可脱性微球囊栓塞治疗外伤性颈总动脉假性动脉瘤伴动静脉瘘1例报告

外伤性颈总动脉假性动脉瘤伴动静脉瘘十分罕见。常因病程较长，瘘口周围组织粘连，难以分离解剖两端的动、静脉，手术易出血，使治疗较为棘手。本院1997年应用可脱性微球囊栓塞治疗1例此种病患者，取得良好效果。     

颈外静脉移植治疗注射毒品所致的假性股动脉瘤

目的探讨注射毒品致假性股动脉瘤的临床特点及颈外静脉移植治疗的可行性。方法2002年6月~2006年2月,对注射毒品所致的20例假性股动脉瘤行手术治疗,并移植颈外静脉重建股动脉缺损。结果所有病例均成功保存肢体,无缺血坏死及小腿骨筋膜室综合征发生。伤口一期愈合9例,余11例出现淋巴漏,二期愈合4例,再次手术行局部皮瓣转移修复7例。1例因吻合口破裂出血而结扎股动脉,1例有股神经损伤的表现。16例随访1~24个月,无复发,足背动脉可扪及搏动,10例术后血管彩超显示移植的颈外静脉通畅。结论手术是治疗注射毒品所致的假性股动脉瘤唯一有效的方法;在瘤体切除后大隐静脉往往因炎症而不能利用,移植颈外静脉修复重建股动脉缺损是可行的。     

鱼刺刺破食管及颈动脉致假性颈总动脉瘤1例的护理

对1例鱼刺扎伤咽喉部致左颈总动脉假性动脉瘤患者进行3次手术治疗,患者痊愈出院.认为术前心理护理对患者积极配合治疗,防止瘤体破裂是抢救成功的关键环节.术后重点做好颅脑症状的观察、紧急大出血的预防和处理、高位食管瘘的护理、预防菌血症的发生,促进感染瘘口的愈合以及呼吸道的管理是保证治疗成功的重要措施.     

鱼刺刺破食管及颈动脉致假性颈总动脉瘤1例的护理

对1例鱼刺扎伤咽喉部致左颈总动脉假性动脉瘤患者进行3次手术治疗，患者痊愈出院。认为术前心理护理对患者积极配合治疗，防止瘤体破裂是抢救成功的关键环节。术后重点做好颅脑症状的观察、紧急大出血的预防和处理、高位食管瘘的护理、预防菌血症的发生，促进感染瘘口的愈合以及呼吸道的管理是保证治疗成功的重要措施。     

可脱性微球囊栓塞治疗外伤性颈总动脉假性动脉瘤伴动静脉瘘1例报告

外伤性颈总动脉假性动脉瘤伴动静脉瘘十分罕见.常因病程较长,瘘口周围组织粘连,难以分离解剖两端的动、静脉,手术易出血,使治疗较为棘手.本院1997年应用可脱性微球囊栓塞治疗1例此种病患者,取得良好效果.……     

颈动脉瘤的外科治疗

目的　探讨颈动脉瘤的手术治疗方法。方法　回顾性分析探讨 2 1例颈动脉瘤 (2 4个瘤体 ) ,2 2例次的手术方法与结果。 2 4个瘤体中 ,真性动脉瘤 18例次 ,假性动脉瘤 6例次。 2例自动出院 ,19例 2 2次施行手术治疗 ,其中急诊手术 3例次。应用了自体大隐静脉、人工血管、补片修补、包裹、缝合成形等多种术式 ,3例次在手术中应用颈动脉转流管。结果　术后因出血和复发再手术 2例 ,余 17例 2 0次手术均一次成功。未发生中枢神经系统并发症 ,无手术死亡。结论　颈动脉瘤应首选手术治疗 ,手术治疗安全且效果满意。     

颅外颈动脉瘤的诊疗进展

颈动脉颅外段的动脉瘤（extracranial carotid artery aneurysms，ECAA）包括了颈总动脉、颈外动脉和颈内动脉颅外段的动脉瘤。对ECAA的描述，可以追溯到1687年的国外文献报道。     

