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2 최현욱 외: 사행성 혈관을 가진 환자에서 두개강내 스텐트 설치술을 위한 새로운 기법들 를 받고 스텐트를 이용한 혈관성형술을 시행하였다. 73예 중 혈관의 굴곡이 심하여 표준기법으로 스텐트를 두개강내 병변 까지 진행할 수 없었던 11예를 대상으로 하였다. 대상환자의 연령분포는 42-77세로 평균 연령은 64.2세였고, 남녀 비는 4 대 7이었다. 시술 전 대상 병변의 평균 협착율은 71.8%이었다. 스텐트를 이용한 혈관성형술은 뇌경색의 재발을 방지하기 위해 50% 이상의 동맥경화성 협착이 있고 이로 인한 허혈성 증상이 있는 환자 중 1) 적절한 약물적 치료에도 불구하고 허 A 혈성 증상이 재발되거나 진행하는 경우, 2) 환자가 항혈소판 제나 항응고제를 지속적으로 복용을 할 수 없는 경우, 3) 이 전에 뇌경색이 있거나 혹은 무증상이지만 혈관조영술에서 측 부 순환이 없거나 SPECT 검사상 뇌관류가 좋지 않은 경우, 4) 관상동맥 우회술이 계획된 경우 등에서 시행하였다. B 스텐트를 이용한 두개강내 혈관성형술 (표준 기법) 환자는 시술 3일전부터 75 mg Clopidogrel(Plavix, Sanofi- C D E F Fig. 1. Double wire technique for stent placement in the distal internal carotid artery. A. Lateral angiogram of the left ICA shows severe stenosis (>70%) (arrow) of the supraclinoid portion. B. Lateral magnified radioscopic view demonstrates that the balloon-mounted stent is not able to cross the acute angled curve (arrow) of cavernous ICA. C. The navigation of stent delivery system into the target lesion is successfully performed with double wire technique (arrows). D. Balloon-mounted coronary stent is successfully deployed (arrows). There is no procedure-related complication. E, F. Anteroposterior (E) and lateral (F) views of the left ICA arteriogram immediately after stenting reveal sufficient and smooth dilatation of the stenotic segment. 102

3 대한영상의학회지 2005;52: Synthelabo, Korea)과 100 mg aspirin을 매일 복용하였고 동 일한 기간 동안 low-molecular-weight heparin인 nadroparin calcium(fraxiparine, Sanofi-Synthelabo, Korea)을 하루에 2-3회 피하 주사하였다. 모든 시술은 환자가 깨어있는 상태에서 시행하였고 EKG, 동 A 맥 산소 분압 및 혈압을 적절히 감시하였다. 경피적 접근은 오 른쪽 대퇴 동맥을 통해 이루어졌으며 6F 혹은 7F 크기의 sheath 를 대퇴동맥 내로 삽입하였다. 환자의 활성 혈액 응고 시간 (ACT, activated coagulation time)을 시술 내내 초 사이를 유지하게 하기 위해 헤파린을 일시 주사로 5000 IU를 B C D E F Fig. 2. Coaxial double guiding catheter technique for stent placement in the middle cerebral artery. A. Anteroposterior angiogram of the left ICA shows severe stenosis (>80%) (arrow) of the M1 portion of the middle cerebral artery. B. Lateral angiogram of the left ICA demonstrates marked tortuousity of the ICA. C. 8F guiding catheter (black arrow) is positioned in the proximal cervical ICA, and then 5F guiding catheter (white arrow) is coaxially inserted within the 8F catheter. D. Anteroposterior magnified radioscopic view demonstrates that the balloon-mounted stent is not able to cross the acute angled curve (black arrow) of cavernous ICA. So a second wire (white arrow) is inserted across the acute angled curve. E. The navigation of stent delivery system into the target lesions is successfully performed with coaxial double guiding catheter & double wire technique. F. Anteroposterior view of the left ICA angiogram immediately after stenting reveal sufficient and smooth dilatation of the stenotic segment. 103

4 Table. Summery of 11 Cases of Intracranial Stenting Using Several New Techniques No Sex/ Stenosis Used stents Used new Technical Complication related Stent Lesion location Age degree (%) (diameter/length, mm) techniques success to new techniques deployment 01 M/71 Lt MCA 070 S /9 Waiting Yes None Success 02 F/74 Rt MCA 070 S /15 CDGCT Yes None Success 03 F/76 Lt distal VA 060 S /15 DWT Yes None Success 04 F/77 Lt supraclinoid ICA 060 Flexmaster 2.75/12 Waiting Yes None Success 05 F/74 Rt supraclinoid ICA 070 Flexmaster 3.0/12 Waiting Yes None Success 06 F/71 Lt MCA 060 S /11 Waiting Yes None Success 07 F/70 Lt distal VA 080 Flexmaster 3.0/16 Waiting Yes None Success 08 M/53 Lt MCA 080 Flexmaster 2.5/16 CDGCT Yes None Success 09 M/51 Lt MCA 070 Flexmaster 2.5/12 DWT Yes None Success 10 F/42 Lt supraclinoid ICA 075 Flexmaster 2.75/23 DWT Yes None Success 11 M/47 Lt supraclinoid ICA 100 Flexmaster 2.5/26 DWT Yes None Success MCA ; Middle cerebral artery, VA ; Vertebral artery, ICA ; Internal carotid artery, CDGCT ; Coaxial double guiding catheter technique, DWT ; Double wire technique. 104

