颈动脉转流管在颈动脉内膜切除术中的临床应用

目的探讨颈动脉转流管在颈动脉内膜切除术（CEA）中的应用价值。 方法收集胜利油田中心医院神经外科&头颈血管外科2013年1月至2019年8月935例行CEA患者的临床资料,纳入统计标本的有304例症状性颈动脉重度狭窄合并颅内血流代偿较差的患者。术中行转流管转流的患者为转流管组（98例）,术中未行转流管转流的患者为对照组（206例）,通过比较2组患者术后症状改善率、术后并发症发生率及血管再狭窄发生率,对术中转流管的应用进行全面系统的研究。 结果转流管组和对照组的术中颈动脉阻断时间分别为（2.3±0.6）min和（13.6±8.2）min,术后出现颅脑过度灌注发生率分别为1.02%（1/98）和7.28%（15/206）,2组对比差异均有统计学意义（P<0.05）;2组患者术后症状改善率、术后其他并发症发生率及血管再狭窄发生率比较差异无统计学意义（P>0.05）。 结论对于症状性颈动脉重度狭窄合并颅内血管代偿较差的患者,CEA中转流管的熟练应用是安全可靠的。     

外翻式与补片式颈动脉内膜切除术近远期疗效的Meta分析

目的系统评价外翻式颈动脉内膜切除术(e CEA)与补片式CEA(p CEA)治疗颈动脉狭窄的近远期疗效。方法计算机搜索Medline、Pub Med、Ovid、CNKI及CBM数据库已发表的e CEA与p CEA对照研究的文献,时间为1970年5月至2016年10月。根据纳入和排除标准,由2名研究者选择文献,提取资料及数据,采用Cochrane协作网专用软件Rev Man 5.2对近远期疗效指标数据进行Meta分析。结果共检索出1 137篇文献,纳入10篇文献(其中3篇随机对照研究)进行分析,共计3 213例颈动脉狭窄患者,手术干预3 299例次(其中e CEA组1 512例次,p CEA组共1 787例次)。Meta分析结果显示,(1)e CEA组平均手术时间较p CEA组缩短(22±8)min,术中转流管使用率e CEA明显低于p CEA,分别为12.6%(53/421)和50.2%(357/711,OR=0.11,95%CI:0.08~0.15,P0.01)。术后30 d内卒中发生率(OR=0.42,95%CI:0.23~0.76,P=0.004)和30 d后卒中发生率(OR=0.26,95%CI:0.09~0.78,P=0.02)e CEA均低于p CEA,差异均有统计学意义(P0.05)。(2)e CEA降低了术后30 d后再狭窄发生率(OR=0.57,95%CI:0.38~0.86,P=0.008)。结论 e CEA治疗颈动脉狭窄较p CEA具有手术时间短、转流管使用率低的优势;同时e CEA能降低术后30 d内、30 d后卒中的发生,并且明显降低再狭窄发生率。     

血管结构特征与颈动脉内膜切除术后再狭窄的相关性研究

目的应用彩色多普勒血流显像(CDFI)评估颈动脉内膜切除术(CEA)前、术后颈动脉血管结构特征,并分析其与CEA术后再狭窄发生的相关性。方法回顾性连续纳入2014年1月至2019年2月于首都医科大学宣武医院神经外科及血管外科行CEA的颈动脉狭窄患者931例。于术前及术后1周、3个月、6个月、12个月行颈动脉CDFI检查,在术前及术后1周检测并记录颈总动脉远段、颈动脉球部、颈内动脉近段的原始管径,计算颈动脉球部与颈总动脉远段原始管径比值、颈动脉球部与颈内动脉近段原始管径比值。计算所有患者参数的平均值,作为纳入回归分析变量的分组标准。根据术后3个月及以上是否存在轻度(狭窄率30%～50%)及以上首发再狭窄分为再狭窄组与无再狭窄组。采用单因素分析方法分析再狭窄组与无再狭窄组患者的一般及临床影像学资料,采用多因素Logistic回归分析影响CEA术后血管再狭窄的独立危险因素。结果 931例患者中位随访12个月后,101例(10.8%)患者发生血管再狭窄。单因素分析结果显示,再狭窄组中女性患者显著多于无再狭窄组[26.7%(27/101)比12.5%(104/830),P 0.01]。再狭窄组患者术前球部原始管径、术前颈内动脉近段管径小于无再狭窄组[分别为:(6.8±0.9) mm比(7.1±1.0) mm,P=0.001;(4.0±0.8) mm比(4.2±0.7) mm,P=0.006]。再狭窄组患者术后首次颈总动脉远段管径、颈内动脉近段管径均小于无再狭窄组[分别为:(5.6±1.4) mm比(6.9±1.1) mm、(4.3±1.1) mm比(4.9±0.8) mm,均P 0.01];两组患者在术后颈动脉球部与颈总动脉远段管径比值、颈动脉球部与颈内动脉近段管径比值之间差异有统计学意义[分别为:(1.35±0.60)比(1.00±0.41)、(1.7±0.8)比(1.4±0.4),均P 0.01]。多因素Logistic回归分析结果显示,女性(OR=1.938,95%CI:1.117～3.363,P=0.019)、术后颈总动脉远段管径6.8 mm(OR=3.551,95%CI:1.886～6.687,P 0.01)、术后球部与颈总动脉远段管径比值 1.0 (OR=6.683,95%CI:3.322～13.441,P 0.01)是CEA术后血管再狭窄的独立危险因素。结论采用CDFI评估CEA患者术前及术后血管结构特征,可早期预测CEA术后再狭窄的发生,对提高患者远期疗效具有重要的临床参考价值。     