颅外段颈动脉瘤和颈动脉扩张症29例治疗体会

1 临床资料 1986～1997年期间,治疗颅外段颈动脉瘤和颈动脉扩张症29例,其中男性11例,女性18例。发病年龄6～72岁,平均47.6岁。本组包括假性动脉瘤5例(2例为双侧,均有附壁血栓),颈动脉恶性血管内皮肉瘤1例,颈总动脉瘤2例(1例伴附壁血栓),颈外动脉瘤2例,颈内动脉瘤3例,颈动脉分叉部扩张症16例(2例为双侧,伴附壁血栓者1例)。术前伴脑神     

一期动脉瘤切除并动静脉造瘘治疗桡动脉假性动脉瘤：附25例报告

目的：探讨一期动脉瘤切除并动静脉造瘘治疗桡动脉假性动脉瘤的手术方法及其临床操作技巧。 方法：分别对25例慢性肾功能衰竭合并前臂桡动脉假性动脉瘤患者行一期动脉瘤切除、动静脉内瘘手术治疗。 结果：25例手术均成功。23例行动脉瘤切除并动静脉内瘘,其中5例行动静脉端端吻合,18例行动脉端端吻合后再行动静脉端侧吻合;2例患者单纯行瘤体近心端动静脉端侧吻合。所有患者术后3~4周 以上动静脉内瘘均能达到血液透析要求血流量。 结论：前臂形成假性动脉瘤的肾衰患者,可一期行动脉瘤切除并动静脉内瘘。     

颈外静脉修复重建股动脉的临床应用

目的 介绍应用颈外静脉移植修复重建股动脉的临床效果。方法 2002年6月～2006年4月。对22例因注射毒品所致的假性股动脉瘤手术切除后致股动脉缺损患者。应用颈外静脉移植修复晕建。其中男20例。女2例；年龄25～46岁，平均31．2岁。股动脉缺损5～9cm。平均6．8cm。左侧14例。右侧8例。结果 术后伤口Ⅰ期愈合10例，Ⅱ期愈合4例。余8例伤口裂开并溃疡形成。二次手术行局部皮瓣移位修复，创面愈合。除1例因吻合口破裂出血而最终结扎股动脉外。其余均成功重建股动脉缺损。足背动脉均可扪及搏动。18例获1～30个月随访。动脉瘤无复发。12例复查彩色多普勒显示移植的颈外静脉已动脉化，并替代原缺损股动脉。结论 颈外静脉解剖恒定且表浅。切取容易。口径接近于股动脉，可作为自体静脉移植材料修复重建股动脉。手术操作简便。疗效确切。有一定的临床府用价值。     

颈动脉外翻内膜剥脱术治疗颈动脉硬化狭窄

目的观察颈动脉外翻内膜剥脱术治疗颈动脉狭窄的疗效。方法24例颈动脉硬化狭窄患者,其中18例有慢性或一过性脑缺血症状,6例无症状;术前均行彩色超声、数字减影动脉造影(DSA)或CT和MRA扫描检查,颈动脉狭窄程度65％～95％;在颈丛麻醉下行颈动脉外翻内膜剥脱术,手术要点是于颈动脉分叉处斜形切断颈内动脉,外翻颈内动脉剥除有粥样斑块的内膜,同时从颈总动脉切口剥除颈总动脉和颈外动脉增厚的内膜。结果全组无手术死亡,术后随访3～20个月,临床症状均有不同程度改善,一过性脑缺血症状消失,4例仍有轻度慢性脑缺血症状。术后行脑部多普勒超声检查,22例脑部供血有明显改善。结论颈动脉外翻内膜剥脱术是一种安全、有效和合理的手术方式。     

Anomalous carotid vertebral anastomoses and carotid endarterectomy

A case of rare anomalous persistence of a primitive hypoglossal artery in a patient operated on for a carotid stenosis, focusing on the embryology of this vessel and the radiology and surgical management, is described.     

Symptomatic internal carotid thrombosis after carotid endarterectomy

During a study period from 1977 through 1984, 11 (0.4%) of 2651 patients who had undergone carotid endarterectomy at The Cleveland Clinic had early, symptomatic thrombosis of the internal carotid artery (ICA) and underwent urgent reoperations. With only two exceptions, neurologic deficits occurred after lucid intervals when the patients had recovered from general anesthesia and were discovered within the first 8 hours in three patients, within 8 to 24 hours in five patients, and on the second postoperative day in one patient. Surgical management consisted of thrombectomy alone in two patients, thrombectomy and vein patch angioplasty in eight patients, and thrombectomy of the external carotid artery with ligation of the ICA in a single patient in whom retrograde ICA flow could not be reestablished. Eight (73%) of the 11 patients recovered substantial neurologic function after reoperations, six of whom had complete or nearly complete resolution of their symptoms. One patient (9%) sustained a fatal hemorrhagic cerebral infarction. In a collected series of 41 patients from this study and other reports, prompt surgical treatment of thrombosis occurring after carotid endarterectomy was associated with clinical improvement in 61% of patients and appears to be the preferred approach to this catastrophic complication.     

