颈动脉狭窄的诊疗支架颈动脉狭窄的诊疗支架治疗的病例选择围手术治疗的病例选择围手术用药用药脑动脉系统脑动脉系统2颈动脉狭窄的诊疗支架治疗的病例选择围手术用药缺血性脑血管病的病因缺血性脑血管病的病因Albers GW,Chair;J.CHEST 1998;114:683S698S 3颈动脉狭窄的诊疗支架治疗的病例选择围手术用药颈动脉狭窄的诊断颈动脉狭窄的诊断4颈动脉狭窄的诊疗支架治疗的病例选择围手术用药颈动脉狭窄定义颈动脉狭窄定义Paul HL Kao颈总动脉颈总动脉(CCACCA)、分叉或颈内动脉、分叉或颈内动脉(ICAICA)近段动脉硬化斑块形成近段动脉硬化斑块形成斑块溃疡、血栓形成、或远端栓塞是斑块溃疡、血栓形成、或远端栓塞是引起症状引起症状(TIA/stroke/AF)(TIA/stroke/AF)的主要原的主要原因因5颈动脉狭窄的诊疗支架治疗的病例选择围手术用药l动脉粥样硬化动脉粥样硬化l纤维肌发育不良纤维肌发育不良(fibromuscularfibromuscular dysplasiadysplasia)l高安氏病高安氏病（TakayasusTakayasus ArteritisArteritis）l血管炎（血管炎（vasculitis）(包括放疗后包括放疗后)l与神经纤维瘤病相关的狭窄与神经纤维瘤病相关的狭窄颈动脉狭窄的原因颈动脉狭窄的原因6颈动脉狭窄的诊疗支架治疗的病例选择围手术用药临床表现临床表现无症状性狭窄无症状性狭窄 无神经系统症状和体征，影像学无阳性发现无神经系统症状和体征，影像学无阳性发现有症状性狭窄有症状性狭窄 Amaurosis fugax Amaurosis fugax 一过性黑朦一过性黑朦 Transient ischemic attack(TIA)Transient ischemic attack(TIA)Reversible ischemic neurological deficit Reversible ischemic neurological deficit (RIND)(RIND)可逆性缺血性神经功能神经缺失可逆性缺血性神经功能神经缺失 Completed stroke Completed stroke 完全中风完全中风7颈动脉狭窄的诊疗支架治疗的病例选择围手术用药B-modePower angioColor mappingDopplerTCD颈动脉狭窄的诊断颈动脉狭窄的诊断DuplexDuplex超声超声lMRA&CTAMRA&CTAlDSA-DSA-黄金标准黄金标准 狭窄度狭窄度 形态学形态学-钙化、血栓、溃疡钙化、血栓、溃疡8颈动脉狭窄的诊疗支架治疗的病例选择围手术用药9颈动脉狭窄的诊疗支架治疗的病例选择围手术用药10颈动脉狭窄的诊疗支架治疗的病例选择围手术用药11颈动脉狭窄的诊疗支架治疗的病例选择围手术用药12颈动脉狭窄的诊疗支架治疗的病例选择围手术用药13颈动脉狭窄的诊疗支架治疗的病例选择围手术用药14颈动脉狭窄的诊疗支架治疗的病例选择围手术用药NASCETNASCETNorth American Symptomatic North American Symptomatic North American Symptomatic North American Symptomatic Carotid Endarterectomy TrialCarotid Endarterectomy TrialCarotid Endarterectomy TrialCarotid Endarterectomy TrialECSTECSTEuropean Carotid Stenosis European Carotid Stenosis European Carotid Stenosis European Carotid Stenosis Trial Trial Trial Trial 颈动脉狭窄率的测定颈动脉狭窄率的测定15颈动脉狭窄的诊疗支架治疗的病例选择围手术用药颈动脉狭窄与缺血性卒中的关系颈动脉狭窄与缺血性卒中的关系l约约40%40%的前循环系统的前循环系统TIATIA或中风存在同侧颈或中风存在同侧颈动脉的重度狭窄动脉的重度狭窄(75%)(75%)其中其中8%8%完全闭塞完全闭塞 l10%10%症状性颈内动脉狭窄者症状性颈内动脉狭窄者1 1年内发生脑梗年内发生脑梗死，死，5 5年内发生梗死的危险性高达年内发生梗死的危险性高达40%40%l无症状性颈内动脉狭窄无症状性颈内动脉狭窄(80%)80%)每年发生每年发生中风的危险性为中风的危险性为 6%6%l约有约有80%80%的中风发生前无任何症状的中风发生前无任何症状 (如如TIATIA等等)16颈动脉狭窄的诊疗支架治疗的病例选择围手术用药颈动脉狭窄与缺血性卒中的关系颈动脉狭窄与缺血性卒中的关系Figure 3.Annual risk of stroke or vascular death among patients in various high risk subgroups.Wilterdink JL,Easton JD.Arch Neurol 1992;49:857 863.17颈动脉狭窄的诊疗支架治疗的病例选择围手术用药颈动脉狭窄颈动脉狭窄支架治疗的病例选择支架治疗的病例选择18颈动脉狭窄的诊疗支架治疗的病例选择围手术用药颈动脉狭窄的治疗颈动脉狭窄的治疗Established for selected patientsEstablished for selected patientsl lAnti-platelet therapy Anti-platelet therapy Anti-platelet therapy Anti-platelet therapy 抗血小板抗血小板抗血小板抗血小板l lStatin agents Statin agents Statin agents Statin agents 