影响颅内宽颈动脉瘤血管内治疗策略的相关因素研究
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摘要
背景与目的：颅内宽颈动脉瘤仍是血管内治疗的难题之一,主要表现在技术处理困难和容易复发两个方面。目前虽然有多种方法可以采用,但许多因素会影响治疗策略的规划和治疗效果。本研究旨在分析、探讨可能影响颅内宽颈动脉瘤血管内治疗策略的相关因素,以期为提高宽颈动脉瘤的血管内治疗效果提供参考。
方法：回顾分析2007年1月至2011年12月在我中心接受血管内治疗的颅内宽颈动脉瘤患者的相关资料,主要包括：(1)动脉瘤的形态学特点：如动脉瘤形状、大小、部位、瘤颈宽度、瘤体/颈比值、瘤体高/宽比、载瘤动脉直径等；(2)动脉瘤血管内治疗的情况：技术资料、栓塞结果、并发症、影像随访结果；(3)患者的临床状态：如动脉瘤是否破裂和临床转归等。连续变量的分布用均数和标准差(mean±SD)描述,离散变量用频率、百分比描述。采用单因素x2分析及多因素Logistic回归分析探讨可能影响栓塞结果的因素。
结果：(1)共有210例患者(238个颅内宽颈动脉瘤)纳入本研究。其中,破裂动脉瘤154个(64.71%),未破裂动脉瘤84个(35.29%)；前循环动脉瘤占200个(84.03%),后循环动脉瘤38个(15.97%)；动脉瘤平均大小6.94±5.64mm(1.640mm),瘤颈平均4.11±2.47mm(1.0-20mm)；平均瘤高/横径比值(H/D)1.31±0.46(0.45-5.40)；分叉部动脉瘤88个(36.97%),侧壁动脉瘤150个(63.03%)。(2)238个动脉瘤中,1个因术中血栓形成放弃栓塞,技术成功率99.58%,充分栓塞率为81.01%。单纯弹簧圈栓塞55个(23.11%),球囊辅助弹簧圈栓塞71个(29.83%),支架辅助弹簧圈栓塞79个(33.19%),联合支架与球囊技术栓塞17个(7.14%),载瘤动脉单纯支架置入术(Sole Stenting)12个(5.04%),双微导管技术4个(1.68%)。(3)动脉瘤长/宽比≤1(OR=2.847,P=0.006)及瘤颈>4mm(OR=4.772,P=0.000)更倾向于应用支架辅助栓塞,破裂(OR=0.372,P=0.003)及位于分叉部的动脉瘤(OR=0.231,P=0.000)不倾向于应用支架辅助栓塞；瘤颈>4mmm多被选择应用球囊辅助栓塞(OR=3.662,P=0.003)；破裂(OR=0.311,P=0.006)及体/颈比≥1.5的动脉瘤(OR=0.427,P=0.043)更倾向于单纯弹簧圈实施栓塞。(4)破裂动脉瘤的充分栓塞率高于未破裂动脉瘤(OR=2.918,P=0.002),长/宽比≤1的动脉瘤比>1的动脉瘤不容易被充分栓塞(OR=0.399,P=0.010)。(5)除10例院内死亡患者外,200例患者得到临床随访,平均随访时间24.60±16.28个月。7例患者随访期间死亡。134个动脉瘤接受了造影影像随访；良好转归率(包括治愈、好转或稳定)为87.31%,复发率12.69%。直径>15mm的动脉瘤栓塞后容易复发(OR=5.867,P=0.028)。
结论：(1)选用适当的血管内治疗方法治疗颅内宽颈动脉瘤,可以取得满意的中短期疗效。(2)单纯弹簧圈、球囊或支架辅助弹簧圈栓塞是目前治疗颅内宽颈动脉瘤最基本的技术,且支架辅助技术呈上升趋势。(3)颈宽>4mm的动脉瘤多被采用球囊或支架辅助技术栓塞；破裂的或体/颈比≥1.5的动脉瘤,术者更倾向于选择球囊辅助或单纯弹簧圈栓塞；长/宽比≤1的动脉瘤更倾向于选择支架辅助栓塞；分叉部动脉瘤采用支架辅助栓塞率相对低。(4)破裂动脉瘤和长/宽比>1的动脉瘤充分栓塞率更高。(5)动脉瘤大小是影响动脉瘤栓塞后转归的主要因素,直径>15mm的动脉瘤栓塞后更易复发。
Background and Objectives:
Intracranial wide-necked aneurysm is still one of the challenging issues in the field of interventional neuroradiology, largely due to the technical difficulties in their endovascular management and high recurrence rate after treatment. Although various approaches are available, a strategic selection of the proper one, as well as its efficacies, is affected by multiple factors. In this study, we aimed to retrospectively investigate and evaluate the factors affecting the endovascular treatment strategies of intracranial wide-necked aneurysms, with an intention to find some worthy information in improving the therapeutic efficacy of this type of disorders.