Deterioration in carotid baroreflex during carotid endarterectomy

OBJECTIVE: Blood pressure instability after carotid endarterectomy (CEA) has been associated with a disturbance of the baroreflex control mechanism caused by the surgery in the carotid sinus region. The purpose of this study was to determine if a deterioration in carotid baroreceptors occurs during the surgery. METHOD: Heart rate (HR) and blood pressure (BP) were recorded continuously in 60 patients undergoing CEA as well as preoperatively and postoperatively at 2 days and 6 weeks. The baroreflex sensitivity was determined by cross-spectral analysis of HR and systolic blood pressure (SBP). During the surgery, three tests were used to assess the baroreflex response. The first test simulated a sudden fall in systemic blood pressure by clamping the common carotid artery. The second test simulated a rise in systemic blood pressure by applying pressure by using a rubbing action on the luminal surface of the carotid sinus region. The rub test was performed twice, once with the atheromatous plaque in situ and once when the plaque had been removed. The third test is clamp removal and restoration of blood flow through the carotid sinus. RESULTS: Carotid cross-clamping increased mean +/- standard error of the mean SBP from 117 +/- 3 mm Hg before clamping to 125 +/- 3 mm Hg (P <.05) at 30 beats after clamping. The first rub test with the plaque in situ decreased SBP from 121 +/- 3 mm Hg to 117 +/- 3 mm Hg (P <.01) at 10 beats after the rub test, indicating a functioning baroreceptor reflex. The second rub test increased SBP from 126 +/- 3 mm Hg to 128 +/- 3 mm Hg (P <.05). SBP dropped (P <.01) when unclamping suggesting a selective alteration of the baroreflex sensitivity. The baroreflex sensitivity was significantly reduced 2 days postoperatively when compared to preoperative values (P <.05). CONCLUSIONS: These findings suggest that the act of plaque removal could be associated with a partial disruption of baroreceptor mechanism in the carotid artery. This could affect type I baroreceptors.     

Management of carotid coils during routine carotid endarterectomy

BACKGROUND: A coil in the internal carotid artery (ICA), defined as a circular configuration or exaggerated S shape of the ICA, is occasionally encountered during endarterectomy for carotid bifurcation lesions. The significance of coils as an etiology for symptoms is difficult to determine. It is thought, however, that the failure to correct coils and kinks during routine carotid endarterectomy (CE) may lead to turbulence and failure of the CE. Various techniques have been discussed to repair coils. METHODS: Our technique consisted of complete dissection of the coil, routine use of a Javid shunt, standard endarterectomy, resection of the redundant ICA, re-approximation of the posterior wall of the ICA and patch angioplasty of the anterior wall. Three hundred and fifteen patients underwent CE between August, 1998 and February, 2000. Fifteen patients (4.7%) had a carotid coil that was repaired. There were ten men and five women. Mean age was 72.6+/-6.1 years. Ten patients had an asymptomatic stenosis. Four patients had lateralizing symptoms and one patient had dizziness. Fifteen patients underwent preoperative duplex scanning and 14 of these patients had MRA scans performed. All patients had a preoperative stenosis of 80-99% by duplex on the operated side. The right carotid artery was repaired in 12 patients. The left in three patients. The length of resected artery varied from 1.2-2.8 cm (1.93+/-0.49 cm). RESULTS: All patients survived surgery. One patient developed a cerebellar stroke on the third postoperative day. A postoperative carotid duplex scan demonstrated a widely patent repair. There were no cranial nerve injuries in this series. One patient died seven months after surgery from cardiac events with no follow-up duplex exam. There have been no long term strokes or anastomotic complications. Follow-up duplex scans demonstrated widely patent repairs (1-15% stenosis) in seven patients and low end 15-49% stenosis in five patients. CONCLUSIONS: Resection of redundant ICA with re-anastomosis of the posterior wall and patch reconstruction of the anterior wall gives acceptable perioperative and long term results.     

