单纯血流导向装置治疗椎-基底动脉动脉瘤的安全性及疗效分析

doi:10.3877/cma.j.issn.2095-5782.2023.03.008

目的

总结分析单纯血流导向装置（flow diverter，FD）治疗椎-基底动脉动脉瘤的安全性及临床疗效。

方法

回顾性分析哈尔滨医科大学附属第一医院神经外科2019年1月至2022年5月接受FD治疗椎-基底动脉动脉瘤患者的影像学及临床资料，总结分析患者术后神经系统相关并发症情况。根据改良Rankin量表（modified Rankin scale，mRS）评分评价患者接受该治疗方式的临床预后；采用O'Kelly-Marotta（OKM）分级评估患者术后影像学随访动脉瘤闭塞情况。

结果

纳入38例患者共40个动脉瘤，其中破裂动脉瘤1个，未破裂动脉瘤39个。所有患者共置入51枚FD，其中Pipeline血流导向装置（Pipeline embolization devices，PED）44枚，Tubridge FD 7枚，手术成功率为100%。所有FD均成功释放并贴壁完好。所有患者均获得临床随访，中位随访时间为13.0 （2~47）个月。术后总体并发症发生率为13.2%（5/38），其中围手术期并发症发生率为5.3%（2/38），随访期间首次出现并发症3例（3/38，7.9%）。术后总体缺血性并发症发生率为13.2%（5/38），其中缺血合并出血性并发症2例（2/38，5.3%）。末次随访mRS > 2比率为10.52%（4/38），其中死亡率为7.9%（3/38）。24例患者共26个动脉瘤获得影像学随访，中位随访时间7（5~18）个月，动脉瘤完全闭塞（OKM分级D级）16个（16/26，61.5%），动脉瘤次全闭塞（OKM分级C/D级）22个（22/26，84.60%）；无动脉瘤体积进展。

结论

单纯FD治疗椎-基底动脉动脉瘤手术成功率高，安全性较好，术后影像学随访闭塞率高，无动脉瘤体积进展，但仍应警惕致命性缺血性并发症的发生。

关键词: 血流导向装置, 椎-基底动脉瘤, 并发症, 随访研究

Objective

To analyze the efficacy and safety of flow diverter (FD) only in treating vertebrobasilar aneurysms.

Methods

The clinical data of patients with vertebrobasilar aneurysms treated with FD in the First Affiliated Hospital of Harbin Medical University from January 2019 to May 2022 were analyzed retrospectively. Periprocedural complications were recorded and analyzed. The modified Rankin Scale (mRS) was used to evaluate the clinical outcomes, and the O'Kelly Marotta (OKM) grading scale was used to evaluate imaging outcomes.

Results

A total of 38 patients harbouring 40 intracranial aneurysms treated with FD were enrolled. A total of 51 FDs were implanted, including 44 Pipeline embolization devices (PED) and 7 Tunbridge FDs, with a technical success rate of 100%. All FDs were successfully released with proper stent apposition. Thirty-eight patients underwent clinical follow-up, with a median follow-up time of 13.0 (2~47) months. The overall postprocedural complication rate was 13.2% (5/38). Among them, the periprocedural complication rate was 5.3% (2/28), and 3 (7.9%, 3/38) patients first experienced complications during the follow-up. The overall incidence of postprocedural ischemic complications was 13.2% (5/38), including 2 cases (2/38, 5.3%) of ischemia complicated with hemorrhagic complications. The rate of mRS >2 at the last follow-up was 10.52% (4/38), and the mortality rate was 7.9% (3/38). A total of 24 patients with 26 aneurysms underwent imaging follow-up, with a median follow-up time of 7 (5~18) months. Complete aneurysm occlusion (grade D of the OKM grading scale) was observed in 16 (61.5%) patients, and adequate aneurysm occlusion (grade C/D of the OKM grading scale ) was observed in 22 patients (84.60%). No aneurysm growth was observed.

Conclusions

FD was safe in treating vertebrobasilar aneurysms with a high procedure success rate. Imaging follow-up showed a high rate of adequate aneurysm occlusion with no growth. However, fatal ischemic complications remain to be noted.

Key words: Flow diverter, Vertebrobasilar aneurysms, Complication, Follow-up

图1 患者男，56岁，因"右侧肢体麻木无力、言语笨拙伴吞咽困难"入院1A：术前DSA显示基底动脉主干动脉瘤；1B：术中Vaso CT显示支架贴壁良好；1C：术后即刻造影显示动脉瘤腔内血流瘀滞，载瘤动脉通畅；1D、1E：术后患者出现双侧肢体无力及失语，复查DSA显示动脉瘤完全闭塞，载瘤动脉通畅；1F：随后头部CT扫描见脑内出血。

图2 患者女，64岁，因"发作性头晕"入院2A：术前造影可见左侧椎动脉V4段夹层动脉瘤；2B：术中Vaso CT显示支架贴壁良好；2C：术后即刻造影显示载瘤动脉通畅；2D：术后6个月随访可见动脉瘤完全闭塞，载瘤动脉通畅，小脑后下动脉显影正常。

