The appropriate use of carotid endarterectomy

FOR THE FIRST 30 YEARS AFTER CAROTID ENDARTERECTOMY WAS FIRST DEVELOPED, anecdotal evidence was used to identify patients with internal carotid artery disease for whom this procedure would be appropriate. More recently, the appropriateness of carotid endarterectomy for symptomatic patients and asymptomatic subjects has emerged from 7 randomized trials. Risk of stroke and benefit from the procedure are greatest for symptomatic patients with at least 70% stenosis of the internal carotid artery. Within this group, carotid endarterectomy is most beneficial for the following patients: otherwise healthy elderly patients, those with hemispheric transient ischemic attack, those with tandem extracranial and intracranial lesions and those without evidence of collateral vessels. Risk of perioperative stroke and death is higher in the following groups, although they still benefit: patients with widespread leukoaraiosis, those with occlusion of the contralateral internal carotid artery and those with intraluminal thrombus. Patients with 50% to 69% stenosis experience lesser benefit, and some other groups may even be harmed by carotid endarterectomy, including women and patients with transient monocular blindness only. The procedure is indicated for patients presenting with lacunar stroke and for those with a nearly occluded internal carotid artery, but the benefit is muted. Patients with less than 50% stenosis do not benefit. In the largest randomized trial of asymptomatic subjects, the perioperative risk of stroke and death was very low (1.5%), but the results indicated that a prohibitively high number of subjects (83) must be treated to prevent one stroke in 2 years. The subsequent literature reported higher perioperative risks (2.8% to 5.6%). In asymptomatic individuals nearly half of the strokes that occur may be due to heart and small-vessel disease. These limitations counter any potential benefit. Another trial is in progress and may identify subgroups of asymptomatic subjects who would benefit. Meanwhile, most individuals without symptoms fare better with medical care.     

颈动脉内膜切除术的研究现状

<正>脑卒中的高发病率及高病死率,给整个社会、家庭及个人带来的极大的痛苦和负担。在美国是继心脏病和癌症之后的第三大死亡原因,而在我国脑血管病已成为首位死因。颈动脉狭窄是脑卒中发生的重要原因之一,颈动脉内膜切除术(carotid endarterectomy,CEA)自从上世纪问世以来,已成为治疗颈动脉狭窄的"金     

Post carotid endarterectomy seizure

Post carotid endarterectomy seizure is a known clinical presentation in patients who suffer from hyperperfusion syndrome. This case focuses on the importance of identification of high risk patients for developing this syndrome and delaying their discharge from the hospital after successful carotid endarterectomy.     

颈动脉内膜切除术82例的麻醉方式

1 临床资料 2002-04/2003-10进行颈动脉内膜切除术(CEA)82(男66,女16)例,年龄48～84(平均68.6)岁,病程30 d～5 a. 临床表现为:短暂性脑缺血发作70例,头晕18例,失语12例,反应迟钝6例,记忆力减退68例,昏厥17例,脑梗死后肢体偏瘫10例;57例有高血压病史,36例有糖尿病史,23例有冠心病史. 全组术前均经颈部血管多普勒超声,数字减影确诊颈动脉狭窄,颅外段颈动脉狭窄程度参考欧洲与北美缺血性脑血管疾病协作中心经验分为三级[1]. 本组中度狭窄44%(36/82),重度狭窄56%(46/82). 手术采用气管内插管,全身麻醉39例,颈丛麻醉43例. 麻醉后,平卧位,头偏向健侧,胸锁乳突肌前缘切口,分离显露颈总动脉及其分支;静脉注射肝素5000～6000 U,10 min后阻断颈内动脉;内膜及粥样斑块切除后,仔细清理血管内表面,缝合血管,排除血管腔内空气和组织碎片后打结. 本组近期疗效良好,术后患者脑缺血症状消失或明显改善65例,症状改善、好转14例;2例出现脑梗死、偏瘫,1例术后20 h出现颈内动脉血栓形成,血管闭塞,急诊手术清除血栓,加宽补片后治愈,3例并发症患者均使用颈丛麻醉.     

