Carotid endarterectomy in asymptomatic carotid stenosis: a decision analysis

OBJECTIVES: To present a model of decision analysis that allows assessing the trade-off between the short-term risks of performing a carotid endarterectomy and the rate of preventable future events. METHODS: We used data from a systematic review to define values for a base case and perform a sensitivity analysis. The primary endpoint was a comparison of the fatal and disabling stroke-free survival during a 5-year period in a cohort of hypothetical patients who presented asymptomatic severe carotid stenosis and were treated with either immediate prophylactic carotid endarterectomy or medical treatment alone. RESULTS: The difference in estimated fatal and disabling stroke-free survival favoring endarterectomy in patients with asymptomatic severe carotid stenosis is less than 4 days over the course of 5 years. One-way sensitivity analysis demonstrated that if the perioperative rate of death or disabling stroke is greater than 2.1%, then medical treatment is better. A non-surgical strategy is also better if the risk of fatal and disabling stroke with medical treatment is less than 1.09% per year, or if the rate of fatal and disabling stroke beyond 30 days following endarterectomy is greater than 0.51% per year. CONCLUSIONS: In this model, immediate prophylactic carotid endarterectomy seems to offer a minimum net benefit in terms of fatal or disabling stroke-free survival over a 5-year period, when compared to medical treatment alone.     

颈动脉内膜切除术的手术技巧与疗效简

目的探讨颈动脉内膜切除术治疗颈动脉狭窄的手术技巧,提高手术疗效,降低术中不良事件及术后并发症发生率。方法共53例颈动脉狭窄患者,右侧狭窄26例、左侧15例、双侧12例;中度狭窄（30％～69％）35例、重度狭窄（70％～99％）16例、完全闭塞2例。结果其中50例单纯行颈动脉内膜切除术、2例行颈动脉内膜切除术联合动脉瘤夹闭术、1例颈动脉支架成形术后管腔狭窄者行颈动脉内膜切除术并支架取出术。术后颈部CTA及灌注成像提示颈动脉血管形态良好、血流通畅,脑组织灌注不同程度改善。随访3～24个月,1例因心肌梗死死亡、2例术侧颈部皮肤麻木、1例声音嘶哑、3例仍有轻度短暂性脑缺血发作,无脑卒中病例。结论颈动脉内膜切除术是治疗颈动脉狭窄性病变安全、有效的外科方法,正确选择手术适应证及娴熟的手术技巧是保证手术成功、提高疗效的关键。     

高龄颈动脉狭窄患者颈动脉内膜切除术和颈动脉支架成形术的安全性比较简

目的回顾接受颈动脉内膜切除术和颈动脉支架成形术的高龄（≥70岁）颈动脉狭窄患者的临床资料,分析手术安全性。方法共691例颈动脉狭窄患者,121例行颈动脉内膜切除术、570例行颈动脉支架成形术,分析两组患者危险因素、临床特征和术后并发症发生率,评价两种手术方法之安全性。结果术后30d时,两组患者病死率（0．83％对1．05％,P=1．000）、脑卒中（4．13％对1．93％,P=0．258）和心肌梗死（0．83％对0,P=0．175）发生率差异均无统计学意义;但颈动脉内膜切除术组患者术后心脏不良事件（8．26％对1．05％,P=0．000）和脑神经损伤（4．96％对0,P=0．000）发生率高于颈动脉支架成形术组,而窦性心动过缓或低血压发生率低于颈动脉支架成形术组（0对7．54％,P=0．002）。结论高龄患者接受颈动脉内膜切除术或颈动脉支架成形术均有较高的安全性,术前应全面评价患者基础情况,以减少术后并发症发生率。     