腹腔镜下结直肠癌切除术联合肝转移瘤射频消融术治疗结直肠癌肝转移

目的探讨腹腔镜下结直肠癌切除术联合肝转移瘤射频消融术治疗结直肠癌肝转移(colorectal cancer liver metastases,CRLM)患者的临床疗效。方法选取2016年5月至2017年3月于普宁市人民医院诊治的105例CRLM患者,按随机数字表法分为对照组(50例)和观察组(55例),对照组行腹腔镜结直肠癌切除术联合肝转移灶切除术,观察组行腹腔镜下结直肠癌切除术联合肝转移瘤射频消融术,采用独立样本t检验比较两组患者相关手术指标(手术时间、术后肛门首次排气、住院时间等),采用χ~2检验比较术后并发症(吻合口狭窄、吻合口出血、切口感染等)、术后复发率及生存率。结果观察组患者手术时间[(254.57±33.41)min vs(290.52±36.42)min;t=5.276,P 0.001]、术中出血量[(187.16±89.52)ml vs(383.63±88.34)ml;t=11.302,P 0.001]、术后肛门首次排气时间[(2.48±0.36)d vs(3.50±0.25)d;t=16.702,P 0.001]、住院时间[(13.25±4.60)d vs(18.73±4.10)d;t=6.419,P 0.001]、治疗费用[(37072±505)元vs(41059±504)元;t=40.442,P 0.001]及术后VAS评分[(4.02±0.26)分vs(7.25±0.63)分;t=34.906,P 0.001]均显著低于对照组。观察组和对照组患者观察组和对照组患者术后切口感染(1.82%vs 12.00%)、吻合口狭窄(1.82%vs 4.00%)、吻合口出血(1.82%vs 4.00%)、输尿管损伤(1.82%vs 4.00%)、吻合口瘘(0%vs 2.00%)、粘连性肠梗阻(1.82%vs 12.00%)、排尿困难(0%vs 2.00%)等并发症发生率差异无统计学意义(P均 0.05)。观察组和对照组患者术后3年局部复发率分别为12.73%(7/55)、20.00%(10/50),差异无统计学意义(χ~2=1.021,P=0.312)。观察组患者术后1年、2年和3年的生存率分别为90.91%(50/55)、85.45%(47/55)、81.82%(45/55),对照组分别为90.00%(45/50)、86.00%(43/50)、84.00%(42/50),差异均无统计学意义(χ~2值分别为0.025、0.006、0.088,P值分别为0.874、0.936、0.767)。观察组患者术后1年、2年和3年的无瘤生存率分别为76.36%(42/55)、72.73%(40/55)、45.45%(25/55),对照组分别为76.00%(38/50)、60.00%(30/50)、40.00%(20/50),差异均无统计学意义(χ~2值分别为0.002、0.062、0.318,P值分别为0.965、0.804、0.573)。结论腹腔镜下结直肠癌切除术联合肝转移瘤射频消融术可显著减少CRLM患者术中出血量,加快术后康复时间,减少术后并发症,近期疗效和安全性良好。     

