颈动脉内膜剥脱术治疗颈动脉重度狭窄30例体会

目的 探索如何更快度过颈动脉内膜剥脱术治疗颈动脉重度狭窄的学习曲线。方法 2015年6月至2022年9月采用颈动脉内膜剥脱术治疗颈动脉狭窄患者30例研究,术前完成病情评估和危险因素分析,术中根据患者情况选择补片和转流管,严格血压管控,术后双抗药物维持,控制并发症发生。术后长期随访,观察有无缺血性脑血管事件发生。结果 30例患者均顺利完成颈动脉内膜剥脱术,技术成功率100%,其中1例患者术后15个月发现颈内动脉远端吻合口再狭窄。其余患者随访时间内均未发现手术侧出现需要临床干预的再狭窄。围手术期患者未出现症状性脑出血,脑梗死,高灌注和死亡等严重并发症。最短随访1个月,最长随访7年零3个月,无短暂性脑缺血发作,脑卒中发生,有2例死亡,但均与脑卒中事件无关。结论 完善的术前评估,精细的术中操作,严格的术后管理可以让单中心开展颈动脉内膜剥脱术更快地度过学习曲线。     

颈动脉狭窄患者内膜剥脱术与支架植入术1年疗效Meta分析

目的利用Meta分析法探讨颈动脉内膜剥脱术（CEA）与颈动脉支架植入术（CAS）对颈动脉狭窄治疗1年内死亡和卒中、死亡、卒中、重度再狭窄及闭塞事件发生情况并进行评价。方法制定原始文献的纳入标准、排除标准及检索策略,搜索关于CEA及CAS治疗对颈动脉狭窄的对照研究。应用RevMan4.2.2软件对纳入文献进行定量评价。以优势比（OR值）及双侧95%可信区间（CI）作为效应尺度进行分析。结果纳入本研究的文献共6篇,1037例患者接受CAS治疗,1681例接受CEA治疗,将发生死亡和卒中、死亡、卒中事件统计数据合并;累计1586例接受CAS治疗,2196例接受CEA治疗,进行再狭窄及闭塞的统计数据合并。术后1年内CAS与CEA患者死亡和卒中、死亡、卒中事件发生差异无统计学意义,其OR值分别为0.81（95%CI0.56～1.18）、0.75（95%CI0.47～1.19）、0.78（95%CI0.53～1.16）。CAS患者再狭窄率高于CEA患者[OR=1.99（95%CI1.44～2.74）,P〈0.05）。结论对于颈动脉狭窄患者,CEA与CAS的1年死亡和卒中、死亡、卒中事件发生无明显差异,CAS术后重度再狭窄及闭塞率为CEA术的1.99倍。由于在缺乏足够数量的随机对照试验的情况下,纳入部分非随机对照试验的Meta分析,使论证强度受到一定的限制,有待更多大样本高质量随机对照试验对本研究结果进一步验证。     

颈动脉狭窄患者CEA应用颈动脉转流效果观察

目的:探讨颈动脉狭窄患者行颈动脉内膜剥脱术(CEA)术中使用颈动脉转流有效性及安全性。方法:回顾性分析79例颈动脉狭窄患者,术中通过经颅多普勒监测双侧大脑中动脉血流速度(VMCA)。阻断颈动脉前后记录系统收缩压、术侧VMCA、对侧VMCA。将79例患者分为两组:A组V2-a<40%V1-a 41例,使用颈动脉转流;B组V2-a≥40%V1-a 38例,未使用颈动脉转流。提高血压使术侧VMCA达到50%V1-a,即刻和恢复血供后记录系统收缩压、术侧VMCA、对侧VMCA。结果:A组、B组不良事件发生率分别为22.0%、5.3%(P=0.032);A组、B组主要不良事件发生率分别为9.8%、5.3%(P=0.743)。结论:颈动脉狭窄患者行CEA术,术中使用颈动脉转流增加不良事件发生率,但对主要不良事件发生率无明显影响,不常规推荐使用颈动脉转流管。     

颈动脉内膜剥脱术在治疗及预防缺血性脑卒中的临床研究

目的 观察颈动脉内膜剥脱术(CEA)对脑缺血症状的改善作用.方法 对80例颈动脉狭窄患者采用CEA治疗,剥离颈动脉斑块.结果 手术均获成功,术后患者脑缺血症状均有改善,未出现1例脑卒中和死亡病例,78例随访0.5~1.5 a未发生卒中病例.结论 CEA治疗颅外段颈动脉狭窄安全有效,对预防卒中、改善各种脑缺血症状具有重要...     

