The Efficacy Evaluation Of Treatment For BCTA With Hybrid Revascularization

Background and purposeTo analyze the clinical efficacy of hybrid reconstruction combined endovascular and graft bypass therapy for cerebral ischemia due to BCTA. Materials and methodsMarch 2009 to June 2014, 20 patients underwent surgery treatment due to brachiocephalic takayasu arteritis in Endovascular surgery at First Affiliated Hospital of Zhengzhou University。Including 1 male and female 19 cases,aged 17-43 years, mean 26.7 years. Seven patients were treated with thoracotomy carotid revascularization and 13 patients underwent hybrid reconstruction combined endovascular and graft bypass therapy. And comparing the advantages and disadvantages of the two different revascularization, including before and after surgery in patients with symptomatic improvement, perioperative complications, the long-term graft patency and so on.Preoperative CTA, DSA and vascular color Doppler ultrasound showed that all patients had bilateral carotid and vertebral artery occlusion and stenosis of multiple different degrees.6 patients in thoracotomy bypass group, are used in staging carotid revascularization by the Academician Wang Zhonggao advocated, namely a thoracotomy aortic-unilateral internal carotid artery bypass grafting, and left neck graft branch to prepare two reconstruction of the contralateral internal carotid artery, two patients received two reconstruction.13 patients underwent hybrid reconstructions, including 6 patients under the left subclavian artery stenting + left subclavian artery- the left common carotid or internal carotid artery grafting; 2 patients underwent brachiocephalic artery stenting + right subclavian artery- right common carotid or internal carotid artery grafting;3 cases underwent right subclavian artery stenting + right subclavian artery- the right internal carotid artery grafting; 1 patient underwent right subclavian artery- the right internal carotid artery grafting + right vertebral artery stenting; 1 severe patient with left femoral artery- left axillary artery- the left common carotid artery grafting+ retrograde vertebral artery stenting. We In-depth analysis the advantages and disadvantages of surgical methods, and comprehensively evaluate its clinical efficacy. ResultsAll surgical procedures was successfully completed according to the plan, with the successful rate of 100%. There were no associated with occlusion of the internal carotid artery in patients during the intraoperative exploration,and carotid bifurcation are unobstructed. There were no perioperative stroke, brain hemorrhage and deaths. There was no significant difference(P> 0.05) in the improving of the postoperative major symptoms(headache, dizziness, blurred vision, etc.) of the two groups patients, but in terms of improving of the secondary symptoms(such as pulseless, between upper limbs lame) there is significance(P <0.05). Two groups of patients in the peri-operative complications difference is remarkable: as incision bleeding(P = 0.022), pericardial effusion(P = 0.001), disconnection delay(P = 0.007), use of antibiotics over three days(P = 0.00), the thoracotomy surgery group was significantly higher than the composite.There is no statistically significant in pain(P = 0.521), pleural effusion(P = 0.356), high perfusion(P = 0.333) and so on.Patients appearing incision bleeding or hematoma were treated with local pressure dressing after remission, no undergoing surgical exploration again. There was no postoperative infection or graft infections, and hybriding surgery group were routinely using broad-spectrum antibiotics three days, and the use of antibiotics in thoracotomy bypass group were more than three days.There was no serious complications in patients with infection. 3 patients appeared numbness, soreness and discomfort in surgical side upper extremity because of brachial plexus traction, with no special treatment, and ease or disappear after one week; The high intracranial pressure symptoms(including short-term headache, dizziness, nausea, vomiting) are more common in both groups(85.7% thoracotomy group, hybrid surgery group 53.8%), but there were no statistical significance. By intravenous mannitol, glycerol, fructose and control of blood pressure the symptom was disappeared in 3-5 days. The hybrid surgery patients operated limb skin temperature increased and touch pulse, and limb weakness was significantly reduced compared with preoperative, but no significant changes in thoracotomy group.All patients were followed up for an average time of 2.3 years. 3 patients who underwent arterial stenting occur stent restenosis after 3 to 8 months, giving balloon dilatation; the patient with left femoral artery- left axillary artery- the left common carotid artery grafting+ retrograde vertebral artery stenting weer found the axillary artery anastomotic stenosis(stenosis rate weer 70%) after 8 months, balloon dilatation given. long-term aspirin weer given in all postoperating patients, and 12 patients continue oral prednisone in 6-15 months, ranging satisfactory symptom control. ConclusionsThe carotid revascularization is the effective methods in therapying cerebral ischemia due to brachiocephalic takayasu arteritis.Hybrid operative technique in BCTA can avoid traumatic thoracotomy, and recent results were satisfactory, but Long-term effect needs further observation.Endovascular stent grafts are likely to be increasingly deployed, and targeted biologic therapies may reduce the need for vascular intervention.