原作出处：Tsukada T, Aimi Y, Yokoyama H, et al. Stent insertion for chronic total occlusion of the common carotid artery in a patient with Takayasu arteritis using an adjunctive retrograde approach via superficial temporal artery puncture: illustrative case. Journal of Neurosurgery: Case Lessons. 2026;11(8): e CASE25897. doi:10.3171/CASE25897
以下为AI解读，仅供参考。
大动脉炎所致颈总动脉（CCA）慢性完全闭塞（CTO），是神经介入领域高难度、高风险的炎性血管病变，其疾病本质与治疗挑战均显著区别于普通动脉粥样硬化性闭塞。
1. 疾病核心病理与临床特点
（1）炎性血管重塑特殊
大动脉炎属于特发性大血管炎，以主动脉弓及其分支慢性肉芽肿性炎症为核心，病变血管壁长期处于增厚、纤维化、钙化状态，管壁结构高度异质化，伴随持续低度炎症活动，最终形成颈总动脉起始部长段、坚硬、解剖扭曲的慢性完全闭塞。本例患者17岁确诊大动脉炎，激素治疗至22岁后自行中断、未再规律随访，炎症在长达40年间持续进展，导致血管病变极度顽固。
（2）卒中机制以栓塞为主
本例患者反复发生脑梗死（两次均表现为肢体麻木、轻偏瘫、构音障碍，并出现自发再通），根源并非单纯脑灌注不足，而是右侧颈总动脉闭塞盲端血流淤滞形成血栓，血栓脱落栓塞大脑中动脉所致；且闭塞段无顺行血流，血栓易反复形成、脱落，导致脑梗反复自发再发与再通。
（3）病变顽固、常规方案失效
本例患者同时合并左侧颈总动脉严重狭窄，并已出现短暂性右侧面部下垂、构音障碍等短暂性脑缺血发作（TIA）症状，双侧病变使脑血流储备极度脆弱，治疗策略必须兼顾双侧、分步实施。此外，长期炎症未控导致血管壁严重纤维化钙化，单纯旁路手术围术期出血、卒中风险高，常规介入亦难以奏效。
FIG. 1. Images obtained at the onset of right middle cerebral artery occlusion. A: MR diffusion-weighted image at onset. A high signal intensity was observed in the right caudate nucleus, basal ganglia, and cerebral cortex. B: MR angiogram at onset. Occlusion of the proximal right middle cerebral artery was observed. C: Right brachiocephalic artery angiogram showing occlusion from the origin of the right CCA. D: Right brachiocephalic artery angiogram (equilibrium phase). Contrast stagnation is observed at the blind end of the right CCA (arrow). E: Right brachiocephalic artery angiogram revealing occlusion of the right middle cerebral artery. F: MR angiogram obtained 3 days after onset, revealing recanalization of the right middle cerebral artery. G: Cervical CT angiogram showing occlusion of the right CCA (arrow) and severe stenosis of the left CCA (arrowhead).
2. 介入治疗核心难点
（1）顺行入路极易失败
常规股动脉→头臂干→颈总动脉顺行路径下，纤维化、钙化的坚硬管壁会严重阻碍导丝、导管通过，极易误入假腔引发医源性夹层，甚至导致颈内动脉（ICA）闭塞。本例首次顺行尝试时，微导管即进入CCA假腔，术者果断终止操作——这一决策虽避免了灾难性后果，也凸显了此类病变顺行入路的高失败率与高风险。
（2）真腔寻路极度困难
炎性长段闭塞无明确真腔轨迹，血管解剖扭曲、管壁僵硬，普通导丝支撑力不足，无法精准穿透闭塞段进入真腔。本例右侧颈总动脉自起始部即完全闭塞，闭塞段坚硬且走行扭曲，顺行路径下导丝根本无法寻及真腔。
（3）血流保护存在解剖限制
右侧颈总动脉可通过球囊导引导管夹持实现近端保护，利用锁骨下盗血代偿脑灌注；但左侧颈总动脉起始部闭塞因解剖位置限制，无法实现该策略。这一解剖限制直接影响术中对侧病变的处理优先级与手术顺序安排。
（4）炎性病变术后风险更高
血管壁持续炎症使支架内血栓、再狭窄风险显著高于普通粥样硬化闭塞。本例患者术前ESR 65mm/h、ANA 1:1280，处于活动期，对围术期抗栓方案（术前14天双抗）、支架选择（开环[Open-cell]设计）及操作精度均提出极高要求。
整体治疗并非一次完成，而是遵循先左后右、先易后难的分阶段策略：
1. 第一阶段：尝试右侧CCA顺行开通→导丝进入假腔，风险过高，果断终止
2. 第二阶段：处理左侧CCA狭窄（患者同期存在左侧CCA狭窄相关TIA症状）→行顺行支架植入
3. 第三阶段：待左侧术后恢复、患者状态稳定后，再行右侧CCA逆行开通
● 病变处理：球囊预扩后于左侧ICA释放SpiderFX远端保护装置
● 支架组合：Carotid WALLSTENT（覆盖CCA夹层入口）+第二枚Carotid WALLSTENT（自ICA延伸至CCA）+PRECISE（连接两枚WALLSTENT）
● 球囊后扩：SHIDEN 4×40mm球囊全程扩张
● 术后情况：因夹层延伸至颈动脉分叉，出现术后低血压及灌注不足症状，经去甲肾上腺素维持5天后恢复