颈动脉内膜斑块剥脱术中颈动脉阻断对局部脑氧饱和度的影响

目的 观察颈动脉内膜斑块剥脱术（CEA）中患侧颈动脉阻断对局部脑氧饱和度的影响。方法 2014年2月至2015年2月择期行CEA治疗重度颈动脉狭窄52例,麻醉诱导前及颈动脉阻断前后监测局部脑氧饱和度。以芬太尼、异丙酚、罗库溴铵诱导,气管插管术后以异丙酚和瑞芬太尼维持麻醉。术中连续监测并记录心率（HR）、平均动脉压（MAP）、脑电双频指数（BIS）、局部脑氧饱和度等。结果 HR在颈动脉阻断前后均无明显变化（P>0.05）;MAP在颈动脉阻断后明显增高（P<0.05）,而在阻断开放后逐渐恢复到术前水平;bis在颈动脉阻断前后均无明显变化（>P>0.05）;患侧局部脑氧饱和度在颈动脉阻断后呈下降趋势,但是无统计学差异（P>0.05）,在阻断开放后逐渐恢复,开放后30 min明显高于术前水平（P<0.05）。>结论 CEA术中患侧颈动脉阻断对患者局部脑氧饱和度没有影响;CEA术可以改善患侧局部脑供氧。     

颈动脉内膜切除与支架置入治疗症状性颈动脉狭窄的疗效比较

目的 探讨颈动脉支架置入术与颈动脉内膜切除术治疗颈动脉狭窄的近期疗效及安全性.方法 195例症状性颈动脉狭窄(≥60％)患者,随机分为颈动脉内膜切除术组(CEA组,97例),颈动脉支架组(CAS组,98例).CEA组在全麻下行颈动脉内膜切除术,CAS组采用自膨式镍钛合金支架治疗.分别评价两组术中、术后7d、30 d和90 d内终点事件发生率(卒中/死亡)及治疗相关的并发症,术中、术后7d、术后30 d及90d行颈动脉超声,头颅CT/MRI、NIHSS评分.结果 CAS组术后7d内死亡1例,卒中2例,发生率3.1％.CEA组术后7d死亡1例,2例卒中,发生率为3.1％,两组差异无统计学意义(P＞0.05).术中及术后7 d CEA组术后并发脑神经损伤较CAS组高(P＜0.05),卒中/死亡、急性颈动脉闭塞、高灌注综合征、局部血肿形成,两组差异无统计学意义(P＞0.05).CAS组与CEA组神经功能缺失表现均明显改善,两组差异无统计学意义(P＞0.05).术后7d、30 d、90 d两组头颅CT/MRI差异无统计学意义(P＞0.05).结论 CAS及CEA在治疗症状性颈动脉狭窄,预防卒中复发方面具有相似的近期效果,但其远期效果有待于进一步研究.     

Extended BSI for continuous EEG monitoring in carotid endarterectomy

OBJECTIVE: Carotid endarterectomy is a common procedure as a secondary prevention of stroke, and is often performed with selective shunting. Although various EEG parameters have been proposed to determine if the brain is at risk during carotid artery clamping, the common procedure is still the visual assessment of the EEG. Here, we propose an extension to the previously described brain symmetry index (BSI) [van Putten M, Peters J, Mulder S, de Haas J, Bruijninckx C, Tavy D. A brain symmetry index (BSI) for online EEG monitoring in carotid endarterectomy. Clin Neurophysiol 2004, 115(5), 1189-94.], as an additional quantitative criterion for shunt need in carotid endarterectomy. METHODS: An extension of the Brain Symmetry Index was implemented to capture both spatial (hemispheric) (sBSI) and temporal changes (tBSI) in the EEG. In this pilot study, the method is exemplified by simulation and by application to EEG records from 25 patients who underwent a carotid endarterectomy. RESULTS: Simulations show that hemispheric asymmetry is captured by changes in sBSI, only, while temporal symmetry changes, not due to changes in hemispheric asymmetry, are reflected by changes in tBSI. Combinations of changes induced changes in both parameters. This was confirmed by analysis 25 EEG records. Unilateral EEG changes during test-clamping are reflected by DeltasBSI>0.05, diffuse changes by DeltatBSI>0.02 and combinations by simultaneous changes in both features. CONCLUSIONS: In this pilot study, we present a doublet of quantitative EEG features, that in principle detects any change in the spectral characteristics of the EEG, decomposing the changes into a measure that captures spatial symmetry changes (sBSI), and a measure that quantifies diffuse temporal changes, that are not due to changes in spatial symmetry (tBSI). Both features are normalized with values ranging from [0-1], and can easily be implemented on-line to support the visual analysis of the EEG in the decision for selective shunting. SIGNIFICANCE: Quantitative real-time EEG analysis will assist in the EEG interpretation for selective shunting in carotid endarterectomy.     

