EVT治疗的难点和挑战：以“徒劳的再通”为核心的系统分析

Difficulties and Challenges of EVT: A Systematic Analysis Centered on “Futile Recanalization”

摘要: 急性缺血性脑卒中大血管闭塞(LVO)患者行血管内治疗(EVT)的再通率显著提升，但“徒劳的再通”(解剖再通后未达90天功能独立或预后恶化)是核心瓶颈。本文以其为线索，剖析关键挑战：筛选层面，Mismatch评分难辨“可挽救半暗带”，串联病变、ICAS相关闭塞及基底动脉闭塞(BAO)因评估缺失，BAO“徒劳再通”率达45%~55%；中远端血管闭塞(MeVO/DMVOs)因血管细小、器械适配差，EVT再通率75.1%却无预后优势，且死亡率、出血风险更高；再灌注损伤(出血转化发生率41.2%，PH2患者死亡率46%；无复流患者功能独立率仅为灌注良好者64%)阻断疗效；术后评估标准不统一，长期管理中血压控制矛盾、抗栓选择两难加剧问题。未来需通过精准筛选工具、专用器械及个体化方案，推动EVT向“临床获益”转化。

Abstract: The recanalization rate of endovascular treatment (EVT) for patients with acute ischemic stroke and large vessel occlusion (LVO) has been significantly improved, but “futile recanalization” (failure to achieve 90-day functional independence or worse prognosis after anatomical recanalization) remains a core bottleneck. Taking this as a clue, this article analyzes the key challenges: in patient selection, the Mismatch score cannot distinguish the “salvageable ischemic penumbra”; tandem lesions, ICAS-related occlusion, and basilar artery occlusion (BAO) lack targeted assessment, with the rate of “futile recanalization” in BAO reaching 45%~55%; for medium and distal vessel occlusions (MeVO/DMVOs), due to small vessel caliber and poor device adaptation, EVT achieves a recanalization rate of 75.1% but no prognostic advantage, along with higher mortality and bleeding risk; reperfusion injury (hemorrhagic transformation rate of 41.2%, 46% mortality in PH2 patients; functional independence rate of no-reflow patients only 64% of that in well-perfused patients) blocks therapeutic efficacy; inconsistent postoperative assessment standards, and dilemmas in long-term blood pressure control and antithrombotic selection further exacerbate the problem. In the future, precise screening tools, dedicated devices, and individualized regimens are needed to promote the transformation of EVT towards “clinical benefit”.