颈动脉狭窄手术及介入治疗的围术期管理

背景 脑卒中是造成人类死亡的主要原因之一.15％～20％的缺血性脑血管病归因于颈动脉狭窄或闭塞,颈动脉内膜剥脱术(carotid endarterectomy,CEA)和颈动脉血管腔内球囊成形及支架植入术(carotid angioplasty and stenting,CAS)对预防缺血事件发生有效,但围手术期卒中、死亡等并发症对围术期管理提出挑战. 目的 对颈动脉狭窄手术及介入治疗围术期管理进行综述. 内容 重点阐述CEA和CAS围术期危险因素控制、术前评估、麻醉方法与管理、术中神经功能监测和脑保护. 趋向 积极谨慎的围术期管理是保证颈动脉狭窄患者围术期脑氧供需平衡、降低围术期并发症的有效措施.     

Intrapatient comparison of restenosis between carotid artery angioplasty with stenting and carotid endarterectomy

AIM: Comparison of restenosis in patients who underwent both carotid artery angioplasty with stenting (CAS) and contralateral carotid endarterectomy (CEA). METHODS: From our CAS data registry (1998-present) all patients with a history of contralateral CEA at any other time were selected (n = 63). Mean age was 70.6, SD = 6.8 for CAS and 68.2, SD = 6.1 for CEA and symptomatic carotid artery stenosis was present in 24% of patients pre-CAS and 40% pre-CEA. All CEAs were primary interventions, 19% of CAS were secondary to restenosis after previous ipsilateral CEA. All patients were followed up prospectively with duplex at 1 year (CAS: n = 58, CEA: n = 59), 2 years (CAS: n = 44, CEA: n = 53), 3 years (CAS: n = 27, CEA: n = 41), and every year thereafter. Within each patient we compared restenosis (>50%) between CAS and CEA procedures. RESULTS: After a follow-up of 28.7 months for CAS (SD = 16.9) and 54.4 months for CEA (SD = 39.5) the rate of = or > 50% restenosis for CAS vs CEA at 1, 2, and 3 years was 23% vs 10%; 31% vs 19%; and 34 vs 24%, respectively (log rank P = NS). CONCLUSIONS: Our intrapatient comparison of patients who underwent both CAS and contralateral CEA did not reveal significant difference in restenosis between both procedures.     

Eversion carotid endarterectomy for recurrent stenosis after carotid angioplasty/stenting

Restenosis requiring treatment after carotid angioplasty/stenting is uncommon in clinical practice. Treatment options include repeat angioplasty (with or without another stent) or carotid endarterectomy. This report describes a patient with recurrent stenosis treated with eversion carotid endarterectomy and stent removal.     

A comparison of carotid angioplasty with stenting versus endarterectomy with regional anesthesia

Introduction: Percutaneous transluminal angioplasty with stenting (PTAS) has been considered a potential alternative to carotid endarterectomy (CEA) for stroke prevention. Interventionalists have suggested that PTAS carries less anesthetic risk than CEA. The treatment of carotid stenosis with local or regional anesthesia (LRA) allows direct intraprocedural neurologic evaluation and avoids the potential risks of general anesthesia. Methods: We retrospectively analyzed the clinical charts of 377 patients who underwent 414 procedures for the elective treatment of carotid stenosis in 433 cerebral hemispheres with LRA between August 1994 and May 1997. Group I (312 hemispheres) underwent PTAS, and group II (121 hemispheres) underwent CEA. Results: The indications for treatment included the following: asymptomatic severe stenosis (n = 272; 62.8%), transient ischemic attack (TIA; n = 100; 23.1%), and prior stroke (n = 61; 14.1%). The early neurologic results for the patients in group I (n = 268) included 11 TIAs (4.1%), 23 strokes (8.6%), and 3 deaths (1.1%). The early neurologic results for the patients in group II (n = 109) included 2 TIAs (1.8%), one stroke (0.9%), and no deaths. The total stroke and death rates were 9.7% for the patients in group I and 0.9% for the patients in group II (P = .0015). The cardiopulmonary events that led to additional monitoring were evident after 96 procedures in group I (32.8%) and 21 procedures in group II (17.4%; P = .002). Conclusion: PTAS carries a higher neurologic risk and requires more monitoring than CEA in the treatment of patients with carotid artery stenosis with LRA. The proposed benefit for the use of PTAS to avoid general anesthesia cannot be justified when compared with CEA performed with LRA. (J Vasc Surg 1998;28:397-403.)     

Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial

Background: Carotid angioplasty (CA) has been suggested to be a safer and more costeffective alternative to carotid endarterectomy (CEA) in the management of symptomatic severe internal carotid artery (ICA) disease. Methods: The study was conducted as a prospective consecutive randomised trial of CEA versus CA for symptomatic severe ICA disease in a university teaching hospital. All patients were assessed before and after surgery by a neurologist. The study consisted of 23 patients with focal carotid territory symptoms and severe ICA stenosis (> 70%) who were randomized to either CEA or CA. However, only 17 had received their allocated treatment before trial suspension. CEA with patching or CA with stenting were used as interventions. The main outcome measures were death or disabling or nondisabling stroke within 30 days. Results: All 10 CEA operations proceeded without complication, but 5 of the 7 patients who underwent CA had a stroke (P=0.0034), 3 of which were disabling at 30 days. Conclusions: After referral, the Data Monitoring Committee subsequently concluded that the trial was suspended. The investigators and the Ethics Committee subsequently concluded that the trial could not be restarted - even in an amended format - primarily because of problems with informed consent. We review many of the ethical dilemmas encountered in the performance of this study. If future trials do suggest a selected role for CA, it is essential that both the inclusion and the exclusion criteria are fully documented.     

Durability of eversion carotid endarterectomy: comparison with primary closure and carotid patch angioplasty

OBJECTIVES: Despite numerous studies in which various methods for arteriotomy closure after carotid endarterectomy (CEA) have been addressed, the optimum surgical technique to reduce complications and late carotid restenosis has yet to be firmly established. The purpose of this study was to prospectively compare the results of the eversion CEA technique with those of conventional CEA with either primary closure or carotid patch angioplasty, and to determine under clinical conditions whether eversion CEA influences the results and restenosis rate.Patients and Methods: Over a 3-year period, 322 CEAs performed on 296 consecutive patients were concurrently evaluated. This study included 118 eversion CEAs, 97 CEAs with primary closure, and 107 CEAs with patch angioplasty. There were no differences in demographics, in surgical indications, or in the severity of carotid disease (not significant [NS]). The choice of CEA technique was not randomized because of technical considerations and surgeon preference. After entry into the protocol, no patients were excluded or withdrawn. Carotid restenosis was defined as a > 60% lumen reduction at the CEA site with established duplex ultrasonography criteria. RESULTS: The mean operative time for eversion CEA was 31 minutes, for CEA-primary closure it was 39 minutes, and for CEA-patch angioplasty it was 46 minutes (P <.01). The operative mortality rate for eversion CEA was 0.8% (1 patient), for CEA-primary closure it was 1.0% (1 patient), and for CEA-patch angioplasty it was 2.8% (3 patients) (NS). The postoperative stroke rate was 0.8% after eversion CEA, 1.0% after CEA-primary closure, and 2.8% after CEA-patch angioplasty (NS). The combined stroke and death rate in each group was thus 0.8% for eversion CEA (1 stroke-death), 1% for CEA with primary closure (1 stroke-death), and 5% for CEA with patch angioplasty (1 stroke-death, 2 fatal myocardial infarctions, and 2 nonfatal strokes) (NS). Transient ischemic attacks occurred in 2.5% after eversion CEA, in 5.2% after CEA-primary closure, and in 2.9% with CEA-patch angioplasty (NS). The mean clinical follow-up for all three groups was 23 months (range, 6-42 months) (NS). The restenosis rate was 1.7% after eversion CEA, 9.3% after CEA-primary closure, and 6.5% after CEA-patch angioplasty (P <.05). CONCLUSIONS: This prospective, nonrandomized clinical study indicates that eversion CEA is an effective surgical option comparable to conventional CEA with either primary arteriotomy closure or carotid patch angioplasty. No differences were found between eversion CEA and these more widely accepted CEA closure techniques with respect to operative morbidity and mortality. These data indicate, however, that eversion CEA has a lower restenosis rate than conventional CEA closure techniques and thus superior long-term durability.     