颈动脉狭窄复合手术术后并发症及相关因素研究

目的:探讨颈动脉狭窄复合手术（颈动脉内膜剥脱术联合血管内治疗）术后并发症及其相关因素。方法:回顾性收集2016年1月—2018年7月在北京天坛医院经复合手术行颈动脉血运重建的53例患者临床资料,从病历系统中获取个人基本信息、手术时长、术中麻醉管理、术后并发症、ICU停留时间、住院时长、住院费用等相关信息;主要结局指标采...     

颈动脉内膜剥脱术治疗颈动脉狭窄

目的 探讨颈动脉内膜剥脱术的适应证及手术操作要点.方法 回顾性总结12例因短暂性脑缺血伴有颈动脉硬化狭窄患者行颈动脉内膜剥脱术的,临床资料.结果 所有患者的短暂性脑缺血表现消失.部分患者慢性脑缺血症状也得到明显改善.术后1例出现一过性神志模糊,1例出现高血压,2例出现伤口轻度肿胀,治疗后均康复出院.术后未出现偏瘫或脑出血等严重并发症.结论 对于短暂性脑缺血病人(TIA),经Doppler超声或数字减影动脉造影术(DSA)检查发现颈总动脉或颈内动脉狭窄＞60%者,可以考虑行颈动脉内膜剥脱术(CEA).对于双侧颈动脉狭窄者,分期手术治疗较为安全.     

颈动脉狭窄的治疗进展

颈动脉内膜剥脱术一直被认为是治疗有症状和无症状严重颈动脉狭窄的金标准,而颈动脉血管支架成形术是近10余年新出现的技术。其微创的特点对于颈动脉内膜剥脱术而言,无疑是一种技术上的进步,特别是有高度手术风险的患者颈动脉血管支架成形术是最好的选择。文章分别阐述两种手术的特点,提出颈动脉狭窄治疗的最佳选择及当前面临的焦点问题。     

颈动脉内膜剥脱术抑或颈动脉支架术: 颈动脉狭窄手术治疗的金标准之争

脑卒中是当今第三大致死病因,是成年人致残的首要原因。颈动脉狭窄是导致缺血性卒中事件发生的最常见原因。20世纪80～90年代已有多个随机对照试验证实颈动脉内膜剥脱术相比于内科药物治疗对于预防卒中具有明显优势。近年来,随着介入技术和器材的不断进步,血管腔内介入治疗愈发成熟,其安全性及有效性正在为一些大规模的临床随机对照试验所证实,腔内介入治疗颈动脉狭窄正在挑战着外科内膜剥脱术的＂金标准＂地位。     

颈动脉内膜剥脱术及颈动脉支架置入术治疗颅外颈动脉硬化狭窄术后早期并发症比较

目的比较颈动脉内膜剥脱术(carotid endarterectomy,CEA)及颈动脉支架置入术(carotid stenting,CAS)治疗颅外颈动脉硬化狭窄后早期并发症发生情况,为临床治疗方法的选择提供理论依据。方法 2005年1月-2007年12月,分别采用CEA(CEA组,36例)和CAS(CAS组,27例)治疗63例颅外颈动脉狭窄患者。男42例,女21例;年龄52～79岁,平均67.5岁。左侧28例,右侧35例。颈动脉狭窄度为60%～95%,平均79%。主要临床症状为中风和短暂性脑缺血发作。头颅CT检查:24例有陈旧性脑梗死(cerebral infarction,CI),22例见多发性腔隙性CI,余17例未见明显异常。分析两种术式治疗后7 d内脑部、心血管及局部并发症发生情况。结果术后7 d内CEA组3例(8.3%)出现脑部并发症,2例(5.6%)出现心血管并发症,5例(13.9%)出现局部并发症;CAS组8例(29.6%)出现脑部并发症,1例(3.7%)出现心血管并发症,3例(11.1%)出现局部并发症;CAS组患者脑部并发症发生率明显高于CEA组,差异有统计学意义(χ2=4.855,P=0.028);但两组心血管、局部并发症发生率以及总并发症发生率比较,差异均无统计学意义(P>0.05)。结论对于颅外颈动脉硬化狭窄患者,CEA是首选治疗方式。     

一站式颈动脉内膜剥脱术联合椎动脉转位术的临床研究分析

目的 探索一站式颈动脉内膜剥脱术联合椎动脉转位术在同侧颈动脉重度狭窄至闭塞合并椎动脉V1段重度狭窄至闭塞患者中的治疗效果。方法 回顾性分析2017年6月—2020年9月阜外医院采用一站式颈动脉内膜剥脱术联合椎动脉转位术治疗同侧颈动脉重度狭窄至闭塞合并椎动脉V1段重度狭窄至闭塞患者的临床资料。进而分析一站式颈动脉内膜剥脱术联合椎动脉转位术在同侧颈动脉重度狭窄至闭塞合并椎动脉V1段重度狭窄至闭塞治疗中的意义。结果 纳入患者12例,其中男10例、女2例,平均年龄（67.8±6.0）岁。全部患者手术均成功。随访时间为1～3年,术后患侧椎动脉V1段的狭窄程度由83.5%±11.8%下降至24.9%±14.3%(P<0.001),术后患侧颈动脉狭窄程度由85.6%±11.0%下降至0%(P<0.001)。术后随访显示术前有症状的患者症状较术前均有改善,1年和3年通畅率均为100.0%,未出现周围神经损伤、围手术期死亡、卒中等。结论 一站式颈动脉内膜剥脱术联合椎动脉转位术能同期处理同侧颈动脉狭窄和椎动脉狭窄病变,改善脑部血供,改善患者症状,具有较高的推广价值。     

