Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China.
Department of Neurology, Third Affiliated Hospital of Second Military Medical University, Shanghai, China.
Vascular. 2021 Aug;29(4):535-542. doi: 10.1177/1708538120965300. Epub 2020 Nov 23.
Cerebral hyperperfusion syndrome is a fatal complication that can occur after stent angioplasty in patients with severe carotid artery stenosis. Staged angioplasty can prevent cerebral hyperperfusion syndrome. Conventional staged angioplasty consists of small balloon angioplasty in the first stage and carotid artery stenting in the second stage two to four weeks later. Sometimes, antegrade flow during stage 1 could hardly be maintained and stent will be needed. Solitaire stents were used in some patients in our center. This study aimed to examine the safety and effectiveness of Solitaire stents in staged angioplasty.
A retrospective analysis was performed on patients with severe carotid artery stenosis and preoperative computed tomography perfusion indicating risk of cerebral hyperperfusion syndrome from 2011 to 2018. Small balloon angioplasty (<3 mm in diameter) only was performed in stage 1 (group 1). If antegrade flow during stage 1 is compromised, then a solitaire stent is deployed (group 2). After two to four weeks, cerebral angiography was undertaken in both groups to determine whether to perform stage 2. If the residual stenosis was more than 50%, carotid artery stenting was deployed. Angiographic results, clinical results, and follow-up results were collected and analyzed.
Twenty-five patients were included in the study (group 1, = 19; group 2, = 6). After stage 1, no patient in group 2 and two patients in group 1 developed new symptomatic cerebral infarction (0.0% vs. 10.5%, =1.000). One patient in group 2 and three patients in group 1 (16.7% vs. 15.8%, =1.000) developed symptomatic cerebral hyperperfusion syndrome. One patient in group 2 ( = 4) and three patients in group 1 ( = 12) (25% vs. 25%, =1.000) developed hyperperfusion phenomenon. Two patients in group 2 and five patients in group 1 (33.3% vs. 26.3%, =1.000) developed symptomatic cerebral hyperperfusion syndrome or hyperperfusion phenomenon. One patient in group 1 developed symptomatic cerebral hyperperfusion syndrome and hyperperfusion phenomenon. After stage 2, no new cerebral infarction occurred in both groups. No patient in group 2 ( = 3) and one patient in group 1 ( = 17) developed symptomatic cerebral hyperperfusion syndrome (0.0% vs. 5.9%, =1.000). In the combined analysis of both stages, two patients (10.5%) developed new symptomatic cerebral infarction and four patients (21.1%) developed symptomatic cerebral hyperperfusion syndrome in group 1, no patient (0.0%) developed symptomatic cerebral infarction and one patient (16.7%) developed symptomatic cerebral hyperperfusion syndrome in group 2. There was no significant difference in symptomatic cerebral infarction and symptomatic cerebral hyperperfusion syndrome between the two groups ( = 1.000; = 1.000). Three patients in group 2 and 17 patients in group 1 (50% vs. 89.5%, =0.070) underwent stage 2 angioplasty. No cerebral hemorrhage or cerebral infarction occurred in the Solitaire group during the one-year follow-up period.
Solitaire stents deployment may reduce ischemic events in staged angioplasty for severe carotid stenosis.
严重颈动脉狭窄患者支架血管成形术后可发生致命性的脑过度灌注综合征。分期血管成形术可以预防脑过度灌注综合征。传统的分期血管成形术由第一阶段的小球囊血管成形术和第二阶段的颈动脉支架置入术组成，间隔两到四周。有时，第一阶段的前向血流难以维持，需要支架。我们中心的一些患者使用 Solitaire 支架。本研究旨在检查 Solitaire 支架在分期血管成形术中的安全性和有效性。
对 2011 年至 2018 年术前 CT 灌注显示有脑过度灌注综合征风险的严重颈动脉狭窄患者进行回顾性分析。第一阶段仅行小球囊血管成形术（直径<3mm）（组 1）。如果第一阶段的前向血流受损，则放置 Solitaire 支架（组 2）。两到四周后，两组均行脑血管造影以确定是否进行第二阶段。如果残余狭窄超过 50%，则行颈动脉支架置入术。收集并分析血管造影结果、临床结果和随访结果。
本研究共纳入 25 例患者（组 1，n=19；组 2，n=6）。第一阶段后，组 2 中无患者发生新的症状性脑梗死，而组 1 中有 2 例（0.0%比 10.5%，=1.000）。组 2 中有 1 例和组 1 中有 3 例（16.7%比 15.8%，=1.000）发生症状性脑过度灌注综合征。组 2 中有 1 例（4%）和组 1 中有 3 例（12%）（25%比 25%，=1.000）发生过度灌注现象。组 2 中有 2 例（33.3%）和组 1 中有 5 例（26.3%）（33.3%比 26.3%，=1.000）发生症状性脑过度灌注综合征或过度灌注现象。组 1 中有 1 例发生症状性脑过度灌注综合征和过度灌注现象。第二阶段后，两组均无新的脑梗死发生。组 2 中无患者（0.0%）和组 1 中有 1 例（5.9%）发生症状性脑过度灌注综合征（0.0%比 5.9%，=1.000）。在两阶段的联合分析中，组 1 中有 2 例（10.5%）发生新的症状性脑梗死，4 例（21.1%）发生症状性脑过度灌注综合征，组 2 中无患者发生症状性脑梗死，1 例（16.7%）发生症状性脑过度灌注综合征。两组之间在症状性脑梗死和症状性脑过度灌注综合征方面无显著差异（=1.000；=1.000）。组 2 中有 3 例和组 1 中有 17 例（50%比 89.5%，=0.070）行第二阶段血管成形术。Solitaire 组在一年的随访期间未发生脑出血或脑梗死。
在严重颈动脉狭窄的分期血管成形术中放置 Solitaire 支架可减少缺血性事件。
