颅外段颈动脉狭窄的治疗策略

目的：探讨颅外段颈动脉粥样硬化性狭窄的治疗方法。方法回顾性分析上海中山医院血管外科2012年1～6月51例颅外段颈动脉粥样硬化性狭窄患者的临床资料,16例行颈动脉内膜剥脱术（carotid endarterectomy,CEA）,35例行颈动脉支架置入术（ carotid artery stenting ,CAS）。结果51例手术均获成功,1例CAS术后即刻脑卒中,1例CEA术后第3天短暂性脑缺血发作（transient ischemic attack,TIA）,1例CAS术后颈动脉窦压迫。全组术后随访9～15个月,平均13．6月,复查颈动脉B超,无严重再狭窄。结论根据颅外段颈动脉粥样硬化性狭窄患者的相关医学资料,对于有下列情况之一的患者我们倾向于行CEA：①6个月内1次或多次TIA,且颈动脉狭窄度≥70％;②6个月内1次或多次轻度非致残性卒中发作,症状或体征持续超过24小时且颈动脉狭窄度≥70％;③对于经颈部血管CTA和颈动脉全脑血管造影发现的颈动脉狭窄段≥2 cm。对于有下列情况之一的患者我们倾向于行CAS：①无症状性颈动脉狭窄度≥70％;②有症状性狭窄度范围50％～69％;③无症状性颈动脉狭窄度＜70％,但血管造影或其他检查提示狭窄病变处于不稳定状态。     

Current management of the patient with internal carotid artery occlusion

Despite the recent controversy concerning surgical therapy of patients with carotid artery disease, rational therapeutic plans can be developed based on available data. The patient who is symptomatic from occlusion of one or both internal carotid arteries is at particularly high risk for development of stroke and can ill-afford indecision. All symptomatic patients, therefore, with any of the extracranial occlusive disease patterns described are potential surgical candidates. Conversely, among the asymptomatic patients with these same patterns of occlusion, only those with internal carotid occlusion and contralateral stenosis should be considered for surgical therapy. Treatment must be individualised and directed at revascularising stenotic (not occluded) internal carotid arteries, or important collateral vessels such as the external carotid artery and in fewer cases the vertebral artery. The asymptomatic patient with unilateral internal carotid artery occlusion and no contralateral lesions should be monitored closely with Duplex scanning for development of a contralateral stenosis. When a stenosis of 80% or greater is encountered, strong consideration should be given to prophylactic endarterectomy in these patients due to their high risk for stroke. Endarterectomy for a 50-60% stenosis may also be reasonable in a single patent internal carotid artery. In the absence of a significant contralateral stenosis, no treatment is necessary. Individuals with internal carotid artery occlusion and symptoms referable to a contralateral carotid stenosis should also be managed with endarterectomy of the stenotic carotid artery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Subclavian artery to external carotid artery bypass with saphenous vein graft in the treatment of common carotid artery stenosis

A case of TIAs due to proximal common carotid artery stenosis which was successfully treated with autogenous saphenous vein graft between the subclavian artery and the external carotid artery is presented. A 57-year-old, right handed female was admitted to our hospital for the treatment of left common carotid artery stenosis which was pointed out at a local hospital. She had a 7-years' history of repeated transient right hemiparesis and/or left amaurosis fugax. No neurological deficit was revealed on admission. Angiography showed an 80% irregular stenosis of the left common carotid artery at its origin, hypoplastic A1-portion of the left anterior cerebral artery and hypoplasia of the left posterior communicating artery. No other stenotic lesions were disclosed in a four-vessel study. Several kinds of surgical procedures have been reported for the treatment of common carotid stenotic lesion, in accordance with the site and extension of the lesion and hemodynamic factors. To maintain a sufficient blood flow of the left internal carotid artery, we considered four different operative methods such as (1) endarterectomy of the common carotid artery, (2) subclavian to common carotid artery bypass, (3) subclavian to external carotid artery bypass and (4) subclavian to middle cerebral artery bypass. The first two operative procedures force to clamp the common carotid artery which was the only one feeding artery of the left middle cerebral artery because of poor cross flow in this case. These procedures were thought highly possibly to give rise to cerebral infarction on the left side. The fourth method needs a long graft which has higher risk of bypass occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Asymptomatic high-grade internal carotid artery stenosis: is stratification according to risk factors or duplex spectral analysis possible?