颈动脉内膜剥脱术治疗中重度颈动脉狭窄的临床研究

目的以颈动脉支架置入术(CAS)为对照,分析颈动脉内膜剥脱术(CEA)在治疗中重度颈动脉狭窄的临床价值。方法将100例颈动脉狭窄患者按手术方法不同分为观察组(CEA)和对照组(CAS),记录2组围术期手术相关并发症;记录手术用时、住院时间、治疗费用;随访12个月,记录2组包括死亡在内的不良反应发生率及改良Rankin评分情况。结果观察组与对照组在围术期手术相关并发症、住院时间、术后6个月不良反应发生率及改良Rankin评分比较均无明显差异(P均0.05)。但观察组治疗经费低于对照组(P0.05)。结论颈动脉支架置入术治疗中重度颈动脉狭窄效果良好,术后近期和远期疗效及治疗安全性与颈动脉内膜剥脱术相当,但颈动脉内膜剥离术费用成本较低,并发症少。     

黄连素对颈动脉粥样硬化斑块的干预研究

目的探讨黄连素对颈动脉粥样硬化斑块干预的效果及机制。方法将92例伴有颈动脉粥样硬化斑块的缺血性脑血管病患者随机分成研究组及对照组;研究组口服黄连素,对照组口服氟伐他汀;于治疗前、治疗后2及4个月进行颈动脉超声检查,测量颈动脉TMT、颈动脉粥样硬化斑块面积及数量,以及检查治疗前、治疗后2及4个月sICAM-1、sVCAM-1、sE-selectin数值。结果与治疗前相比,治疗后4个月2组颈动脉IMT及颈动脉粥样硬化斑块面积、数量减小,差异有显著性（P〈0.05）,2组之间差异无显著性（P〉0.05）。与治疗前相比,治疗后2组sICAM-1、sVCAM-1、sE-selectin均降低,有显著差异（P〈0.05）,2组之间差异无显著性（P〉0.05）。结论黄连素可用于治疗颈动脉粥样硬化斑块,从而可应用于缺血性脑血管病的二级预防。     

右美托咪啶联合全身麻醉在颈动脉内膜切除术中的应用简

目的评价右美托咪啶在颈动脉内膜切除术中的安全性和有效性,并探讨其脑保护作用机制。方法40例颈动脉狭窄性病变患者分别于麻醉诱导前静脉输注右美托咪啶0．40μg／kg（右美托咪啶组）或等量生理盐水（对照组）,并记录给药前（T0）、气管插管前（T1）、气管插管后1min（T2）、显露颈动脉即刻（T3）、拔除气管插管前（T4）、拔除气管插管后1min（T5）时的平均动脉压和心率、麻醉药物剂量、麻醉恢复情况,以及围麻醉期血清TNF-α和IL-6表达变化。结果与T。时相比,右美托咪啶组患者其余各时间点平均动脉压和心率降低（均P〈0．05）,术中丙泊酚和瑞芬太尼剂量明显减少（均P〈0．05）,意识恢复时间和拔除气管插管时间缩短（均P〈0．05）,呛咳、躁动和术后寒战等不良反应轻微（均P〈0．05）。术后两组患者血清TNF—α和IL-6表达水平均升高（P〈0．05）,以对照组显著。结论颈动脉内膜切除术中应用右美托咪啶联合全身麻醉,围麻醉期可维持更平稳的血流动力学状态,减少麻醉药物剂量,麻醉复苏迅速且平稳,安全性和有效性良好,并可抑制TNF-α和IL-6等炎性因子的释放而发挥脑保护作用。     

