课件：颅内支架介入治疗.ppt

75646 (A) DEC/07,颅内支架概览,颅内支架分类,3,颅内辅助支架的作用,问题： 宽的瘤颈使得动脉瘤内的弹簧圈容易移位或部分脱出到载瘤动脉里，这可能造成严重的并发症。 解决方案： 颅内辅助支架主要用于辅助宽颈动脉瘤的弹簧圈栓塞，防止弹簧圈的移位或部分脱出。,4,支架的基础知识与常用术语,6,开环 vs. 闭环,闭环设计,开环设计,“游离” 的尖端,7,颅内支架不同的网眼设计,Solitaire AB -闭环,Leo Plus 闭环,Neuroform 开环,Enterprise 闭环,未连接点,8,输送性和可回收性,输送性：支架能够被输送到病变部位的能力，尤其是通过远端病变或通过迂曲的解剖结构的能力。 可回收性：支架被释放后，可以被重新收回且被重新放置到更优位置的能力。这是一项非常重要的能力，分为完全回收和部分回收。,柔软性,Flexibility为柔软性，支架在闭合状态下随血管的弯曲而弯曲的能力。柔软性越好，支架的通过性越佳。,9,10,顺应性,Comfortability，支架在打开状态下随血管的弯曲而弯曲的能力。 顺应性好，有利于支架完全贴壁和保持血管的正常生理弯曲。 顺应性差可能导致血栓的形成,11,支架的贴壁性,支架的贴壁性：支架与血管壁贴合的能力。 贴壁性不好可能导致血栓和支架移位的发生,径向支撑力,是支架对血管壁的支撑能力 -决定支架对弹簧圈的支撑能力 -衡量支架的稳定性和移位效应,12,13,开环 vs. 闭环,14,毛刺现象和打折现象,毛刺现象：Gator-Backing，指支架被置于弯曲解剖处时，网丝向外扩张/伸出的趋势。类似鳄鱼背脊。 打折现象：支架的弯曲能力，弯曲能力差支架容易在弯曲处发生打折现象，容易造成血管的闭塞,15,支架短缩？,支架释放/撑开前后轴向上长度的差异 所有支架都有一定程度的短缩 取决于支架的材质和设计 对支架的精确释放有重要的意义，但. 如果支架可以完全回收重新放置，20%的短缩率是可以接受的(如Solitaire AB) 如果支架不能回收和重新放置，就需要有更低的短缩率,16,金属/血管比？,在覆盖支架的血管部位，支架的金属表面积/血管表面积 该指标目前尚不能用于反映颅内支架的性能 低金属/血管比可能降低管壁的不良反应。,17,潜在并发症1,支架内再狭窄（In-stent restenosis）: 狭窄是血管腔的变窄或阻塞。当支架植入血管后，血管壁的内皮被损伤，机体对损伤进行一系列主动修复。虽然此种修复是必要的，但在一些情况下，这种修复可能过度-过度的修复可能导致疤痕组织在支架内聚集，导致血管腔的狭窄或阻塞，这称为“支架内再狭窄”。 可能导致脑缺血性损伤。,18,潜在并发症2,血栓（thrombosis）: 支架植入后，可能导致血栓形成。 -急性、亚急性 -迟发型 可能导致脑缺血性卒中。,19,潜在并发症3,支架移位 边支闭塞 其他,Solitaire AB产品信息,21,*Not approved for sale in the United States.,“Internal Use only“For ev3 Inc. Presentation Use Only Not for Distribution,21,22,产品结构图,解脱点,推送导丝,导入鞘,全长,有用长度,远端标记,近端标记,“Internal Use only“For ev3 Inc. Presentation Use Only Not for Distribution,22,Solitaire AB的产品特点,23,24,输送,推送导丝: 0.016” 的推送导丝，同弹簧圈的推送一样简便 微导管 4mm支架使用0.021” Rebar 6mm支架使用0.027” Rebar 输送和释放可一人操作 可用于远端和迂曲的血管,25,产品型号,至少保证支架释放后能够覆盖瘤颈两端各4mm的距离，即有用长度至少超出瘤颈宽度8mm,26,支架短缩,短缩主要发生在尺寸较大的血管里 Solitaire AB的短缩主要发生在近端 有用长度不发生短缩 回收区是发生短缩的主要位置，释放后 先确保支架远端准确覆盖了动脉瘤远端4mm，释放，瘤颈近端也可以达到4mm的覆盖。,Solitaire AB 支架重叠 - 4 mm,27,支架重叠的中点正对支架近端标记.,28,Solitaire AB 支架重叠 - 6 mm,29,支架网眼重叠试验1st释放,C,0.99,1.69,1.34,0.25,0.67,1.45,0.95,Cell A,0.65,Cell B,Cell C,A,B,30,支架网眼重叠试验2nd释放,A,C,B,0.72,1.10,0.95,Cell A,0.34,0.82,0.91,1.15,1.44,1.77,Cell B,Cell C,31,支架网眼重叠试验3rd释放,A,B,C,0.43,0.97,0.97,Cell A,0.32,0.61,0.69,Cell B,1.77,1.90,2.62,Cell C,32,解脱,Solitaire AB 使用NDS-2解脱盒电解脱. 解脱时: 轻微回撤微导管，暴露解脱点 保持微导管在解脱点近端1-2mm处 可以在填圈前或后解脱,支架操作过程,34,器械尺寸选择,根据病变情况参考说明书选择SOLITAIRE AB及微导管 : Solitaire AB与Rebar配合使用 支架尺寸 1）直径：参考目标血管节段的近端、远端的较大直径尺寸 2）长度：需要保证其有用长度能够覆盖动脉瘤颈两端各4mm的距离。,操作动画（可替代操作图示）,ProductSolitaire ABSolitaire_AB.exe,35,36,操作-微导管到位,推送微导管到合适的位置： 确保当支架释放后，支架两端能够覆盖瘤颈两端各4mm的距离。,37,操作图示插入支架,将导引鞘部分插入RHV 旋紧RHV 持续滴注，确认可见液体从导引鞘近端流出,37,38,操作图示插入支架,旋松RHV 推送导引鞘直到稳定在微导管的卡口处 旋紧RHV 轻柔的向前推送the SOLITAIRE AB 进入微导管,38,39,操作图示支架到位和释放,当支架推送导丝的柔软部分完全进入微导管的尾端，撤掉导引鞘 一直推送SOLITAIRE AB 直到支架远端标记到达微导管的末端，确保在支架释放后，能够充分覆盖瘤颈两端至少4mm的距离。 注：推送过程中如遇很大阻力请停止推送,40,操作图示支架到位和释放,保持支架位置不动，小心回撤微导管，释放支架。 为达到支架的充分释放，微导管需要撤到支架近端标记的近端。,41,操作图示支架的回收和重新释放,支架回收： 保持支架位置不动，小心推送微导管，直到支架全部收到微导管里。 SOLITAIRE AB可以完全回收2次。,42,操作图示-填弹簧圈,将微导管（远端头端 2.5F）通过支架网眼送入动脉瘤内，填圈。,解脱 使用NDS-2解脱盒,CR00049 Rev.B,Not available for sale in the United States,解脱原理,Covidien | August 4, 2019 | Confidential,44 |,Insertion Needle （钢针）,Solitaire AB Detachment Zone （支架解脱点）,解脱点的金属结构在外部电流到达、然后离开的过程中发生电解腐蚀。 如Solitaire AB的电流途径是：电流从解脱盒发出，到达支架解脱点；支架解脱点发生电解腐蚀；然后电流通过导电途径到达钢针。完整的电流回路是解脱的必要条件) （虽然钢针也接收到电流，但是由于有一定的保护，所以结构上不会受到影响） 促进电流运动的因素： 盐水冲洗 肌肉,（+）,（-）,45,解脱盒参数,电压(9V) 电流1 mA 按钮： Stop Start On Timer显示解脱过程正消耗的时间 (分.