FIG. 2. Antegrade recanalization attempt for right CCA chronic occlusion and carotid artery stent placement for left CCA stenosis. A: A balloon-guiding catheter was placed proximal to the vertebral artery to sandwich the CCA origin. A Guidepost was inserted into the occluded CCA using a RADIFOCUS guidewire. B: The SL-10 microcatheter and CHIKAI 14 guidewire entered the false lumen of the CCA. C: Left CCA angiogram showing high-grade stenosis of the left CCA. D: After balloon angioplasty and deployment of a SpiderFX device in the internal carotid artery, angiography showed dissection of the CCA. E: With the balloon-guiding catheter expanded in the CCA for proximal protection, three stents were deployed in a connected fashion from the ICA to the CCA, followed by balloon angioplasty. F: Left CCA angiogram showing good expansion.
1. 入路建立：STA（颞浅动脉）切开穿刺
● STA条件：直径仅1mm，无法触及且超声不可见
● 暴露方式：耳前3cm切口，沿颧弓下缘暴露主干，微探头超声确认位置
● 穿刺置鞘：21G Surflo针头穿刺→CHIKAI X10导丝→RADIFOCUS导丝→置入5Fr Glidesheath Slender薄壁鞘
2. 逆行通路步骤&器械
（1）微导管：Fencer Micro Catheter（1.9Fr/2.6Fr，135cm）
（2）初始导丝：CHIKAI 14→逆行进入CCA
（3）硬导丝探索：Astato XS 9-12（锥头负荷12gf）送至CCA起始部
（4）影像确认：Cone-beam CT确认CCA真实走行方向
（5）真腔穿透：更换Astato XS 9-40（锥头负荷40gf）自假腔穿刺进入头臂干真腔
（6）抓捕拉通（Pull-through）：Headway 21/Goose Neck Snare SK 700（7mm）经股动脉9Fr导管送入头臂干，抓捕逆行导丝
（7）轨道建立：Pull-through拉出体外→替换为CHIKAI 14（315cm）贯通轨道
3. 近端保护与血流控制（仅限右侧CCA）
● 球囊导引导管夹持（Sandwich）：股动脉9Fr Optimo置于头臂干+桡动脉6Fr Optimo置于右锁骨下动脉，夹持CCA起始部
● 脑灌注代偿：利用锁骨下盗血现象，经左侧椎动脉→右侧椎动脉→右侧脑组织，维持球囊阻断期间灌注
● 重要限制：左侧CCA起始部闭塞因解剖位置限制，无法实现此近端保护策略
4. 远端栓塞保护与支架释放
● 沿拉通轨道将SpiderFX滤器（4mm）送入右侧ICA
● 球囊扩张：在滤器保护下，以Coyote ES 2.5×40mm球囊对全段闭塞行预扩
● 支架串联策略：
✔ PRECISE 9×40mm（ICA至CCA）
✔ PRECISE 8×40mm（CCA起始部至头臂干）
✔ PRECISE 10×40mm（中段连接两支架）
✔ 后扩张：SHIDEN 5×40mm球囊三次全程塑形
5. 闭合与止血
撤出STA鞘管，以9-0尼龙线缝合5针妥善止血，预防皮下血肿及假性动脉瘤。
FIG. 3. Retrograde approach for right CCA chronic occlusion with carotid artery stent insertion. A: Three-dimensional CT angiogram showing that the diameter of the right STA at the planned puncture site (arrow) was 1.0 mm. B: The STA was punctured with a 21-gauge Surflo needle, and an image was taken from the Surflo. C: A 5-Fr Glidesheath Slender sheath was placed in the external carotid artery. D: A 4-Fr catheter was guided into the ICA, and an attempt was made to guide a SpiderFX device (arrow); however, it could not be guided because of a sharp bend. E: Cone-beam CT was used to confirm that the Fencer microcatheter was located at the origin of the CCA. F: An Astato XS 9–12 guidewire (arrow) was used to penetrate the occluded site. It was then captured with a snare (arrowhead) and pulled through the guiding catheter from the femoral artery approach. G: The balloon-guiding catheter was inflated to sandwich the CCA, and balloon angioplasty (arrow) was performed under blood flow occlusion. H: An external carotid artery angiogram was obtained from the STA puncture sheath. A filter protection device (arrow) was guided into the right ICA using a guidewire that was pulled through. I:Three stents were deployed in a connected manner. J: Brachiocephalic artery angiogram revealing good expansion of the CCA.