Methods:
Patients with wide-necked aneurysm(s) who received endovascular treatment in our centre between Jan,2007and Dec,2011were analyzed retrospectively with particular attention on the following aspects.
1) Morphological characteristics:such as the aneurysm shape, size, location, neck size (N), dome-to-neck ratio (D/N), height-to-diameter transversa ratio (H/D) and the diameter of parent artery.
2) Clinical and imaging records:including the patients'presentations, results of treatment, technique data, procedure related complications, and the clinical and imaging follow-up information. Data were statistically processed by either single-factor X2or multi-factor logistic regression analysis. Results are represented as frequency or ratio and mean±SD accordingly for un-continuous variants and continuous variants, respectively.
Results:
1)210patients with wide-necked aneurysms (in total of238aneurysms) were included in the study. Among all the aneurysms,154were ruptured and84un-ruptured, representing64.71%and35.92%, respectively.200(84.03%) occurred in anterior circulation and38(15.97%) in the posterior circulation;88(36.97%) are bifurcation aneurysms and150(63.03%) lateral ones. The aneurysms are6.94±5.64mm (1.6-40mm) in size, with their neck size at4.11±2.47mm (1.0-20mm) in average; Average H/D is1.31±0.46(0.45-5.40).
2) Among all the238aneurysms,237(99.58%) were received successful endovascular treatment except that one fell into abeyance because of the thrombosis during procedure, and81.01%of the237aneurysms got adequate embolization. Specifically,55(23.11%) received standard coiling,71(29.83%) balloon-assisted and79(33.19%) stent-assisted coiling,17(7.14%) a combined technique with both stent and balloon assisting,12(5.04%) sole stenting and12(7.14%) double catheter technique.
3) Aneurysms with H/D≤1(OR=2.847, P=0.006) and with N≥4mm (OR=4.772, P=0.000) were well suited for stent-assisted embolization, while ruptured (OR=0.372, P=0.003) and bifurcation aneurysms were not. Aneurysms with N≥4mm were preferable for balloon-assisted embolization (OR=3.662, P=0.003), too. Ruptured ones (OR=0.311,P=0.006) and those with D/N≥1.5(OR=0.427, P=0.043) were prone to be chosen for standard coiling.
4) The rate of adequate embolization is higher in ruptured than in un-ruptured aneurysms (OR=2.918, P=0.002). The aneurysms with H/D≤1are much more difficult to get adequate embolization (OR=0.399, P=0.010).
5) All200patients but10in-hospital death got follow-up of24.60±16.28months in average. Among them7died.134aneurysms underwent imaging follow-up, showing87.31%of satisfactory evolution (including improvement and no-change) and12.69%of worsening. Worsening tend to happen in those patients with aneurysms more than15mm in size (OR=5.867, P=0.028).
Conclusions:
1) Satisfactory short-or midterm quality of occlusion could be expected for those wide-necked aneurysms receiving appropriately selected endovascular treatment.
2) Standard coiling, balloon-or stent-assisted embolizations are the mainstream methods for the endovascular treatment of intracranial wide-necked aneurysms, with the stent-assisted embolization getting a rising tendency.
3) Aneurysms with neck size≥4mm are suited for balloon-or stent-assisted embolization. For ruptured aneurysm and those with D/N≥1.5, the operators favors balloon-assisted or standard coiling much more than stenting. Aneurysms with≤1are more appropriate for stent-assisted embolization, yet this do not include aneurysms located at the bifurcation.