颈动脉内膜切除术相关并发症及处理

目的分析颈动脉内膜切除术(carotid endarterectomy,CEA)后并发症的原因并探讨其处理原则。方法回顾性总结1992年2月至2002年3月280例颈动脉内膜切除术(其中治疗陈旧性脑中风242例,预防性颈动脉内膜切除术38例)的临床资料。结果术后合并高血压59例(21·1%)、低血压30例(10·7%)、脑灌注损害16例(5·7%)、皮下血肿5例(1·8%)、脑卒中5例(1·8%)、颈动脉血栓4例(1·4%)、颅神经损害1例(0·4%)。术后随访:5年内血管再狭窄73例(26·1%)。结论根据残端指数选择性应用临时性转流,术中严格控制血压可减少术后并发症的发生。     

Prevention of stroke during carotid endarterectomy

From 1976 through 1985, 2857 carotid reconstructive procedures were performed on 2087 patients. Postoperative neurologic deficit occurred in 59 patients (2.1%). Thirty one patients (1.2%) suffered deficits that were permanent while 25 patients (0.9%) cleared to be discharged normal. In the last 5 years of the study, an aggressive approach was taken in cases where the patient was noted to have a postoperative neurologic change. It is routine to allow the patient to awaken in the operating room and to perform a simple neurologic examination prior to transport to the recovery room. If a neurologic change occurs during the postoperative period, immediate exploration is undertaken without preliminary testing. With this policy, 20 patients underwent exploration of the operated carotid artery and six of these patients recovered completely. To reduce the stroke rate from carotid endarterectomy (CE), technical errors must be kept to a minimum. Prevention of hypoperfusion with a shunt and careful mobilization of the artery to prevent microembolization should be practiced. Postoperative thrombosis can be decreased by the routine use of platelet antiaggregates and the avoidance of perioperative hypotension. Reperfusion of injury can be minimized by control of postoperative hypertension and proper preoperative selection of patients. Postoperative neurologic deficit following CE remains a relatively rare event and consequently sufficient experience in the treatment of this problem is difficult to acquire.     

Management of postoperative stroke after carotid endarterectomy

Major postoperative stroke after carotid endarterectomy is often due to carotid thrombosis, and prompt thrombectomy can reverse the neurologic deficit. We advise reoperation providing the stroke occurs within several hours of carotid endarterectomy, preferably when the patient is in the recovery room, and reoperation can be done immediately. We do not delay reoperation for angiography. Reoperation has not been beneficial for strokes that occur later in the patient's course or when there has been a severe preoperative neurologic deficit. Patients with a mild postoperative stroke, especially if the stroke represents worsening of a preoperative deficit, will often improve without intervention.     

颈动脉内膜剥脱术后大脑高灌注损伤的预防和处理

目的 探讨颈动脉内膜剥脱术(CEA)后发生高灌注损伤的术前高危因素、预防及处理措施.方法 2002年1月至2008年3月,在全程脑保护概念指导下,60 例颈动脉狭窄患者实行CEA 手术.术前患者均行颈部彩超和CT 血管成像检查,评价双侧颈动脉狭窄程度及侧支循环;术中采用全身麻醉、选择性颈动脉转流、经颅彩色多普勒(TCD)脑血流监测,维持脑血流;术后保留气管插管、镇静、脑冰袋、维持血压平稳,TCD 指导下应用脱水、降压药物预防和处理高灌注损伤.结果 60 例患者颈动脉平均狭窄率82豫依11豫,其中20 例行颈动脉转流,转流率为33%.34 例(57%)做补片成型.术后3 例(5%)出现头痛,1 例(1.7%)抽搐,无脑出血.38 例(63.3%)平均血流速度(MFV)增加幅度少于100%,22例(36.7%)增加超过100%,4 例(6.7%)术后出现症状患者的MFV 增加超过200%.结论 全程脑保护概念应用于CEA 手术,能有效减少术后大脑高灌注的发生.     

