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精益迭代、技术革命，造就了一个创新开拓的时代。本次血管创新论坛VINNOVA于4月10-11日在线上召开，带来名家云集、内容丰富的创新学术盛宴。BD外周星与血管创新论坛秉持相同“推陈出新，新益求新”的精神核心，在VINNOVA大会上带来4大板块的精彩内容，本期为大家带来"「支行」-再谈主髂动脉闭塞的新技术”内容回顾。
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主髂闭塞治疗最新指南解读
王利新教授
医院
近年来，随着人口老龄化加剧和相关危险因素影响，主髂动脉闭塞症（AIOD）发病率逐年攀升。大量研究结果显示，AIOD腔内治疗疗效不次于开放手术，且住院时间更短、围手术期并发症及死亡率更低。
年10月国内发布了《主髂动脉闭塞症的诊断和治疗：中国专家共识》，建议对于AIOD应首先选择腔内治疗，针对严重钙化病变，建议使用覆膜支架，如合并股总动脉分叉病变，建议行复合手术。
AIOD诊疗亚太共识中指出，腔内治疗对于生活受限的间歇性跛行及显著血流动力学改变的主髂动脉闭塞的患者治疗安全有效。
年5月SCAI发布了主髂动脉介入治疗器械选择最新指南，该指南对主髂动脉介入手术所有11种器械的比较性有效数据进行了全面回顾。
球扩式支架在主髂动脉分叉病变、弥漫性或局灶性CIA病变治疗中获得最强推荐级别。球扩覆膜支架在累及主动脉下端和髂动脉分叉病变、中度至重度钙化病变治疗中，均获得了最强推荐级别（COR）和最高级别证据（LOE）。
最后，王利新教授对本次演讲进行简要总结：腔内治疗是主髂动脉闭塞治疗首选；球扩式覆膜支架有较好的安全性和较高的血管通畅率，获得了最强的推荐级别和最高级别的证据。
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球扩式覆膜支架的循证医学之路
郭连瑞教授
医院
主髂动脉分叉处血流动力学复杂，是动脉粥样硬化好发部位，其病变特点有：多发多节段病变，钙化多为环型或蔓延扁平状，髂动脉迂曲明显，球囊扩张破裂风险相对较高。
年SVS发布了AIOD诊疗指南，该指南对于严重钙化病变或动脉瘤样病变，建议使用覆膜支架。开放手术治疗的一期通畅率优于腔内治疗，两者二期通畅率及保肢率相仿，腔内治疗长期随访结果仍欠缺。年ESV、ESVS发布了外周动脉疾病诊疗指南，建议病变延伸至股总动脉的AIOD行杂交手术，单纯髂动脉病首选腔内治疗。年5月SCAI发布了主髂动脉介入治疗器械选择最新指南，球扩式覆膜支架治疗主髂动脉分叉病变、弥漫性或局灶性CIA病变获得了最高推荐级别，自膨式覆膜支架治疗弥漫性EIA病变、中度至重度钙化病变获得了IIa级推荐。
COBEST研究是一项对比分析球扩式覆膜支架与球扩式金属裸支架的前瞻性、多中心RCT研究，5年的随访结果显示,TASCC/D级病变覆膜支架有着更好的远期通畅率，尤其球扩覆膜支架的一期通畅率更是达到了80％以上。
郭连瑞教授认为球扩式覆膜支架在以下几种情况中较为适用:1.需要精准定位的短段狭窄或闭塞病变；2.严重钙化、血管破裂风险较高或已经发生血管破裂的病变；3.血栓或溃疡性斑块的治疗。
从临床实际病例来看，球扩覆膜支架有较良好的柔顺性，可用于髂动脉迂曲狭窄的病变，能够获得满意的结果，为复杂主髂动脉病变提供了较好的治疗选择。
而在开口分叉、严重钙化、回弹较强的病变中，使用覆膜支架也是较好的选择，可避免破裂，获得良好的临床治疗效果。