4) Ruptured aneurysms and those with H/D>1win a higher rate of adequate embolization.
5) Aneurysm size was the primary factor affecting the evolution of the aneurysms after endovascular treatment, and diameter>15mm was the only independent risk factor for recurrence in this study.
方法：回顾分析2007年1月至2011年12月在我中心接受血管内治疗的颅内宽颈动脉瘤患者的相关资料,主要包括：(1)动脉瘤的形态学特点：如动脉瘤形状、大小、部位、瘤颈宽度、瘤体/颈比值、瘤体高/宽比、载瘤动脉直径等；(2)动脉瘤血管内治疗的情况：技术资料、栓塞结果、并发症、影像随访结果；(3)患者的临床状态：如动脉瘤是否破裂和临床转归等。连续变量的分布用均数和标准差(mean±SD)描述,离散变量用频率、百分比描述。采用单因素x2分析及多因素Logistic回归分析探讨可能影响栓塞结果的因素。
结果：(1)共有210例患者(238个颅内宽颈动脉瘤)纳入本研究。其中,破裂动脉瘤154个(64.71%),未破裂动脉瘤84个(35.29%)；前循环动脉瘤占200个(84.03%),后循环动脉瘤38个(15.97%)；动脉瘤平均大小6.94±5.64mm(1.640mm),瘤颈平均4.11±2.47mm(1.0-20mm)；平均瘤高/横径比值(H/D)1.31±0.46(0.45-5.40)；分叉部动脉瘤88个(36.97%),侧壁动脉瘤150个(63.03%)。(2)238个动脉瘤中,1个因术中血栓形成放弃栓塞,技术成功率99.58%,充分栓塞率为81.01%。单纯弹簧圈栓塞55个(23.11%),球囊辅助弹簧圈栓塞71个(29.83%),支架辅助弹簧圈栓塞79个(33.19%),联合支架与球囊技术栓塞17个(7.14%),载瘤动脉单纯支架置入术(Sole Stenting)12个(5.04%),双微导管技术4个(1.68%)。(3)动脉瘤长/宽比≤1(OR=2.847,P=0.006)及瘤颈>4mm(OR=4.772,P=0.000)更倾向于应用支架辅助栓塞,破裂(OR=0.372,P=0.003)及位于分叉部的动脉瘤(OR=0.231,P=0.000)不倾向于应用支架辅助栓塞；瘤颈>4mmm多被选择应用球囊辅助栓塞(OR=3.662,P=0.003)；破裂(OR=0.311,P=0.006)及体/颈比≥1.5的动脉瘤(OR=0.427,P=0.043)更倾向于单纯弹簧圈实施栓塞。(4)破裂动脉瘤的充分栓塞率高于未破裂动脉瘤(OR=2.918,P=0.002),长/宽比≤1的动脉瘤比>1的动脉瘤不容易被充分栓塞(OR=0.399,P=0.010)。(5)除10例院内死亡患者外,200例患者得到临床随访,平均随访时间24.60±16.28个月。7例患者随访期间死亡。134个动脉瘤接受了造影影像随访；良好转归率(包括治愈、好转或稳定)为87.31%,复发率12.69%。直径>15mm的动脉瘤栓塞后容易复发(OR=5.867,P=0.028)。
结论：(1)选用适当的血管内治疗方法治疗颅内宽颈动脉瘤,可以取得满意的中短期疗效。(2)单纯弹簧圈、球囊或支架辅助弹簧圈栓塞是目前治疗颅内宽颈动脉瘤最基本的技术,且支架辅助技术呈上升趋势。(3)颈宽>4mm的动脉瘤多被采用球囊或支架辅助技术栓塞；破裂的或体/颈比≥1.5的动脉瘤,术者更倾向于选择球囊辅助或单纯弹簧圈栓塞；长/宽比≤1的动脉瘤更倾向于选择支架辅助栓塞；分叉部动脉瘤采用支架辅助栓塞率相对低。(4)破裂动脉瘤和长/宽比>1的动脉瘤充分栓塞率更高。(5)动脉瘤大小是影响动脉瘤栓塞后转归的主要因素,直径>15mm的动脉瘤栓塞后更易复发。
Background and Objectives:
Intracranial wide-necked aneurysm is still one of the challenging issues in the field of interventional neuroradiology, largely due to the technical difficulties in their endovascular management and high recurrence rate after treatment. Although various approaches are available, a strategic selection of the proper one, as well as its efficacies, is affected by multiple factors. In this study, we aimed to retrospectively investigate and evaluate the factors affecting the endovascular treatment strategies of intracranial wide-necked aneurysms, with an intention to find some worthy information in improving the therapeutic efficacy of this type of disorders.
