支撑架术围手术期的治疗（Peri-operative stenting treatment）

• 颈动脉支架后血小板激活和经常发生术后栓塞 Platelet activation and frequent post-op emboli following carotid stenting

• 没有理想的大的临床试验 - 大部分基于心脏学的实验 No large trials of optimal approaches – largely based on cardiology

• 最广泛的推荐的方案：氯吡格雷（300-600mg 负荷剂量+75mg/每日）+阿司匹林 Most widely recommended regimen – clopidogrel (300-600mg loading plus 75mg od, plus aspirin)

• 小样本研究相对于阿司匹林+肝素，阿司匹林+氯吡格雷减少神经事件 Asp + Clop associated with reduced neurological events v aspirin plus heparin in one small study

• 阿司匹林+氯吡格雷减少颈动脉内膜剥脱术后栓塞 Asp + Clop associated with reduced emboli post carotid endarterectomy
’
• 可选择的方案建议 Alternatives regimens suggested eg glycoprotein IiB/IIIA, VWF antagonists suggested but no hard data（截止写稿为止没有过硬的资料）


	Nytroglicerine 0.2 mg

轻度并发症

1. 颈动脉痉挛 Carotid artery spasm

通常由EPD（embolic protection devices,）引起，自发缓解，如果持续性导致血流受限：硝酸甘油 100-300μg 动脉注射


	硝酸甘油 100-300μg 动脉注射

2. 低血压/心动过缓 Sustained hypotension / bradycardia

1）暂时性心动过缓和低血压 Transient bradycardia and hypotension

• 颈动脉分叉扩张的生理性反应 Physiological response to dilatation of carotid bifurcation.

• 治疗前0.5mg-1mg 阿托品 Pre-treatment with 0.5mg-1mg atropine.

• 颈动脉支架后12小时脱离监护 Close monitor 12h post CAS.

除外其它原因的低血压

– 容量不足 Volume depletion

– 心脏疾病 Cardiac pathologies

– 血管入路部位出血 Bleeding from the site of vascular access.

2）严重持续性低血压

颈动脉支架的 4%-11% of CAS.
与严重钙化相关 Associated with severe calcification.
颈动脉窦反射 Carotid sinus reflex.
监护掉线 Close monitoring.
对静脉输液和血管加压素有反应 Responds to IV fluids and vasopressors.

3. 颈动脉夹层 Carotid artery dissection

• 颈内动脉严重迂曲或扭结 Severe "bends" or "kinks" in the ICA.

颈动脉扭结


	植入支架

• 颈动脉内过度操作相关，包括导丝、球囊导管和支架 Aggressive hardware (guide wires, balloon catheters, stents) within the ICA.

• 颈内动脉支架远端后扩张 Postdilatation of the distal stent edge within the ICA.

• 颈总动脉内导管鞘头端过度操作 Aggressive manipulation of the guiding sheath tip, in the common carotid artery.

4. 造影剂脑病（非常罕见）Contrast encephalopathy (very rare)

非常罕见（<0.1%），一种短暂的神经系统综合征，主要与长时间手术、大量造影剂有关。Very rare (< 0.1%), a transient neurological syndrome mostly related to a prolonged procedure, large volume of contrast medium.
基底神经节和皮层有明显的“染色”对比，但CT没有影像学上的脑异常。marked contrast "staining" in the basal ganglion and the cortex, but no radiographic brain abnormalities in CT.

Break in the blood brain barrier. Patients typically recover completely within 24 hours without a permanent neurological deficit. break in the blood brain barrier. patients typically recover completely within 24 hours without a permanent neurological deficit.

造影剂冲破血脑屏障导致。患者通常在24小时内完全恢复，而没有永久性的神经缺陷。

鉴别诊断：脑梗死和高灌注综合征 Ddx: massive cerebral infarction or hyperperfusionsyndrome

5. 轻度暂短性脑缺血发作 Minor embolic neurological events (TIAs)

• 来自介入治疗时从病变脱落的碎渣 Debris from the site of the lesion during the intervention
• 患者神经状态发生明显变化 Significant change in the patient’s neurological status.

• 维持血压/心率/气道 Maintain blood pressure/ heart rate/ viable airway.

• 如果患者发生不合作和极度躁动：呼叫麻醉科医生 If the patient becomes uncooperative and agitated: anesthesiologist!


	颈动脉支架后，轻度脑梗

CREST试验 [标准风险患者]：4年间 CAS和CEA之间主要终点事件的无显著差异

1. 卒中
2. 心肌梗死(MI)
3. 死亡
4. 同侧卒中

尽管使用CAS的中风的风险更高，CEA发生心肌梗死的风险较高（但无显著差异）。

CREST trial [standard risk patients]: no significant differences between CAS and CEA for the primary endpoint: periprocedural

stroke, myocardial infarction (MI), or death and ipsilateral stroke up to four years although a higher risk of stroke with CAS and

a higher risk of MI with CEA were observed.