High-grade (80% to 99% diameter reduction) asymptomatic internal carotid artery stenoses are associated with an increased neurologic event rate (transient ischemic attack, stroke, asymptomatic internal carotid artery occlusion) compared to less severe asymptomatic lesions. However, many do remain free of associated events. To determine which are most dangerous, we compared risk factors and duplex scan results in two groups with asymptomatic high-grade internal carotid artery stenoses. Group A included 31 patients with 33 unoperated high-grade lesions that remained asymptomatic for at least 12 months (mean 30 months). Group B included 25 patients with 26 initially asymptomatic lesions that subsequently were associated with a neurologic event (mean time to event 7.4 months). The groups did not differ significantly in average age, sex, aspirin use, smoking, or prevalence of hypertension, diabetes, or cardiac disease. With respect to the index high-grade lesion, there was no difference in the frequency of a greater than 50% contralateral internal carotid artery stenosis or greater than 50% ipsilateral external carotid stenosis. However, on duplex scanning, high-grade stenoses with greater than 6.5 kHz end-diastolic frequencies were more frequently associated with an event than high-grade lesions with lower end-diastolic frequency (p = 0.0004). Similarly, seven of 23 lesions (30%) with end-diastolic frequency greater than 6.0 kHz were associated with subsequent internal carotid artery occlusion compared to only one of 29 (3.5%) with end-diastolic frequency less than or equal to 6.0 kHz (p = 0.025). Analysis of internal carotid artery end-diastolic frequency may help select a subgroup of patients with asymptomatic high-grade lesions who are at greatest risk for subsequent neurologic symptoms or ICA occlusion or both.     

Resection and reconstruction of the carotid bifurcation with polytetrafluoroethylene grafts; operative technique. Preliminary results in 25 procedures and indications

Although carotid endarterectomy is the standard procedure, the purpose of this paper is to describe a new surgical technique and indicate its role in the surgery of cervical cerebrovascular disease. The technique consists of resection of the pathologic carotid artery bifurcation followed by its total replacement with a bifurcated thin-wall polytetrafluoroethylene (PTFE) graft constructed by the surgeon. Prosthetic graft reconstruction of the carotid bifurcation (PGRCB) was performed in 21 patients (25 procedures) from November 1984 to May 1987. Many patients were over 70 years old. The indications for surgery were transient ischemic attacks (TIA)'s in 10 patients (high-grade stenosis), established stroke with mild deficit in 3 patients (high-grade stenosis). Eight patients (high-grade stenosis) were asymptomatic and 4 had vertebro-basilar symptoms. In 11 procedures the indications were the same as for standard carotid endarterectomy (significant stenosis and/or ulcerated plaque). In 14 cases, the procedure was justified by extensive lesions involving a long segment of the internal carotid artery (2 restenoses, 12 calcified lesions). In the perioperative period, there were no deaths and no TIA's. The 25 procedures were assessed one month postoperatively by ultrasonic imaging and venous substraction angiography. All the grafts were patent with perfect restoration of the carotid bifurcation anatomy. Systematic follow-up study was carried out in 1987. Three patients had died of non-neurologic causes and one was lost to study. The remaining 19 procedures were evaluated with an average follow-up of 19 months (range 7 to 32 months). The patients were asymptomatic and all the grafts remained patent including one stenosis (greater than 50%) at the common carotid artery anastomosis. Because recent studies have documented a much higher rate of technical defects or recurrent stenosis after carotid endarterectomy, we believe that PGRCB merits consideration, particularly in difficult endarterectomies, and in recurrent carotid stenosis. Furthermore it seems acceptable to advocate PGRCB in aneurysms of the internal carotid artery and in post-irradiation arteritis.     

The prevalence of carotid artery stenosis in patients undergoing aortic reconstruction.

