血管内手術における頭蓋内動脈穿孔時の対処

Responding to Arterial Perforation during Endovascular Neurosurgery

Ⅰ．はじめに

　頭蓋内血管に対する血管内治療において，術中に遭遇するトラブルとして，血栓塞栓症，内膜解離，攣縮などが比較的頻度が高い．一方で，頻度は低いものの，稀にマイクロカテーテルやマイクロガイドワイヤーによる動脈穿孔に遭遇することがある．脳動脈瘤塞栓術施行時の術中瘤壁穿孔に関しては，穿孔した際の状況に応じてさまざまな対処法が成書に記載されている．しかし，血管の穿孔損傷における状況評価と対処法，予防法などに関しては，具体的な報告が意外に少ない．今回われわれは，2つの異なるタイプの病態における血管損傷例を参考に，その対応に関して考察したので報告する．

　During endovascular neurosurgery, various devices, such as catheters, are passed through the intracranial arteries to access target vessels;the arteries can thereby be perforated. Even though such incidents are serious and should be dealt with appropriately, few case reports or standard procedures have been published. Herein, we report two cases of arterial perforation that occurred recently in our hospital. In the first case, the patient had been treated preoperatively using feeder occlusion of an arteriovenous malformation;the microcatheter perforated the feeder, which branched from the middle cerebral artery. The feeder and perforation site were occluded by injection of n-butyl 2-cyanoacrylate（NBCA）through the same microcatheter, and complete hemostasis was thereby achieved. The second case occurred during an embolization of the middle meningeal artery（MMA）to treat a refractory chronic subdural hematoma;the microcatheter perforated a branch of the MMA. Both the perforation and the artery were embolized using platinum coils and by injecting NBCA, and hemostasis was achieved. Considering the anatomical and pathological properties of the injured vessels, favorable results were achieved with appropriate intervention.