表1 患者随访结果

项目	数值，n（%）
临床随访时间[月，M（范围）]	13（2~47）
随访期间并发症
缺血性并发症	5（13.2）
出血性并发症	2（5.3）
末次随访mRS
< 2	34（89.7）
≥2	4（10.3）
死亡	3（7.9）
影像学随访时间[月，M（范围）]	7（5~18）
动脉瘤闭塞OKM分级
D	16（61.5）
C/D	22（84.6）
支架内狭窄/血栓形成	3（11.5）

表1 患者随访结果

项目	数值，n（%）
临床随访时间[月，M（范围）]	13（2~47）
随访期间并发症
缺血性并发症	5（13.2）
出血性并发症	2（5.3）
末次随访mRS
< 2	34（89.7）
≥2	4（10.3）
死亡	3（7.9）
影像学随访时间[月，M（范围）]	7（5~18）
动脉瘤闭塞OKM分级
D	16（61.5）
C/D	22（84.6）
支架内狭窄/血栓形成	3（11.5）

[1]	Li M, Chen S, Wei X, et al. Prevalence of unruptured cerebral aneurysms in chinese adults aged 35 to 75 years: a cross-sectional study[J]. Ann Intern Med, 2013, 159(8): 514-521.
[2]	Mardjono Tjahjadi MN. Presigmoid approach to vertebrobasilar atery aneurysms: a series of 31 patients and review of the literature[J]. World Neurosurg, 2016, 92: 313-322.
[3]	Shi G, Xu S, Gareev I, et al. Overlapping stent-assisted coil embolization for vertebrobasilar dissecting aneurysms: a single-center study[J]. Neurol Res, 2021, 43(9): 701-707.
[4]	Choi HH, Cho YD, Yoo DH, et al. Stent-assisted coil embolization of anterior communicating artery aneurysms: safety, effectiveness, and risk factors for procedural complications or recanalization[J]. J Neurointerv Surg, 2018, 11(1): 49-56.
[5]	Alwakeal A, Shlobin NA, Golnari P, et al. Flow diversion of posterior circulation aneurysms: systematic review of disaggregated individual patient data[J]. AJNR Am J Neuroradiol, 2021, 58(4): 391-400.
[6]	O'Kelly CJ, Krings T, Fiorella D, et al. A novel grading scale for the angiographic assessment of intracranial aneurysms treated using flow diverting stents[J]. Interv Neuroradiol, 2010, 16(2): 133-137.
[7]	Griessenauer CJ, Ogilvy CS, Adeeb N, et al. Pipeline embolization of posterior circulation aneurysms: a multicenter study of 131 aneurysms[J]. J Neurosurg, 2019, 130(3): 923-935.
[8]	Demetrius K, Lopes M, Dong-Kyu Jang MP, et al. Morbidity and mortality in patients with posterior circulation aneurysms treated with the pipeline embolization device: a subgroup analysis of the international retrospective study of the pipeline embolization device[J]. Neurosurgery, 2017, 83(3): 488-500.
[9]	Albuquerque FC, Park MS, Abla AA, et al. A reappraisal of the pipeline embolization device for the treatment of posterior circulation aneurysms[J]. J Neurointerv Surg, 2015, 7(9): 641-645.
[10]	Catapano JS, Ducruet AF, Cadigan MS, et al. Endovascular treatment of vertebral artery dissecting aneurysms: a 20-year institutional experience[J]. J Neurointerv Surg, 2022, 14(3):257-261.
[11]	Dmytriw AA, Kapadia A, Enriquez-Marulanda A, et al. Vertebral artery aneurysms and the risk of cord infarction following spinal artery coverage during flow diversion[J]. J Neurosurg, 2021, 134(3): 961-970.
[12]	Wang C, Zhu D, Xu X, et al. Use of flow diverter device in basilar artery for aneurysm treatment: case series and literature review[J]. Front Neurol, 2022, 13: 990308.
[13]	吴桥伟, 李立, 邵秋季, 等. Pipeline Flex血流导向装置治疗颅内复杂动脉瘤的安全性及短期疗效[J]. 中华介入放射学电子杂志, 2020, 8(1): 28-32.
[14]	吴桥伟, 李立, 邵秋季, 等. Pipeline Flex血流导向装置治疗后循环大型动脉瘤单中心临床经验[J]. 中华介入放射学杂志, 2021, 30(1): 1-4.
[15]	吴桥伟, 李立, 邵秋季, 等. 血流导向装置治疗颅内大型未破裂动脉瘤的临床疗效分析[J]. 中华神经外科杂志, 2020, 36(3): 269-273.
[16]	Zhu D, Yan Y, Zhao P, et al. Safety and efficacy of flow diverter treatment for blood blister-Like aneurysm: a systematic review and meta-analysis[J]. World Neurosurg, 2018, 118: e79-e86.
[17]	Rautio R, Alpay K, Sinisalo M, et al. Treatment of intracranial aneurysms using the new Surpass Evolve flow diverter: safety outcomes and six-month imaging follow-up[J]. J Neuroradiol, 2022, 49(1): 80-86.
[18]	Adeeb N, Griessenauer CJ, Dmytriw AA, et al. Risk of branch occlusion and ischemic complications with the pipeline embolization device in the treatment of posterior circulation aneurysms[J]. AJNR Am J Neuroradiol, 2018, 39(7): 1303-1309.
[19]	Ge H, Yang H, Ren H, et al. Association of thrombelastographic parameters with complications in patients with intracranial aneurysm after stent placement[J]. World Neurosurg, 2019, 127: e30-e38.
[20]	Adeeb N, Griessenauer CJ, Foreman PM, et al. Use of platelet function testing before pipeline embolization device placement[J]. Stroke, 2017, 48(5): 1322-1330.
[21]	吴桥伟, 李立, 邵秋季, 等. 替罗非班在血流导向装置治疗颅内未破裂动脉瘤术中的预防性应用研究[J]. 中华神经外科杂志, 2021, 37(4): 342-347.
[22]	付培基, 李腾飞, 马骥, 等. 高分辨C臂CT联合3D-DSA双容积重建融合技术在颅内动脉瘤血流导向装置（Tubridge）置入术贴壁评估中的初步应用[J]. 中国实用神经疾病杂志, 2020, 23(10): 833-838.
[23]	Kallmes DF, Ding YH, Dai D, et al. A second-generation, endoluminal, flow-disrupting device for treatment of saccular aneurysms[J]. AJNR Am J Neuroradiol, 2009, 30(6): 1153-1158.
[24]	Wang J, Jia L, Duan Z, et al. Endovascular treatment of large or giant non-saccular vertebrobasilar aneurysms: pipeline embolization devices versus conventional stents[J]. Front Neurol, 2019, 55(6): 567-573.
[25]	Kang H, Luo B, Liu J, et al. Postoperative occlusion degree after flow-diverter placement with adjunctive coiling: analysis of complications[J]. J Neurointerv Surg, 2022, 14(4): 371-375.

