Interventional treatment of ischemic cerebrovascular disease
What is stenting?
It is a treatment method in which a catheter with a balloon is introduced into the stenosis for anterior dilatation, and then a special metal stent is introduced into the stenosis and posteriorly dilated to achieve the purpose of rebuilding the blood flow in a prograde manner.
What is balloon dilation angioplasty?
It is a treatment method that uses a catheter with a balloon to introduce into the stenosis and dilate the stenosis to achieve vascular dilatation and reconstruction of the blood flow. This method is mostly used in stenotic lesions where stents cannot be introduced. Yongjian Jin, Department of Neurosurgery, Aviation General Hospital of China Medical University
Carotid artery stenting
What is carotid artery stenting?
Under a special umbrella to prevent dislodged blood clots from entering the intracranial vessels, a microcatheter with a balloon is introduced into the stenosis (carotid stenosis) to dilate it, and then a special metal stent is guided into the stenosis and dilated to achieve the goal of rebuilding the blood flow in a prograde manner. Since the procedure is performed under local anesthesia, the patient can remain conscious during the procedure.
Who is a candidate for carotid stenting?
– Asymptomatic patients with > 80% stenosis or symptomatic patients (TIA or stroke attack) with > 50% stenosis.
– Stenosis < 50% but with ulcerative plaque formation.
– Mild vascular flexion, where the catheter can pass through the stenosis.
– Patients who are elderly or have a lot of underlying systemic diseases and poor general condition.
– Patients with a high degree of contralateral carotid stenosis or occlusion.
– Lesions Highly located lesions above the 2nd cervical vertebra.
– Patients with unremarkable results of internal anticoagulation therapy.
– Restenosis after CEA or radiation therapy.
– Entrapped aneurysms.
– Certain myofibrillar dysplasia with limited stenosis in the stable phase of arteritis.
– Residual stenosis after acute arterial thrombolysis.
Which patients are not candidates for carotid stenting?
– Patients with severe vascular tortuosity that prevents introduction of the interventional catheter into the cranium.
– Patients with soft plaque in the stenosis and who are at risk for cerebral embolism distal to the stenosis.
– Intracranial hemorrhage within 3 months and fresh cerebral infarction within 2 weeks.
– Uncontrollable hypertension.
– Contraindication to heparin, aspirin or other anti-platelet aggregation drugs.
– Hypersensitivity to contrast agents.
– Complete occlusion of the internal carotid artery.
– With intracranial aneurysm and who cannot be treated earlier or simultaneously.
– Previous myocardial infarction within 2 weeks.
– Severe cardiac, hepatic or renal disease.
What are the advantages and disadvantages of carotid artery stenting?
1 Advantages
– Less invasive systemically and can be performed under local anesthesia. Only the femoral artery at the root of the thigh is punctured and the incision is about 2 mm.
– The operation time is short.
– The patient suffers less pain and is hospitalized for fewer days.
– No damage to the normal blood vessels and nerve tissues around the carotid artery, which can reduce the complications of the operation.
– The blood flow is not blocked during the operation, and the complications of cerebral ischemia are low.
2 Disadvantages
– Interventional catheter cannot be introduced into the skull in severe vascular tortuosity.
– The risk of intraoperative plaque dislodgement from the stenosis to the distal end to form embolism.
– High cost of treatment.
How effective is the treatment of carotid artery stenting?
Stenting was introduced in 1989 for the treatment of carotid artery stenosis. Compared to carotid endarterectomy, carotid stenting has a wide range of indications, and many patients who cannot be treated surgically can be treated with carotid stenting, thus effectively preventing the occurrence of stroke. Arterial stenting is less invasive and has fewer complications than surgery, and can be performed under local anesthesia, resulting in less pain and fewer days in the hospital, fewer cardiovascular complications, and better stroke reduction. The efficiency of stenting is 95% and the comorbidity is less than 5%.
Stenting of basilar artery stenosis
What is stenting of the basilar artery?
The procedure is basically the same as internal carotid artery stenting, but with far fewer comorbidities than carotid artery stenting and generally without the placement of an intraoperative shield. Stenting is the first choice for vertebral artery stenosis. By placing a stent, the ischemic symptoms of the vertebral artery are significantly improved and the incidence of cerebral infarction is reduced.
Who needs surgical treatment?
1 For patients with symptomatic bilateral high stenosis.
2Patients with occlusion or dysplasia of the contralateral vertebral artery.
What are the benefits of vertebrobasilar stenting?
Stenting is the first choice in the treatment of vertebrobasilar stenosis and can significantly improve ischemic symptoms in the vertebral arteries and reduce the incidence of cerebral infarction by placing a stent. Arterial stenting is less invasive and has fewer complications than surgery, and can be performed under local anesthesia, resulting in less pain and fewer days in the hospital, fewer cardiovascular complications, and better stroke reduction.
Procedure
Subclavian artery stenosis stenting
What is stenting of subclavian artery stenosis?
The procedure is basically the same as internal carotid artery stenting, but with far fewer comorbidities than carotid artery stenting and generally without the placement of an intraoperative umbrella. Stenting is the first choice for the treatment of subclavian artery stenosis and can significantly improve symptoms of subclavian ischemia by placing a stent.
Do patients with stenosis of the subclavian artery need to be treated?
For patients with a high degree of stenosis or occlusion of the subclavian artery, typical symptoms of cerebral ischemia due to blood theft, and a bilateral blood pressure difference of more than 20 mmHg, surgical treatment may be considered, and stenting of the subclavian artery is currently recommended.
