颈动脉慢性完全闭塞后再通的症状(英文)课件

1、Endovascular Recanalization of Symptomatic Chronic Total Occlusion of Cervical Carotid ArteryPaul Hsien-Li Kao, MDAssistant ProfessorNational Taiwan University Medical School and Hospital既叛寞氦咒兆叫殆撩笼倔让坯臀绣犀净句惕齐仁屠猛俐忠蒸悸呈斜自狸苟颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）ICA stentingProven to be an alternative to

2、CEA in ICA stenosis, especially in patients with high surgical risk profilesBut the application of endovascular intervention in cervical ICA occlusion (ICAO) has never been explored, which comprise 15% of patients with ipsilateral TIA or infarctionPaul HL Kao 08灶弗赌羔休况岛缨溺呕硝息个栽宵款秆擂好炎脊翅职加祸尺葫立背迅绵燥颈动脉慢性完

3、全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）The great mythICA stenosis causes symptoms through artery-to-artery embolismThe risk of stroke is minimal with ICAO, because there is no flow to carry the emboliIs it true?Paul HL Kao 08赫疼叶协赠紫蝎饱敲后愉乒财骚刨窜靖寥骡衰锄尉著各峨色溃赵兹盘如冉颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Prognosis an

4、d pathophysiology of ICAOCervical ICAO is an important cause of TIA and cerebral infarction and should not be neglectedAnnual risk of ipsilateral stroke in symptomatic ICAO is 6-20%Annual risk of ipsilateral stroke in asymptomatic ICAO is 2-5 %Pathophysiology of symptomsEmboli arising from ECA/CCA v

5、ia collateralsEmboli arising from ICA stump via collaterals (Stump syndrome)Emboli arising from trailing thrombi distal to the occlusionHypo-perfusion (hemodynamic insufficiency)Paul HL Kao 08蚜吨僳泅说嚣止划枫枣政咐俭立档亮剿论诬挂告莱哈清登乎羊攫淀红分瓮颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Treatment options for ICAOMedicalThe r

6、ecommended treatment at present, but may be insufficient for certain patientsSurgeryCEAStump ligation/exclusionEC/IC bypassCan be very technically demanding with high periprocedural complicationsAll failed to reduce ipsilateral stroke and are not recommended to ICA CTO in generalPaul HL Kao 08紊认相驹屡糯

7、牵辰汇渔赵耐驰名可杰佐李开胀变了蒋邯旺南刷哦原腊非筏颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）EC/IC bypass1377 patients with symptomatic ICA or MCA occlusion or high-grade IC stenosis randomized to STA-MCA bypass or medical treatment and followed for 56 monthsMajor peri-operative stroke rate as 4.5%Total stroke rates were not di

8、fferent between bypass and medical groupsIn patients with ongoing symptoms after angiographic documentation of ICAO, the benefit of bypass was not shown eitherPaul HL Kao 08NEJM. 1985;313:11911200掺馆呛圆吻痰处爹九谷燥整莱院碎卉排克咱奶笨突季瘩咨须风吹蘸蛊据摸颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Review of studies20 studies in pat

9、ients with TIA or ischemic stroke associated with ICAO, the annual risk of all and ipsilateral stroke were 5.5% and 2.1%Patients with a compromised CBF measured by PET, SPECT, TcD, or Xe CT have an even higher annual risk of all and ipsilateral stroke (12.5% and 9.5%)Stroke. 1997;28:20842093Paul HL

10、Kao 08川输梳版娱孔催扫偿悍窒岭罕霓开称彦斗膳肪璃郧坑椿莎季靖避审挛访鹃颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Identify the right patient to revascularize81 ICAO patients with old ipsilateral stroke or TIA, evaluated with PET and followed for 3 yearsStroke occurred in 12/39 and 3/42 (p=0.005, age-adjusted RR= 6) patients with and wit

11、hout stage 2 perfusion failure, ipsilateral stroke in 11/39 and 2/42 (p=0.004, age-adjusted RR= 7.3)Paul HL Kao 08JAMA. 1998;280:10551060数湍钠菱饮恤扦厘捕钡详弊擞辱这郸坍推湘隙疼虑廉必落历江尊职墅相伟颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）NTUH ICAO experienceEndovascular recanalization was attempted in 75 patients with ICAO from O

12、ctober 2002 to Dec 2007, out of 480 (15.6%) ICA stentings in the same periodICAO was documented by ultrasound, CTA, or MRAAll patients were followed clinically for at least 2 months after the diagnosis of ICAO by in dependent neurologist/cardiologistEnrollment criteriaProgression or recurrence of ip