内膜斑块剥脱术与支架置入术治疗颈动脉狭窄的Meta分析

目的 探讨颈动脉内膜斑块剥脱术（CEA）与颈动脉支架置入术（CAS）治疗颈动脉狭窄的疗效。方法 计算机检索Pubmed、Embase数据库,收集CEA与CAS治疗颈动脉狭窄的随机对照研究,应用Stata软件进行统计分析。结果 共纳入12项研究,共7 401例患者。Meta分析结果显示:术后30 d,CAS组卒中和死亡联合事件发生率（OR=1.51,95% CI为1.23~1.84;P<0.001）、任意卒中事件发生率（or ci为1.18~1.83;P<0.001）均明显高于cea组;而心肌梗死发生率（or ci为0.28~0.75;p="0.002）、颅神经损伤发生率（OR=0.08,95%" ci为0.04~0.14;P<0.001）均明显低于cea组。两组致残性卒中和死亡联合事件发生率（or ci为0.93~1.77;p="0.13）、病死率（OR=1.52,95%" ci为0.96~2.41;p="0.07）、致残性卒中发生率（OR=1.16,95%" ci为0.79~1.71;p="0.46）无明显差异。结论 CAS治疗颈动脉狭窄短期安全性和有效性与CEA类似。     

颈动脉支架置入术与颈动脉内膜切除术治疗颈动脉狭窄的近期疗效及安全性观察

目的分析颈动脉狭窄患者分别行支架置入术及内膜切除术后的安全性及近期临床疗效。方法 80例颈动脉狭窄患者经会诊及患者同意后,按照手术方案不同分为CEA组和CAS组。其中CEA组40例行内膜切除术,CAS组40例行支架置入术。比较2组近期疗效及相关并发症情况。结果 2组治疗前后NIHSS评分比较无明显差异(P0.05),组内治疗后评分(4.1±1.7,3.9±1.8)均较治疗前(6.5±2.4,6.3±3.1)明显降低(P0.05);随访6个月,CEA组颈动脉再狭窄率5.0%,与CAS组的7.5%比较无明显差异(P0.05);不良反应组间比较差异有统计学意义(P0.05)。结论颈动脉支架置入术及内膜切除术治疗颈动脉狭窄疗效无差异。支架置入术患者住院时间短,恢复较快,且术后并发症较少,安全性较高。     

普罗布考对颈动脉内膜切除术后再狭窄相关表达基因影响的研究

目的观察抗氧化剂普罗布考对颈动脉内膜切除术后早期再狭窄形成过程的影响，并探讨其作用机制。方法采用血管内膜气体损伤结合高脂饲料喂养的方法建立新两兰兔颈动脉粥样硬化动物模型，在此动物模型基础上行颈动脉内膜切除术，实验组在术前14d开始用普罗布考胃管灌入并设立对照进行比较，采用病理及免疫组化等方法，观察术后早期再狭窄过程中普罗布考对细胞凋亡和细胞间粘附分子-1（ICAM-1）、基质金属蛋白酶-2（MMP-2）表达的影响。结果抗氧化剂普罗布考可有效地减少颈动脉内膜切除术后新内膜厚度，增加术后血管残腔的面积．减少血管平滑肌细胞的增殖和迁移，在此过程中普罗布考可上调Bcl-2的表达，抑制新内膜发生的凋亡，抑制颈动脉内膜切除术后ICAM-1、MMP-2的表达。结论抗氧化剂普罗布考抗再狭窄的作用机制与抑制颈动脉内膜切除术后ICAM-1、MMP-2的表达，减少新内膜的凋亡有关。     

