椎动脉V1段巨视、影像解剖与V1段狭窄的支架置入

发布时间：2018-03-26 06:08

本文选题：椎动脉V1段　切入点：动脉狭窄　出处：《兰州大学》2007年硕士论文

【摘要】： 目的：缺血性卒中大约有1／4的患者累及后循环或椎基底循环。动脉粥样硬化性狭窄可发生在椎基底动脉全程，但以椎动脉V1段为多见，在颅外脑血管狭窄患者中，25％～40％发生在椎动脉V1段。本研究旨在：1．通过尸体解剖椎动脉V1段，观察正常椎动脉的开口部位以及进入横突孔的位置，分别测量椎动脉开口的外径及椎动脉V1段的长度，为椎动脉V1段支架置入提供指导性数据。2．观察颈椎横突孔的形状，测量横突孔的矢状径与横径的长度，为椎动脉V1段狭窄的支架置入提供解剖学依据。3．通过全脑血管造影筛选有症状的椎动脉V1段狭窄(狭窄率≥50％)并接受支架成形术治疗的患者，进行支架大小的统计，用颈部彩色多谱勒测定的方法，对支架治疗前后椎动脉V1段的狭窄率与血流动力学的变化进行比较，从而为由于椎动脉V1段狭窄引起的脑供血不足的血管内临床治疗提供依据。　　方法：1．对9具尸体双侧椎动脉V1段(n=18)进行解剖，从颈前方由浅入深逐层解剖胸锁乳突肌区和颈根部，游离椎动脉的起源血管，观察椎动脉开口的部位及进入横突孔的位置及血管的走行特征，测量(精确度0.02mm)椎动脉开口的外径以及椎动脉V1段的长度。　　 2．测量颈椎C1—C7横突孔的横径及矢状径。　　 3．通过全脑血管造影筛选有椎动脉供血不足症状的椎动脉V1段狭窄(狭窄率≥50％)，并接受支架成形术治疗的患者35例，对36枚(1例为两侧支架置入)3种类型支架进行大小的统计，通过彩色多普勒血流显像(Color Doppler flow imaging，CDFI)测算实施支架前、后椎动脉V1段的狭窄率，支架前、后椎动脉V1段、间隙段收缩期峰值流速(Peak systolic Velocity，PVS)以及椎间隙段的博动指数(Pulsatile index，PI)，进行统计学处理。　　结果：1、椎动脉起始的部位：左侧发自锁骨下动脉第一段上后壁有7例(77.8％)呈垂直上行(90°)穿横突孔，发自锁骨下动脉第一段上前壁2例(22.2％)；右侧发自锁骨下动脉第一段上后壁6例(66.7％)呈垂直上行，发自锁骨下动脉第一段上前壁3例(33.3％)。 2、椎动脉V1段的长度与开口的外径：长度(mm)：左侧37.8±4.9，右侧36.4±5.7；外径(mm)：左侧曲行组4.72±0.37(n=3，33.3％)，，左侧直行组4.25±0.135(n=6，66.7％)；右侧曲行组4.35±0.41(n=4，44.4％)，右侧直行组3.95±0.38(n=5，55.6％)。 3、双侧椎动脉穿横突孔的位置：左侧椎动脉7例(77.8％)穿C6横突孔，变异2例(22.2％)其中1例穿C5横突孔，另1例穿C4横突孔：右侧椎动脉8例穿C6横突孔(88.9％)，变异只有1例(11％)为穿C5横突孔。 4、颈椎横突孔的形状及其横径与矢状径：颈椎横突孔的形状大体可分为圆形、纵椭圆形、横椭圆形，不规则形四种，不论左侧或右侧C1、C2横突孔均以纵椭圆形为主，C3—C7以横椭圆形为主，横突孔的横径(mm)多数以C4为最大(6.4±0.8)，C7为最小(5.3±1.7)：矢径(mm)以C1为最大6.8±1.0)，C7为最小(4.1±1.2)。 5、椎动脉V1段狭窄支架置入前后狭窄率与血流动力学的改变：35名患者36支椎动脉V1段狭窄狭窄率=50％，其中双侧狭窄6例，一侧狭窄对侧闭塞12例，单侧椎动脉V1段狭窄17例。9侧使用Bxsonic(5×20mm)支架，6侧为AVEgfx(BX，4×20 mm)支架，21侧使用Firebird(4×18mm)支架。支架置入术前、后椎动脉V1段内径分别为：1.3±0.4 mm与2.7±0.7 mm(p＜0.001)；狭窄率从64±9％降至23±17％(p＜0.001)，术前收缩期血流峰植(PSV)的异常高流速242±102cm／s，术后降至87±45cm／s(P＜0.001)。术前患侧椎动脉椎间隙段的搏动指数(PI)值为0.77±019，健侧为0.96±0.17(P=0.011)。　　结论：1、椎动脉V1以近似90°起源于锁骨下动脉的第一段，椎动脉起点变异较少，一般起源于锁骨下动脉的上后壁，在锁骨下动脉上起始处的方位呈向后上方集中的趋势，是锁骨下动脉的最大一个分支。 2、右侧椎动脉V1段开口外径相对左侧较细；左侧椎动脉V1段开口外径曲行组小于直行组，双侧椎动脉V1段的长度曲行组与直行组差异无显著性。 3、椎动脉V1段动脉未见分支。 4、椎动脉穿经第6颈椎横突孔(双侧平均为88.3％)上行，左侧椎动脉穿横突孔部位变异2例(22.2％)，1例穿C5横突孔，另1例穿C4横突孔；右侧椎动脉穿横突孔部位变异只有1例(11％)为穿C5横突孔。 5、颈6横突孔不论是矢状径还是横径均大于椎动脉V1段的外径。 6、椎动脉V1段走行过程中少有变异，但是在进入横突孔前无明显分支且缺乏骨性结构的限制，所以适合血管内介入治疗，且通过椎动脉V1段狭窄支架前后狭窄率及血流动力学指标的变化，说明椎动脉V1段狭窄的血管内治疗是安全有效的。
[Abstract]:Objective: ischemic stroke is about 1 / 4 of the patients with posterior circulation or vertebrobasilar circulation. Atherosclerotic stenosis can occur in vertebrobasilar artery course, but in V1 segment of vertebral artery was more common in patients with extracranial arterial stenosis, 25% to 40% occurred in the V1 vertebral artery. The purpose of this study is to: 1. the autopsy of V1 segment of vertebral artery, the opening part of the vertebral artery and to observe the normal position into the transverse foramen, vertebral artery were measured and the diameter of the vertebral artery V1 segment length, provide guidance and data.2. observation of cervical transverse foramen in the shape of V1 segment of vertebral artery stenting, sagittal length measurement of transverse foramen the diameter and transverse diameter, and provide anatomic basis.3. through cerebral