中间导管“特洛伊木马”技术输送Willis覆膜支架行颅内动脉腔内隔绝术治疗颈内动脉海绵窦病变

2019-11-22 彭亚 宣井岗 陈荣华 中国脑血管病杂志

Willis支架系统作为国产专用于颅内血管系统的覆膜支架,顺应性较好,被应用于治疗外伤性颈内动脉海绵窦瘘(traumatic carotid cavernous fistula,TCCF)、颈内动脉大型或巨大动脉瘤、颈内动脉假性动脉瘤,取得了良好效果。但对于部分迂曲血管,Willis支架仍难以输送至颅内病变部位。

Willis支架系统作为国产专用于颅内血管系统的覆膜支架,顺应性较好,被应用于治疗外伤性颈内动脉海绵窦瘘(traumatic carotid cavernous fistula,TCCF)、颈内动脉大型或巨大动脉瘤、颈内动脉假性动脉瘤,取得了良好效果。但对于部分迂曲血管,Willis支架仍难以输送至颅内病变部位。
 
笔者采用中间导管“特洛伊木马”技术,将Willis支架置入目标位置并实施颅内动脉腔内隔绝术治疗颈内动脉海绵窦病变,即将中间导管头端在同轴技术下,越过病变处到达病变远端,在中间导管内输送Willis支架到达中间导管头端,然后回撤中间导管,支架即可顺利定位在病变部位。因该方法借用中间导管到位、支架在中间导管内输送与回撤,笔者将其形容为“特洛伊木马”技术。现将结果报道如下。
 
患者1:男,62岁,2018年2月因车祸致颅脑外伤、右侧前中颅底骨折2个月伴右眼外突4d入住常州市第一人民医院。神经系统检查:患者意识模糊,格拉斯哥昏迷量表(GCS)评分11分,右眼外突伴球结膜充血水肿,右侧眼眶闻及吹风样杂音。
 
行全脑DSA,显示为右侧颈内动脉海绵窦瘘,全偷流,盗血明显(图1a),静脉引流向眼静脉和岩下窦并通过海绵间窦向对侧海绵窦引流。术前给予氯吡格雷75mg+阿司匹林100mg/d,1次/d。3d后行右侧颈内动脉海绵窦瘘Willis覆膜支架(微创神通公司,上海)腔内隔绝术。在全身麻醉下穿刺右侧股动脉,肝素化(肝素钠2500IU),使用6F长鞘(Cook,bloomington,USA)经股动脉选择性置于右侧颈内动脉C2段,在路径图下,将5FNavien(Medtronic公司,美国)中间导管在0.89mm(0.035in)导丝导引下,到达颈内动脉岩骨段,再通过0.36mm(0.014in)导丝结合微导管同轴技术,将5FNavien中间导管越过海绵窦段到达病变远端,中间导管内造影确定瘘口位置。
 
采用4.5mm×16.0mmWillis覆膜支架,在0.36mm(0.014in)导丝导引下输送到中间导管头端(图1b),然后一边回撤中间导管,一边将支架调整到位(图1c),确定支架近端和远端覆盖瘘口后,采用608kPa(6atm)扩张球囊释放支架(图1d)。支架释放后造影,显示瘘口消失,略有对比剂内漏(图1e)。术后即刻行血管造影计算机体层扫描(Dyna CT),未见颅内明显出血。术后继续双抗治疗(氯吡格雷75mg+阿司匹林100mg/d)3个月。术后1个月随访,突眼及杂音消失,复查CT血管成像(CTA)显示右侧颈内动脉通畅,瘘口完全消失(图1f)。



图1患者1治疗前后影像资料。1a右侧颈内动脉造影侧位,示右侧颈内动脉海绵窦瘘,盗血明显;1b在路径图下示Navien5F越过瘘口处,同时将Willis支架4.5mm×16.0mm输送到中间导管远端;1c路径图下示回撤中间导管,支架定位在瘘口处;1d路径图下示缓慢充盈球囊至608kPa(6atm)打开支架;1e置入支架后即刻右侧颈内动脉造影,侧位示颈内动脉恢复血流,瘘口有少许对比剂内漏;1f术后1个月CT血管成像复查,示右侧颈内动脉通畅,瘘口消失
 