急性ST段抬高型心肌梗死急诊经皮冠状动脉支架术后支架内再狭窄相关因素分析

目的:分析急性ST段抬高型心肌梗死急诊冠状动脉支架(PCI)术后支架内再狭窄相关危险因素。方法:入选我院2005年至2014年,急性ST段抬高型心肌梗死行急诊PCI病例,并因再发症状于我院复查冠状动脉造影的患者333例,男性270例(81. 1%),女性63例(18. 9%)。根据支架内狭窄是否≥50%,分为再狭窄组及无再狭窄组。记录患者的一般情况和手术情况,分析相关危险因素。结果:平均复查时间25. 04个月(中位数12个月),复查造影支架内再狭窄组132例及无再狭窄组组201例。再狭窄组年龄小于无再狭窄组组[(56. 08±10. 10) vs.(58. 40±10. 42)岁,t=-2. 032,P=0. 043];再狭窄组LDL-C高于无再狭窄组组[(3. 17±0. 81) vs.(2. 95±0. 82) mmol/L,t=2. 404,P=0. 017];应用球囊后扩张比例再狭窄组低于无再狭窄组组(13. 6%vs. 45. 3%,χ~2=36. 319,P0. 001)。多因素Logistic回归分析显示:年龄(OR=0. 962,95%CI:0. 934～0. 991,P=0. 010)、CK-MB(OR=0. 998,95%CI:0. 996～1. 000,P=0. 033)及使用球囊后扩张(OR=0. 139,95%CI:0. 068～0. 284,P0. 001)减少支架内再狭窄的发生,糖尿病病史(OR=1. 902,95%CI:1. 036～3. 492,P0. 038)增加支架内再狭窄的危险。结论:急性ST段抬高型心肌梗死患者,急诊PCI术中行球囊后扩张术支架内再狭窄率较低,且明显降低支架内再狭窄风险。同时糖尿病病史显著增加支架内再狭窄危险。     

尿酸水平对冠状动脉支架内再狭窄的影响

目的探讨尿酸水平对稳定性心绞痛患者支架置入后发生支架内再狭窄的影响。方法 136例稳定性心绞痛成功行支架置入治疗患者,根据术后12~18个月冠状动脉造影结果分为再狭窄组62例及对照组74例;对冠状动脉造影结果用计算机辅助的定量分析法评价。结果对照组尿酸水平明显低于再狭窄组[(364.21±42.47)μmol/L vs(440.66±69.05)μmol/L,P=0.000];对照组术后12~18个月的最小管腔直径明显大于再狭窄组[(2.12±0.38)mmvs(0.76±0.37)mm,P=0.013];狭窄程度术后12~18个月对照组明显低于再狭窄组[(35.84±12.34)%vs(84.53±14.26)%,P=0.000];对照组晚期管腔丢失明显小于再狭窄组[(0.27±0.14)mmvs(1.66±0.57)mm,P=0.000]。尿酸与支架术后再狭窄有关(OR=0.680,95%CI:0.564~0.937,P<0.05)。结论尿酸水平增高可能是稳定性心绞痛患者支架置入后发生支架内再狭窄的原因之一。     

颈动脉内膜切除术中转流管的应用及侧支代偿对其的影响

目的探讨颈动脉内膜切除术（CEA）中转流管应用的优缺点,以及对侧颈动脉闭塞及前、后交通动脉开放对其的影响。方法回顾性分析2000年1月—2011年9月共308例CEA病例,根据是否应用转流管分为两组,转流组63例,未转流组245例。比较两组术中微栓子数量,术后卒中及死亡率。比较两组中对侧颈动脉狭窄程度以及前、后交通动脉开放的比例,分析其对转流管应用的影响。结果①转流组患者微栓子的中位数为25个,未转流组为10个,两组差异有统计学意义（P〈0.05）。②术后1个月内缺血事件的发生率,转流组患者卒中1例（1.6%）,无一例死亡;未转流患者卒中6例（2.4%）,死亡4例（1.6%）。两组的卒中及病死率差异均无统计学意义（P〉0.05）。③术前对侧颈动脉狭窄的程度,转流组患者中有8例闭塞,8例重度狭窄,47例轻中度狭窄或无狭窄。未转流组患者中,分别为9、36、200例。两组闭塞率（12.7%比3.7%）比较,差异有统计学意义（P〈0.05）。术前前交通动脉及后交通动脉均未开放的患者,转流组有35例（55.6%）,未转流组有81例（33.1%）,两组比较差异有统计学意义（P〈0.01）。结论 CEA中使用转流管虽增加微栓子的数量,但并未增加围手术期卒中及死亡率。术前伴有对侧颈动脉闭塞的患者或前、后交通动脉均未开放的患者,使用转流管的比例明显高于其他患者。     