What are the advantages of subclavian artery stenting?
Subclavian artery stenting is less invasive and has fewer complications than open surgery, and the risk of intraoperative distal cerebrovascular embolism is significantly lower than that of carotid artery stenting. It can be performed under local anesthesia, and the patient suffers less pain and fewer days of hospitalization, with minimal cardiovascular complications.
Intracranial vascular stenting
What is intracranial vascular stenting?
It is a treatment that introduces a small intracranial vascular stent into the middle cerebral artery or basilar artery through a microcatheter to reconstruct the blood flow in a cis-directed manner. Because of the thin intracranial vessels and the abundance of penetrating branches, the technique is difficult.
What is intracranial balloon dilation and angioplasty?
In patients with intracranial artery stenosis who have difficulty in introducing stents, balloon dilatation of the stenotic vessels is performed to improve blood flow.
Which patients need stenting of intracranial arteries (middle cerebral artery, basilar artery)?
– Symptomatic intracranial artery stenosis > 60%.
– Normal vessels distal to the stenosis, posterior circulation lesion < 20 mm in length and anterior circulation lesion < 15 mm in length.
– Residual stenosis after acute arterial thrombolysis.
– Recurrent clinical episodes of neurological dysfunction consistent with the area supplied by the stenotic vessel.
– No serious systemic disease, such as cardiac, hepatic, or renal failure.
Which patients are not suitable for intracranial artery (middle cerebral artery, basilar artery) stenting?
– Severe systemic disease.
– Severe neurological dysfunction left after infarction.
– Asymptomatic or mildly symptomatic with effective drug control.
– Stenotic segment with a vessel diameter of less than 2 mm and extreme angulation of the stenotic segment.
– Unexplained lesions (early arteritis, MoyaMoya , disease congenital dysplasia), diffuse stenosis of intracranial arteries.
– The stenosis involves a significant penetrating branch.
– Within 2 weeks after cerebral infarction, within 2 weeks after myocardial infarction.
Intra-arterial thrombolysis in the acute phase
What is intra-arterial thrombolysis in the acute phase?
It is a treatment method that involves introducing a microcatheter into the site of vascular occlusion (cerebral thrombosis, cerebral tethering) and using thrombolytic drugs (rt-PA, urokinase) to perform super-selective thrombolysis to open the blood vessel and open the blood flow, and if necessary, balloon dilatation angioplasty or stent placement to achieve cis-connected blood flow reconstruction.
Which patients need intra-arterial thrombolysis in the acute phase?
Carotid system indications
– Embolic cerebral infarction.
– Age under 80 years.
– Significant neurological deficits that progressively worsen for more than 1 h.
– Patients with CT suggestive of a blurred basal nucleus, lateral fissure, and slight hypointensity in the insular cortex/frontoparietal lobe without fresh infarct formation, and excluding external cerebral hemorrhage or other significant intracranial disorders.
– Onset within 6 h is best suited to the distal middle cerebral artery; the internal carotid artery or penetrating branches are not indicated.
Indications for the vertebrobasilar artery system
– Embolic cerebral infarction.
– Age under 80 years.
– Significant neurological deficits with progressive worsening lasting more than 1h.
– Patients whose CT indicates no fresh infarct formation in the brainstem or cerebellum, and who exclude external cerebral hemorrhage or other obvious intracranial disorders.
– Within 24-72 hours, most suitable for basilar artery, not for penetrating branches.
Which patients should not undergo acute intra-arterial thrombolysis?
– Clinical symptoms showing significant improvement.
– Intracranial or other organ bleeding tendency.
– History of intracranial or other surgical trauma within 2 months.
– Significant organ dysfunction or failure.
– Pre-treatment systolic blood pressure > 180 mmHg, or diastolic blood pressure > 110 mmHg.(6) Bleeding tendency.
Which patients require acute intra-arterial thrombolysis combined with acute angioplasty?
Indications for the carotid system.
– Thrombotic cerebral infarction.
– Age below 80 years.
– Significant neurological deficits with gradual worsening for more than 1h.
– Combined thrombosis of the middle cerebral artery with stenosis (proximal middle artery at risk) or occlusion or stenosis of the internal carotid artery (except floating thrombus).
– Except for compensatory angiogenesis or penetrating branch occlusion that has developed (bypass surgery may be considered due to the long time window).
– Hemodynamic stenosis after thrombolysis should be treated with early angioplasty (PTA) or stenting (STENT).
– Onset within 6 h.
Vertebrobasilar system
– Thrombotic cerebral infarction.
– Age under 80 years.
– Significant neurological deficits that progressively worsen for more than 1 h.
– Contralateral vertebral artery occlusion or basilar artery obstruction
– Thrombolysis followed by angioplasty or stent placement (poor treatment outcome)
– Within 24-72 hours
Which patients should not undergo acute intra-arterial thrombolysis combined with acute angioplasty?
– Clinical symptoms showing a significant trend towards improvement.
– Intracranial or other organ bleeding tendency.
– History of intracranial or other surgical trauma within 2 months.
– Significant organ dysfunction or failure.
– Pre-treatment systolic blood pressure > 180 mmHg, or diastolic blood pressure > 110 mmHg.(6) Bleeding tendency.
Chief of Department 010-59520364 (Jin Yongjian)
Department head: 010-59520364(Jin Yongjian) Department: 01059520282
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