[1]	易晨, 张亚东, 董茜, 唐海阔, 刘志国. 应用骨盖技术拔除下颌低位骨性埋伏阻生第三磨牙的疗效观察[J]. 中华口腔医学研究杂志(电子版), 2023, 17(06): 424-429.
[2]	杜滨和, 徐楠, 杨云川, 崔培元. 5项改良衰弱指数预测胰十二指肠切除术近期预后的价值探讨[J]. 中华普通外科学文献(电子版), 2023, 17(06): 444-448.
[3]	李建美, 邓静娟, 杨倩. 两种术式联合治疗肝癌合并肝硬化门静脉高压的安全性及随访评价[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 41-44.
[4]	逄世江, 黄艳艳, 朱冠烈. 改良π形吻合在腹腔镜全胃切除消化道重建中的安全性和有效性研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 66-69.
[5]	杨体飞, 杨传虎, 陆振如. 改良无充气经腋窝入路全腔镜下甲状腺手术对喉返神经功能的影响研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 74-77.
[6]	陈垚, 徐伯群, 高志慧. 改良式中间上入路根治术治疗甲状腺癌的有效性安全性研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 619-622.
[7]	陈大敏, 曹晓刚, 曹能琦. 肥胖对胃癌患者手术治疗效果的影响研究[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 651-653.
[8]	代格格, 杨丽, 胡媛媛, 周文婷. 手术室综合干预在老年腹股沟疝患者中的应用效果[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 759-763.
[9]	王敏, 蒋家斌, 李茂新. 预警宣教联合个性化疼痛管理对腹股沟疝手术患者的影响[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 764-767.
[10]	戴玮, 江桂林, 车兆平, 张姣, 王星星, 赵海涛. 无缝手术护理在腹股沟疝腹腔镜手术围手术期的应用效果[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 778-781.
[11]	叶晋生, 路夷平, 梁燕凯, 于淼, 冀祯, 贺志坚, 张洪海, 王洁. 腹腔镜下应用生物补片修补直肠术后盆底缺损的疗效[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 688-691.
[12]	袁伟, 张修稳, 潘宏波, 章军, 王虎, 黄敏. 平片式与填充式腹股沟疝修补术的疗效比较[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 697-701.
[13]	夏松, 姚嗣会, 汪勇刚. 经腹腹膜前与疝环充填式疝修补术治疗腹股沟疝的对照研究[J]. 中华疝和腹壁外科杂志(电子版), 2023, 17(06): 702-705.
[14]	潘冰, 吕少诚, 赵昕, 李立新, 郎韧, 贺强. 淋巴结清扫数目对远端胆管癌胰十二指肠切除手术疗效的影响[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 608-612.
[15]	崔佳琪, 吴迪, 陈海艳, 周惠敏, 顾元龙, 周光文, 杨军. TACE术后并发肝脓肿的临床诊治分析[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 688-693.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Safety and efficacy analysis of flow diverter only in the treatment of vertebrobasilar aneurysms

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Safety and efficacy analysis of flow diverter only in the treatment of vertebrobasilar aneurysms