颈动脉内膜剥脱术治疗老年症状性颈动脉狭窄的研究

目的探讨颈动脉内膜剥脱术(CEA)在老年症状性颈动脉狭窄中的应用。方法回顾分析我院108例老年症状性颈动脉狭窄行CEA患者的临床资料。结果 108例患者行CEA共125例次,成功率100%,其中颈动脉狭窄60%～75%者48例次,占38.4%,狭窄>75%者77例次,占61.6%,围手术期严重并发症2例,发生率1.9%,围手术期死亡1例,占0.9%。101条颈动脉术后1个月经颈多普勒超声显示,颈内动脉最狭窄处血管内径较术前明显增加[(6.11±1.36mmvs 1.59±0.82mm,P<0.05],狭窄程度由术前的(78±21)%降至(14±12)%,最狭窄处收缩期最大流速明显改善[(208±22)cm/s vs(93±18)cm/s,P<0.05]。81例患者术后18个月脑缺血症状较术前改善者75例(92.6%),再发短暂性脑缺血发作5例(6.2%),脑卒中1例(1.2%),发现术侧颈动脉>60%的再狭窄1例(1.2%),低于北美症状性颈动脉剥脱试验水平。结论 CEA是治疗老年症状性颈动脉狭窄的有效方法,在预防老年患者缺血性脑卒中等重大脑血管事件的发生中有重要价值。     

血清超敏C-反应蛋白动态变化与颈内动脉支架置入术后再狭窄的相关性

目的 探讨颈动脉支架置入术(carotid artery stenting CAS)后血清超敏C-反应蛋白(high-sensitive C-reactive protein,hs-CRP)的动态变化及其与支架内再狭窄的相关性.方法 在南京军区南京总医院神经内科行CAS治疗的患者,分别在术前、术后12h、7d、3个月和6个月时检测血清hs-CRP水平,并在6个月后复查脑血管造影,观察有无支架内再狭窄.结果 纳入84例行CAS治疗的患者,15例(24％)患者在CAS术后出现支架再狭窄,其中3例狭窄程度＞50％,12例狭窄程度为30％～50％.所有患者术后12 h时血清hs-CRP水平均显著高于治疗前(P均＜0.01),而术后6个月时较治疗前显著降低(P均＜0.01).单变量分析显示,再狭窄组糖尿病比例显著高于无再狭窄组(P＜0.01).再狭窄组术后7 d[(8.83±1.94) mg/L对(6.77±1.63) mg/L,t=14.398,P=0.044]、术后3个月[(8.26±1.32) mg/L对(4.58± 1.45) mg/L,t=17.569,P=0.008]和术后6个月[(7.04±1.07)mg/L对(3.12±1.28) mg/L,t=21.867,P=0.003]血清hs-CRP水平显著高于无再狭窄组,而术前与术后6个月时血清hs-CRP水平的差值(△hs-CRP)显著低于无再狭窄组[(0.85±0.13) mg/L对(4.89±0.94)mg/L,t=16.987,P=0.000].多变量logistic回归分析显示,△hs-CRP(优势比2.392,95％可信区间1.538 ～3.513,P=0.009)和糖尿病(优势比1.840,95％可信区间1.372 ～2.241,P=0.023)是支架再狭窄的独立危险因素.结论 CAS术后12h时血清hs-CRP水平显著升高,随后持续下降.术后6个月时血清hs-CRP下降程度越明显,发生支架内再狭窄的风险越低.     

颈动脉内膜剥脱术和支架成形术治疗颈动脉狭窄的临床研究

目的探讨颈动脉内膜剥脱术(CEA)和颈动脉支架成形术(CAS)治疗颈动脉狭窄的临床价值。方法选择颈动脉狭窄患者43例,分为CEA组20例和CAS组23例,分析比较CEA和CAS 2种治疗方法的疗效。结果 CEA组成功率为95%,术后随访2年,再狭窄率为10%;CAS组成功率为100%,术后随访2年,发生再狭窄率为13%,2组的手术成功率和术后再狭窄率比较,差异无统计学意义(P>0.05)。结论 CEA和CAS是治疗颈动脉狭窄的有效方法,两者在安全性和有效性方面相同。     

Carotid artery surgery vs. stent: a cardiovascular perspective.

