颈动脉支架术后再狭窄的处理优秀课件.pptx

1、颈动脉支架术后再狭窄的处理颈动脉支架术后再狭窄的处理目录CONTENTS目录CONTENTS01定义定义02病例讨论病例讨论03预防和治疗预防和治疗The Affiliated Jiangning Hospital of Nanjing Medical University01 颈动脉支架后再狭窄（in-stent restenosis，ISR）：是指支架置入术后在支架处或支架边缘5mm范围内发生的50%的管腔狭窄。当支架置入后发生再狭窄或参与狭窄50%时，发生缺血性卒中风险显著增高。The Affiliated Jiangning Hospital of Nanjing Medical Un

2、iversity02 患者张，男，66岁 主诉：因“反应迟钝一天”入院。既往有“高血压病”史多年，有长期烟酒嗜好。查体：神志清楚，反应迟钝，混合性失语。记忆力、计算力欠佳。NIHSS评分4分第一次住院：2014年11月23日The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical Unive

3、rsity02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital

4、 of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02主诉：不能言语伴左侧肢体活动障碍2小时查体：左侧上下肢肌力5-级NIHSS评分6分 入院后2小时症状进行性加重 左侧上、下肢肌力0级The Affiliated Jiangning Hospital of Nanjing Medical University02 CBV：轻度

5、增高；CBF：明显下降；MTT及TTP稍延长；PWI明显大于DWI 判断：脑梗死前期2-1期The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University023*20mm球囊预扩The Affiliated Jiangning Hospital of Nanjing Medical University023*20mm球囊预扩再次置入保护伞The Affiliated Jiangning Hospita

6、l of Nanjing Medical University02 术后左侧肢体肌力恢复至5-级 NIHSS评分6分The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02停用抗血小板药物加强脱水治疗The Affiliated Jiangning Hospital of Nanjing Medical University02四天后七天后患者经治疗后症状好转出院NIHSS评分5分The Af

7、filiated Jiangning Hospital of Nanjing Medical University02患者陈，男，63岁主诉：因“反应迟钝三天”入院。既往有“高血压病”史多年，八年前有“脑出血”病史，无明显后遗症。查体：神志清楚，口齿尚 清。记忆力、计算力欠佳，右侧上下肢肌力5-级。NIHSS评分1分The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02彩色多普勒：RCCA、

8、LCCA斑块形成，RICA内径较窄，LICA血流速度慢存在脑大动脉狭窄？The Affiliated Jiangning Hospital of Nanjing Medical University02RVAThe Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02T

9、he Affiliated Jiangning Hospital of Nanjing Medical University02右颈支架上段扩张不良，管腔重度狭窄左颈C1段动脉瘤The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02LCCA（C1动脉瘤）The A

10、ffiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02The Affiliated Jiangning Hospital of Nanjing Medical University02RICA正位The Affiliated Jiangning Hospital of Nanjing Medical University02RICA正位支架影RICA侧位侧位支架影The Affiliated Jian

11、gning Hospital of Nanjing Medical University02RVA正位RVA侧位The Affiliated Jiangning Hospital of Nanjing Medical University02LICA正位正位支架影LICA侧位侧位支架影The Affiliated Jiangning Hospital of Nanjing Medical University02LICA-3D检查LVA正位The Affiliated Jiangning Hospital of Nanjing Medical University02LVA正位正位支架影LVA

12、侧位The Affiliated Jiangning Hospital of Nanjing Medical University03药物预防 抗血小板药物：血小板活化在ISR发生和发展过程中起着重要作用，但血小板药物对ISR的预防作用与其对血小板功能的抑制程度并不成正比。他汀类药物：除具有降血脂作用外，还可改善内皮作用，具有抑制血管平滑肌增殖、迁移和预防ISR作用。缬沙坦：血管紧张素可通过生长因子促进再狭窄发生，血管紧张素1型受体拮抗药能通过抑制血管紧张素与血管紧张素1型受体结合，抑制再狭窄发生，多项临床试验均显示，口服缬沙坦能降低ISR发生率。吡格列酮：糖尿病患者在裸金属支架置入后，起到降

13、糖和减轻ISR的作用。药物涂层支架 不足：药物涂层支架在阻止平滑肌细胞增殖和减少再狭窄发生的同时，也会阻止血管内皮细胞增殖。导致内皮化延迟，进而引起局部慢性炎症反应和增高远期支架内血栓形成的发生率。The Affiliated Jiangning Hospital of Nanjing Medical University03 目前治疗ISR的方法很多，但尚缺乏具有明显优势的治疗方式。p 经皮腔内血管成形术；p 重复CAS；p 支架取出后行CEA。p 其他：如颈动脉旁路移植术、近距离放射治疗以及裸金属支架置入术等。The Affiliated Jiangning Hospital of Nanjing Medical University个人观点供参考，欢迎讨论