BACKGROUND: Coronary artery disease occurs frequently in patients undergoing aortic reconstruction, and it has been presumed that internal carotid artery occlusive disease is also common. This has led to the practice of screening for and repairing significant carotid lesions in asymptomatic patients prior to aortic reconstruction. The purpose of this study was to determine the true prevalence of internal carotid artery disease in these patients. METHODS: The records of 240 patients who underwent duplex ultrasound screening for carotid artery disease prior to aortic reconstruction were reviewed. Surgery was performed for aortic aneurysm (AA) or aorto-iliac occlusive disease (AO). The prevalence of hyperlipidemia and coronary artery disease was similar between the two groups, but tobacco use, hypertension, and diabetes mellitus differed. RESULTS: Internal carotid artery stenosis > or = 50% occurred in 26.7% of the total group (64 of 240 cases). Stenosis > or = 50% was more common in the AO group (40 of 101 cases, 39.6%) than the AA group (24 of 139 cases, 17.3%, P = 0.0001). Severe disease (70% to 99%) was also more common in the AO group than the AA group (9.9% versus 3.6%, P = 0.0464). CONCLUSION: Internal carotid artery disease occurs commonly in patients undergoing aortic reconstruction, and screening is worthwhile. Significant disease is more common in patients with aorto-iliac occlusive disease than in those with aortic aneurysm, although atherosclerotic risk factors occur with varying frequency in the two groups. These findings suggest that additional factors may contribute to the higher prevalence of internal carotid artery stenosis in aorto-iliac occlusive disease.     

Postoperative stroke in cardiac and peripheral vascular disease.

The postoperative stroke rate in 330 patients requiring coronary artery (170) or peripheral vascular (160) surgery was compared with the presence of carotid bruits and the results of noninvasive screening (Doppler imaging and spectral analysis of flow) to determine prevalence and significance of carotid lesions) and their relationship to perioperative stroke. Carotid lesions were suspected because of bruits in 70 patients with peripheral vascular disease (PVD) and in 28 patients with coronary artery disease (CAD). Noninvasive tests showed high grade stenosis or occlusion in 62 patients with PVD and in 14 with CAD. Forty-four patients with PVD and 101 patients with CAD had normal Doppler studies. The rest in both groups had plaquing without major stenosis. Noninvasive tests uncovered severe, occult lesions in only 13 patients (9 PVD, 4 CAD). Postoperative neurologic complications occurred in 16 patients (13 strokes: 5 PVD, 8 CAD and 3 TIAs: 2 PVD, 1 CAD). Thirteen neurologic complications occurred in patients having nonstenotic plaques or normal carotids without bruits. Only three of the strokes and 1 TIA occurred in patients with bruits and detectable carotid stenosis. Few of the postoperative strokes or TIAs were focal (2 PVD, 1 CAD), and the rest were nonfocal. None of the postoperative strokes or TIAs were associated with postoperative carotid occlusion. Physical examination is not an accurate method of determining severity of carotid disease. Severe carotid stenosis is more common in PVD patients than in CAD patients, but there is no significant difference in postoperative stroke rate. No direct relationship has been found between a bruit, severity of disease, and incidence of perioperative stroke.     

Accuracy of duplex scanning in the detection of stenosis after carotid endarterectomy

The results of duplex ultrasonography in grading stenosis after carotid endarterectomy (78 sites) were compared with those of contrast angiography in 71 patients studied for recurrent or contralateral occlusive disease of the carotid bifurcation. Duplex and angiographic studies were performed within one month of each other at a mean postoperative interval of 44 months (range 3 to 122 months). Stenosis of the common carotid (CCA) and internal carotid artery (ICA) was classified into five disease categories (normal or less than 15% diameter reduction [DR], 16% to 49% DR, 50% to 75% DR, greater than 75% DR, and occlusion). The overall accuracy of duplex scanning compared with angiography in predicting recurrent carotid bifurcation disease was 83%, a level of agreement similar to classification of disease involving the nonoperated, contralateral bifurcation (overall accuracy 87%). Recurrent stenosis (greater than 50% DR) or occlusion of the CCA or ICA after endarterectomy was identified with an accuracy of 97%. Overestimation of severity of recurrent stenosis accounted for 11 of 13 duplex classification errors (85%). Presence of moderate (30% to 50% DR) recurrent stenosis of the CCA, tortuosity of the ICA, and severe contralateral carotid bifurcation disease were associated with velocity spectra that predicted a more severe recurrent stenosis at the endarterectomy site compared with angiographic grading. The level of agreement between duplex scanning and angiography was comparable to the interobserver variability in angiographic interpretation. The accuracy reported justifies the use of duplex scanning to grade the severity of carotid bifurcation recurrent stenosis and to follow these lesions for disease progression.     

