is small, with few side effects, and the operation is simple and easy, and is suitable for intracranial large vessel embolism and thrombosis, such as in the internal carotid artery and vertebrobasilar artery. Early super-selective intra-arterial contact thrombolysis means that after the site of vascular occlusion is clarified by routine DSA, a microcatheter with multiple lateral holes is used to selectively enter the arterial embolism and inject thrombolytic agent directly before and after the embolus and within the embolus, which is suitable for occlusion of all branches of large and small vessels above the internal carotid artery and occlusion of the vertebrobasilar system. Venous sinus contact thrombolysis is performed by puncturing the femoral artery using the Seldinger technique and performing cerebral angiography via the femoral artery to show the site and extent of venous sinus thrombosis. A catheter is delivered from the vein to the venous sinus for thrombolysis, which is indicated for venous sinus thrombosis.
For the prevention and treatment of ischemic cerebrovascular diseases such as carotid artery and vertebrobasilar artery stenosis, percutaneous transluminal angioplasty (PTA), which was introduced in the early 1980s, and endovascular stent placement (SP), which was introduced in the late 1990s, have become the most popular treatments. SP has become a very important treatment for carotid artery stenosis and vertebral basilar artery stenosis, and it has shown great vigor in the treatment of ischemic cerebrovascular disease with its advantages of less trauma, higher safety, wider indications, and fewer complications. and arterial entrapment formation. The stents used can be divided into balloon-expandable stents and self-expandable stents.
For patients with recurrent TIA episodes or recurrent cerebral infarction, especially those with multiple foci of infarction in the so-called watershed area of the cerebral hemispheres detected in CT or MRI examinations, attention should be paid to the screening of cerebral vessels and carotid arteries by ultrasonography or CTA or MRA examinations, because the rate of arterial stenosis in such patients is very high, and if stenosis is detected, cerebral angiography should be performed as far as possible to further confirm the diagnosis to avoid If stenosis is found, cerebral angiography should be performed to further confirm the diagnosis to avoid delaying treatment.
(B) Interventional treatment of hemorrhagic cerebrovascular disease Spontaneous subarachnoid hemorrhage belongs to the category of hemorrhagic cerebrovascular disease, the main cause of which is intracranial aneurysm rupture, accounting for more than 80%. Unless the patient is in a near-death state, early diagnosis and early treatment by cerebral angiography is preferred.
Vascular embolization is mainly used in the interventional treatment of hemorrhagic cerebrovascular disease, initially mainly in the embolization of intracranial aneurysm, and then after long-term clinical practice and exploration, the scope of application has been gradually expanded. For example, embolization of intracranial arteriovenous malformation, embolization of dural arteriovenous fistula, embolization of Galen vein aneurysm-like malformation, embolization of internal carotid artery cavernous sinus fistula, embolization of head and neck hyperemic tumor and embolization of intractable nasal bleeding. Clinical practice has proven that vascular embolization has made many previously considered intractable or incurable diseases easy and treatable. Especially in recent years, some new embolization materials have been introduced, which makes this technique safer and less complicated.