秒). 最长解脱时间: 2分钟,CR00049 Rev.B,Not available for sale in the United States,This is picture of NDS-1,46,配件,连接线: -1副 消毒针(20 G or 22 G),CR00049 Rev.B,Not available for sale in the United States,47,Detachment Zone,Detachment Zone,Push Wire,Introducer Sheath,Total Length,Usable Length,Distal Markers,Proximal Marker,“Internal Use only“For ev3 Inc. Presentation Use Only Not for Distribution,47,Electrolytic Detachment,CR00049 Rev.B,Not available for sale in the United States,48,准备和检测,使用新电池: 电池指示灯常亮：电量足够 电池指示灯闪烁： 更换电池 将连接线接头插到解脱盒上，并旋紧确保连好。 打开开关On, 听到一短提示音 检测：按 Stop钮，所有数字显示 8.,CR00049 Rev.B,Not available for sale in the United States,49,患者与器械的连接,患者 将消毒针插在肩膀(或腹股沟处) 将“黑线”卡在钢针上。 Solitaire 将“红线”卡在支架推送导丝的近端无PTFE涂层处 暴露解脱点（确保微导管未覆盖支架解脱点）。,CR00049 Rev.B,Not available for sale in the United States,50,解脱,按“Start”开始解脱 电压框显示解脱电压(0.0 to 9.9 volts). 如果电压显示0.0 伏, 可能有短路存在，请重新检查连接 如解脱成功，则： 解脱盒发出周期性重复的报警声 “Detach” 灯常亮 或 解脱2分钟后，解脱盒发出周期性重复的报警声 ProductSolitaire ABSolitaire_AB.exe,CR00049 Rev.B,Not available for sale in the United States,操作动画,ProductSolitaire ABSolitaire_AB.exe,51,52,成功的支架释放,Detached Stent,CR00049 Rev.B,Not available for sale in the United States,53,SOLITAIRE AB的输送与输送弹簧圈一样简便，最小使用ID 0.021”的微导管输送。 柔软性好，易于通过迂曲的血管。,使用简便,支架应用,54,支架应用,Distal markers,Proximal marker,辅助支撑弹簧圈,贴壁性好 径向支撑力好 可视性佳,磁共振成像相容性,August 4, 2019 | Confidential,55 |,异议处理,CR00049 Rev.B,Not available for sale in the United States,57,防止填圈过程中支架解脱 假阳性解脱（未解脱） 假阴性解脱（解脱了）,CR00049 Rev.B,Not available for sale in the United States,58,防止填圈过程中支架解脱,如希望在填圈后解脱支架，则手术过程中可以: 用微导管覆盖支架解脱点 在解脱弹簧圈时，用干布覆盖推送导丝近端（体外） -如果导丝交叉可能出现交叉电流，导致支架过早解脱。,干布覆盖支架推送导丝,CR00049 Rev.B,Not available for sale in the United States,59,假阳性解脱（未解脱）,解脱盒已经报警显示解脱，但实际上未解脱,CR00049 Rev.B,Not available for sale in the United States,解脱的优化方法：,解脱前： 消毒针插在患者肩膀或颈部。在针头处滴几滴生理盐水。 消毒针插在肌肉层里。 使用9V新电池。 使用新电解线。,60,优化方法：,解脱中： 确保微导管中持续快速滴注生理盐水 避免消毒针插在脂肪层 支架近端标记与微导管远端标记之间距离2mm 支架推送导丝近端在干燥的操作台表面 确保卸掉微导管与支架推送导丝上的力量,61,国外医生经验,方法： 针头处滴几滴生理盐水 按Stop 重置，按Start 再次解脱 换用BSC的解脱器,62,63,假阴性释放（解脱了）,医生看到支架解脱但解脱盒10秒后仍未报警 (解脱盒设定程序为解脱后5秒报警）: 建议等待解脱时间至2分钟，透视下辨别,CR00049 Rev.B,Not available for sale in the United States,中断解脱,CR00049 Rev.B,Not available for sale in the United States,65,中断解脱并继续解脱,按“STOP”可以中断 “timer”停止计时 电流(0.0 mA) 和电压 (“-.-”) 被切断. 重新开始请短按 (1 秒) “START”. 电流和电压重新显示，“ timer”继续计时,CR00049 Rev.B,Not available for sale in the United States,66,线路连接导致的解脱中断,如果患者方的连接中断, 解脱盒可以识别并长报警及“Detach”灯亮。 检查线路，确保正确连接。 按STOP，“timer”数值将归0。 按START 重新开始。,CR00049 Rev.B,Not available for sale in the United States,2019/8/4,67,可编辑,68,重置Timer,重新解脱（ timer 重新显示“0.0”并重新计时）可以 长按START重置所有参数 Timer归“00.00“. 常规步骤解脱。,CR00049 Rev.B,Not available for sale in the United States,Stenting Techniques,70,Single Stent,Use of a single stent: Place stent, detach, place coils thru the struts Place stent, place coils thru the struts, detach Place catheter, place stent so catheter is jailed along the stent, place coils Place the stent, detach, let it endothelialize for a few days, go back in and coil thru the struts Usage of stent as a temporary assist reinforces the advantage of deployment and retrieval for cases that are not amendable to balloons and where the physician doesnt want to leave in a stent permanently,71,Multiple stents,Stent in Stent technique: Several stents might be