应用脑保护装置实施颈动脉支架成形术的临床经验

目的探讨脑保护装置在颈动脉支架成形术中的价值。方法自2000年10月至2006年8月对65例颈动脉狭窄患者实施了颈动脉支架成形术。共植入支架75个,其中颈内动脉支架68个,颈总动脉支架2个,同时植入锁骨下动脉支架2个,椎动脉支架3个,4例术前安装了临时起搏器。结果65例中2例脑保护装置置放失败,63例成功。63例脑保护装置中26例可见斑块碎片,1例术中出现一过性脑缺血,1例同时置入椎动脉支架后发生椎动脉血栓形成;9例术中出现一过性低血压、心动过缓,4例术前安装临时起搏器者未发生术中低血压。5例出现术后低血压,1例术后原有神经系统症状加重。1例双颈动脉支架成形术后出现高血压。结论颈动脉支架成形术是治疗颈动脉狭窄的有效手段,在有脑保护装置的条件下,正规熟练的操作和严格的预防措施能有效提高安全性,减少并发症。     

Carotid endarterectomy: a safe cost-efficient approach.

The diagnosis-related groups have encouraged physicians to become more efficient in the care of their patients; often, however, raising the question of safety. For 3 years all patients undergoing carotid endarterectomy at our institution were monitored in the intensive care unit for 24 hours and the majority were discharged on the second postoperative day. After review of these patient's hospital records and direct patient interviews, it was clear that many patients did not require a stay in the intensive care unit and could be discharged on the first postoperative day. In January 1991 a prospective policy was established to evaluate the safety and efficacy of outpatient arteriography, same-day admission, selective use of the intensive care unit, and early discharge on the first postoperative day when feasible. During a 10-month period all patients undergoing carotid endarterectomy at our institution were evaluated (n = 52). Eleven patients had had a prior stroke (21%), 31 had either amaurosis fugax or transient ischemic attacks (60%), and 10 had no symptoms (19%). The arteriogram for 49 of the patients was obtained on an outpatient basis or during a prior admission, and these patients were admitted to the hospital on the day of operation. Nine patients were placed under general anesthesia and had shunting procedures, and 43 patients had cervical block anesthesia, eight of whom had shunting (19%). Only five patients required an intensive care unit stay for either hypertension, hypotension, or neurologic complication (one transient ischemic attack and one minor stroke). Forty-six patients (88%) were discharged on the first postoperative day; average length of stay was 1.29 days/patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

Carotid endarterectomy in high-risk patients: a challenge for endovascular procedure protocols

Background

Many studies have sought to identify certain patient population subsets that may be more appropriate for carotid angioplasty and stenting (CAS). Current CAS protocols include “high-risk” patients. The goal of this study was to compare the perioperative outcome of carotid endarterectomy (CEA) between high-risk and non-high-risk patients.

Methods

During a 54-month period, 392 consecutive CEAs were performed in 363 patients (29 bilateral) by a single surgeon and entered prospectively into a registry. A high-risk patient subset (126, 35%) was defined by the presence of a severe medical comorbidity (ie, cardiac dysfunction, pulmonary dysfunction, renal insufficiency) or particular anatomic features (ie, contralateral carotid occlusion, ipsilateral carotid restenosis after CEA, and “high” carotid bifurcation). Of the 126 CEAs, 96 (76%) were performed for symptomatic lesions. Endpoints of the study were perioperative stroke, cardiac complication, or death.

Results

Overall, there were three ischemic strokes (1%) and four cardiac complications (1%). None of the patients died. The stroke and cardiac complication rates for the high-risk and non-high-risk groups were similar (1/126, 1% versus 2/237, 1% and 3/126, 2% versus 1/237, 1%, respectively), but the cardiac morbidity rate was statistically higher in patients with severe medical comorbidity (P = .03), especially in the subset with cardiac dysfunction (P = .005).

Conclusions

CEA can be performed in high-risk patients with perioperative neurologic and cardiac complication rates comparable with those recorded in other patients. The definition of a “high-risk” patient should not be considered per se a reason to abandon CEA in favor of CAS.     

Carotid endarterectomy under regional (conductive) anesthesia.

Carotid endarterectomy is reliable in the prevention of strokes due to arteriosclerotic disease at the carotid bifurcation. This is a retrospective review of 314 carotid endarterectomies performed at the University Health Center of Pittsburgh. The objectives of the study were to determine if regional anesthesia was a safe technique for carotid endarterectomy and to determine whether the neurologic complications that occurred were embolic or ischemic in origin. In patients who were neurologically intact before operation, the perioperative mortality was 0.88% and the incidence of neurologic complications was 3.1%. This is comparable to the current literature. Observations of the awake patient suggested that half the neurologic deficits that occurred in this series were due to embolization rather than to cerebral ischemia. Further more, the incidence of non-neurologic complications under general anesthesia was 12.9%. Under regional anesthesia, the incidence of non-neurologic complications was 2.8%. The data supports carotid endarterectomy under regional block as safe and reliable method.     