患者2:女,76岁,2018年1月因右眼睑下垂伴头痛3周入住常州市第一人民医院。神经系统检查:意识清楚,右眼睑下垂,诊断为右侧眼球外下固定,四肢活动正常。MRI、CTA示鞍区右侧占位,右侧颈内动脉海绵窦段巨大动脉瘤。行全脑DSA,明确诊断为右侧颈内动脉海绵窦段动脉瘤,大小为22mm×17mm×8mm(图2a)。口服氯吡格雷75mg+阿司匹林100mg/d,5d后测血栓弹力图,示双抗达标,遂行右侧颈内动脉动脉瘤Willis覆膜支架腔内隔绝术。全身麻醉下穿刺右侧股动脉,肝素化用法同患者1。
 
将6F长鞘(Cook,bloomington,USA)经股动脉选择性置于右侧颈内动脉C2段。在路径图下,使5F Navien中间导管在0.89mm(0.035in)导丝导引下到达颈内动脉岩骨段,再通过0.36mm(0.014in)导丝结合微导管同轴技术,将5F Navien中间导管越过眼动脉到达颅内段,Willis覆膜支架4mm×13mm在0.36mm导丝导引下输送至中间导管头端(图2b),然后边回撤中间导管边将支架调整到动脉瘤颈处(图2c),确定支架近远端覆盖瘤颈后,缓慢充盈球囊并以608kPa(6atm)的压力维持约10s释放支架(图2d)。支架释放后造影未见动脉瘤显影,颈内动脉通畅(图2e)。术后即刻DynaCT示颅内未见明显出血。术后左上肢肌力Ⅲ级,MR扩散加权成像显示右侧顶叶散在小梗死灶,考虑为术中输送中间导管时颈内动脉微小斑块脱落造成,10d后好转。术后继续双抗治疗(氯吡格雷75mg+阿司匹林100mg/d)3个月。3个月随访,右侧眼睑中度上抬,左侧上肢肌力恢复正常,复查CTA显示右侧颈内动脉通畅,动脉瘤消失(图2f)。



图2患者2治疗前后影像资料。2a右侧颈内动脉造影三维成像,示右侧颈内动脉海绵窦段巨大动脉瘤;2b路径图示使用同轴技术Navien5F越过动脉瘤颈,将Willis支架4mm×13mm输送至中间导管头端;2c右侧颈内动脉工作角度造影,示中间导管回撤支架定位在动脉瘤颈;2d工作角度透视示充盈球囊打开支架;2e支架置入即刻右侧颈内动脉正位造影,示颈内动脉通畅,动脉瘤消失;2f术后3个月CT血管成像复查,示右侧颈内动脉海绵窦段动脉瘤无复发
 
讨论
 
血管内介入技术作为颅内动脉瘤的首选治疗方法,仍存在局限性,如对大型或巨大型动脉瘤不易致密填塞,复发率较高。再如假性动脉瘤,即使采用修饰性弹簧圈结合多支架技术,载瘤动脉壁本身的修复依然使术者担心。面对同样是动脉壁损伤的TCCF,如何更好地修复破损的血管壁,也是术者在闭塞海绵窦瘘口时需格外关注的。近年来,引人关注的方法是使用覆膜支架永久性封闭动脉瘤颈或动脉破损处,而无需使用弹簧圈栓塞。
 
Willis覆膜支架系统由3部分组成:裸支架、自膨式聚四氟乙烯(ePTFE)膜和低顺应性、柔顺性的球囊导管。由于支架整体在透视下可见,有助于支架的精确定位,输送系统直径约3.8F。对于筛选后的颅内血泡样动脉瘤、海绵窦段巨大动脉瘤、假性或夹层动脉瘤和TCCF,覆膜支架可能是消除病变、解决占位效应、保留载瘤动脉最有效的材料,能够提供更为确实的血管重建。但颅内血管有别于外周血管,路径迂曲,覆膜支架用于颅内血管最大困难是有限的顺应性和到位能力。
 
早期,笔者在使用Willis支架时,因为颈内动脉海绵窦段或眼动脉段过于迂曲,在交换导丝技术下仍然无法通过,造成治疗失败退而求次使用其他技术。田彦龙等报道使用Willis的7例患者中,有1例颈内动脉海绵窦段巨大型宽颈动脉瘤,选用4.5mm×16.0mm的覆膜支架,在输送过程中无法通过迂曲的颈内动脉,导致支架从球囊上脱落。Zhang等报道在治疗2例前壁血泡样动脉瘤时,Willis支架在输送进入颅内时,均发生了支架脱落。即使以上意外有其他原因的存在,但血管迂曲、覆膜支架输送性差是不可否认的原因之一。
 