angiography of vertebral artery were symptomatic V1 stenosis of vertebral artery stenosis (V1 stent stenosis rate greater than 50%) and underwent stent angioplasty for the treatment of patients in Statistics for the stent size, determination method of neck color Doppler, compare the changes of stenosis rate and hemodynamics of vertebral artery before and after stent in the treatment of V1 segment, which is due to the V1 segment of vertebral artery stenosis caused by insufficient blood supply to the brain blood vessels provide the basis for clinical treatment.
Methods: 1. of the 9 bodies of bilateral vertebral artery V1 segment (n=18) were dissected by dissecting the sternocleidomastoid muscle and neck root from anterior vertebral artery blood vessel free from the shallower to the deeper, the origin, characteristics of vertebral artery were observed along the site and into the transverse foramen and position measurement accuracy (blood vessels. 0.02mm) vertebral artery diameter and vertebral artery V1 segment length.
2. the transverse diameter and sagittal diameter of the C1 - C7 transverse process of the cervical spine were measured.
V1 segment of vertebral artery by cerebral angiography were 3. vertebral artery insufficiency symptomatic stenosis (stenosis rate greater than 50%), and 35 cases were treated with stenting, of 36 cases (1 cases of stent implantation on both sides) 3 types of stent size statistics, by color Doppler flow imaging (Color Doppler flow imaging, CDFI) estimates support before the restenosis rate after V1 segment of vertebral artery stenting before and after the V1 segment of vertebral artery, gap of systolic peak velocity (Peak systolic, Velocity, PVS) and intervertebral segment of the pulsatile index (Pulsatile, index, PI) were statistically analyzed.
Results: 1 vertebral artery position: left from the wall of the first section after subclavian artery in 7 cases (77.8%) in a vertical upward (90 degrees) in the transverse foramen, from the first part of the subclavian artery anterior wall in 2 cases (22.2%); the right from the first wall section after subclavian artery in 6 cases (66.7%) in a vertical upward, from the first part of the subclavian artery anterior wall in 3 cases (33.3%).
2, vertebral artery V1 segment length with the opening of the outer diameter: length (mm): the left side of the 37.8 + 4.9, 36.4 + 5.7 on the right side; the diameter (mm): left crooked group 4.72 + 0.37 (n=3,33.3%), left straight group 4.25 + 0.135 (n=6,66.7%); right crooked group 4.35 + 0.41 (n=4,44.4%), right straight group 3.95 + 0.38 (n=5,55.6%).
3, bilateral vertebral artery puncture through transverse foramen: 7 cases (77.8%) of the left vertebral artery, 77.8% cases wore C6 transverse foramen, 2 cases (22.2%) were variant, 1 cases wore C5 transverse foramen, and 1 cases wore C4 transverse foramen. 8 cases of right vertebral artery wore C6 transverse foramen (88.9%), and only 1 cases (11%) wore C5 transverse foramen.
