血管搭桥手术的时代过去了吗？（英文）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:Vascular replacement:Complex aneurysmsTumorsIschemiaMoya Moya diseaseAtherosclerosisHistorical use of bypass?Fukushima 1986-20061

2、00 patients, Saphenous veinAneurysm, Menigioma, carotid body, glomus, otherThree types of bypassPetrous to paraclinoidCervical external to petrousCervical external to M2Things ChangeTraditional ways no longer needed:Better Technology?Aneurysms?Better microscopeBetter clipsIntra-operative angiography

3、AnesthesiaBetter surgeons?Better surgical trainingWhat about Ischemia?Results of Bypass Studies:Bypass does not workN Engl J Med. 313 (19):1191-2000, 1985, Nov 7.714 Medical and 663 STA-MCA bypass patientsFollowed 56 monthsNo difference overall between groupsSome surgical subgroup did worse:MCA sten

4、osis, carotid occlusion with TIAAngioplasty and StentDoes new technology and information eliminate the need for traditional techniques?Gamma knife resultsPoor control with large volume tumorsRisk of vascular injury Aneurysm Coiling?UT Southwestern 2002-200695 aneurysms greater then 2.0 CM17 were tre

5、ated by primary endovascularOnly 9 (53%) completely occluded12 (71%) required re-treatmentIschemic disease:Flaws of previous bypass trialsPre operative strokes considered surgical failureSelection bias good surgical candidates not randomizedMedical failure cases did not crossNot enough power to iden

6、tify subgroups which may benefit from bypassIschemia: Need to measure at risk tissueYonas, J NSG 1993Xe CT; compared 5% vs 50% drop in flow with diamox68 patients for 24 months4.4% vs 36% stroke risk in low flow PtsGrubb, JAMA 1998PET evidence of high oxygen extraction, 31 month11/39 (28%) vs 2/42 (

7、5%) ipislateral stroke riskSTA-MCA bypass for ischemia:STA-MCA bypassSTA-MCA bypassSTA-MCA bypassSTA-MCA BypassSTA-MCA resultsJapanese EC-IC Bypass trial (JET)1st 206 patients, surgery group has significantly fewer strokesStanford study of Moya Moya patientsDecreased future risk of strokeRegression of Moya Moya collateralsCoss trialHigh risk group randomizedTraditional techniques still have role.Carotid replacementComplex aneurysmSkull based tumorIschemic diseaseMeasure blood flow to find at risk tis