Bergeron P, Chambran P, Bianca S, Benichou H, Massonat J
Service de Chirurgie cardio-thoracique, Fondation hôpital Saint Joseph, Marseille.
J Mal Vasc. 1996;21 Suppl A:123-31.
Evaluate endovascular treatment of vessels irrigating the brain. Assess risks and indications of balloon angioplasty and stents.
Retrospective study in 38 patients (6 females, 32 males) who underwent revascularization from December 1990 to July 1995: 47 balloon angioplasties and 17 stents (36%). Three patients were asymtomatic, 17 had a past history of transient ischaemia, 5 had amauraosis, 9 signs of vertebrobasilar insufficiency and 2 had an ischaemia of the upper limbs. Endoluminal treatment was performed in 4 brachiocephalic trunks with implantation of 1 stent, in 7 common carotid arteries with 4 stents, in 24 internal carotid arteries with 9 stents, 2 osteal stenosis of the vertebral artery and one external carotid.
There were no complications in patients treated for lesions of the brachiocephalic trunk, the subclavian artery and the vertebral arteries. Among the 7 patients with a stenosis of the common carotid artery, there was one death after reperfusion due to cerebral oedema. For the carotid internal, two groups of patients could be distinguished. In one group of 13 patients with restenosis of the internal carotid artery who were treated by balloon angioplasty, there were 3 transient episodes of ischaemia, one reversible hemiplegia and one silent infarction. A second group of 8 patients had atheromatous stenosis. One was treated by balloon angioplasty with one transient episode of ischaemia and the 7 others were treated with a stent without complications. The rate of neurological complications was 15.7% (6 deficits in 38 patients). The permeability after revascularization was verified at mid-term with repeated echo-Doppler examinations and by angiography one year after operation. Restenosis occurred early after one subclavian stent covered with a patch. Among the 16 Palmaz stents, one implanted in a post-irradiation common carotid occluded after 2 months. The other 15 stents were patent at a mean follow-up of 18 months (2-56), i.e. 93%. There were 2 restenoses after balloon angioplasty in the group of carotid restenosis, i.e. 15%.
Risk in balloon angioplasty of arteries irrigating the brain is a serious problem. Stenosis of the subclavian artery and the vertebral arteries appears to be a good indication. Lesions of the carotid bifurcation should not be treated with balloon angioplasty due to the risk of neurological complications. Among the restenosis after endarterectomy, only those lesions situated in the distal internal carotid are good indications. Stents have greatly improved treatment possibilities. They should be implanted whenever there is a risk of supra-aortic lesions and in certain lesions of the carotid bifurcation in high-risk, patients. Their application in all situations cannot be proposed yet before long-term outcome is established.
评估脑部供血血管的血管内治疗。评估球囊血管成形术和支架的风险及适应证。
对1990年12月至1995年7月期间接受血运重建的38例患者（6例女性，32例男性）进行回顾性研究：47例球囊血管成形术和17例支架置入术（36%）。3例患者无症状，17例有短暂性缺血病史，5例有黑矇，9例有椎基底动脉供血不足体征，2例有上肢缺血。在4例头臂干进行了腔内治疗并植入1枚支架，在7例颈总动脉植入4枚支架，在24例颈内动脉植入9枚支架，2例椎动脉骨部狭窄和1例颈外动脉进行了治疗。
头臂干、锁骨下动脉和椎动脉病变治疗的患者无并发症。7例颈总动脉狭窄患者中，1例再灌注后因脑水肿死亡。对于颈内动脉，可区分两组患者。一组13例颈内动脉再狭窄患者接受球囊血管成形术治疗，发生3次短暂性缺血发作、1例可逆性偏瘫和1例无症状性梗死。另一组8例患者为动脉粥样硬化性狭窄。1例接受球囊血管成形术治疗，发生1次短暂性缺血发作，其他7例接受支架置入术，无并发症。神经并发症发生率为15.7%（38例患者中有6例出现功能缺损）。血运重建后的通畅情况在中期通过重复超声多普勒检查和术后1年血管造影进行验证。1枚覆盖补片的锁骨下支架术后早期发生再狭窄。16枚帕尔马兹支架中，1枚植入放疗后的颈总动脉，2个月后闭塞。其他15枚支架在平均18个月（2 - 56个月）的随访中通畅，即通畅率为93%。颈内动脉再狭窄组球囊血管成形术后有2例再狭窄，即15%。
脑部供血动脉球囊血管成形术的风险是一个严重问题。锁骨下动脉和椎动脉狭窄似乎是良好的适应证。由于存在神经并发症风险，颈总动脉分叉处病变不应采用球囊血管成形术治疗。在动脉内膜切除术后的再狭窄中，只有位于颈内动脉远端的病变是良好的适应证。支架极大地改善了治疗可能性。对于存在主动脉弓以上病变风险的情况以及高危患者颈总动脉分叉处的某些病变，应植入支架。在确定长期疗效之前，尚不能建议在所有情况下应用支架。
