颈动脉狭窄的外科治疗

目的:探讨颈动脉狭窄的外科治疗方法.方法:根据狭窄的部位和程度对82例颅外颈动脉狭窄患者采取不同的手术方法,其中颈动脉内膜切除术65例,颈动脉支架成形术10例.结果:手术均获成功,但颈动脉内膜切除术的术后并发症发生率最低.结论:颈动脉内膜切除术仍然是治疗颅外颈动脉狭窄的主要方法,而颈动脉支架成形术则可以解决颈动脉内膜切除术无法到达部位的狭窄.     

颈动脉内膜剥除术及支架成形术治疗颈动脉狭窄的相关研究

目的：探讨颈动脉内膜切除术及颈动脉支架成形术在治疗颈动脉狭窄中的应用，并对此两种术式的适应证进行讨论。方法：根据狭窄的部位和程度对121例颅外颈动脉狭窄病人采取不同的手术方法；其中104例为颈动脉内膜切除术．17例为颈动脉支架成形术。分析其治疗结果及并发症发生的原因。结果：手术均获成功，但颈动脉内膜切除术术后严重并发症的发生率较支架成形术为低。结论：颈动脉内膜切除术仍然是治疗颅外颈动脉狭窄的主要方法．而颈动脉支架成形术则可应用于颈动脉内膜切除术无法到达的狭窄部位。     

显微颈动脉内膜切除术治疗颈动脉狭窄和闭塞

目的:探讨颈动脉内膜切除术治疗颈动脉粥样硬化性狭窄和闭塞的疗效.方法2005年8月至2008年11月16例患者均经彩色超声、磁共振血管成像(MRA)、CTA、数字减影血管造影证实为中重度颈动脉狭窄,14例狭窄率为60%～99%,2例完全闭塞;12例行标准颈动脉内膜切除术,4例行外翻式颈动脉内膜切除术;2例术中放置转流管;1例术中行补片成形术.所有手术均借助显微镜完成.结果:围手术期及术后随访无卒中、短暂性脑缺血及死亡病例.术后均经彩色超声、MRA检查证实颈内动脉血流通畅,术后原症状改善或消失.1例并发消化道出血,1例围手术期有声嘶、呛水,对症治疗后症状消失,余均无并发症.结论:颈动脉内膜切除术是治疗颈动脉狭窄的有效方法,采用不同术式及技术,对不同颈动脉病变可以达到最佳治疗效果;显微手术有助于高位分叉颈动脉的显露,能有效避免颅神经损伤及其他并发症.     

颅外颈动脉硬化性狭窄手术方法的选择

对治疗颅外颈动脉硬化性狭窄的两种方法,即颈动脉内膜切除术和颈动脉支架成形术进行了比较,认为两种方法的互补可使颅外颈动脉硬化性狭窄的手术治疗提高到新的水平。     

颈动脉内膜切除术治疗颅外颈内动脉重度狭窄的疗效

目的评价颈动脉内膜切除术治疗颅外颈内动脉重度狭窄的近远期疗效.方法20例患者接受21例侧颈动脉内膜切除术.其中缺血性卒中者7例,短暂性脑缺血者11例,无神经系统症状者2例.所有患者均行术前颈动脉Duplex超声检查,19例同时行DSA检查,18例行MRA检查.21侧手术的颈内动脉中,19侧狭窄≥70%,2侧狭窄60%～69%伴斑块溃疡.手术均采取颈丛麻醉,术中选择性地应用转流管和补片缝合.术后定期行超声检查和随访.结果术后30d内无死亡和卒中.围手术期有1例短暂性脑缺血发作和2例术后颅神经损伤.20例患者随访1～63个月,平均(31±20)个月.术后2年生存率和卒中发生率分别为92.3%和0,5年生存率和卒中发生率分别为79.1%和12.5%.2例随访中超声检查发现手术侧颈内动脉50%～60%的再狭窄.结论本组病例中,颈动脉内膜切除术治疗颅外颈内动脉重度狭窄取得了满意的围手术期结果和较好的预防卒中的远期疗效.     

