Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_3751_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

24 Мб

Скачать

☆

<<< < Предыдущая 1 2 3 4 56 / 436 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

2. Analysis revealed that the risk of stroke was higher in those patients with internal carotid

artery/common carotid artery angulation of greater than or equal to 60% and lower in those patients protectedwithcerebralEPD.

3. Additional risk factors revealed in a systematic review of a total of 56 studies (34,398 patients)

includedincreasedinternalcarotidarterycommoncarotidangulation,left-sidedcarotidangioplasty,and stenting,andtargetinternalcarotidstenosiswasgreaterthan10mm.

a. Type III aortic arch, aortic arch calcification with or without ostial involvement, calcifications,

ulcerations,ordegreeofstenosisdidnotdemonstrateincreaseinstrokeordeathrisk.

b. Therewasnocorrelationfoundbetweenthetypeofstentorthetypeofcerebralprotectiondevicein

thissystematicreview.

4.ThetimingofproceduralstrokesintheEVA-3Sanalysiswasinformative.Among17strokesonday0

(at the time of the procedure) 5 occurred during aortic arch navigation before common carotid cannulation,3 duringnavigationacross the stenosis, 1 duringprotection device placement, and8 after dilatationandstentplacementacrossthestenosis.

C.StatutoryQualityAssurance(2009,2014)

1.ReviewofaGermannationwidestatutoryqualityassurancedatabaseincludingallopensurgicaland

endovascularproceduresontheextracranialcarotidarteryrevealedatotalof13,086stentingprocedures forasymptomaticcarotidstenosisbetween2009and2014.

2.Theuseofembolicprotectionwasindependentlyassociatedwithdecreasedhospitalriskforstrokeor

death.

X.EmbolicProtectionDevices

A.PurposeofEPDs

1. Conceptually there are two primary types ofEPDs thatcan be utilizedto protect against cerebral

embolizationduringcarotidarterystenting,thosethatprovideembolicprotectionfromapositiondistalto thetargetstenosis,andthosethatprovideprotectionfromapositionproximaltothetargetstenosis.

2.TheidealEPDwouldbeeasytouse,providecompleteprotectionforallpartsoftheprocedure,and

shouldbeapplicabletoalltypesofplaque.

3.Thedeviceshouldcapturedebris ofallsizes,andthere shouldbeaplanforeffectiveaspirationof

debrispriortoremovalofthedevice.

B.DistalEmbolicProtection

1. Distalembolicprotectionis performedusingafilterdeviceordistalballoon in theinternalcarotid

artery.

a. Aballoon(orfilter)placedinthedistalinternalcarotidtoprovideembolicprotectiondoesisolate

thebrainfromdebrisduringtheintervention,butplacementrequiresthatthetargetlesionbecrossed priortotheestablishmentofprotection.

b. Followingthepredilatation,stentplacement,andpostdilatation,theproximalinternalcarotidartery

https://t.me/med1917

isaspiratedtoremoveanydebrisleftbehindpriortoremovalofthedevice.

c. Theuseofthedistal balloonrequirescollateralflowviaanintactCircleofWillisandcannotbe

employedinthecaseofacontralateralinternalcarotidocclusion.

d. Thisdistalballoonmethodisrarelyusedwiththeavailabilityofnewerfiltersandthedevelopment

ofproximalprotectiondevicealternatives.

2.Distalembolicprotectionismostoftenperformedusingafilterdevice,whichisbasket-likeinshape,

withadistalstraight(curveable)wire.

a. Thedevice isadvancedintheclosedpositionthroughthelevelofstenosis.TheEPDisdeployed

and then the procedure takes place over the wire used as a monorail for predilatation, stent placement,andpostdilatationafterwhichanend-holecathetercanbeadvancedovertheEPDwire forparticulateaspiration.

b. Cerebralperfusioncanbemaintainedthroughouttheprocedureunlikeballoondistalprotection(Fig.