Early postoperative angiographic findings after carotid endarterectomy

Summary This report reviews the early postoperative evaluation of 70 patients who underwent carotid bifurcation endarterectomy within our department (before patients' releasing). Angiography was performed by femoral catheterization or the retrograde brachial route; three times only digital venous techniques were employed. No complications due to radiological procedures occurred. Postoperative angiographic findings include asymptomatic occlusion of ICA, occlusion of ECA, the presence of mural thrombi, diffuse surface roughness, intimal flaps and kink of ICA. Dilatation of the arteriotomized segment was detected with a high rate of frequency. Postoperative vascular changes are then analyzed in relation to surgical techniques, to early postoperative clinical course and to the occurrence of late re-stenoses.     

Prevention of postoperative neurologic deficits after carotid endarterectomy. Is platelet inhibition beneficial?

Aspirin (ASA) and dipyridamole (DIP) have been shown to reduce the incidence of transient ischemic attacks (TIAs), but aspirin's ability to reduce the incidence of postoperative neurologic deficits in patients who require carotid endarterectomy (CE) is controversial. To evaluate the role of adjunctive ASA/DIP in conjunction with CE, 908 CE cases were reviewed. Four hundred sixty-seven patients took ASA (650 mg/day) and DIP (150 mg/day) preoperatively, while 381 received no ASA/DIP. There was no statistical difference in the distribution of postoperative neurologic deficits. Twenty-six transient deficits occurred: 14 (53%) patients were taking ASA/DIP, whereas 12 (47%) were not. Seventeen permanent deficits occurred: ten (58%) patients were taking ASA/DIP and seven (42%) were not. ASA/DIP are useful medications in combating ischemic cerebrovascular disease, but ASA/DIP cannot replace precise operative technique which affords unequaled protection against a postendarterectomy neurologic deficit.     

Reoperation for neurological complications following carotid endarterectomy

BACKGROUND: There remains a dilemma whether or not to re-explore the carotid artery when a neurological complication occurs after carotid endarterectomy. This study reviewed the indications for, findings and clinical outcomes following re-exploration. METHODS: Patients who experienced transient or permanent neurological events following carotid endarterectomy were identified from a prospectively compiled computerized database. Case notes were retrieved to determine time to onset of symptoms, use of carotid artery imaging and details about patients who had surgical re-exploration, and outcomes. RESULTS: Some 780 consecutive carotid endarterectomies were performed over 16 years, with an incidence of major stroke or death of 2.3 per cent (18 patients). Fifty-one patients experienced transient or permanent neurological events following surgery, 25 of whom underwent re-exploration. The findings included carotid thrombosis (ten patients), flap or other technical cause (three), haematoma (two) and no abnormality (ten). The neurological outcome after 30 days was similar, whether or not the carotid artery was re-explored. CONCLUSION: Carotid artery re-exploration was undertaken in approximately half of the patients who developed neurological complications following carotid endarterectomy. Although the cause was identified and a secondary procedure was undertaken in 14 of 25 patients, there was no improvement in clinical outcome at 30 days compared with that of patients managed non-operatively.     

颈动脉硬化内膜剥脱术预防脑梗死

目的 总结行颈动脉硬化内膜剥脱术的经验.方法 2001年北京大学人民医院共治疗颈动脉粥样硬化性狭窄或闭塞94例.行单纯颈动脉硬化内膜剥脱者84例(93次),其中在颈动脉转流管保护下完成64例(73次).对于完全闭塞的13例患者行硬化内膜剥脱和取栓术.结果 13例完全闭塞的颈动脉2例部分再通,1例未再通,10例获完全再通;但1例获完全再通后5小时发现脑出血死亡.1例患者因脑缺氧时间过长最后呈植物状态.除1例术后早期并发一侧上肢麻木外,其他颈动脉狭窄者无论转流或非转流下行内膜剥脱者均未发生脑缺血并发症.随访发现1例行内膜剥脱术后局部再次狭窄20%左右.结论 颈动脉硬化内膜剥脱术为一种安全的预防脑梗死方法,颈动脉转流能提高颈动脉内膜剥脱术的安全性.     

Management of acute postoperative thrombosis following carotid endarterectomy

We reviewed 326 carotid endarterectomies performed from 1960 through 1981 and encountered five instances of acute postoperative thrombosis. Clinical decompensation occurs with the acute onset of severe neurologic deficits, most characteristically dense hemiplegias contralateral to the side that has been operated on. These deficits developed between two and 72 hours postoperatively. Prompt reoperation with thrombectomy and reestablishment of carotid flow within two hours from the onset of the neurologic deficit was performed on four patients with complete resolution of the deficits in three patients. The fourth patient recovered from a severe hemiplegia but retained a slight residual weakness of the hand. The one patient whose condition did not improve underwent thrombectomy more than 24 hours after the onset of her deficit. Time-consuming diagnostic procedures are not warranted as the success of reoperation depends on rapid reestablishment of cerebral flow.