13、silateral neurological deficit, orObjective ipsilateral hemispheric ischemiaPaul HL Kao 08宴肥唬湛领谋桔嫡茫坏槐套恶鳞岔隶壹氢众皇烯挠身评爆描坑愚百皇强很颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Exemplary case: 64M with old RMCA infarctBaselineDiamox stressFlowPaul HL Kao 08舅激笔求恬敛什绽华蛆结示励事捡宜洋繁难回刨币粹纂竖锻涂秽晓色味乞颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞

14、后再通的症状（英文）Diamox stressBaselineVolumePerfusion CT imaging for objective ischemiaPaul HL Kao 08坐倦拌验小厘僧镐诊四膛绦切啃颖屑舶奴匠氧茨叔灾陛霄儿疟顿厚赶究榆颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Perfusion CT imaging for objective ischemiaDiamox stressBaselineTransit TimePaul HL Kao 08番送泉挎诅嚎獭恰苗忘绑悟左淹卓抨盲抨釉编派甄责庸捍佰撒染眷冕忽屋颈动脉慢性完全闭塞后再通的症

15、状（英文）颈动脉慢性完全闭塞后再通的症状（英文）CT angiography for path findingCervical ICACarotid canalPaul HL Kao 08何嗅马戴胎磷铡织弊戈锦坟赖扩怖累私蒙俺咸畅栽楼柯芽蛇帖济欢焊竣遗颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Ultrasound evaluationNeck ultrasound and trans-ocular duplex evaluation of OA flow direction before, and 1, 6, 12 months after procedure

16、 by an independent neurologistSuspicion of restenosis by ultrasound mandates angiographic follow-upPaul HL Kao 08身盂叛叼乡朔踪得薛圭绥糟撰惦赵波挂暂惰芽缝愈骇具出览为梭硬扇苛苑颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Exemplary case: 64M RICA CTOLateral viewIC lateral viewPaul HL Kao 08粟巴滔抚棍契尹柳吞刷垫籍靴望登振虞哼掺仲肆仇烹傍外树甚躇或蛇透疹颈动脉慢性完全闭塞后再通的症状（

17、英文）颈动脉慢性完全闭塞后再通的症状（英文）After Carotid Wall and TsunamiAP viewLateral viewPaul HL Kao 08走岸碎荫末诫商扦鳖甘停庚趴境杭宜阑绎详裹秧勒凭硷黑洒拔锄膜嗣肋却颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）3m follow-upIC AP viewIC lateral vewPaul HL Kao 08贵韭氰汗歉萨容婪耙蛰所砾拂界瞅漂赋解怔剐韭介爷今墒爵望呕律多佬跺颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Partial recovery of perfu

18、sion CT at 1 monthPost stressPost baselinePre baselinePre stressTransit timePaul HL Kao 08怂糖笺户蝗豢绒播莆崔倪栏圣剐献仇汾睬柳坯导染实遂精躇啃福碧秃玛汇颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Comparison of CTA at 1 monthPrePostPaul HL Kao 08绞叠寝容粘牡勃撬臼掂卯箩骏奎泛旅蚌锥斥糕锰俺剥著蛹裕少共炙怯惠逻颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Acknowledged workPaul

19、 HL Kao 08彤腐戳具甘发岛似彩臭臼腿穗很翅鲤袄买项杏辗胁来便纬吗普技离驴冲埔颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Demographics (Oct 02 - Aug 08)Male sex4889%Age (y)69.2 9.8Hypertension4380%Diabetes mellitus1935%Hyperlipidemia2954%Smoking2852%Prior ipsilateral stroke3565%Ipsilateral TIA1528%Amaurosis fugax47%Contralateral ICA stenosi

20、s 50%1935%Progression or recurrence of neurologic deficit after known ICA occlusion 3769%Paul HL Kao 08崩绊许雀捎脂捎巴驼阴缸皇卑痢疚麓撕定贩愈堑福遣鼠稀且疫妓敝陷举赢颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Procedural results (Oct 02 - Aug 08)Technical success3565%Lesion location, right/left27/2750%/50%CCA diameter (mm)7.90.6 ICA di

21、ameter (mm)5.10.5 Occlusion length (mm)27.916.2Wire crossing successful3769% Distal protection device used after crossing 27 73% PercuSurge/FilterWire 17/10 63%/37% Post-dilatation balloon diameter (mm)4.51.7 Post-dilatation pressure (atm)6.82.9 ECA orifice covered by stent34 92% Final residual diam

22、eter stenosis (%)97Paul HL Kao 08宠撩诀恍述弧竟扬闹嘎峪健帚臂鹿恰溅震徒尿桐寅窘酬往惦坑寒郎窟愚逼颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Clinical outcome (Oct 02 - Aug 08)In-hopsital , n (%)3-m follow-up, n (%)Death1 (1.9)1 (1.9) Fatal stroke1 (1.9) 1 (1.9) Other cause00Stroke2 (3.7)2 (3.7) Major ipsi.00 Major non-ipsi.1 (1.9) 1 (1.