4, the shape of the transverse cervical transverse foramen diameter and sagittal diameter: cervical transverse foramen shape can be divided into round, oval, ellipse, irregular shape four, regardless of the left or right C1, C2 transverse foramen were mainly oval, C3 - C7 to cross ellipse transverse foramen diameter (mm) most of the C4 is the largest (6.4 + 0.8), C7 (5.3 + 1.7): minimum radius (mm) to C1 is the largest of 6.8 + 1), C7 was the smallest (4.1 + 1.2).
5, V1 segment of vertebral artery stenosis before and after stent stenosis and hemodynamic change: 35 patients with 36 vertebral artery V1 segment stenosis rate of =50%, including bilateral stenosis in 6 cases, one side of the narrow side occlusion in 12 cases, unilateral vertebral artery V1 segment stenosis in 17 cases of.9 side Bxsonic (5 * 20mm). Frame, 6 side AVEgfx (BX, 4 * 20 mm) stent, 21 side using the Firebird (4 x 18mm). Stent stenting before and after the V1 segment of vertebral artery diameter were 1.3 + 0.4 and 2.7 + 0.7 mm mm (P < 0.001); stenosis rate from 64 + 9% to 23 + 17% (P < 0.001), preoperative systolic peak velocity (PSV) of the abnormally high 242 + 102CM / s, postoperative to 87 + 45cm / S (P < 0.001). The patients with intervertebral segment of vertebral artery pulsatility index (PI) value was 0.77 + 019, contralateral 0.96 + 0.17 (P=0.011).
Conclusion: 1, the first segment of vertebral artery V1 with approximate 90 degrees originated from the subclavian artery, vertebral artery starting point less variation generally originated from subclavian artery on the posterior wall of the subclavian artery in the initial position is on the back above the central tendency, is one of the biggest branch of the subclavian artery.
2, the outer diameter of V1 segment of the right vertebral artery is smaller than that of the left side. The V1 segment opening diameter of the left vertebral artery is smaller than that of the straight line group. There is no significant difference in the length of bilateral vertebral artery V1 segment between the straight line group and the straight line group.
3, there was no branch of the V1 segment of the vertebral artery.
4, vertebral artery penetrated through the transverse foramen of sixth cervical vertebra (bilateral average 88.3%). 2 cases (22.2%) had transversal foramen position in the left vertebral artery, 1 cases wore C5 transverse foramen, and 1 cases wore C4 transverse foramen. Only 1 cases (11%) of the right vertebral artery crossing the transverse foramen were C5 transverse foramen.
5, both the sagittal and transverse diameter of the 6 transverse foramen of the neck were greater than the outer diameter of the V1 segment of the vertebral artery.
6, the course of the V1 artery with little variation, but into the transverse foramen without significant branches and bony structure, so it is suitable for endovascular therapy, and the changes of V1 segment of vertebral artery stenosis stent stenosis rate and hemodynamics, indicating V1 segment of vertebral artery stenosis treatment is safe and effective.

【学位授予单位】：兰州大学
【学位级别】：硕士
【学位授予年份】：2007
【分类号】：R322

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