5 1. Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) Trial Investigators. Design, progress and challenges of a double-blind trial of warfarin versus aspirin for symptomatic intracranial arterial stenosis. Neuroepidemiology 2003;22: Wityk RJ, Lehman D, Klag M, Coresh J, Ahn H, Litt B. Race and sex differences in the distribution of cerebral atherosclerosis. Stroke 1996;27: Suh DC, Lee SH, Kim KR, Park ST, Lim SM, Kim SJ, et al. Pattern of atherosclerotic carotid stenosis in Korean patients with stroke: different involvement of intracranial versus extracranial vessels. AJNR Am J Neuroradiol 2003;24: Akins PT, Pilgram TK, Cross DT 3rd, Moran CJ. Natural history of stenosis from intracranial atherosclerosis by serial angiography. Stroke 1998; 29: Chimowitz MI, Kokkinos J, Strong J, Brown MB, Levine SR, Silliman S, et al. The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology 1995;45: Thijs VN, Albers GW. Symptomatic intracranial atherosclerosis: outcome of patients who fail antithrombotic therapy. Neurology 2000;55: Mori T, Fukuoka M, Kazita K, Mori K. Follow-up study after intracranial percutaneous transluminal cerebral balloon angioplasty. 105

6 AJNR Am J Neuroradiol 1998;19: Lee JH, Kwon SU, Lee JH, Suh DC, Kim JS. Percutaneous transluminal angioplasty for symptomatic middle cerebral artery stenosis: long-term follow-up. Cerebrovasc Dis 2003;15: Mori T, Kazita K, Chokyu K, Mima T, Mori K. Short-term arteriographic and clinical outcome after cerebral angioplasty and stenting for intracranial vertebrobasilar and carotid atherosclerotic occlusive disease. AJNR Am J Neuroradiol 2000;21: Lylyk R, Cohen JE, Ceratto R, Ferrario A, Miranda C. Angioplasty and Stent Placement in Intracranial Atherosclerotic Stenoses and Dissections. AJNR Am J Neuroradiol 2002;23: Gupta R, Schumacher HC, Mangla S, Meyers PM, Duong H, Khandji AG, et al. Urgent endovascular revascularization for symptomatic intracranial atherosclerotic stenosis. Neurology 2003; 61: Shin YS, Kim SY, Bang OY, Jeon P, Yoon SH, Cho KH, et al. Early experiences of elective stenting for symptomatic stenosis of the M1 segment of the middle cerebral artery: reports of three cases and review of the literature. J Clin Neurosci 2003;10: Nakahara T, Sakamoto S, Hamasaki O, Sakoda K. Double wire technique for intracranial stent navigation. J Vasc Interv Radiol 2003;14: Eckard DA, Krehbiel KA, Johnson PL, Raveill TG, Eckard VR. Stiff guide technique: technical report and illustrative case. AJNR Am J Neuroradiol 2003;24: New Techniques for Intracranial Stent Navigation in Patients with Tortuous Arteries 1 Hyun Wook Choi, M.D., Young Baek Koo, M.D., Tae Hong Lee, M.D., Hak Jin Kim, M.D., Jun Woo Lee, M.D., Chang Won Kim, M.D., Suk Kim, M.D., Ki Seok Choo, M.D., Yeon Joo Jeong, M.D., Suk Hong Lee, M.D. 1 Department of Diagnostic Radiology, Pusan National University Hospital, Pusan Purpose: We wanted to describe several new techniques of intracranial stenting that are helpful for navigating the stent delivery system in the tortuous carotid or vertebral arteries. Materials and Methods: Between May 1998 and June 2004, 65 patients with 73 symptomatic, stenotic intracranial arteries (more than 50%) were successfully treated with stent-assisted angioplasty. In eleven of the total cases, the standard technique failed to navigate the stent delivery system into the objective lesion because of the tortuous path of the carotid or vertebral arteries. In these cases, several new techniques were used to overcome the vessels' tortuous path. The several new techniques were 1) the waiting method (20 30 minutes) after advancement of microwire across the lesion; 2) the double wires technique using an additional microwire; and 3) the coaxial double guiding catheters technique using an additional smaller guiding catheter. Five lesions were located in the middle cerebral arteries, four were in the supraclinoid internal carotid arteries, and two were in the distal vertebral arteries. Results: In all difficult cases, intracranial artery stenting was performed successfully by using the several new techniques. The waiting method made smooth stent navigation possible in 5 cases, the double wire technique was successful in 4 cases and the coaxial double guiding catheter technique was successful in 2 case. There was no complication related to the new techniques. Conclusion: In difficult cases where the standard technique failed to navigate the stent delivery system into the objective lesion because of the vessels' tortuous path, these new techniques for intracranial stent navigation were usefully implemented. Index words : Angioplasty Intracranial atherosclerosis Stents Address reprint requests to : Tae Hong Lee, M.D., Department of Diagnostic Radiology, Pusan National University Hospital. 1-10, Ami-dong, Seo-gu, Busan Korea. Tel Fax