Evolution of the treatment of carotid occlusive disease: indications for carotid angioplasty and stenting versus carotid endarterectomy

Carotid endarterectomy (CEA) was established as the gold standard for treatment of carotid occlusive disease by several landmark papers published in the 1990's. Several decades of experience with CEA, however, has revealed high-risk subsets of patients in whom CEA carries increased risk of adverse events. These patients have subsequently been the focus of several randomized trials and registry databases which evaluated and proved non-inferiority of carotid angioplasty and stenting (CAS) in recent years. CAS is now considered an appropriate and equivalent alternative to CEA in these high-risk patients, defined by the presence of severe cardiac, pulmonary, or renal disease or by the presence of local factors such as prior neck radiation, prior neck operations, contralateral carotid occlusion, or surgically inaccessible lesions. Although ongoing trials in normal-risk patients may ultimately expand the indications for CAS, there is currently insufficient evidence to recommend CAS in these patients over CEA. In addition, specific subsets of patients, such as octogenarians or those with anatomic complexity, may have increased incidence of adverse events with CAS and are best served by CEA.     

Primary iliac stenting versus transluminal angioplasty with selective stenting

BACKGROUND: The preferential use of primary iliac stenting vs selective stenting is controversial. This study compares the early and late clinical outcomes of primary vs selective iliac stenting at our institution. METHODS: A total of 110 consecutive patients with iliac stenosis (149 lesions) underwent primary stenting over a recent 5-year period (primary stent group). The early technical and clinical success and late clinical outcomes were compared with 41 patients (41 iliac lesions) who had percutaneous transluminal angioplasty (PTA) followed by selective stenting for suboptimal PTA (selective stent group). All patients were evaluated clinically and by duplex scanning with ankle-brachial indexes at 1, 6, and 12 months and every 12 months thereafter. RESULTS: The perioperative complication rate for the primary stent group was 2.7% (three minor hematomas) vs 24% for the selective stent group (P < .0001). The overall early clinical success rate was 97% for the primary stent group vs 83% for the selective stent group (P = .002), however, the rate was 100% for short stenosis (A and B lesions <5 cm TASC classification) in both groups; in contrast to 93% for the primary stent group vs 46% for the selective stent group for longer stenoses (TASC - C and D lesions, P = .0003). The overall late clinical success was comparable for both groups: 88% for the primary stent group vs 80% for the selective stent group, however, this rate was superior for the longer lesions in the primary stent group, 84% vs 46% (P = .007). The primary patency rates at 1, 2, 3, and 5 years were 98%, 94%, 87%, and 77% for the primary stent group vs 83%, 78%, 69%, and 69% for the selective stent group (P = .030). These rates were comparable in both groups for shorter lesions: 100%, 98%, 98%, and 87% for the primary stent group vs 100%, 93%, 85%, and 85% for the selective stent group (P = .637). However, they were superior for the primary stent group in longer lesions: 96%, 90%, and 72% vs 46%, 46%, and 28% for the selective stent group at 1, 2, and 3 years (P < .0001). CONCLUSIONS: The overall early clinical success rate was superior for the primary stent group. However, the initial (early) and late clinical success rates were comparable for short lesions (TASC - A and B lesions), but were inferior in selective stenting for longer lesions (TASC - C and D). Therefore, primary stenting should be offered to all TASC - C and D lesions.     