Stroke is a major health catastrophe that is responsible for the third most common cause of death and the leading cause of disability. Carotid artery stenosis is an important cause of brain infarctions and the risk of stroke is directly related to the severity of carotid artery stenosis and to the presence of symptoms. Familiarity with different methods of measuring degrees of carotid artery stenosis is a key in understanding the role of revascularization of this disorder. Carotid endarterectomy (CEA), surgical removal of the carotid atherosclerotic plaque, is intended to prevent stroke in patients with carotid artery stenosis and currently the most commonly performed vascular procedure in the United States. Several randomized clinical trials had demonstrated the benefits of CEA in selected groups of patients with symptomatic and asymptomatic carotid artery stenosis. However, CEA can cause stroke, the very thing it intended to prevent, and is associated with significant perioperative complications such as those related to general anesthesia, cardiac or nerve injury. Moreover, several anatomical and medical conditions may limit candidates for CEA. Carotid artery stenting (CS) is an evolving and less invasive technique for carotid artery revascularization. Recent studies demonstrated that CS with embolic protection devices has become an alternative to CEA for high-surgical-risk patients and the procedure of choice for stenoses inaccessible by surgery. The role of CS in low risk patients awaits the completion of several ongoing studies.     

颈动脉狭窄的干预治疗:支架还是内膜剥脱?

颈动脉狭窄是卒中的常见原因.颈动脉血管成形和支架正成为颈动脉内膜剥脱术后治疗颈动脉狭窄的一种有效方法.两种方法孰优孰劣是近来争论的焦点,现通过比较近来对颈动脉内膜剥脱术和颈动脉血管成形和支架术对比的试验研究,认为未来几年是评价两种方法的重要时期.     

Carotid Endarterectomy: Current Concepts and Practice Patterns

Background Stroke is the number one cause of disability and third leading cause of death among adults in the United States. A major cause of stroke is carotid artery stenosis (CAS) caused by atherosclerotic plaques. Randomized trials have varying results regarding the equivalence and perioperative complication rates of stents versus carotid endarterectomy (CEA) in the management of CAS. Objectives We review the evidence for the current management of CAS and describe the current concepts and practice patterns of CEA. Methods A literature search was conducted using PubMed to identify relevant studies regarding CEA and stenting for the management of CAS. Results The introduction of CAS has led to a decrease in the percentage of CEA and an increase in the number of CAS procedures performed in the context of all revascularization procedures. However, the efficacy of stents in patients with symptomatic CAS remains unclear because of varying results among randomized trials, but the perioperative complication rates exceed those found after CEA. Conclusions Vascular surgeons are uniquely positioned to treat carotid artery disease through medical therapy, CEA, and stenting. Although data from randomized trials differ, it is important for surgeons to make clinical decisions based on the patient. We believe that CAS can be adopted with low complication rate in a selected subgroup of patients, but CEA should remain the standard of care. This current evidence should be incorporated into practice of the modern vascular surgeon.     

Comparative Review of the Treatment Methodologies of Carotid Stenosis

The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.     

Symptomatic and asymptomatic carotid stenosis: just when we thought we had all the answers

The management of symptomatic and asymptomatic carotid stenosis has been a hotly debated topic for decades. The publication of four randomized controlled trials of carotid endarterectomy has clarified many of the issues. Patients with symptomatic carotid stenosis >70% benefit most with an absolute risk reduction of 17% over 2 years with numbers needed to treat of 3-6, whereas in patients with asymptomatic carotid stenosis >60%, the absolute risk reduction is 1% per annum (numbers needed to treat = 14-17). There is doubt about the benefit in women >70 years of age with asymptomatic stenosis. Carotid angioplasty and stenting is in its infancy and may one day supplant carotid endarterectomy as the treatment of choice; however, currently indications for this procedure include participation in randomized controlled trials, surgically inaccessible stenosis, in patients with combined symptomatic carotid and symptomatic coronary artery disease or in patients with severe co-morbidities that preclude formal carotid endarterectomy.     

解除颈动脉狭窄对认知功能的影响

解除颈动脉狭窄对认知功能的影响日益引起重视,颈动脉内膜切除术和颈动脉支架置入术均可改善认知功能.解除颈动脉狭窄后认知障碍改善可能与脑血流灌注增加、白质病变减轻以及无症状腔隙性梗死发生率降低有关.