椎動脈起始部狹窄血管內(nèi)介入治療中國專家共識（2024版）

椎動脈起始部狹窄血管內(nèi)介入治療中國專家共識(2024版)椎動脈起始部狹窄(vertebralarteryo(二)文獻檢索(三)推薦等級設(shè)置5個選項：(1)強推薦；(2)弱推薦；(3)無明確推薦意見；(4)弱不推薦；(5)強不推薦。通過統(tǒng)計投票結(jié)果中不同選項及組合的投票比例，將推薦等級分為I、Ⅱ、Ⅲ、IV級，具體代表意義見表1。I級(一致推薦或一致不推薦)投票100%一致，所有專家完全達成共識Ⅱ級(強推薦或強不推薦)投票75%~99%一致，絕大多數(shù)專家達成共識Ⅲ級(弱推薦或弱不推薦)投票50%~74%一致，多數(shù)專家達成共識，但少數(shù)專家存在分歧IV級(專家未達成一致性結(jié)論)(一)椎動脈的解剖結(jié)構(gòu)椎動脈一般起自鎖骨下動脈中段，向上經(jīng)第6至第1頸椎的橫突孔，再向后方穿過枕下三角，然后通過枕骨大孔進入顱內(nèi)；雙側(cè)椎動脈匯合形成基底動脈。椎動脈在解剖學上分為四段，分別為頸段(V1段)、椎間段(V2段)、枕段(V3段)和顱內(nèi)段(V4段)[5]。人群中約11%存在椎動脈發(fā)育不良，包括椎動脈纖細、椎動脈僅供血至小腦后下動脈、椎動脈缺如等[6-7,3]。研究表明，存在主要來自后交通動脈，其次為頸外動脈系統(tǒng)中枕動脈-咽升動脈之間的吻合、肋 為：輕度狹窄(狹窄率≤為49%)、中度狹窄(狹窄率為50%~69%)和重度狹窄 (狹窄率為70%~99%)。(一)臨床表現(xiàn)(二)輔助檢查(一)藥物治療聚集治療3~6個月后改用單一抗血小板聚集治療(推薦等級：Ⅱ級)。(2)合后6個月停用抗血小板聚集藥(推薦等級：Ⅱ級)。(二)血運重建4.6年隨訪中年腦卒中風險為0.4%,高于無椎動脈狹窄人群(年腦卒中風險<0.等);(2)后交通動脈缺如或Willis環(huán)代償不良；(3)前循環(huán)血管重度狹窄純藥物球囊擴張的VA0S患者術(shù)后再狹窄率為11.9%[50]。雖然與裸球囊相比，窄設(shè)計的支架，臨床主要使用冠脈或外周支架等[38]。最常用的兩種用于VAOS裂風險。研究報道表明，球囊擴張支架治療VAOS再狹窄率為10%~67%,支架斷裂率為4%~25%[52-54]。也有研究報道應(yīng)用開環(huán)設(shè)計的頸動脈自膨脹支架治療局部鈣化明顯、血管直徑大或血管走行扭曲的VAOS,結(jié)果表明，對于椎動脈內(nèi)徑>4.5mm且鎖骨下動脈直徑<10mm的VAOS,開環(huán)頸動脈自膨脹支架置入手術(shù)成功率100%,術(shù)后3~34個月隨訪的血管再狹窄率為3.1%,且無支架斷裂[55]。98%,30d神經(jīng)功能預(yù)后良好率為80%;并發(fā)癥發(fā)生率為9.1%,主要為動脈夾層病變且長度較短的支架為宜(推薦等級：Ⅱ級)。(2)橈動脈入路穿刺成功置管后，可給予血管舒張劑減少血管痙攣(推薦等級：Ⅱ級)。(3)支架植入術(shù)限，建議繼續(xù)口服藥物治療，定期復查血管超聲或CTA;若血流受限，建議行血管內(nèi)介入治療或外科手術(shù)治療(推薦等級：Ⅱ級)。6.外科手術(shù)：VAOS的外科手術(shù)包括椎動脈內(nèi)膜剝脫術(shù)、椎動脈轉(zhuǎn)位術(shù)、椎動脈搭橋術(shù)、復合手術(shù)等。研究表明，外科手術(shù)對VAOS癥狀改善率高，血管長Ma等[73]、Choi等[74]分別報道了應(yīng)用復合手術(shù)方法入治療的同質(zhì)化水平，從而為開展全國性VAOS治療登記研究及多中心隨機對照[1]SchneiderV,DirschingerR,WustrowI,etal.Endovasculartherapryorigin[J].Vasa,2020,49(3):205-213.DOI:10.1024/03culationregistry[J].ArchNeurol,1998,55(4):470-478.DOI:10.100[3]XingPF,ZhangYW,LiZF,etal.The"distayforthetreatmentofposteriorcirculationtandemocclusions:asingle-centreexperience[J].Neuroradiology,2020vedisease[J].ClinNeuroradiol,2019,29(3):435-443.DOI:10.1007/ritingGroup,BranchofVascularDiseasesandHyperteCare.Chineseexpertconsensusonthemanagementofsubclavian/extracranialvertebralarteryste[6]Valenzuela-FuenzalidaJJ,Rojas-Navlinicalimplications:asystematicreviewandMeta-analysence[J].SurgRadiolAnat,2024,46(7):963-975.DOI:10.1007/s00276-hypoplasia[J].JUltrasoundMed,2019,38(11):3037-30422/jum.15011.