No gender influences on clinical outcomes or durability of repair following carotid angioplasty with stenting and carotid endarterectomy

Introduction To determine if gender influences clinical outcomes and durability of repair after carotid angioplasty with stenting (CAS) or carotid endartercetomy (CEA), an analysis of patient records was performed.Methods This study included 89 CAS patients (47 men and 42 women) and 93 CEA patients (53 men and 40 women). Patients underwent duplex scans 6, 12, 24 months postprocedure. The outcomes of periprocedural mortality, major adverse events, strokes, and myocardial infarctions were assessed. Incidence of critical restenosis and recurrence of symptoms was also assessed.Results No significant differences were noted between men and women who had undergone either CAS or CEA (P > .05) for clinical outcomes and durability of repair. No differences for periprocedural mortality, major adverse events, critical restenosis, recurrent neurologic symptoms, and adverse event free survival were found.Conclusions These results do not indicate substantial gender influences on clinical outcomes or durability of repair following CAS and CEA.     

Percutaneous transluminal angioplasty and primary stenting of the iliac arteries in 288 patients

Purpose: This study reports the initial and late results of percutaneous transluminal angioplasty (PTA) and intravascular stenting for atherosclerotic occlusive disease of the iliac arteries.Methods: The preprocedural and postprocedural clinical records, arteriograms, segmental limb pressure measurements (ankle-brachial [ABI] and thigh-brachial [TBI] indexes), and pulse volume recordings of 288 patients who underwent PTA and primary stenting of the common iliac (354, 69.4%) and external iliac (156, 30.6%) arteries were reviewed. Initial and late clinical, hemodynamic, and angiographic success were assessed by objective criteria. Data on patients who underwent unsuccessful attempts at iliac stent placement are unavailable; results are not reported on an intent-to-treat basis.Results: Clinical follow-up data (mean, 11.9 months) are available for 268 of 288 patients (93.1%) and for 394 of 424 limbs (92.9%). The initial success rates, as determined by TBI, ABI, and clinical limb status, were 90.2%, 87.8%, and 74.6%, respectively. The Kaplan-Meier estimates of angiographic patency (101 arteries) were 96%, 81%, and 73% at 6, 12, and 24 months. Cumulative patency rates were 84%, 76%, and 57% on the basis of TBI, ABI, and clinical limb status at 24 months. Factors associated with initial success included the need for multiple stents (p = 0.0001), a higher degree of initial stenosis (p = 0.0001), lower severity of baseline ischemia (p = 0.007), younger age (p = 0.0015), and the preprocedural patency of the ipsilateral superficial femoral artery (p = 0.002). A higher degree of initial stenosis (p < 0.001) and superficial femoral artery patency (p = 0.004) were also associated with late success.Conclusions: PTA and stenting of the iliac arteries is associated with reasonable angiographic, hemodynamic, and clinical success. The outcome is favorably affected by higher initial severity of stenosis and greater extent of disease, lower severity of baseline ischemia, younger age, and by patency of the ipsilateral superficial femoral artery. (J Vasc Surg 1997;25:829-39.)     

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.     

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。     

Carotid endarterectomy and endovascular angioplasty with stenting in patients with atherosclerotic stenoses and occlusions of the internal carotid artery

The authors made a comparative assessment of carotid endarterectomy and endovascular angioplasty with stenting in patients with atherosclerotic lesions of the carotid arteries. The authors consider that indications to stenting and carotid endarterectomy are identical in patients with stenose and occlusions of the carotid arteries. Contraindications to angioplasty of carotid arteries are determined. It was shown that angioplasty and stenting in atherosclerotic lesions of the carotid arteries was an effective method with a less number of complications as compared with carotid endarterectomy and are thought to be an adequate alternative to open surgical method of treatment of patients with stenoses and occlusions of the carotid arteries.