支架取栓术再通失败的原因：注册分析与分类系统的提出。
Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System.
机构信息
From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., J.G., P.J. Mosimann, F.Z., E.P., T.D., P. Mordasini).
Department of Neurology (J.K., M.R.H., M.A., U.F.), University Hospital Bern and University of Bern, Inselspital, Bern, Switzerland.
出版信息
AJNR Am J Neuroradiol. 2018 Oct;39(10):1848-1853. doi: 10.3174/ajnr.A5759. Epub 2018 Aug 30.
BACKGROUND AND PURPOSE
In 5%-10% of patients with acute ischemic stroke with an intention to treat with mechanical thrombectomy, no reperfusion can be achieved (Thrombolysis in Cerebral Infarction score = 0/1). Purpose of this analysis was a systematic assessment of underlying reasons for reperfusion failures.
MATERIALS AND METHODS
An intention-to-treat single-center cohort ( = 592) was re-evaluated for all patients in whom no reperfusion could be achieved ( = 63). Baseline characteristics of patients were compared between patients with and without reperfusion failures. After qualitative review of all cases with reperfusion failures, a classification system was proposed and relative frequencies were reported. In a second step, occurrence of delayed recanalization at 24 hours after reperfusion failure and dependency on IV-tPA were evaluated.
RESULTS
In 63/592 patients with an intention to perform stent-retriever thrombectomy, no reperfusion was achieved (TICI 0/1, 10.6%, 95% CI, 8.2%-13.1%). Older patients (adjusted OR per yr = 1.03; 95% CI, 1.01-1.05) and patients with M2 occlusion (adjusted OR = 3.36; 95% CI, 1.82-6.21) were at higher risk for reperfusion failure. In most cases, no reperfusion was a consequence of technical difficulties (56/63, 88.9%). In one-third of these cases, reperfusion failures were due to the inability to reach the target occlusion (20/63, 31.7%), while "stent-retriever failure" occurred in 39.7% (25/63) of patients. Delayed recanalization was very rare (18.2%), without dependence on IV-tPA pretreatment status.
CONCLUSIONS
Reasons for reperfusion failure in stent-retriever thrombectomy are heterogeneous. The failure to establish intracranial or cervical access is almost as common as stent-retriever failure after establishing intracranial access. Systematic reporting standards of reasons may help to further estimate relative frequencies and thereby guide priorities for technical development and scientific effort.
背景与目的
在接受机械取栓治疗的急性缺血性脑卒中患者中，有 5%-10%的患者无法实现再灌注（血栓切除术脑梗死评分=0/1）。本分析的目的是系统评估再灌注失败的潜在原因。
材料与方法
对 592 例接受支架取栓治疗的患者进行意向治疗单中心队列分析，其中 63 例患者未能实现再灌注（=63）。比较再灌注成功与失败患者的基线特征。对所有再灌注失败的病例进行定性分析后，提出了一种分类系统，并报告了相对频率。在第二步中，评估再灌注失败 24 小时后的延迟再通和 IV-tPA 的依赖性。
结果
在 592 例拟行支架取栓治疗的患者中，有 63 例未实现再灌注（TICI 0/1，10.6%，95%CI 8.2%-13.1%）。年龄较大的患者（每增加 1 岁的调整优势比=1.03；95%CI 1.01-1.05）和 M2 闭塞的患者（调整优势比=3.36；95%CI 1.82-6.21）再灌注失败的风险更高。在大多数情况下，无再灌注是技术困难的结果（56/63，88.9%）。在这些病例的三分之一中，再灌注失败是由于无法到达目标闭塞部位（20/63，31.7%），而“支架取栓失败”发生在 39.7%（25/63）的患者中。延迟再通非常罕见（18.2%），与 IV-tPA 预处理状态无关。
结论
支架取栓治疗中再灌注失败的原因是多种多样的。未能建立颅内或颈部通路与建立颅内通路后支架取栓失败的发生率几乎相同。系统报告原因的标准可能有助于进一步估计相对频率，从而指导技术发展和科学努力的优先级。
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