国家级医学继续教育项目第七期颈动脉硬化狭窄外科治疗及进展学习班第二轮通知

国家级继续医学教育项目“第七期颈动脉硬化狭窄外科治疗及进展学习班”将于2010年9月15日-9月18日在复旦大学附属华山医院举办。本次学习班将安排国内知名专家教授系统讲解颈动脉硬化狭窄外科治疗的应用解剖、流行病学研究、影像学检查、不同颈动脉内膜切除术的手术技巧、术中监护、围手术期处理、并发症防治、颈动脉狭窄的腔内治疗等专题;进行应用转流管及血管补片的颈动脉内膜切除术及外翻式颈动脉内膜切除术手术演示;进行不同脑保护装置下颈动脉支架成型术的手术演示。     

外翻式颈动脉内膜剥脱术在颅外颈动脉狭窄治疗中的应用

颈动脉内膜剥脱术（CEA）已有50多年的历史，是治疗颅外颈动脉狭窄安全、有效的方法，其手术方法也在不断改进。作者于2002年10月-2003年10月在法国冈城大学医疗中心研修期间参加了56例外翻式颈动脉内膜剥脱术（ECEA），现报道如下。     

颅外颈动脉狭窄的支架成形术治疗

颈动脉狭窄是引起中风从而致残甚至死亡的主要原因。颈动脉内膜切除术(CEA)是公认的标准术式，但近年国内、外学者越来越多地将颈动脉支架成形术(carotid angioplasty and stenting，CAS)应用于颅外颈动脉狭窄的治疗。1980年，Kerber等首先报道应用腔内球囊扩张术治疗颈动脉狭窄。以后     

颈动脉狭窄的外科手术治疗

目的探讨颈动脉内膜切除术(CEA)治疗颈动脉狭窄的疗效。方法对2001年1月—2011年5月90例颈动脉狭窄患者行颈动脉内膜切除术93次,其中男78例,女15例;年龄50～78(平均65.6岁)。术前有短暂性脑缺血发作62例(TIA),31例术前患过脑梗死。所有患者术前均行脑血管造影和\或CTA明确颈动脉狭窄,狭窄程度均>80%。对侧颈动脉狭窄或闭塞者22例。结果 90例术后临床症状改善,包括TIA消失,记忆力明显好转,语言障碍恢复等。术后80例获得随访1～36个月。15例发现有手术部位再狭窄,狭窄率小于25%,其中1例脑卒中,1例TIA保守治疗好转。其余13例无临床症状。结论颈动脉内膜切除术是治疗颈动脉狭窄的安全、有效的方法。     

改良式颈动脉内膜剥脱术对重度颈动脉狭窄的早期疗效分析

目的评价在传统的颈动脉内膜剥脱术基础上进行术式改良的改良式颈动脉内膜剥脱术治疗重度颈动脉狭窄的疗效以及早期结局。方法回顾性分析2018年3月至2019年4月南方医院血管外科采用改良式颈动脉内膜剥脱术治疗7例重度颈动脉狭窄患者的临床资料。结果共行7次改良式颈动脉内膜剥脱术,手术均获得成功,颈动脉平均阻断时间为(14.1±4.4)min。术后发生轻症脑梗死1例,未发生切口血肿、颅神经损伤、颅脑高灌注、心肌梗死或死亡。术后改良Rankin量表评分0分1例,1分6例,结果较术前有所改善(t=2.500,P0.05)。结论改良式颈动脉内膜剥脱术能避免颈内动脉因血管缝合导致的管腔丢失,保证术后通畅率,术后并发症发生无明显升高,但仍需大样本和远期随访进行验证。     

Carotid endarterectomy in chronic renal failure patients: report of two cases

Chronic renal failure is one of the risk factors for carotid atherosclerosis. We report two cases of stenosis of the carotid bifurcation treated by carotid endarterectomy. A 66-year-old man with a 17-year history of hemodialysis experienced repeated episodes of right hemiparesis. Cerebral angiography showed severe stenosis of the cervical carotid bifurcation bilaterally. Left and right carotid endarterectomy operations were performed one month apart. The postoperative course was uneventful, and the patient returned home without neurological symptoms. The second case was in a 49-year-old woman with a 15-year history of hemodialysis had vertigo of one month duration. Cerebral angiography revealed occlusion of the left subclavian artery, and the distal left axillary artery was filled by retrograde flow from the left vertebral artery. Stenosis of the right carotid bifurcation was also noted. Right carotid endarterectomy was performed without any complications. Although a high incidence of intraoperative complications and of recurrent stroke after carotid endarterectomy (CEA) has been reported in chronic renal failure patients, the poor prognosis of the natural history of severe carotid stenosis in chronic renal failure should be taken into consideration. The cases reported indicate that carotid endarterectomy is safe and justified for carotid stenosis in chronic renal failure patients.     