Microsurgical endarterectomy under barbiturate protection: a prospective study

Carotid endarterectomy has the potential to improve on the natural history of untreated carotid artery disease with respect to subsequent infarction in symptomatic patients with causative angiographic lesions. This benefit of a reduced risk of stroke can be realized only if the perioperative morbidity and mortality rates are kept low. An approach to symptomatic carotid artery bifurcation disease is outlined, with a defined protocol of microsurgical endarterectomy utilizing barbiturate protection during the period of potential focal temporary cerebral ischemia. This protocol includes preoperative antiplatelet therapy, barbiturate anesthesia, the avoidance of an internal shunt, the use of the operating microscope, and strict control of postoperative hypertension. A series of 200 consecutive endarterectomies performed within this protocol in 180 patients and the resultant combined permanent morbidity and mortality rate of 1.5% are reported.     

颈动脉内膜剥脱术治疗动脉粥样硬化性颈内动脉闭塞症

目的 探讨颈动脉内膜剥脱术治疗颈内动脉闭塞症的疗效.方法 回顾分析2004年6月至2005年10月手术治疗的32例动脉粥样硬化性颈内动脉闭塞症的临床资料,探讨外科治疗适应证、手术要点和围手术期并发症的预防.所有患者明确颈内动脉狭窄率＞70%,术中放置颈动脉转流管和选择性应用补片修补成形,围手术期给予抗血小板药物和降纤药物治疗,双功DUPLEX超声随访.结果 本组无围手术期死亡及脑梗塞等严重合并症发生,1例患者术后出现右侧舌下神经损伤表现.术后随访5～20个月.随访期间患者无脑梗塞发生,双功DUPLEX超声检查提示颈内动脉通畅,未发现≥50%的颈内动脉术后再狭窄,2例患者发现≥50%颈内动脉扩张.结论 颈动脉内膜剥脱术是治疗动脉粥样硬化性颈内动脉闭塞症的有效而安全的手术.术中精细操作,合理应用转流管、补片,以及合理的血管开放顺序是预防围手术期并发症的关键.     

Carotid endarterectomy under local anesthesia: single institutional experience

The aim of this study is to review our experience and results of carotid endarterectomy performed under local anesthesia. We evaluated 300 patients who had undergone carotid endarterectomy with local anesthesia in our department. Surgical indication, outcome, operative technique, and complications were assessed. The patients were 58.20+/-2.76 years old and 153 (51%) were symptomatic. The perioperative course was uneventful. A shunt was inserted because of neurological deterioration in 20 patients (6.6%) with full recovery of the deficit after shunt insertion. Operative time was 52.02+/-12.86 min. There were 9 patients with postoperative neurological complications with one patient who died after 34 days. The remaining 8 patients with reversible neurological deficits recovered and were symptom-free on discharge. The mean length of hospital stay was 2.11+/-1.34 days. Carotid endarterectomy performed under local anesthesia is associated with low morbidity and mortality rates. The surgeon can assess the neurological status during the procedure and provide for a more meticulous endarterectomy. It is also associated with decreased shunt usage, decreased operative time and shorter length of hospital stay.     

Carotid endarterectomy in patients with asymptomatic intracranial aneurysm.

The patient with symptomatic extracranial carotid artery disease who, on angiography, is found to have a coexisting intracranial aneurysm presents a therapeutic dilemma. Relief of the carotid stenosis, with a potential increase in cerebral blood pressure, might increase the risk of aneurysm rupture. Conversely, repair of the aneurysm may be hazardous because of the low flow imposed by the carotid stenosis, particularly in the event of perioperative hypotension. We reviewed 19 patients treated with 20 carotid endarterectomies in the face of concurrent asymptomatic intracranial aneurysm. There were no instances of aneurysm rupture during the operation or the 30 days following operation. The literature reported to date consists of a total of 20 patients with only one incidence of aneurysm rupture in the postoperative period. We conclude that carotid endarterectomy is unlikely to precipitate rupture of an intracranial aneurysm during the operation or postoperative period.     

Carotid endarterectomy under cervical epidural anesthesia. Analysis of neurologic manifestations

Carotid endarterectomy can be complicated by neurological events due to different mechanisms. Monitoring cerebral function is difficult under general anaesthesia. By contrast, the monitoring of awareness and neurological deficit is very easy under regional anaesthesia. The aim of this study was to assess the requirement for arterial shunting during endarterectomy performed under cervical epidural anaesthesia, to analyse the neurological events and to compare the value of clinical and electroencephalographic monitoring. Sixty-four patients were included in this study. Cervical epidural anesthesia was performed with 0.375% bupivacaine and 100-150 micrograms fentanyl. In 19 high risk patients, a one-channel electroencephalographic filter processor (Cerebral function monitor, Critikon) was placed over the affected hemisphere. Before surgery, it was estimated, on angiographic and Doppler data, that 18 patients needed an arterial shunt for carotid clamping. An arterial shunt was in fact inserted during surgery in only four patients, because of cerebral ischaemia after carotid clamping. Transient obnubilation was observed during carotid clamping in three other patients; it disappeared on unclamping in two, and on increasing blood pressure in the third. An additional patient suffered from a very short loss of awareness after declamping, due to cerebral embolism. The cerebral function monitor never documented false positive results, but failed to detect one out of every five neurological events. Controlateral carotid occlusion and preoperative stroke were documented to correlate with peroperative neurological events. Cervical epidural anaesthesia, which maintains consciousness during surgery, reduced in high-risk patients the need for arterial shunting as well as that for the analysis of neurological events.