Concomitant subclavian and carotid artery disease: the need for a combined surgical correction.

To determine the importance of carotid artery disease in patients undergoing revascularization of the proximal subclavian artery for a subclavian steal syndrome, an 18-year experience of 55 patients was reviewed. Concomitant carotid artery disease (> 50% stenosis) was present in 35 patients (Group I: 63.6%). Twenty patients (Group II: 36.4%) had no evidence of hemodynamically significant carotid disease. Twenty-five patients in Group I (Group IA: 71.4%) were treated by endarterectomy (CEA) for all their carotid lesions while one or both carotid lesions were left untreated in 10 patients (Group IB: 28.6%). The actuarial 5-year freedom rate from neurological events was 87.2% in Group IA, 34.9% in Group IB (p < 0.001) and 100% in Group II (Group IB vs. II, p < 0.001; Group IA vs. Group II, p = ns). All untreated carotid lesions had a deleterious effect on the early and late functional results after surgical reconstruction of the subclavian artery. We conclude that the combined correction of subclavian and carotid lesions should be recommended in every case.     

Which asymptomatic patients should undergo routine screening carotid duplex scan?

The benefits of obtaining a routine screening carotid duplex scan have not been established for patients with peripheral vascular disease but no signs or symptoms of carotid artery disease. We retrospectively reviewed all carotid duplex scans (4,000) performed at our institution between 1985 through 1989 and found for analysis 91 scans in 78 patients who underwent a screening duplex scan because of the presence of peripheral vascular disease. Patients with carotid bruits, abnormal carotid pulses, and focal or nonspecific neurologic symptoms were excluded. Thirty-three percent of these patients had carotid stenosis of 16% to 50%, 14% had carotid stenosis greater than or equal to 50%, and 5% had stenosis greater than or equal to 75%. Individual risk factors for atherosclerosis, including elderly age, coronary artery disease, hypertension, diabetes, smoking, and a recent or past history of cardiac or vascular surgery, did not predict the detection of high-grade carotid stenosis. However, all 11 of the patients with carotid stenosis greater than or equal to 50% were 68 years of age and older, and this age range, in combination with the various risk factors, increased the incidence of significant carotid artery stenosis (greater than or equal to 50%) to as high as 45%. We conclude that routine screening carotid duplex scan is indicated in elderly patients (age greater than or equal to 68 years) with peripheral vascular disease, even in the absence of any signs or symptoms of carotid artery disease, when other atherosclerotic risk factors are present.     

Simultaneous approach of internal carotid artery revascularization at the base of the skull and coronary arteries bypass without extracorporeal circulation

The best surgical approach for the treatment of patients with severe cerebral artery disease and simultaneous serious coronary artery disease remains controversial. In this report, we present a case of a 65-year-old man admitted to the hospital with unstable angina. Triple coronary artery obstructive disease and severe right internal carotid artery stenosis in the retroparotid region were diagnosed. A combined, simultaneous surgical procedure was performed. A lesion located in the retroparotid space required an approach by a presternocleidomastoid cervicotomy extended distally. Venous grafting of the internal carotid artery was performed. After carotid reconstruction, the three coronary arteries were revascularized without extracorporeal circulation. The patient showed a satisfactory postoperative outcome.     