最后，郭连瑞教授对本次演讲进行简要总结：1.COBEST研究证明对于TASCB级病变，覆膜支架和裸支架无明显差异，但对于TASCC/D级病变，球扩式覆膜支架组在长期通畅率和临床预后有显著优势。2.球扩式覆膜支架推荐使用在开口分叉处、严重钙化、回弹较强和TASCC/D级病变中，并获得了最强的推荐级别和最高级别的证据。
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CERAB技术解析和支架性能要求
袁丁教授
医院
目前临床治疗主髂动脉分叉病变最常用的方法是KISSING支架植入，但该技术存在一定问题：1.KISSING支架总直径与主动脉支架差异越大，越易引起ISR；2.支架进入主动脉2cm增加ISR的发生率；3.进入主动脉支架易发生交叉，这种交叉构型的KISSING支架通畅率较差；4.覆膜支架与主动脉间有残腔区，裸支架交叉点与原主髂分叉点存在血流滞留区。
主动脉分叉血管腔内覆膜支架重建术（CERAB）是治疗主髂动脉病变的有效方法，该项技术首先在腹主动脉内置入直径较大的球扩式覆膜支架，然后进行球囊后扩，使得腹主动脉支架呈锥形结构，再在其内分别经双侧髂动脉对吻置入小口径球扩覆膜支架，并同时进行球囊后扩张。该技术旨在消灭残腔和血流滞留区，恢复生理血流。CERAB的技术核心是三枚球扩覆膜支架，优势在于定位精准、容易可控、易于KISSING、放大后扩。
CERAB真实世界报道数据显示：CERAB的远期通畅率显著高于KISSING支架，随访病例中并未出现因覆膜支架的植入导致IMA缺血、臀肌缺血、脊髓缺血。同时，CERAB技术可以继续植入一枚覆膜支架以保证肠系膜下动脉血流通畅。LifeStream和VBX两种覆膜支架后扩特性对比结果显示：LifeStream支架可后扩至14mm,而VBX支架最大可后扩至16mm，但VBX后扩的短缩率远超于LifeStream。
最后，袁丁教授对本次演讲进行简要总结：1.CERAB技术是对球扩覆膜支架的升级应用；2.针对AIOD病变，CERAB是具有符合主髂原始血流状态的技术；3.覆膜支架对腹主动脉段侧枝的影响并发症目前尚未报道；4.目前总体数据例，数据仍旧需要累积。
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讨论
在三位讲者主题演讲结束后，符伟国教授组织各位点评专家在线上展开精彩讨论。
符伟国
教授
无论是最新髂动脉介入治疗器械指南还是专家共识，都高度认可了球扩式覆膜支架的疗效。LifeStream球囊扩张式血管覆膜支架进入中国市场，为我们治疗主髂动脉疾病提供了更多选择，为CERAB技术的应用推广提供保障。
在主髂动脉分叉病变治疗中，覆膜支架已逐渐替代了裸支架。LifeStream作为一款球扩式覆膜支架，填补了国内空白，为主髂动脉分叉病变的治疗提供了一大利器。球扩式覆膜支架定位准确，并且可以根据管腔直径，适度扩张支架，具有很好的可塑性。
陆清声
教授
丁明超
教授
球扩式覆膜支架在后扩时，随着后扩球囊直径的变化其长度也会相应变化。因此在行KISSING支架植入时，若要后扩，确保能够做到同时、同比例、同压力的传递，否则会影响手术疗效。
★
精彩推荐
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?BD外周星
VINNOVA｜「动容」-动脉血栓清除装置的设计与应用精彩回顾?BD外周星
VINNOVA｜「蔚来」-静脉专用支架的设计精彩回顾?BD外周星
VINNOVA｜「囊括」-特殊球囊的设计与应用精彩回顾血管资讯学术会议专区
网址:xgzx.talkmed.