Reoperation for carotid stenosis is as safe as primary carotid endarterectomy.

PURPOSE: Patients with recurrent carotid artery stenosis are sometimes referred for carotid angioplasty and stenting because of reports that carotid reoperation has a higher complication rate than primary carotid endarterectomy. The purpose of this study was to determine whether a difference exists between outcomes of primary carotid endarterectomy and reoperative carotid surgery. METHODS: Medical records were reviewed for all carotid operations performed from September 1993 through March 1998 by vascular surgery faculty at a single academic center. The results of primary carotid endarterectomy and operation for recurrent carotid stenosis were compared. RESULTS: A total of 390 operations were performed on 352 patients. Indications for primary carotid endarterectomy (n = 350) were asymptomatic high-grade stenosis in 42% of the cases, amaurosis fugax and transient ischemic symptoms in 35%, global symptoms in 14%, and previous stroke in 9%. Indications for reoperative carotid surgery (n = 40) were symptomatic recurrent lesions in 50% of the cases and progressive high-grade asymptomatic stenoses in 50%. The results of primary carotid endarterectomy were no postoperative deaths, an overall stroke rate of 1.1% (three postoperative strokes, one preoperative stroke after angiography), and no permanent cranial nerve deficits. The results of operations for recurrent carotid stenosis were no postoperative deaths, no postoperative strokes, and no permanent cranial nerve deficits. In the primary carotid endarterectomy group, the mean hospital length of stay was 2.6 +/- 1. 1 days and the mean hospital cost was $9700. In the reoperative group, the mean length of stay was 2.6 +/- 1.5 days and the mean cost was $13,700. The higher cost of redo surgery is accounted for by a higher preoperative cerebral angiography rate (90%) in redo cases as compared with primary endarterectomy (40%). CONCLUSION: In this series of 390 carotid operations, the procedure-related stroke/death rate was 0.8%. There were no differences between the stroke-death rates after primary carotid endarterectomy and operation for recurrent carotid stenosis. Operation for recurrent carotid stenosis is as safe and effective as primary carotid endarterectomy and should continue to be standard treatment.     

Reconstructive vascular surgery in stenosis and kinking of the internal carotid artery

Combination of stenosis and kinking of the internal carotid artery was revealed in 7.9% of 126 patients who underwent operation for stenosis of the bifurcation of the carotid artery. Among 9 patients with kinking of the internal carotid artery (ICA) 5 had a C-shaped kink, 2 - an S-shaped kink, and 2 patients looping of the artery. The combination led to a great measure to diminished volumetric cerebral blood flow (30-35 ml/min/g). The operations were performed under conduction anesthesia. Average time of ICA compression - 13 min. 26 sec. Retrograde pressure ranged from 42 to 88 mm Hg. In 2 cases the ICA was implanted into a new opening in the common carotid artery after eversion endarterectomy. The defect in the bifurcation was sutured. In 5 cases (4 with a C-shaped kink and 1 with an S-shaped kink) the artery was replanted into the former opening after eversion endarterectomy and resection of the kinked segment of the ICA. In 2 patients with looping of the artery the loop was resected with end to end anastomosis into the ICA and typical endarterectomy from the bifurcation of the carotid artery. There were no fatal outcomes. The results of operative treatment were good.     