Two successful cases of coronary artery bypass grafting followed by transluminal carotid angioplasty with stenting]

In coronary artery bypass grafting (CABG), carotid artery disease is an important factor that affects the incidence of perioperative stroke. The incidence of stroke following cardiac surgery is about 5 times higher in patients with carotid lesions than in patients without them. However, therapeutic strategies for those cases have not established in recent years. We report 2 successful cases of CABG following transluminal carotid angioplasty with stenting (TCAS) for concomitant coronary and carotid artery disease. The first case was a 71-year-old male who had left main trunk (LMT) and three-vessel coronary artery disease (CAD) and a 90% stenosis of the right internal carotid artery (ICA). One month after TCAS, triple CABG with cardiopulmonary bypass (CPB) was performed. The second case was a 75-year-old male who had LMT and single vessel CAD and a 99.9% stenosis of the lt. ICA. Considering his poor general conditions, combined strategy of off-pump CABG and PTCA was performed following TCAS. During and after cardiac surgery, they had no cerebral complications. Postoperative myocardial scintigraphy showed improved imaging in both cases. Preoperative TCAS is a safe and minimally invasive procedure for the patients with carotid artery stenosis who need CABG.     

Relationship between oxidative stress parameters and atherosclerotic signs in the carotid artery of stable renal transplant patients

Reactive oxygen species (ROS) may participate in atheroma plaque formation, which may be noninvasively diagnosed by Doppler ultrasound of carotid artery. We sought to determine the relationship between the presence of carotid artery lesions and oxidative parameters to identify factors that may influence these lesions in renal transplant patients. Fifty renal transplanted patients with stable renal function and without diabetes mellitus were studied for more than 1 year posttransplantation. Echo Doppler examination of the carotid artery was performed to assess the intimal media thickness (IMT), atheroma plaques, calcification, and stenosis. Data were collected on oxidative parameters: malondialdehyde (MDA), glutathione peroxidase (GPx), catalase, superoxide dismutase (SOD), glutathione reductase (GR), and lipid profile. The serum GPx level among patients without atheroma plaques, calcification, or stenosis was higher than in those with ultrasound signs. The LDL cholesterol fraction was lower in patients with no ultrasound signs of atherosclerotic lesions; total cholesterol values showed the same behavior. In conclusion, transplanted patients with atheromatous plaques, calcification, and carotid stenosis have a greater degree of hypercholesterolemia and lower antioxidant activity (lower GPx). Recipient age was the principal risk factor for the presence of increased IMT, atheroma plaque, calcification, and/or stenosis of carotid artery in renal transplant patients.     

Simultaneous carotid endarterectomy and coronary revascularization

BACKGROUND: Combined cardiac operation and carotid endarterectomy using our technique is an acceptable approach to simultaneous correction of both carotid and cardiac disease. METHODS: From August 1989 to March 1998, 121 consecutive patients underwent combined operations. Of these patients, 112 had coronary artery bypass grafting and carotid endarterectomy, and 9 had coronary artery bypass grafting, carotid endarterectomy, and valve repair or replacement. All patients had a critical stenosis of 85% or more of the carotid artery. Mean age of the patients was 69.2 years; 80 patients were 65 years old or older. There were 88 men and 33 women. Notable risk factors included chronic obstructive pulmonary disease (19.8%), congestive heart failure (28%), preoperative myocardial infarction and unstable angina (66.9%). Of the patients, 20.7% had a stenosis of greater than 50% of the left main coronary artery. The technique used was correction of both the carotid and coronary lesions during a single aortic cross-clamp period using retrograde continuous blood cardioplegia for myocardial protection. Systemic hypothermia to 25 degrees C was used for cerebral protection. RESULTS: Mean cross-clamp time was 118 minutes. Seven patients (5.8%) sustained perioperative cerebrovascular accidents. Two patients had transient ischemic attacks. The procedure-related mortality rate was 5.8%. CONCLUSIONS: The described technique is a good method for simultaneous repair of coronary and carotid lesions in a high-risk group of patients with concomitant disease. We will continue to use it.     

