经桡动脉或肱动脉途径行近端栓子保护的颈动脉支架置入术：在保持安全性和有效性的同时拓展技术边界
Carotid Artery Stenting With Proximal Embolic Protection via a Transradial or Transbrachial Approach: Pushing the Boundaries of the Technique While Maintaining Safety and Efficacy.
作者信息
Montorsi Piero, Galli Stefano, Ravagnani Paolo M, Tresoldi Simone, Teruzzi Giovanni, Caputi Luigi, Trabattoni Daniela, Fabbiocchi Franco, Calligaris Giuseppe, Grancini Luca, Lualdi Alessandro, de Martini Stefano, Bartorelli Antonio L
机构信息
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy
Department of Clinical Sciences and Community Health, University of Milan, Italy Centro Cardiologico Monzino, IRCCS, Milan, Italy.
出版信息
J Endovasc Ther. 2016 Aug;23(4):549-60. doi: 10.1177/1526602816651424. Epub 2016 Jun 6.
PURPOSE
To compare the feasibility and safety of proximal cerebral protection to a distal filter during carotid artery stenting (CAS) via a transbrachial (TB) or transradial (TR) approach.
METHODS
Among 856 patients who underwent CAS between January 2007 and July 2015, 214 (25%) patients (mean age 72±8 years; 154 men) had the procedure via a TR (n=154) or TB (n=60) approach with either Mo.MA proximal protection (n=61) or distal filter protection (n=153). The Mo.MA group (mean age 73±7 years; 54 men) had significantly more men and more severe stenosis than the filter group (mean age 71±8 years; 100 men). Stent type and CAS technique were left to operator discretion. Heparin and a dedicated closure device or bivalirudin and manual compression were used in TR and TB accesses, respectively. Technical and procedure success, crossover to femoral artery, 30-day major adverse cardiovascular/cerebrovascular events (MACCE; death, all strokes, and myocardial infarction), vascular complications, and radiation exposure were compared between groups.
RESULTS
Crossover to a femoral approach was required in 1/61 (1.6%) Mo.MA patient vs 11/153 (7.1%) filter patients mainly due to technical difficulty in engaging the target vessel. Five Mo.MA patients developed acute intolerance to proximal occlusion; 4 were successfully shifted to filter protection. A TR patient was shifted to filter because the Mo.MA system was too short. CAS was technically successful in the remaining 55 (90%) Mo.MA patients and 142 (93%) filter patients. The MACCE rate was 0% in the Mo.MA patients and 2.8% in the filter group (p=0.18). Radiation exposure was similar between groups. Major vascular complications occurred in 1/61 (1.6%) and in 3/153 (1.96%) patients in the Mo.MA and filter groups (p=0.18), respectively, and were confined to the TB approach in the early part of the learning curve. Chronic radial artery occlusion was detected by Doppler ultrasound in 2/30 (6.6%) Mo.MA patients and in 4/124 (3.2%) filter patients by clinical assessment (p=0.25) at 8.1±7.5-month follow-up.
CONCLUSION
CAS with proximal protection via a TR or TB approach is a feasible, safe, and effective technique with a low rate of vascular complications.
目的
比较经肱动脉（TB）或经桡动脉（TR）途径行颈动脉支架置入术（CAS）时，近端脑保护与远端滤网保护的可行性和安全性。
方法
在2007年1月至2015年7月期间接受CAS的856例患者中，214例（25%）患者（平均年龄72±8岁；154例男性）通过TR（n = 154）或TB（n = 60）途径接受手术，采用Mo.MA近端保护（n = 61）或远端滤网保护（n = 153）。Mo.MA组（平均年龄73±7岁；54例男性）的男性患者明显更多，狭窄程度也比滤网组（平均年龄71±8岁；100例男性）更严重。支架类型和CAS技术由术者自行决定。TR和TB入路分别使用肝素和专用闭合装置或比伐卢定和手动压迫。比较两组之间的技术和手术成功率、转为股动脉入路、30天主要不良心血管/脑血管事件（MACCE；死亡、所有卒中及心肌梗死）、血管并发症及辐射暴露情况。
结果
1/61例（1.6%）Mo.MA患者与11/153例（7.1%）滤网患者需要转为股动脉入路，主要原因是进入靶血管存在技术困难。5例Mo.MA患者出现对近端闭塞的急性不耐受；4例成功转为滤网保护。1例TR患者因Mo.MA系统太短而转为滤网保护。其余55例（90%）Mo.MA患者和142例（93%）滤网患者的CAS技术成功。Mo.MA组患者的MACCE发生率为0%，滤网组为2.8%（p = 0.18）。两组之间的辐射暴露相似。Mo.MA组和滤网组分别有1/61例（1.6%）和3/153例（1.96%）患者发生主要血管并发症（p = 0.18），且均局限于学习曲线早期的TB入路。在8.1±7.5个月的随访中，通过多普勒超声在2/30例（6.6%）Mo.MA患者中检测到慢性桡动脉闭塞，通过临床评估在4/124例（3.2%）滤网患者中检测到慢性桡动脉闭塞（p = 0.25）。
结论
经TR或TB途径行近端保护的CAS是一种可行、安全且有效的技术，血管并发症发生率低。
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