3.10).

c. Although most commonly used, distal EPD is not ideal because there is no protection while the

lesioniscrossed.

d. Thelandingzoneinthedistalcervicalcarotidmustbestraighttoallowthedevicetodeploywithout

causingdissectionandtoattaincorrectappositionofthedevicetothevesselwall.Ifthedeviceis notwellopposed,debris/particleslessthan150µmembolizepastthedevice.

e. Thefiltermayalsobecomefilledwithdebrisandrequireaspirationbeforeclosingthedeviceprior

toremovalpostprocedure.

f. Thedevicemaybecomefilledwithdebrisrequiringcatheteraspirationpriortoclosing(Fig.3.11;

Table3.2).

C.ProximalEPD

1.WithaproximalEPD,protectionisestablishedfirstpriortocrossingthetargetlesionorperformingan

intervention.

a. Itcanalsobeusedinatortuousinternalcarotidarterybecausenodistallandingzoneisrequired.

2.Withproximalprotection,thereisocclusionoftheexternalcarotidandthecommoncarotidarterywith

flowreversal.

3. Useof this type of EPD requires a patent external carotid artery on the side of thetarget internal

carotidstenosis.

a. The aortic arch and common carotid configuration must also accommodate the 9 French guiding

catheter(6Frenchworkingchannel).

b. Aswiththedistalinternalcarotidballoon,thisproximalEPDalsorequirescollateralflowviaan

intact Circle of Willis and may not be an option in the case of a contralateral internal carotid occlusion.

c. Thecommoncarotidballoonisinflatedfirstandsubsequentlytheexternalcarotidballoonisinflated

withthe combination suspending flow intheinternal carotid arteryduring theperformance ofthe interventions.

d. Debrisisremovedviacatheteraspiration.

e. Followingaspiration,theexternalcarotidballoonisdeflatedfirstfollowedbythecommoncarotid

https://t.me/med1917

balloondeflation(Fig.3.12;Table3.3).

D.TranscarotidCarotidArteryRevascularization

1.Arecentvariationtotheconceptofproximalprotectionisahybridopenandendovasculartechnique

wherebyaccesstothecommoncarotidisachievedbyacutdownjustabovetheclavicle.

2.Femoralveinaccessisalsoachievedwithavenousreturnsheathanddilator,whichservestocreatea

conduitbetweenthecommoncarotidarteryandthefemoralvein.

3.Thisconduitisestablishedinorderthatflowreversalcanbeemployedduringcarotidangioplastyand

stentingwithouttheneedforpercutaneousdistalorproximalEPDdevices.

i. This has been studied with a proprietary device, the Silk Road Enroute Transcarotid

NeuroprotectionSystem.

ii. IntheSafetyandEfficacyStudyforReverseFlowUsedDuringCarotidArteryStentingProcedure

(ROADSTER)multicentertrial,thedevicewasfoundtobesafewithanoverallriskofstroke,risk ormyocardialinfarctionof3.5%witha99%technicalsuccessrate(Fig.3.13;Table3.4).

E.Considerations

1.ByconsideringthesethreeoptionsavailableforcerebralEPDsandtheclinicaltrialdata,EPDuseis

mandatoryforreimbursementbyMedicareanditisusedin95%ofallCAScases.48,

2.Stabileetalstudiedproximalversusdistalprotectiondevicesandfoundfeweremboliccomplications

inthosecaseswhereproximalprotectiondeviceswereemployed.

XI.Summary

Diseaseinvolvingtheextracranialandcervicalcarotidandvertebralarteriesismostcommonlyrelatedto atheroscleroticdiseasebutmayoccurbecauseoftrauma,radiationexposure,collagenvasculardisease, or extrinsic compression. Regardless of the cause, stenosis, occlusion, and atherosclerotic plaque involving the carotid and vertebral arteries are risk factors for ischemic stroke. There have been considerable advances over the last three decades with regard to optimal medical therapy for the prevention of stroke. Interventions such as CEA and CAS are safe methods of revascularization in symptomatic and asymptomatic patients, and vascular providers must consider the patient’s disease process,medicalcomorbidities,andoperativeriskwhenplanningthebestmethodofrevascularization.

https://t.me/med1917

FIGURE3.1 CarotidUltrasound(DUS).A,Normalcarotidbulb.B,Normalproximalinternalcarotidartery(ICA).