needed to cover the neck area Some physicians will put stents in each other to make their own flow diversion product X or Y - stenting: A second stent is brought in through the first stent and deployed. Kissing Technique: The stents are deployed next to each other,72,Stenting Techniques,73,Stenting Techniques,* Field experience,74,Y-Stenting,One stent is put in and deployed. A second stent is brought in through the first stent and deployed.,75,Kissing Technique with Straight Stent First,Instead of bringing in another stent through the stent, the stents are deployed next to each other.,76,Kissing Technique with Branch Stent First,In both cases, the first stent did not move when the second stent was deployed.,Medical Therapy,78,Pre-procedure Elective,Daily doses, starting 3- 4 days prior to procedure, want to load the patient with anti- platelets: Aspirin: 325 1,300 mg Plavix: 75 mg Aspirin: Takes 2 4 hours to alter platelet function Reduces risk of vascular mortality Plavix: Takes 2 days to alter platelet function,* General accepted practice, Medication regime statements are not the recommendation of ev3,79,Pre-procedure Emergency,Right before procedure: Aspirin: 325 - 1300 mg Plavix: 300 600 mg Disadvantage of giving Plavix shortly before procedure is that it is not as effective for platelet blockage 50% of platelets blocked in 3 -4 hrs,* General accepted practice, Medication regime statements are not the recommendation of ev3,80,Post-procedure,After procedure continue Plavix (75 mg) and aspirin (325 mg) for 30 90 days. Then: Stop both (not very common) or Stop Plavix and continue aspirin at 325 mg or 81 mg (baby aspirin) for life (most common),* General accepted practice, Medication regime statements are not the recommendation of ev3,Tips and Tricks,82,Tips and Tricks,Coiling When the catheter is jailed, keeping the stent attached during catheter removal will give additional stability. Keeping the stent attached until the end of the procedure, preserves the option to retrieve / reposition if the coils dont sit well. Stent works very well for bifurcation, as you can put a stent through the struts. Also not t&t The ability to retrieve / reposition gives incredible peace of mind! (this is positioning not tip and tricks),83,Tips and Tricks,Delivery Rebar is the preferred micro catheter. The stent delivers best through it. If you get a Rebar in position, the stent will follow. Why? Use Rebar with only one marker After putting stent through the hub, flush the micro catheter before bringing in the stent. Should have continuous flush going For most accurate positioning, move the stent minimum of 2 marker lengths distal past the AN. This will be app. 4 mm.,84,Tips and Tricks,Detachment To avoid accidental premature detachment, keep detachment zone covered with the microcatheter until you are ready to detach. When detaching the stent, expose detachment zone by unsheathing the catheter. Keep micro catheter 1-2 mm proximal to the detachment zone to avoid longer detachment times or a false positive.,Clinical,86,Clinical Papers,A Novel Self-Expanding Fully Retrievable Intracranial Stent (SOLO): Experience in Nine Procedures of Stent-assisted Aneurysm Coil Occlusion Thomas Liebig, Hans Henkes, Jrg Reinartz, Elina Miloslavski, and Dietmar