South Australian carotid endarterectomy study

OBJECTIVE: To determine the operative morbidity and mortality of carotid endarterectomy in South Australia. DESIGN: This was a prospective study on consecutive patients already selected independently by their treating clinicians for carotid endarterectomy. Patients were assessed before and after the operation by independent neurologists. SETTING AND PARTICIPANTS: The study involved all patients undergoing carotid endarterectomy in South Australia in public and private hospitals over the 20-months period of the study. All vascular surgeons agreed to participate. INTERVENTION: Two hundred and thirty-nine carotid endarterectomies were performed on 223 patients, always as primary procedures. MAIN OUTCOME MEASURES: Patient characteristics, angiographic findings and indications for surgery were documented before the operation by neurologists who then carried out postoperative assessments and determined neurological status at discharge. Follow-up at six and twelve months was by letter and telephone enquiry to general practitioners or direct to patients. RESULTS: The perioperative death and stroke rate was 6.3% including one stroke after angiography and before endarterectomy. Fourteen patients (5.9%) had strokes after the operation and three died as a result (1.3%). Three patients had reversible ischaemic neurological deficits. In 58 asymptomatic patients, operative morbidity was 3.4%. However, in 42 patients who had had a stroke before the operation, there were seven who had operative complications (16.7%). Neurological complication rates for individual surgeons varied from 0 to 13.8%. In the subsequent 12 months, follow-up of 214 patients revealed nine additional deaths (three known to be caused by stroke, four not caused by stroke and two of unknown cause) and six more cerebral infarctions (involving both operated and unoperated sides), an annual mortality plus stroke morbidity rate of 4.2%-5.1%. CONCLUSIONS: The morbidity and mortality of carotid endarterectomy in South Australia is acceptable by world standards but is high in the subgroup with a preceding stroke. In this audit, carotid endarterectomy had an average risk at least equal to one year of untreated carotid artery disease and did not diminish the expected stroke and death incidence after one year.     

颈动脉内膜剥脱术在颈内动脉完全闭塞患者治疗中的应用

目的总结颈动脉内膜剥脱术（CEA）治疗颈内动脉完全闭塞的经验。方法25例颈内动脉完全闭塞患者行CEA,术中切除标本送病理,术后定期复查,长期随访。结果术中即时成功率为88％;术后30d内无死亡病例;7例出现并发症,经治疗均好转;术后平均随访9个月,20例手术后颈动脉通畅患者症状均有不同程度改善,余5例颈动脉闭塞患者症状无明显改善或加重。结论CEA治疗颈内动脉完全闭塞安全有效,能够改善脑缺血引起的症状和预防缺血性脑卒中。     

颈动脉内膜切除术的麻醉管理

目的:探讨颈动脉内膜切除术(CEA)的麻醉管理.方法:回顾分析了26例CEA的麻醉管理.其中男25例,女1例,平均年龄(68.3±13.2)岁.结果:所有患者均采用全身麻醉复合颈丛阻滞.颈动脉阻断期间,应用血管活性药物将血压维持在较基础值高10%～20%的水平.平均阻断时间为(24.4±7.1) min,苏醒时间(7.1±2.2) min.术后除1例发生缺血再灌注损伤外(经处理后痊愈),没有1例发生麻醉相关并发症.结论:全身麻醉复合颈丛阻滞可安全用于CEA术.     

颈动脉内膜剥脱术治疗颈动脉硬化狭窄疗效评价

目的 观察颈动脉内膜剥脱术(CAE)治疗颈动脉硬化狭窄的疗效.方法 42例颈动脉硬化狭窄,其中有慢性脑缺血症状7例,一过性脑缺血症状(TIA)23例,12例无症状;术前均行彩色超声波显像、DSA动脉造影或CT和MRA扫描检查,颈动脉狭窄程度65%～95%;在颈丛麻醉或全麻下行CAE,术中置放动脉转流管14例;手术方法:经典颈动脉内膜剥脱术18例和外翻颈动脉内膜剥脱术24例.结果 术后随访3～20个月,临床症状均有不同程度改善;TIA症状消失,5例仍有轻度慢性脑缺血症状,1例手术后4天出现脑栓塞,经治疗后症状缓解;36例脑部供血有明显改善.结论 CAE是治疗颈动脉硬化狭窄的一种安全、有效的手术方式.     

颈动脉内膜切除术治疗症状性颈动脉狭窄40例总结

目的探讨应用颈动脉内膜切除术（CEA）治疗症状性颈动脉狭窄的早期疗效和体会。方法 40例症状性颈动脉狭窄行CEA手术的患者纳入本研究。所有病例均具有脑缺血的临床症状。全组均经颈部彩色多普勒成像、经颅多普勒超声初期筛查检出,9例、3例、28例分别应用增强磁共振血管成像、CT血管造影、数字减影血管造影确诊为颈动脉粥样斑块形成并颈动脉狭窄。40例颅外段颈动脉狭窄程度均≥70%,其中合并溃疡病变5例,一侧颈内动脉狭窄伴另一侧颈内动脉完全闭塞1例。患者全部行全身麻醉联合颈丛神经阻滞麻醉。术中全部放置动脉临时分流管,行颈动脉血管补片成形术32例。结果全组围手术期无死亡病例,脑缺血症状明显改善31例（77.5%）,症状好转9例（22.5%）。术后并发高灌注综合征1例,血流动力学不稳定1例。症状性颈动脉狭窄围手术期并发症5.0%（符合美国AHA≤6%的标准）。40例均获随访,在术后6周及3个月复查双侧颈部血管超声,无1例血管再狭窄发生。结论 CEA是治疗症状性颈动脉狭窄安全且有效的方法。     

Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy

Context  Little is known about how clinical practice is affected by disseminating results of clinical trials prior to publication in peer-reviewed journals. Objective  To determine whether prepublication release of carotid endarterectomy (CEA) trial results via National Institutes of Health Clinical Alerts was associated with prompt changes in patient care that were consistent with the new medical evidence. Design, Setting, and Patients  Longitudinal data series analysis using acute care hospital discharge data from the Healthcare Cost and Utilization Project for patients who had CEA performed in acute care hospitals in 7 states (New York, California, Pennsylvania, Florida, Colorado, Illinois, and Wisconsin). The trials were the North American Symptomatic Carotid Endarterectomy Trial (NASCET clinical alert released February 1991) and the Asymptomatic Carotid Atherosclerosis Study (ACAS clinical alert released September 1994). Main Outcome Measure  Carotid endarterectomy rate during each month from 1989 (2 years before the NASCET clinical alert) to 1996 (2 years after the ACAS clinical alert), adjusted for age and sex. Because both trials were limited to patients 80 years or younger in hospitals with low mortality, we also stratified CEA rates by patient age and hospital mortality rate. Results  From 1989 through 1996, 272,849 CEAs were performed in the acute care hospitals in these 7 states, with the annual number increasing from 22,300 to 51,495. After the NASCET clinical alert, the adjusted CEA rate increased 3.4% per month (95% confidence interval [CI], 1.6%-5.3%) during the following 6 months and then increased 0.5% per month (95% CI, 0.2%-0.8%; P<.04) after journal publication of the NASCET study. After the ACAS clinical alert, the CEA rate increased 7.3% per month (95% CI, 6.0%-8.5%) during the following 7 months and then decreased by 0.44% per month (95% CI, -0.86% to -0.0002%; P<.04) after journal publication of the ACAS study. After the ACAS clinical alert, the CEA rate increased more in patients aged 80 years or older than in younger patients; whereas, after journal publication of ACAS, the CEA rate decreased more rapidly in the older population. The overall proportion of CEAs performed in low-mortality hospitals did not change substantially after release of the clinical alerts or after journal publication. Conclusion  In this study, prepublication dissemination of CEA trial results with clinical alerts was associated with prompt and substantial changes in medical practice, but the observed changes suggest that the results were extrapolated to patients and settings not directly supported by the trials.      

The problem of recurrent stenosis following carotid endarterectomy.

From 1977 to 1985, 306 consecutive patients underwent carotid endarterectomy by a single surgeon. The post-operative stroke and death rates were 1.3% and 2.6%. Of the 184 patients with follow-up duplex scanning, 24 (13%) had a recurrent stenosis of 50% or greater. Of 15 possible risk factors studied to assess a possible relationship with recurrent stenosis, four were definitely associated and a fifth probably implicated. The four definitely associated risk factors for recurrent stenosis were an age of 70 years or older (p = 0.0025), female gender (p = 0.0001), ulcerated lesions (p = 0.013), and asymptomatic lesions (p = 0.041). The fifth risk factor that may play a role (though not reaching statistical significance) was combined carotid endarterectomy and myocardial revascularization (p = 0.066). In these patients, we recommend using vein patch angioplasty to reduce the recurrence rate.     

颈动脉内膜剥脱术治疗颈动脉硬化狭窄的回顾性分析

目的:评价颈动脉内膜剥脱术(CEA)治疗颅外颈动脉硬化狭窄(CAS)的临床效果及并发症。方法:回顾性分析2016年1月～2019年4月弋矶山医院血管外科收治的7例行CEA的中重度颈动脉狭窄患者的临床资料。术中均未使用颈动脉转流管,其中行经典CEA的患者5例,外翻CEA的患者2例。结果:有1例患者术后出现伤口血肿,经切口引流,伤口加压治疗后痊愈。无感染、脑梗死及死亡病例。术前有头昏头痛、短暂性脑缺血发作的患者术后相关的临床症状均有明显改善,甚至完全消失。结论:CAS通过行CEA临床效果良好,虽手术存在严重的如脑梗死等并发症发生的可能性,但可通过手术细节的精准控制做到手术风险可控,是治疗颅外CAS的有效手段。     

Endogenous endophthalmitis following ipsilateral carotid endarterectomy

We report a case involving a 75-year-old lady who presented to our department of ophthalmology complaining of a 1 day history of ocular pain and reduced vision in the right eye, associated with rigors and diarrhoea. This patient, who had undergone a right carotid endarterectomy (CEA) 4 days previously, was subsequently confirmed to have developed endogenous endophthalmitis. To our knowledge, endogenous endopthalmitis has not previously been described as a postoperative complication of CEA, and should be considered in patients presenting with ocular complaints after this type of surgery.