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。     

Carotid surgery following previous carotid endarterectomy is safe and effective

With the perceived high risk of repeat carotid surgery, carotid angioplasty and stenting have been advocated recently as the preferred treatment of recurrent carotid disease following carotid endarterectomy. An experience with the operative treatment of recurrent carotid disease to document the risks and benefits of this procedure is presented. A review of a prospectively acquired vascular registry over a 10-year period (Jan. 1990-Jan. 2000) was undertaken to identify patients undergoing repeat carotid surgery following previous carotid endarterectomy. All patients were treated with repeat carotid endarterectomy, carotid interposition graft, or subclavian-carotid bypass. The perioperative stroke and death rate, operative complications, life-table freedom from stroke, and rates of recurrent stenosis were documented. During the study period 56 patients underwent repeat carotid surgery, comprising 6% of all carotid operations during this period. The indication for operation was symptomatic disease recurrence in 41 cases (73%) and asymptomatic recurrent stenosis >/=80% in 15 cases (27%). The average interval from the prior carotid endarterectomy to the repeat operation was 78 months (range 3 weeks-297 months). The operations performed included repeat carotid endarterectomy with patch angioplasty in 31 cases (55%), interposition grafts in 19 cases (34%), and subclavian-carotid bypass in 6 cases (11%). There were three perioperative strokes with one resulting in death for a perioperative stroke and death rate of 5.4%. One minor transient cranial nerve (CN IX) injury occurred. Mean follow-up was 29 months (range, 1-116 months). Life-table freedom from stroke was 95% at 1 year and 90% at 5 years. Recurrent stenosis (>/=80%) developed in three patients (5.4%) during follow-up, including one internal carotid artery occlusion. Two patients (3.6%) underwent repeat surgery. Repeat surgery for recurrent cerebrovascular disease following carotid endarterectomy is safe and provides durable freedom from stroke. Most patients are candidates for repeat endarterectomy with patching, but interposition grafting is often required. These results strongly support the continued role of repeat carotid surgery in the treatment of recurrent carotid disease.     

症状性颈动脉狭窄82例的外科治疗

目的回顾应用颈动脉内膜切除术 (CEA)治疗症状性颈动脉狭窄的早期效果和经验。方法对 82例症状性颈动脉狭窄患者行CEA手术。全组均经颈部血管多普勒超声 ,数字减影(DSA)确诊颈动脉粥样斑块形成 ,颈动脉狭窄。手术采用全身麻醉 39例 ,颈丛麻醉 4 3例。术中放置动脉临时转流管 5 6例。结果全组无死亡病例。随访 76例 ,随访时间 4～ 18个月 ,平均 12 4个月 ,短暂性脑缺血发作 (TIA)消失、头晕、昏厥症状明显改善者 5 7例 ,反应好转 ,肢体肌力提高Ⅰ～Ⅱ级者 14例。术后并发脑梗塞 2例 ,颈动脉内血栓形成 1例。结论CEA是治疗症状性颈动脉狭窄的有效方法。     

Coexisting carotid stenosis in patients undergoing cardiac surgery: indications and guidelines for simultaneous operations

The coexistence of critical carotid stenosis with coronary artery or valvular heart disease occurs in a small percentage of patients requiring open heart surgical procedures. Recognition of such combined lesions by noninvasive carotid testing identifies patients at risk for neurologic events. Our experience with 62 patients having combined simultaneous carotid and cardiac operations among 2,400 open heart surgery patients was compared with the results in 110 patients with only carotid endarterectomy operations. The outcomes indicated that carotid endarterectomy can be performed simultaneously with open heart surgical procedures with morbidity and mortality rates similar to those of isolated cervical artery operations. Thus, patients with significant coexisting carotid artery disease defined with specific criteria and coronary artery disease need not be exposed to cerebral ischemic events or to myocardial infarctions that often accompany staged operations.     

Stenosis of one carotid artery with occlusion of the contralateral carotid

Summary 23 patients with unilateral internal carotid artery stenosis (>70%) and contralateral internal carotid artery occlusion in the neck are reported. The symptoms are referable to the side of the occlusion in 13 cases (57%), to the side of stenosis in 7 cases (30%) and non-localizing in 3 cases (13%). All 23 patients had a carotid endarterectomy performed on the side of the stenotic lesion. There was no operative mortality. Late neurological symptomatology after surgery was referable to the side of stenosis in 13% and to the side of occlusion in 9%. The authors consider that, in cases of significant stenosis (greater than 70%) of an internal carotid artery with a contralateral occlusion, preference should always be given to endarterectomy of the stenotic side, reserving extra-intracranial by-pass of the occluded side for patients who remain symptomatic after endarterectomy of the stenotic side.