● 抗栓方案：术前14天起双抗（阿司匹林100mg+氯吡格雷75mg）；术后双抗3个月，后改为阿司匹林单药长期维持
● 激素控制：确诊活动性大动脉炎（ESR 65mm/hr，ANA 1:1280），予泼尼松龙35mg/日起始，逐步减量至5mg/日维持，无炎症复发
● 麻醉方式：STA入路采用局部麻醉，降低全麻相关风险
● 术后用药：双抗3个月后改为阿司匹林单药；严格抗栓是预防急性支架血栓（大动脉炎患者风险更高）的基石
● 右侧顺行入路夹层：微导管进入CCA假腔，果断终止操作，避免ICA闭塞——技术失败时知进退是核心决策能力
● 左侧术后低血压：因夹层延伸至颈动脉分叉，每次血压下降即出现右侧肢体轻瘫及构音障碍，需去甲肾上腺素维持5天——提示左侧治疗改变了脑血流动力学
● STA穿刺相关风险：皮下血肿、假性动脉瘤、面神经损伤、伴行静脉损伤、血管破裂；因管径极小，必须严格控制鞘管/导管尺寸，术后需可靠缝合
● 开环vs闭环：本例右侧长段闭塞选用PRECISE开环支架，既往研究提示其支架内再狭窄率显著低于闭环支架
● 随访结果：术后3个月CTA显示右侧CCA及左侧ICA支架均通畅，无再狭窄及支架周围炎症征象
FIG. 4. Imaging findings 3 months after the procedure. A: Three-dimensional CT angiography volume rendering demonstrating good long-term patency of both the stented right CCA and left ICA with no evidence of restenosis. B:Multiplanar reconstruction (MPR) of the right CCA. C: MPR of the left ICA. In panels B and C, there are no signs of in-stent stenosis, indicating stable postoperative outcomes.
1. 手术排序：双侧病变时应策略性分步处理——本例先顺行处理左侧以解除TIA症状，再逆行处理右侧复杂CTO
2. 逆行是有效的“退路”：当大动脉炎CCA-CTO顺行入路进入假腔时，STA逆行+Pull-through拉通可安全建立轨道
3. 影像导航不可或缺：Cone-beam CT是确认纤维化病变解剖走行、辅助硬导丝从假腔精准穿入真腔的关键
4. 导丝递进策略：逆行探索先用Astato XS 9-12（12gf）探路，确认假腔后更换Astato XS 9-40（40gf）强力穿透，器械递进逻辑清晰
5. 近端保护有条件：球囊导引导管夹持技术仅适用于右侧CCA，左侧起始部闭塞无法实现
6. 抗栓是底线：大动脉炎患者支架血栓风险更高，术前14天双抗是必须遵守的硬性时间窗
7. 开环支架优选：长段炎性闭塞建议优先考虑开环设计，以降低远期再狭窄率
大动脉炎致颈总动脉慢性完全闭塞，顺行不通则逆行——STA切开穿刺、锥束CT导航、12gf探路/40gf穿透、抓捕拉通建轨、串联开环支架，是实现微创血运重建的有效技术路径；但需严格把握手术分序、近端保护限制与围术期抗栓窗口。
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