[8]VilimasA,GaigalaiteV,UrbonasM,etal.AssociationofveMedicina(Kaunas),2022,58(9):1189.DOI:10.3390/medicina58091189.ischemicstroke[J].Medicine(Baltimore),2021,100(38):e2[10]DharmasarojaPA,UransilpN,PiyabhanP.Fetaloriginofposteriorcerebralarteryrelatischemicstroke[J].JClin6/j.jocn.2019.07.006.60/112137-20210325-00743.BianY,MiaoY,WangKYocclusion[J].NatlMedJChina,2021,10160/112137-20210325-00743.[12]BurleVS,PanjwaniAnosis:anarrativereview[J].Cure59/cureus.28068.[13]MadonisSM,JeovascDis,2021,65:55-59.DOI:10.1016/j.pcad.2021.02.006.[14]PaikJJ,LubinG,Gromattorsindermatomyositis:asystematicRheumatol,2023,41(2):348-358.DOI:10.55563/clinexprheu[15]GoetzLH,SchorkNJ.Personalizedmedicine:motivation,challenges,andprogress[J].FertilSteril,2018,109(6):952-963.DOI:10.10[16]RadakD,BabicS,SagicD,etal.Endovasculartreatment0(1):92-97.DOI:10.1016/j.jvs.2014.01.023.[17]JenkinsJS,StewartM.Endovasculartreatmentystenosis[J].ProgCardiovascDis,2017,59(6):619-625.DOI:10[18]DrazykAM,MarkusHS.Recentadvancesintomaticvertebralarterystenosis[J].CurrOpinNeurol,2018,31(1):1-7.DOI:10.1097/WC0.0000000000000515.[19]ZhangJ,XingY,CuiL.Duplexultrasonognofextracranialvertebralartery:aitalsubtractionangiography[J].FrontNeurol,2022,13:814972.DOystRev,2022,5(5):CD013692.DOI:10.1002/14651858.CD013692.pub2.ofatherosclerosis:currentviewandfuinmodificationtreatment[J].I:10.1007/s12471-017-0959-2.[22]NaylorAR,RiccoJB,deBorstery(ESVS)[J].EurJVascEndovascmentofvertebralarteryorigins[J].JNeuroimaging,2020,30(1):449.DOI:10.1111/jon.12674.anceimagingrevealshiddenetiologiesofsymptomaticvertebralarteriallesions[J].JStrok10.1016/j.jstrokecerebrovasdis.2013.02.021. uraloptimization[J].TrendsCardiovascMed,565-575.DOI:10.3969/j.issn.1673-5765.2013.07.012.ExpertConsensusGrouponStatinDrugsfrthepreventionandtreatmentofischemicstroke/transientischemicattack[J].ChinJStroke,203604437596643097851527missionStrokePreventionandContro015)./upload/file/20160718(2016年修訂版)[J].中國循環(huán)雜志，2016,31(10):937-950.DOI:10.3969/j.issn.1000-3614.2016.10.001.JointCommitteeforRevisionofChineseGuidelinesforPreventidelinesfortheprevChineseadults(Revisedin2016)[J].ChinJCircul,2016,31(用專家共識[J].中國卒中雜志，2019,14(10):1034-1044.DOI:10.3969/j. issn.1673-5765.2019.10.013.ChinesonalNeuroradiologySocietyofChineseStrokenicalapplicationoftsn.1673-5765.2019.10.013.tithromboticsinneurointerventionalprocedures:Guidelineupdate[J]. 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