血管搭桥手术的时代ppt课件

1、Is the age of the Cerebral Bypass Gone?Jonathan White, M.D.Associate Professor of NeurosurgeryUT Southwestern Medical CenterDallas, TexasHistorical Indications For Bypass:nVascular replacement:nComplex aneurysmsnTumorsnIschemianMoya Moya diseasenAtherosclerosisHistorical use of bypass?nFukushima 198

2、6-2006n100 patients, Saphenous veinnAneurysm, Menigioma, carotid body, glomus, othernThree types of bypassnPetrous to paraclinoidnCervical external to petrousnCervical external to M2Things ChangeTraditional ways no longer needed:Better Technology?Tumors:nBetter microsurgerynMicroscopenUltrasonic asp

3、iratorTumors: Gamma KnifeAneurysms?nBetter microscopenBetter clipsnIntra-operative angiographynAnesthesianBetter surgeons?nBetter surgical trainingAneurysms: Coils and StentsWhat about Ischemia?Results of Bypass Studies:Bypass does not worknN Engl J Med. 313 (19):1191-2000, 1985, Nov 7.n714 Medical

4、and 663 STA-MCA bypass patientsnFollowed 56 monthsnNo difference overall between groupsnSome surgical subgroup did worse:nMCA stenosis, carotid occlusion with TIAAngioplasty and StentDoes new technology and information eliminate the need for traditional techniques?Gamma Knife?Gamma knife resultsnPoo

5、r control with large volume tumorsnRisk of vascular injury Aneurysm Coiling?UT Southwestern 2002-200695 aneurysms greater then 2.0 CM17 were treated by primary endovascularOnly 9 (53%) completely occluded12 (71%) required re-treatmentIschemic disease:Flaws of previous bypass trialsnPre operative str

6、okes considered surgical failurenSelection bias good surgical candidates not randomizednMedical failure cases did not crossnNot enough power to identify subgroups which may benefit from bypassIschemia: Need to measure at risk tissuenYonas, J NSG 1993nXe CT; compared 5% vs 50% drop in flow with diamo

7、xn68 patients for 24 monthsn4.4% vs 36% stroke risk in low flow PtsnGrubb, JAMA 1998nPET evidence of high oxygen extraction, 31 monthn11/39 (28%) vs 2/42 (5%) ipislateral stroke riskSTA-MCA bypass for ischemia:STA-MCA bypassSTA-MCA bypassSTA-MCA bypassSTA-MCA BypassSTA-MCA resultsnJapanese EC-IC Byp

8、ass trial (JET)n1st 206 patients, surgery group has significantly fewer strokesnStanford study of Moya Moya patientsnDecreased future risk of strokenRegression of Moya Moya collateralsnCoss trialnHigh risk group randomizedTraditional techniques still have role.nCarotid replacementnComplex aneurysmnSkull based tumornIschemic diseasenMeasure blood flow to find at r