颈动脉内膜切除术或联合导管取栓术治疗慢性症状性颈内动脉闭塞

目的 观察颈动脉内膜切除术(CEA)或联合应用Fogarty导管(2F)取栓术治疗慢性症状性颈内动脉闭塞的临床疗效.方法 回顾性纳入2008年4月至2013年12月单纯采用CEA或术中联合Fogarty导管(2F)取栓术治疗的12例慢性症状性颈内动脉闭塞患者,所有患者均为颈内动脉起始处节段性闭塞.7例患者采用单纯CEA手术,3例行CEA联合Fogarty导管(2F)取栓术,2例再通失败后行颈外动脉CEA+颈内动脉起始处缝扎术.评估其近期及远期临床疗效.结果 12例患者中,术中颈内动脉即刻通畅10例,再通成功的比例为10/12.术后3例出现过度灌注综合征,给予严格控制血压、适当脱水后症状逐步缓解;无脑出血、脑梗死、神经损伤等严重并发症的患者.术后随访5～ 64个月,无新发脑梗死患者;10例再通成功者均未出现再闭塞,1例出现轻度狭窄;2例偶有短暂性脑缺血发作(TIA),但持续时间较术前明显缩短.2例开通失败的患者,1例症状缓解,1例仍有TIA.结论 慢性症状性颈内动脉闭塞患者,CEA或联合Fogarty导管取栓术是安全有效的方法,但需要全面的术前评估及谨慎地选择患者.     

颈动脉内膜切除术疗效观察

目的探讨颈动脉内膜切除术的适应证及效果。方法18例颈动脉狭窄患者行DSA颈动脉造影证实，其中右侧者9例，左侧者7例；双侧者2例。20侧颈动脉狭窄均程度为：狭窄程度70％～99％者12侧；30％～69％者8侧，其中狭窄程度为40％者1侧。结果18例施行20侧颈动脉内膜切除术中，疗效好者16例，中等者1例，差者1例，其中2例双侧颈动脉内膜切除术患者术后疗效均好。术后经3个月至2．5年的随访，手术后全部患者无脑卒中发生，并且脑缺血表现明显改善。结论颈动脉内膜切除术是治疗颈动脉狭窄的有效方法。     

颈动脉粥样硬化斑块内纤溶酶原激活抑制物-1表达的研究

目的观察颈动脉粥样硬化(AS)斑块内纤溶酶原激活抑制物-1(PAI-1)的mRNA和抗原的表达情况.方法分别应用原位杂交和免疫组织化学测定颈AS斑块内PAI-1mRNA和抗原表达.结果相对于正常动脉内膜,颈AS病变内膜PAI-1阳性细胞数明显增多(P＜0.05),其中颈AS严重病变肩区阳性细胞数最多,且以单核-巨噬细胞为主.结论PAI-1与颈AS发生有关.     

The safety and feasibility of outpatient carotid endarterectomy

Background

Carotid endarterectomy (CEA) is one of the most commonly performed and studied surgical procedures for extracranial ischemic disease.

Objective

The authors reviewed the outcome of 39 consecutive carotid endarterectomy procedures performed by a single surgeon with emphasis on the safety of discharging patients the same day of the procedure.

Methods

Retrospective analysis was performed over a two-year period on patients who were admitted as outpatients and underwent CEA. Following CEA, patients were observed for 4–6 h in the recovery room and Duplex ultrasonography was completed to assess the endarterectomy repair. Determination was then made whether patients could be safely discharged home.

Results

Over a two year period, CEA was performed 39 times in 37 outpatients. Twenty-five patients (64%) were discharged within 6 h of surgery completion. The remaining 14 patients (36%) were admitted to the hospital for varying reasons. Six patients (43%) stayed either due to personal preference or the lack of supervision at home and six other patients (43%) stayed because of mild hemodynamic instability. Of the two remaining patients, one was admitted for chest pain and the other for a small wound hematoma. No patients developed postoperative neurologic deficits. Two-tailed Fisher test analysis of collected variables revealed that patients who had general anesthesia were more likely to be admitted (p < 0.02).

Conclusion

Patients undergoing CEA can be safely discharged the same day after a brief period of postoperative observation. One factor that may predict the need for postoperative admission is the use of general anesthesia.     