颈动脉弹性功能与冠状动脉搭桥术后血管狭窄程度的关系

目的 探讨颈动脉弹性功能与冠状动脉搭桥术(CABG)后血管狭窄程度的关系.方法 对住院行冠状动脉旁路术的男性冠心病患者,搭桥血管狭窄程度采用Gensini积分法,通过超声血管回声跟踪技术动态观察颈动脉β(血管硬化值)、Ep(血管的弹性系数)、AC(血管的顺应性)的变化.结果 共有46例(46/97)患者出现不同程度的搭桥血管狭窄,搭桥血管狭窄患者颈动脉β(12.48±2.16)、Ep(140.41±32.46)高于搭桥血管通畅患者β(9.27±2.19)、Ep(109.72±31.27),搭桥血管狭窄患者AC(0.65±0.09)低于搭桥血管通畅患者AC(0.79±0.11),2组患者间颈动脉血管弹性参数β、Ep、AC测值差异有统计学意义(P<0.05).结论 颈动脉血管弹性功能测定可评价CABG术后血管狭窄.     

A prospective evaluation of C-reactive protein in the progression of carotid artery stenosis

OBJECTIVE: Our institution previously reported an association between elevated C-reactive protein (CRP) and carotid artery stenosis. Based on this finding, we sought to further evaluate the association of CRP levels with ultrasound progression of carotid artery stenosis, and/or clinical events. METHODS: A prospective observational study of patients evaluated for carotid artery stenosis was performed at a tertiary medical center from 2003-2007. Patients underwent serial lab draws for serum CRP, as well as serial duplex ultrasounds of their carotid bifurcations. Examinations were performed at 6-month intervals. Initial risk factors and CRP levels were evaluated with univariate statistics. Ultrasound progression of disease was evaluated with Kaplan-Meier curves and Cox regression analysis. RESULTS: During the study period, 271 patients completed study requirements with a mean follow-up of 37 (+/-6) months. Initial duplex examination revealed 114 (41%) of patients had 0% to 15%, 94 (35%) had 16% to 49%, and 63 (23%) had 50% to 79% stenosis of the carotid bifurcation. Sixty-three patients (23%) demonstrated progression of disease by ultrasound examination, 27 (10%) progressed to carotid endarterectomy, and three (1%) experienced a stroke during follow-up. Mean CRP levels were higher among patients that progressed on duplex examination (6.7 +/- 1.28 vs 4.6 +/- 0.4 mg/dl, P < .05). Kaplan-Meier analysis revealed a significant difference in freedom from progression of carotid artery disease for patients with 1(st) and 3(rd) quartile CRP levels (log-rank test P < .05). Adjusting for diabetes, hyperlipidemia, hypertension, coronary artery disease, aspirin or other anti-inflammatory uses, and statin therapy, 4(th) quartile CRP was independently associated with disease progression (OR 1.8, 95% CI; 1.03-2.99, P < .05). CONCLUSIONS: High CRP levels predict ultrasound progression of disease in patients with carotid artery stenosis. In addition, CRP levels may provide additional information to help guide ultimate therapy for evaluation and follow-up of patients with borderline lesions identified by duplex exam.     

Vertebro-basilar ischaemia. Its relation to stenosis and occlusion of the vertebral artery

Summary Bilateral vertebral angiography has been performed on 44 cases of vertebrobasilar ischaemia (VB I), excluding transient ischaemic attacks, and on 20 cases of carotid ischaemia with lesions of the vertebral artery (VA). Significant lesions (stenosis of more than 50% of the lumen and occlusion) of the VA were found in 72% of VB I and 70% of carotid ischaemia cases. In the VB I group, occlusions are as frequent as stenosis (17 occlusions and 15 stenosis); on the contrary, occlusions are half as frequent as stenosis in the carotid ischaemia group. Bilateral lesions are also more often discovered after VB I than after carotid ischaemia. Topographically, the lesions are mainly at the ostium and in the third portion of the VA. The possibility that vertebro-basilar strokes are related to significant lesions of the VA in its cervical part is emphasized. Haemodynamic disorder can explain infarcts related to bilateral lesions and some of those reported after unilateral lesions. Embolism may be suggested in cases of significant stenosis and of certain unilateral occlusions.     

