微小血管：67 例小于 2.0mm 的远端血管动脉瘤的血流导向装置治疗。
Tiny Pipes: 67 Cases of Flow Diversion for Aneurysms in Distal Vessels Measuring Less Than 2.0 mm.
机构信息
Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Department of Neurosurgery, University of California Irvine, Orange, California, USA.
出版信息
World Neurosurg. 2019 Jul;127:e193-e201. doi: 10.1016/j.wneu.2019.02.204. Epub 2019 Mar 13.
BACKGROUND
Flow diversion is increasingly used for off-label treatments of distal circulation aneurysms. Reports of use in sub-2.0-mm vessels are scant.
METHODS
A prospectively collected, institutional review board-approved cerebral aneurysm database was reviewed to identify patients who underwent flow diversion with a 2.5-mm diameter Pipeline embolization device.
RESULTS
Sixty-seven aneurysms were treated in 67 procedures (66 [99%] successful, 64 [96%] single device, 2 [3%] with 2 devices) in 57 patients. Average age was 56 years and 60% were female. Aneurysm location was 51 (76%) anterior cerebral artery, 14 (21%) middle cerebral artery, and 2 (3%) posterior cerebral artery. Aneurysm size was 4.1 ± 3.0 mm (1-20 mm). Safety outcomes included 3 major strokes (4.5%) resulting in permanent neurologic deficit (modified Rankin Scale score 6,4,4), including 1 mortality (1.5%). Acute stent thrombosis was observed intraprocedurally or within 24 hours of each stroke. There were 2 small-volume (<10 cm, 40 cm) dependent intracerebral hemorrhage (3.0%) that resolved without permanent neurologic deficit. For effectiveness, 71% of patients underwent follow-up angiography. Complete occlusion was achieved by 88% at 6 months, 86% at 12 months, and 89% at last follow-up. A slight vessel diameter reduction was apparent on average 6.9 months after the procedure, which was statistically significant at the proximal (P = 0.001) but not distal (P = 0.317) device end. Preoperative average parent vessel diameter was 1.9 mm proximally (range, 1.1-2.6 mm) and 1.7 mm distally (range, 1.0-2.3 mm) of the Pipeline embolization device. Follow-up average vessel diameter was 1.7 mm proximally (range, 0.7-2.4 mm) and 1.6 mm distally (range, 0.6-2.1 mm). Flow delay associated with vessel diameter reduction occurred once. There were no cases of asymptomatic vessel occlusion.
CONCLUSIONS
Flow diversion can be safe and effective for aneurysms originating from vessels <2.0 mm in diameter. Heightened vigilance for the prevention and management of acute stent and vessel thrombosis is warranted in these cases.
背景
血流导向装置越来越多地用于治疗远端循环动脉瘤的超适应证治疗。关于在直径<2.0mm 的血管中使用的报告很少。
方法
对前瞻性收集的机构审查委员会批准的脑动脉瘤数据库进行回顾，以确定接受 2.5mm 直径 Pipeline 栓塞装置治疗的患者。
结果
67 例患者 67 例次（66 例[99%]成功，64 例[96%]单次使用装置，2 例[3%]使用 2 个装置）接受了治疗。平均年龄为 56 岁，60%为女性。动脉瘤位置为 51 例（76%）前交通动脉，14 例（21%）大脑中动脉，2 例（3%）后交通动脉。动脉瘤大小为 4.1±3.0mm（1-20mm）。安全性结果包括 3 例（4.5%）大卒中和永久性神经功能缺损（改良 Rankin 量表评分 6、4、4），其中 1 例（1.5%）死亡。术中或每例卒后 24 小时内观察到急性支架内血栓形成。2 例小体积（<10cm，40cm）依赖性颅内出血（3.0%）未遗留永久性神经功能缺损。对于有效性，71%的患者进行了随访血管造影。6 个月时完全闭塞率为 88%，12 个月时为 86%，最后一次随访时为 89%。术后平均 6.9 个月时，支架近端（P=0.001）但支架远端（P=0.317）血管直径缩小，差异有统计学意义。术前近端母血管直径为 1.9mm（范围，1.1-2.6mm），Pipeline 栓塞装置近端为 1.7mm（范围，1.0-2.3mm）。随访时近端血管直径为 1.7mm（范围，0.7-2.4mm），远端血管直径为 1.6mm（范围，0.6-2.1mm）。发生一次与血管直径缩小相关的血流延迟。无症状血管闭塞的病例均未发生。
结论
对于直径<2.0mm 的血管起源的动脉瘤，血流导向装置治疗是安全有效的。在这些情况下，需要警惕急性支架内和血管内血栓形成的预防和管理。
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