Khne Neuroradiology 2006:48:471-478 Immediate and midterm follow-up results of using an electrodetachable, fully retrievable SOLO stent system in the endovascular coil occlusion of wide-necked cerbral aneurysms Kivilcim Yavuz, M.D., Serdar Geyik, M.D., Almila Gulsun Pamuk, M.D., Osman Koc, M.D., Isil Saatci, M.D., and H. Saruhan Cekirge, M.D. J Neurosurg 107 : 1 7, 2007,竞争产品,优点,网眼大 Y stent技术 操作简单 可回收 可应用于更广泛的血管直径 支架重叠，类似“FD”效果,网眼大 弹簧圈调出，范围3mm?,88,89,产品信息纵览,90,Stent Images,Solitaire,Neuroform & Wingspan are same BUT Wingspan has higher radial force,Leo Plus,Enterprise,91,Radial Force,92,Radial Force,Physicians would like to see comparison data, the numbers dont really tell them anything Clinical importance: Measure for migration and stability A higher radial force signals that stent might grab the vessel wall better and doesnt migrate Comparison: Enterprise, Solitaire and Wingspan have almost same radial force, so Solitaire is ok.,93,Metal to vessel ratio,94,Conformability,95,Conformability,Physicians dont commonly ask for this data: Enterprise is considered good Comparison: Enterprise is fine and Solitaire is significantly better,96,Wall Apposition,Solitaire,Enterprise,Leo,Neuroform,Stents deployed in 3mm vessel, 2.4 mm bend radius,97,Wall Apposition,Solitaire,Enterprise,Leo,Neuroform,Stents deployed in 4mm vessel, 2.4 mm bend radius,98,Wall Apposition,Important data for the physicians. Clinical importance: Cells of stents that dont have a good wall apposition, cant expand that well and this can have an effect on getting the catheter thru - will have to jail the catheter Potential of coil herniation Comparison: Solitaire AB maintains better wall apposition than Enterprise and Neuroform,99,Gator-Backing,Neuroform3 3.5x20,Leo 3.5x25,Solitaire AB 4x20,Enterprise 4.5x22,Wingspan 3.5x15,100,Kinking,Solitaire AB 4x20,Enterprise 4.5x22,Leo 3.5x25,Neuroform3 3.5x20,Wingspan 3.5x15,101,Gator-Backing and Kinking,For some physicians this is important, for others it is nice-to-know though wouldnt stop them from using a stent they like. Clinical relevance: May result in coil herniation Unlikely that kinking will result in vessel occlusion, though it might limit catheter access Comparison: Gator-backing and kinking not observed in Solitaire AB and Enterprise,102,Stent Cell Area,103,Stent Cell Size,104,Cell area and size,Physicians would like to know both data Clinical relevance: Want to know whole area for potential coil herniation The size is important for catheter size to be able to go thru Comparison: Able to place a 3 mm stent through Solitaire AB for bifurcation / Y-stenting, while other stents have much smaller cell size A catheter diameter of 3 mm can cross Solitaire, while a catheter diameter of 1.3 mm can cross the Enterprise. The largest catheter that can pass through in Solitaire is 8F. This is larger than most devices used in neurovascular intervention. Solitaire AB cell length is similar to Enterprise, though Solitaire is twice as wide, therefore cell area of Solitaire is twice as large.,105,Working area foreshortening,Working area of Solitaire AB does not foreshorten,106,Delivery method,Solitaire AB: Device attached to pushwire, loaded into a sheath. Pushed through entire catheter. Electrolytic detachment. Enterprise: Device is loaded into a sheath, loaded over the guidewire and pushed through the entire catheter. Device is released from the guidewire when released from the catheter. Neuroform and Wingspan: Device loaded over polymer tube and preloaded at tip of catheter. Guidewire access through polymer tube. Device is released when catheter is pulled back. Leo: Device hooked onto pushwire, loaded into a sheath. Pushed through entire catheter. Device detaches when pushwire tip exits catheter and unhooks from device.,107,Delivery method,Clinical relevance: Solitaire AB is easy to use, delivers like a coil, no extra steps needed. Disadvantage is potential loss of guidewire access. Stent needs to be able to be delivered at the right place Comparison: Physicians will choose stents based on aneurysm size and location, stent and delivery characteristics. It is important to understand of your physician what he takes into configuration and how Solitaire will work in his practice.,Market Overview,109,Projected Market size,110,Estimated Market Overview,111,Outlook Solitaire AB,Potential risks: Product availability Full range of sizes Flow Diversion,Stents and Balloons,113,Stents,Advantages Straight forward and easy procedure Small risk of coil herniation Choice between coiling thru the struts or jailing the catheter. Can put stent in a few days before coiling and let it endothelialize If a loop pops out, you only have to pull out that specific coil,114,Stents,Disadvantages Permanent foreign body in the brain, no long-term results available yet Need life-time medication to minimize in-stent restenosis or thrombosis Stent can jump Difficulty deploying the stent in tortuous environment Several stents might be necessary to cover the neck (stent in stent technique) Safety: Risk of catheter stuck in stent,115,Balloons,Advantages Prevents misplacement of coils and reduces risk of ischemic events After procedure no foreign material remains in vessel Safety: No need to place catheter deep in AN for coil delivery In case of rupture, a placed balloon allows for immediate hemorrhage control Allows coverage of complex and difficult located wide neck aneurysms Usually no meds needed (even though some physicians prefer to give Plavix and / or aspirin),116,Balloons Assisted Coiling HyperGlide/HyperForm,Disadvantages No permanent barrier Procedure increases in complexity and duration Training required Need to control the inflation and deflation Instability, balloon can jump Blood can re-enter the AN, increasing the pressure and leading to potential AN rupturing Can only see after balloon has been removed and all coils delivered, if a loop pops out. If so all coils will have to be pulled out.,117,Strategic Implications,Its not (necessarily) an either / or story Stent or Balloon can be used in most cases Engage the discussion with your physician ! Highlight benefits of both and how they can work complementary ACOMM : rarely treated w/o balloon PCOMM : balloon and stent work well,118,Key Messages,“Fully deployable. Completely retrievable.” Ease in delivery Accuracy and deployment control Optimal coil mass support Electrolytic detachment,119,Sales Tools,Available Q1: Brochure Competitive overview In-service presentation Case study booklet Website Targeted in Q2: Wall ch