C-E,Leftcarotidstenosis.TransverseandsagittalDUSimagesatthecarotidbifurcationdemonstratesoftplaque

https://t.me/med1917

withintheICA.F-H,Rightcarotidbruit.DUSdemonstratesthecarotidbulbwithcalcifiedshadowingatherosclerotic

plaqueintheICA.Peaksystolicvelocityatthebulbis273cm/ssuggestiveof>70%stenosis.

CasecourtesyofDr.GowthamanGunabushanam.

https://t.me/med1917

FIGURE3.2 Computedtomographicangiography(CTA).A,SagittalCTAofnormalcarotidbifurcation.B,Axial

CTAdemonstratesthecarotidbulbontherightandtheinternalandexternalcarotidarteriesontheleft.C,AxialCTA

throughtheuppercervicalcarotidarteriesbilaterally.D,SagittalCTAdemonstrateshigh-gradecalcificstenosis.E

andF,SequentialaxialCTAimagesillustratemixedcalcifiedandnoncalcifiedplaqueandthemarkedrightinternal

carotidarterystenosis.GandH,CTAoftheleftcarotidarteryviewedintheinvertedformatdemonstratesthe

calcificplaqueasblackandmildluminalirregularitywithouthemodynamicallysignificantstenosis.The3Dvolume

renderedimageswithvesseltrackingandaxialsegmentationarehelpfulforassessmentofthecharacterofthe

https://t.me/med1917

plaqueandthedegreeofstenosis.IandJ,Incontrast,ontheright,thereisalongsegmentbutlessernarrowing

thanontheleft,andtheplaqueiscomposedofbothcalcifiedandnoncalcifiedplaque,whichmaybemorefriable

andcarryhigherriskofdistalembolization.Plaquecharacterizationaswellasanatomicfeaturesofthetargetlesion

willinfluencetreatmentdecisions.

FIGURE3.3 Magneticresonanceangiography(MRA).A,Time-of-flight(TOF)noncontrastMRAdemonstrates

thevasculature,whichisbetterresolvedonthepostcontrastMRAseries(B).CandD,Carotidstenosis(arrow)is

bestevaluatedonthepostcontrastaxialsourceimageandtheMIP(maximumintensityprojection)reconstruction.

https://t.me/med1917

FIGURE3.4 Digitalsubtractionangiography(DSA).AandB,APobliqueandlateralDSAofthecommoncarotid

arterydemonstrateanormalconfigurationinthisyoungadultpatient.CandD,Thecervicalinternalcarotidartery

maybetortuouswithhairpinor360°loops,whichareeasilyappreciatedonCTAbutmaybedifficulttonavigate

whencarotidstentingorintracranialinterventionarecontemplated.E,This65-year-oldpatientpresentedwithhand

claudicationandsubclavianstenosiswasdemonstrated.FandG,DSAwithinjectionoftherightvertebralarteryin

thearterialandvenousphasesdemonstratesretrogradeflowintheleftvertebralarterywithfaintfillingofthe

subclavianartery—subclavianstealphenomenon.H,Followingtransfemoralleftsubclavianstentplacement,the

vertebralarterywaspreservedandantegradeflowrestored.

https://t.me/med1917

FIGURE3.5 ArchAnatomy.A,Normalarchconfiguration.B,Moretortuousgreatvesselsinthiselderlypatient

maymakeinterventionsmorechallenging.Notetheleftvertebralarteryarisesdirectlyfromtheaorticarch.C,A

commonoriginoftheinnominateandleftcommoncarotidarteriesmayrequirearecurvecatheterfornavigationas

inthiscase.DandE,Thispatientwasscheduledforarightcarotidstent;however,thehostilearchandtheacute

reversecurveoftheinternalcarotidstenosisledtheoperatortoabandonthisapproachforcarotidendarterectomy.

https://t.me/med1917

<<< < Предыдущая 1 2 3 4 56 / 436 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
31.08.202625 Мб0Книга_3744_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202625 Мб0Книга_3745_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3748_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3749_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3750_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3751_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3752_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3753_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3754_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3755_Библиотеки_им_академика_М_И_Перельмана.pdf
#
31.08.202624 Мб0Книга_3756_Библиотеки_им_академика_М_И_Перельмана.pdf