362例缺血性脑血管病脑血管狭窄与侧支循环特点分析

目的分析脑动脉狭窄的病变特点及侧支循环的模式,探讨脑动脉闭塞或严重狭窄时侧支循环代偿建立的情况与患者神经功能的关系。方法回顾性分析362例缺血性脑血管病患者资料,全部患者均接受DSA检查。对脑血管狭窄病变的特点及侧支循环与神经功能缺损的关系进行分析。结果 362例缺血性脑血管病患者中,334例共存在716处脑动脉狭窄病变;其中单纯颅内动脉狭窄143例（42.81%）,单纯颅外动脉狭窄84例（25.15%）,颅内、颅外动脉均存在狭窄107例（32.04%）;单纯前循环病变173例（51.80%）,单纯后循环病变58例（17.37%）,前、后循环联合病变103例（30.84%）。300处颅外动脉狭窄中,颈内动脉颅外段狭窄185处（61.67%）,椎动脉颅外段狭窄96处（32.00%）;416处颅内动脉狭窄中,大脑中动脉狭窄171处（41.11%）。脑动脉闭塞且有侧支循环的患者与无侧支循环的患者间NIHSS评分差异有统计学意义。脑梗死与TIA患者责任血管狭窄程度差异无统计学意义（P〉0.05）。结论颅外动脉狭窄好发于颈内动脉颅外段,颅内动脉狭窄好发于大脑中动脉。TIA患者发展为脑梗死的可能性大。     

The role of intravenous digital subtraction angiography in the evaluation of extracranial carotid artery disease. Can the decision for carotid artery surgery be made solely on the basis of its findings?

This retrospective study compared intravenous digital subtraction angiography (IV-DSA) with conventional catheter angiography (CA) performed on 105 patients with suspected cerebrovascular disease. Comparisons were made considering CA as the "gold standard." Factors reviewed for correlation included carotid artery stenosis, ulceration, fibromuscular disease, vessel occlusion, and subclavian and intracranial lesions. Each IV-DSA was judged as to its quality. Eighty-seven patients (83%) had interpretable IV-DSA studies. IV-DSA differed from CA regarding stenosis on 46 carotid arteries (26%). Of 47 excellent quality IV-DSA studies, 18 (38%) were in disagreement with CA regarding stenosis. For the subcategory of patients having hemodynamically significant stenosis (greater than 50% luminal narrowing) according to CA, the sensitivity of IV-DSA was 85%. Specificity was 94% with an overall accuracy rate of 92%. The authors believe these high values are somewhat misleading. The IV-DSA interpretation of stenosis differed from CA in 32 of 48 patients (67%) in this group with a mean difference of 30%. IV-DSA identified 3 of 11 intracranial lesions (27%). Surgical therapy was modified in 13 of 87 patients (15%) on the basis of angiographic interpretation of carotid artery stenosis compared with IV-DSA. We conclude that IV-DSA should be used as a screening tool and the decision for carotid artery surgery made solely on its findings should be reached with the knowledge of its limitations and that any patient with hemispheric cerebral symptoms warrants CA as the first diagnostic examination.     

Novel stent/CEA strategy for patients with bilateral carotid artery stenosis and coronary artery disease: report of 2 cases

Recently, there are increasing numbers of patients with occlusive carotid artery disease and coronary artery disease. Simultaneous or two-staged surgery for both lesions has been recommended for these patients to reduce the incidence of perioperative complications. However, therapeutic options for the patients with bilateral carotid artery stenosis and coronary artery disease have not been established. In this report, we describe two patients who successfully underwent carotid endarterectomy (CEA) and carotid artery stenting (CAS) on each carotid artery in parallel with coronary artery bypass grafts (CABG). A 49-year-old male with severe stenosis of the bilateral internal carotid artery (ICA) and heart failure underwent CAS on the right side. Next day, he successfully underwent CABG and CEA on the left side at the same time. A 62-year-old male with severe stenosis of the bilateral ICA and coronary artery disease underwent CAS on the right side and CEA on the left side with an interval of 7 days. Subsequently, CABG was performed uneventfully. No perioperative complication occurred in either patient. The results suggest that combination therapy of CAS and CEA would be a valuable option for patients with complex carotid/coronary artery diseases.