血管内支架置入术在治疗钝性脑血管损伤中的作用变化。
The changing role of endovascular stenting for blunt cerebrovascular injuries.
机构信息
From the Department of Surgery (C.P.S., J.P.S., S.M.S., N.R.M., D.M.F., T.C.F., M.A.C., L.J.M.), University of Tennessee Health Science Center, Memphis, Tennessee.
出版信息
J Trauma Acute Care Surg. 2018 Feb;84(2):308-311. doi: 10.1097/TA.0000000000001740.
BACKGROUND
Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVIs). Without question, early anticoagulation is the mainstay of therapy for these injuries. However, the role of endovascular stenting for BCVI remains controversial. Our purpose was to examine the use of endovascular stents for BCVI and outcomes and describe which injuries are being treated with stents.
METHODS
Patients with BCVI from 2011 to 2016 were identified and stratified by age, sex, and injury severity. Patients were then divided into two groups (previous study [PS] = 2011-2012 and current study [CS] = 2013-2016) based on a paradigm shift in BCVI diagnosis and treatment at our institution. Beginning in 2013, a multidisciplinary team assumed care of patients with BCVI from interventional radiology. Digital subtraction angiography was used to confirmatory injuries in both groups and heparin used for initial therapy.
RESULTS
In the CS, 237 patients were diagnosed with BCVI compared with 128 patients in the PS. Both groups were clinically similar with no difference in distribution of vessels injured. Beginning in 2013, there was a significant decrease in the use of stents for these injuries. In fact, in the CS, only 21 (8.9%) patients were treated with endovascular stenting compared to 44 (34%) patients in the PS. Of patients in the CS, 14 had grade III pseudoaneurysms and seven had grade II dissections. Despite this reduction in stenting, there was no significant change in the BCVI-related stroke rate between the CS and the PS (4.2% vs. 3.9%).
CONCLUSION
Anticoagulation alone is adequate therapy for the majority of BCVI. Nevertheless, there is still a role for endovascular stents in the treatment of BCVI. Their use should be reserved for enlarging carotid pseudoaneurysms and dissections with significant narrowing. The prospect of determining which injuries benefit from stent placement warrants prospective investigation.
LEVEL OF EVIDENCE
Therapuetic/care management, level IV.
背景
就管理而言，很少有损伤像钝性脑血管损伤 (BCVI) 那样引起如此多的争论。毫无疑问，早期抗凝是这些损伤治疗的主要方法。然而，血管内支架治疗 BCVI 的作用仍然存在争议。我们的目的是检查 BCVI 的血管内支架治疗和结果，并描述哪些损伤正在用支架治疗。
方法
从 2011 年到 2016 年，确定了 BCVI 患者，并按年龄、性别和损伤严重程度进行分层。然后，根据我院 BCVI 诊断和治疗范式的转变，将患者分为两组（既往研究 [PS] = 2011-2012 年和当前研究 [CS] = 2013-2016 年）。从 2013 年开始，多学科团队从介入放射学开始负责 BCVI 患者的治疗。数字减影血管造影用于在两组中确认损伤，并在初始治疗中使用肝素。
结果
在 CS 中，诊断为 BCVI 的患者有 237 例，而 PS 组有 128 例。两组的临床特征相似，受伤血管的分布无差异。从 2013 年开始，这些损伤使用支架治疗的比例显著下降。事实上，在 CS 中，只有 21 例（8.9%）患者接受了血管内支架治疗，而 PS 组有 44 例（34%）。CS 组中有 14 例患者为 III 级假性动脉瘤，7 例为 II 级夹层。尽管支架治疗减少，但 CS 组与 PS 组的 BCVI 相关卒中率没有明显变化（4.2%比 3.9%）。
结论
抗凝治疗是大多数 BCVI 的充分治疗方法。然而，血管内支架在 BCVI 的治疗中仍然有作用。它们的使用应保留用于扩大有明显狭窄的颈动脉假性动脉瘤和夹层。确定哪些损伤受益于支架放置的前景需要前瞻性研究。
证据水平
治疗/护理管理，IV 级。
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