Faggioli Gianluca, Ferri Monica, Rapezzi Claudio, Tonon Caterina, Manzoli Lamberto, Stella Andrea
Department of Vascular Surgery, University of Bologna, Bologna, Italy.
J Vasc Surg. 2009 Jan;49(1):80-5. doi: 10.1016/j.jvs.2008.08.014. Epub 2008 Oct 22.
Carotid artery stenting (CAS) leads to frequent embolic brain lesions; their source has not been clearly identified yet. In order to investigate this phenomenon, we have evaluated embolic brain lesions (BL) after CAS and correlated them with aortic arch (AA) characteristics.
The AAs of 59 patients undergoing CAS under distal protection were evaluated by angiography and transesophageal echocardiography (TEE). AAs were stratified according to morphology (type I and II "simple" vs type III and bovine "difficult"), atherosclerotic arch lesions (complicated: >5 mm or with mobile debris vs uncomplicated: <5 mm), and tortuosity index (TI; sum of all angles diverging from ideal carotid axis, <150 vs >150). Diffusion weighted imaging (DWI) was performed before and within 24 hours from CAS. New BL were considered ipsilateral (IL) if ipsilateral to the site of CAS and non-ipsilateral (CL) if contralateral to it or bilateral. Normality distribution was by Shapiro-Wilk test (variables reported as medians +/- interquartile range) and statistical significance (P < .05) by Wilcoxon and Fisher's exact test.
Difficult arches were present in 17 patients (28.8%), complicated aortic plaque in 21 (35.5%), and TI > 150 in 34 (57.6%). New BL appeared in 34 or 57.6% patients (6 or 18% IL and 28 or 82% CL). The mean number of BL was 5.7 (range, 0 to 20), 4.7 IL, and 5.7 CL, with a median volume of 560.95 +/- 1677.7 mm(3). Type of arch and TI were not correlated with mean number of BL. Mean volume of BL were greater in patients with difficult AA, complicated plaques, and TI > 150 (258 (572) mm(3) vs 15.6 (353) mm(3), P = .2; and 86 (828) mm(3) vs 85.9 (352) mm(3), P = .4 172 (766) mm(3) vs 0 (228) mm(3), P = .06, respectively). In patients with all three AA characteristics, mean number and volume of BL was significantly greater compared with other patients. Specifically, this increase was due mainly to CL (IL 0 (117) mm(3) vs 0 (172) mm(3), P = .9; CL 564 (687) mm(3) vs 0 (133) mm(3), P = .001). None of the technical details considered was correlated with either IL or CL.
BL are frequent after protected CAS and are correlated with AA characteristics, thus underlining the role of catheterization maneuvers in determining embolic events. TEE may be useful in patient's selection for CAS.
颈动脉支架置入术（CAS）常导致脑栓塞性病变；其来源尚未明确。为研究这一现象，我们评估了CAS术后的脑栓塞性病变（BL），并将其与主动脉弓（AA）特征相关联。
对59例行远端保护下CAS的患者的AA进行血管造影和经食管超声心动图（TEE）评估。根据形态（I型和II型“简单”与III型和牛型“复杂”）、动脉粥样硬化弓病变（复杂：>5 mm或有活动碎片与不复杂：<5 mm）以及迂曲指数（TI；偏离理想颈动脉轴的所有角度之和，<150与>150）对AA进行分层。在CAS术前及术后24小时内进行扩散加权成像（DWI）。新出现的BL如果与CAS部位同侧则视为同侧（IL），如果与CAS部位对侧或双侧出现则视为非同侧（CL）。通过Shapiro-Wilk检验进行正态分布检验（变量以中位数±四分位数间距报告），通过Wilcoxon检验和Fisher精确检验进行统计学显著性检验（P < 0.05）。
17例患者（28.8%）存在复杂弓，21例（35.5%）存在复杂主动脉斑块，34例（57.6%）TI>150。34例患者（57.6%）出现新的BL（6例或18%为IL，28例或82%为CL）。BL的平均数量为5.7（范围0至20），IL为4.7，CL为5.7，中位数体积为560.95±1677.7 mm³。弓的类型和TI与BL的平均数量无关。AA复杂、存在复杂斑块和TI>150的患者BL的平均体积更大（分别为258（572）mm³对15.6（353）mm³，P = 0.2；86（828）mm³对85.9（352）mm³，P = 0.4；172（766）mm³对0（228）mm³，P = 0.06）。具有所有三种AA特征的患者中，BL的平均数量和体积显著高于其他患者。具体而言，这种增加主要归因于CL（IL为0（117）mm³对0（172）mm³，P = 0.9；CL为564（687）mm³对0（133）mm³，P = 0.001）。所考虑的技术细节均与IL或CL无关。
在有保护措施的CAS术后BL很常见，且与AA特征相关，从而强调了导管操作在确定栓塞事件中的作用。TEE可能有助于CAS患者的选择。