他丁类药物他丁类药物他丁类药物他丁类药物l lCarotid endarterectomy Carotid endarterectomy Carotid endarterectomy Carotid endarterectomy 颈动脉内膜剥离术颈动脉内膜剥离术颈动脉内膜剥离术颈动脉内膜剥离术l lAngioplasty and stentingAngioplasty and stentingAngioplasty and stentingAngioplasty and stentingUnder investigationUnder investigation正在确立的新疗法正在确立的新疗法ExtracranialExtracranialExtracranialExtracranial to Intracranial bypass to Intracranial bypass to Intracranial bypass to Intracranial bypassAtherectomyAtherectomyAtherectomyAtherectomy 动脉狭窄旋切术动脉狭窄旋切术动脉狭窄旋切术动脉狭窄旋切术Laser Assisted Angioplasty Laser Assisted Angioplasty Laser Assisted Angioplasty Laser Assisted Angioplasty 激光辅助的血管成型术激光辅助的血管成型术激光辅助的血管成型术激光辅助的血管成型术ThrombolysisThrombolysisThrombolysisThrombolysis AngiojetAngiojetAngiojetAngiojet 血管射频消融术血管射频消融术血管射频消融术血管射频消融术19颈动脉狭窄的诊疗支架治疗的病例选择围手术用药CarotidCarotidendarterecendarterectomytomy(CEA)(CEA)is a surgical procedure removing plaque material from the lining of an artery20颈动脉狭窄的诊疗支架治疗的病例选择围手术用药The procedure to remove plaque build-up from an artery.A surgeon scrapes away the arterial lining,where plaque has formed,and the artery is stitched closed.Endarterectomy:researches Endarterectomy:researches 研究结果研究结果lNorth American Symptomatic Carotid North American Symptomatic Carotid North American Symptomatic Carotid North American Symptomatic Carotid EndarterectomyEndarterectomyEndarterectomyEndarterectomy Trial(NASCET)Trial(NASCET)Trial(NASCET)Trial(NASCET)lEuropean Carotid European Carotid European Carotid European Carotid StenosisStenosisStenosisStenosis Trial(ECST)Trial(ECST)Trial(ECST)Trial(ECST)Results:Results:Results:Results:Dramatic risk reduction with surgery Dramatic risk reduction with surgery Dramatic risk reduction with surgery Dramatic risk reduction with surgery for severe for severe for severe for severe stenosisstenosisstenosisstenosis 结果结果结果结果:CEA:CEA:CEA:CEA明显降低颈动脉严重狭窄患者的中风危险性明显降低颈动脉严重狭窄患者的中风危险性明显降低颈动脉严重狭窄患者的中风危险性明显降低颈动脉严重狭窄患者的中风危险性NASCET.N Engl J Med 1991;325:445-453 ECST.Lancet 1991;337:1235-124321颈动脉狭窄的诊疗支架治疗的病例选择围手术用药l lContralateralContralateralContralateralContralateral occlusion occlusion occlusion occlusion 对侧对侧对侧对侧CCACCACCACCA闭塞闭塞闭塞闭塞lHigh or bifurcation lesions High or bifurcation lesions 高位或分叉部病变高位或分叉部病变lLow or Low or ostialostial CCA lesions CCA lesions 低位或靠近低位或靠近CCACCA开口处开口处lNeck radiation Neck radiation 颈部放射治疗颈部放射治疗lPrior radical neck dissection Prior radical neck dissection 既往颈部切开术既往颈部切开术lPrior carotid Prior carotid endarterectomyendarterectomy 既往既往CEACEAlShort,obese necks Short,obese necks