颈动脉内膜切除术400例临床经验简

目的探讨颈动脉内膜切除术围手术期管理策略和临床疗效。方法356例颈动脉粥样硬化性重度狭窄（70％-99％）患者共实施400例次（双侧狭窄44例）颈动脉内膜切除术,分别采用标准式（120例次）、外翻式（255例次）和补片式（25例次）术式,其中368例次未行术中转流。结果所有患者手术均获成功,12例术后出现缺血性卒中（4例）、脑出血（1例）、声音嘶哑（1例）、癫痫发作（2例）、术后再闭塞（2例）、再狭窄（1例）和切口血肿（1例）等并发症。术后随访1。36个月,无一例出现脑卒中和其他严重并发症,患者生活质量明显改善。结论成熟的医疗团队对颈动脉重度狭窄患者颈动脉内膜切除术治疗成功的意义至关重要。于围手术期密切监测患者病情变化,可有效预防术后并发症,对降低病死率、提高患者生活质量和延长寿命具有重要临床意义。     

内膜斑块剥脱术治疗颈动脉狭窄的临床分析

目的 探讨颈动脉狭窄的手术治疗方法及疗效。方法 2006年2月至2015年7月采用颈动脉内膜斑块剥脱术（CEA）治疗颈动脉狭窄18例,所有病人均经颅脑多普勒超声检查或MRA筛选,头颈部CTA或DSA确诊,均在全麻下进行CEA。结果 术后临床症状改善17例,1例术后6 d死于大面积脑梗死。术后17例随访1~24个月,2例手术部位再狭窄（其中1例因反复短暂性脑缺血发作行支架治疗好转）;3例仍有短暂性脑缺血发作,保守治疗后好转;其余12例无明显并发症,恢复良好。结论 CEA是治疗颈动脉狭窄安全、有效的方法,对防治缺血性脑卒中有重要意义。     

颈动脉内膜切除术相关喉上神经外侧支显微解剖研究简

目的通过对尸头标本喉上神经外侧支的显微解剖,探讨颈动脉内膜切除术中喉上神经外侧支的保护方法。方法解剖10具（20侧）尸头标本,平均年龄（54．43±4．08）岁。于手术显微镜下找到颈动脉鞘,在其内部探查迷走神经主干,并向上分离至喉上神经起点;然后沿喉上神经向下分离,仔细辨认喉上神经走行至其分叉部,再向下分离喉上神经外侧支至咽下缩肌表面,穿人咽下缩肌之前测量外侧支厚度。分别分离二腹肌、颈总动脉、颈内动脉、颈外动脉和甲状腺上动脉,显露以二腹肌后腹下缘为上界、颈外动脉内侧缘为外侧界、甲状腺上动脉上缘为下界的解剖三角区域,观察并统计喉上神经外侧支出现概率,测量喉上神经外侧支中点至乳突尖、下颌骨角和颈动脉分叉部间的距离。结果共10具（20侧）喉上神经外侧支厚度为（0．93±0．83）mm（0．72-1．15mm）,其中1侧出现在解剖三角区域外,其余19侧均位于解剖三角区域内,出现概率为19／20;解剖三角区域内喉上神经外侧支中点位于下颌骨角后方（0．34±0．96）cm（．1．62-2．43cm）、下方（1．28±0．93）cm（-1．33～3．42cm）,乳突尖前方（2．84±1．09）cm（0．51～5．14cm）、下方（4．51±0．76）cm（2．82-6．39cm）,颈动脉分叉部前上方（1．64±0．89）cm（0．57．3．78cm,19／20）。结论在颈动脉内膜切除术中,以下颌骨角、乳突尖和颈动脉分叉部作为解剖标志,对于保护喉上神经外侧支具有重要临床意义。     

Prevention of ischemic stroke: The role of carotid endarterectomy in symptomatic patients

Carotid endarterectomy (CE) has recently been proved to be beneficial in symptomatic patients with severe (70–99%) appropriate carotid stenosis. After discussing the historical evolution of CE as a possible preventive treatment of ischemic stroke, we review the results of North American and European trials in order to give practical information for the management of cerebrovascular patients.

---

Sommario Recentemente è stata dimostrata l'efficacia della endoarterectomia carotidea (E.C.) in pazienti sintomatici con stenosi carotidea appropriata di grado elevato (70–99%). Dopo una analisi della evoluzione storica della E.C. quale possibile trattamento preventivo dell'ictus ischemico, abbiamo effettuato una revisione critica dei risultati dello studio Nordamericano ed Europeo, con lo scopo di fornire informazioni pratiche per la gestione del paziente cerebrovascolare.