Outcome after carotid endarterectomy for asymptomatic carotid stenosis

Objective: To compare the long-term outcome in patients with asymptomatic carotid stenosis (ACS) among those treated with carotid endarterectomy (CE) or medical therapy.

Background: Until randomized trials are completed, treatment of ACS will depend on identification of subgroups likely to benefit from CE.

Methods: A retrospective cohort study was done on 215 patients with ACS: 107 underwent CE, and 108 were treated medically (MED). A neurologist reviewed medical records and performed a telephone interview to detect outcome (stroke and death). Mean follow-up was 3.8 years; only 4% were lost to follow-up.

Results: Among CE patients, there was a 4.7% risk of postoperative ipsilateral stroke within 30 days. Four of five postoperative strokes occurred among patients with prior contralateral symptoms. There was no significant difference between CE and MED in the cumulative lifetable 5-year risk of ipsilateral stroke, any stroke, or survival free of any stroke. Among diabetics, however, there were no ipsilateral strokes at 5 years after CE compared to 20% in MED (p = 0.03). Excluding postoperative complications, the 5-year risk of ipsilateral stroke was reduced among CE patients who “ever smoked” (CE 1%, MED 8%, p = 0.03) and the 5-year risk of any stroke was reduced among CE patients who had no prior myocardial infarction (CE 6%, MED 16%, p=0.02). Among those with prior contralateral carotid territory symptoms, the 5-year risk of any stroke was worse in the MED patients (CE 5% MED 32%, p=0.004). Among CE patients, a Cox proportional hazards model determined that the independent predictors of worse long-term outcome were: a history of myocardial infarction; admission systolic blood pressure greater than 160 mm Hg; and age greater than 65.

Conclusion: The approach to patients with ACS will await completion of large, randomized clinical trials, now in progress. Even if these studies are negative, there may remain specific subgroups of patients who show clear benefit from carotid endarterectomy.     

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。     

Hemodynamic effect of carotid stenting and carotid endarterectomy

BACKGROUND: Carotid angioplasty with stent placement (CAS) may offer an alternative treatment to carotid endarterectomy (CEA). However, in contrast to CEA, which has been shown to normalize impaired cerebral hemodynamics, the effects of CAS remain unclear. To investigate alterations in cerebral hemodynamics, we prospectively studied patients undergoing CAS and compared them with a group of similar patients undergoing CEA. METHODS: Twenty-three patients undergoing CAS for recently symptomatic internal carotid artery (ICA) stenosis were prospectively studied. Volume flow in the ICAs and basilar artery (BA) were measured with magnetic resonance volume flow quantification before CAS and 1 month after. The results were compared with those in 13 similar patients undergoing CEA and 40 control subjects without ICA stenosis. RESULTS: After CAS, volume flow in the ipsilateral ICA increased from 114 +/- 17 to 231 +/- 17 mL/min (P < .001), and total volume flow (ICAs plus BA) increased from 495 +/- 24 to 552 +/- 28 mL/min (P < .05). No significant changes were seen in the contralateral ICA and BA after CAS. Total volume flow and flow in the stenosed ICA normalized after CAS compared with control subjects. Volume flow values similarly improved after CEA. CONCLUSIONS: CAS results in a normalization of impaired cerebral hemodynamics, as assessed by magnetic resonance volume flow measurements. The degree of improvement is similar to that seen after CEA.     

Operative assessment of carotid endarterectomy: Internal carotid arterial back pressure, carotid arterial blood flow, and carotid arteriography.

Determination of ICA back pressure, electromagnetic measurement of internal carotid arterial blood flow, and performance of operative carotid arteriography have been assessed in a series of elective carotid endarterectomies. If ICA back pressure is used to determine the need for an internal shunt, our data suggest that a minimal pressure of 60-70 mmHg is required to insure adequacy of collateral cerebral blood flow in all patients. Internal carotid arterial blood flow was not significantly increased after endarterectomy. Although flow measurements are of some interest, their routine measurement does not appear to have significant clinical usefulness. Operative carotid arteriography is a valuable technique in identifying unsuspected technical errors at the site of endarterectomy and should be used routinely.