近几年,随着中间导管用于血管内介入治疗,如Navien中间导管,其到位较高,提供较强支撑力,为输送Willis支架提供了新的思路。在大多数治疗中,神经介入医师只是将中间导管输送至尽量接近病变处以提供强有力的支撑,希望Willis支架顺利到达病变部位。但对一些血管迂曲的病变,仅依靠近端支撑、交换导丝导引等技术,仍然无法将顺应性差的长覆膜支架输送到位。“特洛伊木马”技术可在中间导管内相对容易地输送Willis支架到达中间导管头端,然后回撤中间导管,支架即可顺利定位在病变部位。
 
“特洛伊木马”技术使用要点如下:(1)尽量使用5F中间导管,输送性更好;(2)中间导管头端蒸汽塑形小弯;(3)微导丝、微导管同轴系统输送中间导管,必要时使用球囊、Solitaire支架辅助提供反张力输送中间导管;(4)中间导管长度宜<125 cm,否则Willis支架无法突出中间导管头端;(5)使用6F90 cm长鞘提供近端支撑。笔者的初步经验显示,“特洛伊木马”技术对国产Willis覆膜支架到位有一定的帮助,操作简便,提高支架输送准确性,降低并发症,并为一些到位困难的支架提供新的操作思路。
 
原始出处:

彭亚,宣井岗,陈荣华,邵华明,朱旭成,曹洁.中间导管“特洛伊木马”技术输送Willis覆膜支架行颅内动脉腔内隔绝术治疗颈内动脉海绵窦病变[J].中国脑血管病杂志,2018(09):489-492+495.

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#插入话题
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  3. [GetPortalCommentsPageByObjectIdResponse(id=1972267, encodeId=be3619e226746, content=<a href='/topic/show?id=f4bf1869ec7' target=_blank style='color:#2F92EE;'>#Willis覆膜支架#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=18697, encryptionId=f4bf1869ec7, topicName=Willis覆膜支架)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=4b1f500, createdName=zengjiayao, createdTime=Thu Jun 11 20:08:00 CST 2020, time=2020-06-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1818901, encodeId=d41e1818901b1, content=<a href='/topic/show?id=04c5985e6c8' target=_blank style='color:#2F92EE;'>#隔绝术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=98576, encryptionId=04c5985e6c8, topicName=隔绝术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ad9f79, createdName=般若傻瓜, createdTime=Wed Aug 26 20:08:00 CST 2020, time=2020-08-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1820255, encodeId=0ebf18202550d, content=<a href='/topic/show?id=eb271003894b' target=_blank style='color:#2F92EE;'>#颅内动脉腔内#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100389, encryptionId=eb271003894b, topicName=颅内动脉腔内)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a5d7367, createdName=zhwj, createdTime=Sun Aug 09 04:08:00 CST 2020, time=2020-08-09, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1956173, encodeId=339a19561e300, content=<a href='/topic/show?id=567f905e2b2' target=_blank style='color:#2F92EE;'>#覆膜支架#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=90572, encryptionId=567f905e2b2, topicName=覆膜支架)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdqq.qlogo.cn/qqapp/1103841572/F82CC4A89F97BD21D3DDB7AD5F2AD09D/100, createdBy=52952500022, createdName=ms6829001416292975, createdTime=Wed Jan 15 15:08:00 CST 2020, time=2020-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1810550, encodeId=fc09181055066, content=<a href='/topic/show?id=6be18536e84' target=_blank style='color:#2F92EE;'>#腔内隔绝术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=28, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85367, encryptionId=6be18536e84, topicName=腔内隔绝术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e05e201, createdName=appleandpeer, createdTime=Fri Apr 17 11:08:00 CST 2020, time=2020-04-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2019561, encodeId=c191201956149, content=<a href='/topic/show?id=b66068019c6' target=_blank style='color:#2F92EE;'>#特洛伊木马#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=68019, encryptionId=b66068019c6, topicName=特洛伊木马)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdqq.qlogo.cn/qqapp/1103841572/F82CC4A89F97BD21D3DDB7AD5F2AD09D/100, createdBy=52952500022, createdName=ms6829001416292975, createdTime=Sat Mar 07 22:08:00 CST 2020, time=2020-03-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1615748, encodeId=fc741615e4892, content=<a href='/topic/show?id=4b501005114a' target=_blank style='color:#2F92EE;'>#颈内动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=100511, encryptionId=4b501005114a, topicName=颈内动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=71c019667486, createdName=644982816_68283327, createdTime=Sun Nov 24 04:08:00 CST 2019, time=2019-11-24, status=1, ipAttribution=)]
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