頭蓋内動脈硬化性狭窄に対するPTA/stentingの臨床成績と問題点  [in Japanese] Clinical Results and Problems of PTA/Stenting for Intracranial Atherosclerotic Stenoses  [in Japanese]

頭蓋内動脈硬化性狭窄に対する治療は抗血小板剤などの内科的治療が一般的であり, 一部の症例にバイパス手術(EC/IC bypass)などの外科手術が行われているに過ぎなかった. 一方, 従来より頭蓋外の頭頸部血管に対して経皮的血管拡張術(PTA)およびステント留置術(stenting)が行われてきたが, 血管内治療の器具と手技の進歩に伴い頭蓋内血管に対するPTA/stentingの良好な成績が報告されるようになっている. 今回, われわれは87例, 88病変の頭蓋内動脈硬化性狭窄に対してPTA/stentingを行ったので, その治療成績と問題点について報告する. 対象と方法 対象は2002年12月までに頭蓋内動脈硬化性狭窄に対してPTA/stentingを施行した87例, 88病変で, うちPTAのみ施行した症例が61例, stentingを施行した症例が26例であった. 部位の内訳はPTA61例中, 内頸動脈33例(うち硬膜内病変10例), 中大脳動脈17例, 椎骨脳底動脈11例で, 一方stenting26例中, 内頸動脈20例(うち硬膜内病変なし), 中大脳動脈0例, 椎骨脳底動脈6例であった.

Recently, PTA/stenting for intracranial atherosclerotic stenoses has been reported as a treatment option. We describe clinical results of PTA/stenting for 87 patients of intracranial atherosclerotic stenoses (88 lesions). The procedure was performed under local anesthesia via percutaneous transfemoral route. In 61 patients, we performed PTA only and used stent in 26 patients. In 87 patients, technical success rate was 97% and the mean stenosis rate before PTA/stenting, 77.0%, decreased to 25.4% after the procedure. In particular, 26 cases of stenting showed remarkable improvement of the mean stenotic rate (77.7% to 5.5%). The morbidity, neurological deficit.s at 30 days and mortality rate was 10.3%, 6.9% and 2.3%, respectively. The ischemic complications such as cerebral embolism, dissection, and stent thrombosis occurred, while there were hemorrhagic complications such as intracranial bleeding due to hyperperfusion, rupture of associated intracranial aneurysm and cerebellar hemorrhage caused by bleeding tendency. In addition, the restenosis after stenting tends to occur less than that PTA only. Because of the high morbidity and mortality rate compared with the procedure for extracranial lesions, PTA/stenting for intracranial arterial stenoses may require stricter indications and t,he prevention from predictable complications of this procedure. Long-term follow up and study of t,he natural history of the intracranial atherosclerotic stenoses seem to be important to establish this treatment.