Methods:
Patients with wide-necked aneurysm(s) who received endovascular treatment in our centre between Jan,2007and Dec,2011were analyzed retrospectively with particular attention on the following aspects.
1) Morphological characteristics:such as the aneurysm shape, size, location, neck size (N), dome-to-neck ratio (D/N), height-to-diameter transversa ratio (H/D) and the diameter of parent artery.
2) Clinical and imaging records:including the patients'presentations, results of treatment, technique data, procedure related complications, and the clinical and imaging follow-up information. Data were statistically processed by either single-factor X2or multi-factor logistic regression analysis. Results are represented as frequency or ratio and mean±SD accordingly for un-continuous variants and continuous variants, respectively.
Results:
1)210patients with wide-necked aneurysms (in total of238aneurysms) were included in the study. Among all the aneurysms,154were ruptured and84un-ruptured, representing64.71%and35.92%, respectively.200(84.03%) occurred in anterior circulation and38(15.97%) in the posterior circulation;88(36.97%) are bifurcation aneurysms and150(63.03%) lateral ones. The aneurysms are6.94±5.64mm (1.6-40mm) in size, with their neck size at4.11±2.47mm (1.0-20mm) in average; Average H/D is1.31±0.46(0.45-5.40).
2) Among all the238aneurysms,237(99.58%) were received successful endovascular treatment except that one fell into abeyance because of the thrombosis during procedure, and81.01%of the237aneurysms got adequate embolization. Specifically,55(23.11%) received standard coiling,71(29.83%) balloon-assisted and79(33.19%) stent-assisted coiling,17(7.14%) a combined technique with both stent and balloon assisting,12(5.04%) sole stenting and12(7.14%) double catheter technique.
3) Aneurysms with H/D≤1(OR=2.847, P=0.006) and with N≥4mm (OR=4.772, P=0.000) were well suited for stent-assisted embolization, while ruptured (OR=0.372, P=0.003) and bifurcation aneurysms were not. Aneurysms with N≥4mm were preferable for balloon-assisted embolization (OR=3.662, P=0.003), too. Ruptured ones (OR=0.311,P=0.006) and those with D/N≥1.5(OR=0.427, P=0.043) were prone to be chosen for standard coiling.
4) The rate of adequate embolization is higher in ruptured than in un-ruptured aneurysms (OR=2.918, P=0.002). The aneurysms with H/D≤1are much more difficult to get adequate embolization (OR=0.399, P=0.010).
5) All200patients but10in-hospital death got follow-up of24.60±16.28months in average. Among them7died.134aneurysms underwent imaging follow-up, showing87.31%of satisfactory evolution (including improvement and no-change) and12.69%of worsening. Worsening tend to happen in those patients with aneurysms more than15mm in size (OR=5.867, P=0.028).
Conclusions:
1) Satisfactory short-or midterm quality of occlusion could be expected for those wide-necked aneurysms receiving appropriately selected endovascular treatment.
2) Standard coiling, balloon-or stent-assisted embolizations are the mainstream methods for the endovascular treatment of intracranial wide-necked aneurysms, with the stent-assisted embolization getting a rising tendency.
3) Aneurysms with neck size≥4mm are suited for balloon-or stent-assisted embolization. For ruptured aneurysm and those with D/N≥1.5, the operators favors balloon-assisted or standard coiling much more than stenting. Aneurysms with≤1are more appropriate for stent-assisted embolization, yet this do not include aneurysms located at the bifurcation.
4) Ruptured aneurysms and those with H/D>1win a higher rate of adequate embolization.
5) Aneurysm size was the primary factor affecting the evolution of the aneurysms after endovascular treatment, and diameter>15mm was the only independent risk factor for recurrence in this study.
引文
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