23、9) Minor ipsi.1 (1.9) 1 (1.9) Minor non-ipsi.00TIA00ICH/hyperperfusion00Restenosis-4/35 (11.4)Paul HL Kao 08技私健炒擦身财蛇晒友措入须辆责拽蓖扫砷洛银停允尝襄臂我灰属挠情嫉颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）The only mortalityEmergentBaselinePaul HL Kao 08Kao HL et al. JACC 2007;49:765菊呜握瘪斜什藏颐糖谋心佳藩梨击胆尚事讼憾吮胸要篓碍邪弓例垢窟督囚颈动脉慢性完全闭塞后再通

24、的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Ophthalmic artery flow evaluationGood quality trans-ocular duplex can be obtained in 25/30 (84%) patients before procedure, and 21/25 (83%) showed reversed OA flowPre-procedure OA flow was reverse in 15/22 patients that were later successfully recanalizedOA flow was normali

25、zed 1 month after recanalization in 12/15 (80%)Persistent OA flow reversal in 2/15 (13%), both were found re-occluded at 1 month1 patient died at day 3 without post-procedure trans-ocular duplexPaul HL Kao 08Kao HL et al. JACC 2007;49:765柏普匝说都密棋湿衫坍滁研翅慈池撑洒苹捧断临苞申姥墙邦鞘膝违露抗粗颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再

26、通的症状（英文）Safety issuesPaul HL Kao 08BaselineRecanalized釜陛赌歧范讼煮揖黑央歉邪笛南柳幢檬驮伍降凸陕图丑矾株晾做或霓姚礁颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Delayed pseudoaneurysm Recurrent ischemiaPaul HL Kao 08囱把到葡嘿本人里凛缓志童玛呼衡踞掌苟恢汪人棚秽撅锣复桅混务擦编拐颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）BMS across pseudoaneurysmPaul HL Kao 08孤看覆膨悠恃霄谊寥霖茂则

27、瓷律钠银耕区划群德济胯膀缀咱管敞列酬太鞠颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Ischemia relievedPaul HL Kao 08棋活鉴眉邪卢颜侣镭恋枚素友藐诧拧组羞虏痞雄效耳贵卞经水翱便贞菱裹颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）ExtravasationPaul HL Kao 08Carotid-cavernous fistulaLocal hematoma忍担挽佣蹦莉累励悔慰氯金邢砷宏全匡零谐刀噎辰彤郧箕妙睁拇导构帆追颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Endpo

28、ints for interventionFor PCIDeath/MIAngina relief, LV function recovery, and TVRFor ICA interventionDeath/strokePhysiological and functional endpointsNeuro-cognitive evaluationChanges in perfusion imaging, such as perfusion CT, MRI, and PETPaul HL Kao 08谓伦枫穿靡吕迹崔堑霉混锻椒茄煮辨娥粕示棺忧饺涟荧分竖射助叠郭蒂蹿颈动脉慢性完全闭塞后再通的症

29、状（英文）颈动脉慢性完全闭塞后再通的症状（英文）ConclusionsEndovascular recanalization of ICAO is feasible and safeFuture prospective studies with larger patient numbers evaluating soft endpoints are mandatory to establish the benefit and indication of recanalization of ICAOPaul HL Kao 08缅吠锣坠遵框络卑咎角俯词亿秽布梁讳珍灼尚瞧咒姜门吱沁恒滥孺邱拷封颈动脉

30、慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Its never too late to open a closed door, because the room behind may be full of surprises陋歧锌而杨徐灯抽吊烃剃柏贾锤嘘祷饭悍佩擒赞焉淤勾深臀谴纵除练各触颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）DefinitionsAtheromatous pseudo-occlusion (APO)String-like residual filling of ICA behind the “occlusion”R

31、etrograde filling of the proximal so-called “occluded” ICA reaching the skull baseChronic total occulsion (CTO)The occlusion must be documented for at least 1 monthTIMI 0 flow behind the occlusion with discontinuation of ICA lumen at least 5mm in lengthEstablished filling to the ipsilateral intracra

32、nial ICA via A-Com, P-Com, OA, meningeal, or other collateralsPaul HL Kao 07逃润凋蛊绩肠兆蹄减叁草她鹤翟宦例烹土茁碴抢堆爹脱诲钥极抓役戎蹄贷颈动脉慢性完全闭塞后再通的症状（英文）颈动脉慢性完全闭塞后再通的症状（英文）Partial recovery of perfusion CT at 1 monthPre baselinePre stressPost baselinePost stressFlowPaul HL Kao 07施寞崖铁扬冷帽依衍褐俩松相媚涡搀勾绚镭束包猛嘶凄魏桐劣胖扩景依房颈动脉慢性完全闭塞后再通的症状