Brott TG, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010

Risk factors for periprocedural distal embolization during CAS are the following:

颈动脉病变：Carotid lesion	1. 软斑块，新鲜血栓
内科治疗 medical treatment	1. 术前双抗差 2. 操作时肝素化不充分（检查ACT）
支架技术 stenting technique	1. 没有保护措施 2. 导丝操作粗鲁 3. 支架释放前后，球囊扩张粗鲁 4. 球囊通过高度钙化狭窄病变动作粗鲁 5.试图通过高度迂曲颈总动脉时间过长，动作粗鲁

脑梗死 Brain embolization：

• 颈动脉支架后需要前后位颅内动脉判断是否有脑梗死，需要与颈动脉支架前的DSA比较。DSAIntracranial DSA in AP and lateral projections. Compare with pre CAS angio.

• 颅内栓塞最可能的位置是大脑中动脉分支和颈内动脉远端 The most likely sites of intracranial embolism are the distal ICA and the middle cerebral artery branches.

• 没有术前颅内DSA不做颈动脉支架 DO dot perform CAS without pre op intracranial DSA!

脑梗死？时间就是大脑！

大血管栓塞：试图尽可能快的再通阻塞的分支（机械的血栓取出或溶栓剂）

6. 血管入路并发症 Complications at the site of the vascular access

重度并发症

1. 严重栓塞性中风 Major embolic stroke

2. 颅内出血 Intracranial hemorrhage (ICH)

突然头痛或失去意识，立即终止操作，用鱼精蛋白中和肝素，即刻进行脑CT检查

• 颈动脉支架严重并发症通常危及生命 life-threatening and usually fatal.

• 发生率 0.3% of CAS.

• 过度抗凝、高血压控制不良、积极尝试颅内神经血管抢救，特别是脆弱的浆果动脉瘤。combination of excessive anticoagulation, poorly controlled hypertension, aggressive attempts at intracranial neurovascular rescue, presence of a vulnerable berry aneurysm.

• 最近（＜三周）发生缺血性中风的颈动脉支架CAS in the presence of a recent (<3 weeks previously) ischemic stroke.

3. 高灌注综合征 Hyperperfusion syndrome

脑过度灌注综合症(cerebral hyperperfusion syndrome, CHS)

• 临床表现 Clinical presentation:

– 同侧疼痛、恶心、呕吐 Ipsilateral headaches, nausea, vomiting

– 血压显著提高 Markedly elevated blood pressure

– 局部癫痫发作和精神状态改变 Focal seizures and altered mental status

– 致命颅内出血 Fatal intracranial hemorrhage

• 颈动脉支架后脑灌注综合征发生率1.16%，颅内出血发生率0.74% The incidence of CHS 1.16% and ICH 0.74% after CAS.

• 颈动脉内膜剥脱后脑高灌注综合征发生率1.95，颅内出血发生率0.37% CHS 1.95% and ICH 0.37% after CEA.

颈动脉内膜剥脱剥脱后高灌注综合征发生在几天内，而颈动脉支架发生高灌注综合征在术中或术后立即发生。可能和术中肝素和抗血小板药物相关，特别是静脉 glycoprotein IIB/IIIA antagonists（百度没有查到这个药）

高灌注综合征的患者危险因素通常包括：

严重的颈动脉狭窄，而且侧支循环发育差。severe carotid stenosis and poor collateral circulation
对侧颈内动脉完全闭塞 complete occlusion of the contralateral ICA
或患者Wilis循环没有发育 patients with an underdeveloped circle of Willis.

D. Canovas, J. Estela, J. Perendreu, et al. www.intechopen.com.

高灌注综合征与存在已久的低灌注导致微循环的自我调节损害有关
The mechanism is related to long-standing hypoperfusion that results in impaired autoregulation of the microcirculation

高灌注综合征处理 Hyperperfusion syndrome: management

• 识别由此并发症的患者 identification of patients predisposed to this complication.

• 密切监测和细心控制血压 careful monitoring, and meticulous blood pressure control.

4. 颈动脉破裂非常罕见 Carotid perforation (very rare)

Aggressive balloon dilatation.

5. 急性支架血栓形成非常罕见 Acute stent thrombosis (very rare)

• 双抗 Double antiplatelet agent.
• 支架大小合适以及支架贴壁 Proper stent sizing and careful stent opposition to the arterial wall.

• 近端支架血管造影正常到远端正常 Stenting from an angiographically "normal" proximal segment to an angiographically “normal” distal segment.

颈动脉支架并发症危险因素 CAS: Increased risk for complications

1. 高血压 High blood pressure.

2. 长、不规则和钙化颈动脉病变 Long, irregular, and calcified carotid lesions.

3. 严重动脉粥样硬化和颈动脉与主动脉弓成角 Significant atherosclerosis and angulation of the aortic arch.

颈动脉与主动脉弓成角 Significant atherosclerosis and angulation of the aortic arch.

In conclusion

颈动脉支架相对于颈动脉内膜剥脱术是一个选项 CAS is an alternative procedure for CEA.
有经验的医生并发症发生率比最好的颈动脉内膜剥脱术最好的结果低 If used by experienced doctor the complication rate is low-comparable with best CEA results.
阿喀琉斯之踵是围手术期的栓塞。虽然大多数是亚临床的。必须全面了解并发症的知识，对于预防，避免和治疗是必需的。The Achilles tendon is the periprocedural embolization –although mostly subclinical.Thorough knowledge of the omplications is mandatory to prevent, avoid and treat.

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颈动脉支撑架并发症和处理

支撑架术围手术期的治疗（Peri-operative stenting treatment）

轻度并发症

1. 颈动脉痉挛 Carotid artery spasm