颈动脉内膜切除课件

颈动脉内膜切除CEA的历史CEA循证医学证据手术治疗研究热点CEA的历史ThomasWillisDeCerebri

Anatome1621-1675Carotid&StrokecerebralclaudicationJohnRamsayHunt1872-1937HansChiari1851-1906“Itmayaddtoourknowledgeofencephalomalaciaandtheaccuracyofvascularlocalizationifthemainvesselintheneckisalsoconsidered"EarlyCarotidSurgeryMillerFisher1951，8CasesCarreaR,MolinsM,MurphyG.Surgicaltreatmentofspontaneousthrombosisoftheinternalcarotidarteryintheneck:carotid-carotidalanastomosis:reportofacase.Acta

Neurol

Latinoam.1955;1:71–78EastcottHHG,PickeringGW,RobC.Reconstructionofinternalcarotidarteryinapatientwithintermittentattacksofhemiplegia.Lancet.1954;2:994–996EarlyCEARCTCASANOVANASCETECSTACAS……Loftus&AtosCEA循证医学证据颈动脉内膜切除NASCET（theNorthAmericanSymptomaticCarotidEndarterectomyTrial）ECST（EuropeanCarotidStenosisTrial）ACAS（AsymptomaticCarotidArteryStenosisTrial）ACST(AsymptomaticCarotidStenosisTrial）颈动脉内膜切除NASCET（NorthAmericanSymptomaticCarotidEndarterectomyTrial）症状性颈内动脉狭窄重度狭窄（70-99％）可从CEA获益[2年卒中率：药物26％vs.CEA9％，绝对危险度降低17％]中度狭窄（50-69％）也可从CEA获益，特别是男性TIA和轻度卒中发作的患者。NorthAmericanSymptomaticCarotidEndarterectomyTrial.Methods,patientcharacteristics,andprogress.Stroke1991Jun;22(6):711-20Benefitofcarotidendarterectomyinpatientswithsymptomaticmoderateorseverestenosis.NorthAmericanSymptomaticCarotidEndarterectomyTrialCollaborators.NEnglJMed1998Nov12;339(20):1415-25颈动脉内膜切除ECST（EuropeanCarotidSurgeryTrial）症状性颈内动脉重度狭窄可从CEA获益[2-3年不良事件率降低12.3%vs.21.9%]Randomisedtrialofendarterectomyforrecentlysymptomaticcarotidstenosis:finalresultsoftheMRCEuropeanCarotidSurgeryTrial.Lancet1998May9;351(9113):1379-87RothwellPM,GutnikovSA,WarlowCP,etal.ReanalysisofthefinalresultsoftheEuropeanCarotidSurgeryTrial.Stroke.2003Feb;34(2):514-23.CEAMedication颈动脉内膜切除ACAS（AsymptomaticCarotidAtherosclerosisStudy）ACST（AsymptomaticCarotidStenosisTrial）无症状的颈内动脉狭窄重度狭窄（>60％）可从CEA获益[5年卒中率降低5.1%vs.11%]Endarterectomyforasymptomaticcarotidarterystenosis.ExecutiveCommitteefortheAsymptomaticCarotidAtherosclerosisStudy.JAMA1995May10;273(18):1421-1428Carotidendarterectomyforasymptomaticcarotidstenosis:asymptomaticcarotidsurgerytrial.Stroke2004Oct;35(10):2425-7主要内膜切除研究和疗效颈动脉内膜切除术已经被证实优于内科保守治疗，用于卒中的一级或二级预防，并成为颈动脉狭窄治疗的“金标准”2年卒中发作率从药物治疗的26％降低到9％（NASCET）3年卒中发作率和死亡率从26.5％降低到14.9％（ECST）5年卒中发作率从11％降低到5.1％（ACAS）手术治疗CEA适应证的选择术前患者管理抗血小板治疗控制血压控制危险因素术前侧支代偿的判断无症状重度狭窄（>70%）症状性中度以上狭窄（>50%）症状性严重溃疡斑块病变手术体位和切口高分叉颈动脉切口显露颈阔肌显露胸锁乳突肌颈静脉-面总静脉结扎面总静脉面总静脉小分支控制咽升动脉（右侧）咽升动脉ECA内斑块切除ECA缝合修复去除阻断夹的顺序缝合后多普勒检测Surgicel缝合颈动脉鞘静脉补片手术要点体位肌肉界限神经的保护转流管的使用远端斑块及内膜的处理颈动脉鞘并发症颅内出血控制血压延期清醒局部出血严密缝合耐心止血减少牵拉神经损伤减少不必要的分离低灌注缺血适当降压栓塞轻柔操作Shunt放置远端斑块及内膜的处理心肌缺血适当降压研究热点Shunt是否的判断TCD残端压力EEG全部选择快速手术转流管的选择SimpleBrenerEdwardPatch-angioplastyOcclusiveCarotid颈动脉支架成形术Wholey注册研究2003年；53个中心；11243例患者；12392例颈动脉支架技术成功率98.9%围手术期并发症：TIA发作3.07%，卒中3.34%，与手术有关的死亡率0.64%，与手术无关的死亡率0.77%,总的死亡和卒中发作率是4.75%术后1年、2年和3年再狭窄率分别是2.7%,2.6%,2.4%术后1年、2年和3年卒中复发的风险在分别是1.2%,1.3%,1.7%。WholeyMH,Al-MubarekN.Updatedreviewoftheglobalcarotidarterystentregistry.

CatheterCardiovascInterv.2003Oct;60(2):259-66目前已经完成的和正在进行的对比研究CAVATAS（EndovascularversussurgicaltreatmentinpatientswithcarotidstenosisintheCarotidandVertebralArteryTransluminalAngioplastyStudy）EVA-3S（Carotidangioplastyandstentingwithandwithoutcerebralprotection:clinicalalertfromtheEndarterectomyVersusAngioplastyinPatientsWithSymptomaticSevereCarotidStenosis）SAPPHIRE（StentingandAngioplastywithProtectioninPatientsatHighRiskforEndarterectomy）TESCAS-C（TrialofEndarterectomyvsStentingtoCarotidAtherovascularStenosis-China）CARESS（CarotidRevascularizationEndarterectomyversusStentTrial）SPACE（Stent-ProtectedPercutaneousAngioplastyoftheCarotidversusEndarterectomy;）CEAvs.CASCAS:HighCEAriskpatients[SAPPHIRE]CEA:Anytime[EVA-3S]Differentpopulation,Differentchoice[CREST,SPACE]Moreexperience,Moreefffective[……..]EverytrialisagoodexperiencetoCAS.Sundt’sGradingScaleofCarotidPatient’sRiskSundtGradeClinicalStatus%RiskINeurologicallystable;nomedicalrisk0.7IINeurologicallystable;angiographicrisk1.7IIINeurologicallystable;majormedicalrisk2.2IVNeurologicallyunstable6.4VAcutecarotidocclusion6.8VIRecurrentstenosis8.2Loftus’4High-RiskCategoriesPredicablelydifficultoperationsHighriskformedicalcomplicationsHighriskforintraoperativeischemiaHighriskforpostoperativeocclusion/stroke基本认同观点—2005CEA远期疗效肯定，再狭窄率低无需长期用药，患者依从性好手术创伤大手术可操作范围有限严重溃疡、极度狭窄病变严重钙化病变难以耐受长期抗血小板治疗患者CAS微创快捷远期疗效尚不肯定，再狭窄率相对CEA略高需长期服用抗血小板制剂价格昂贵手术难以达到的部位多发、多支病变合并其他疾病难以耐受手术的患者优点缺点适应证优点缺点适应证未来研究方向高龄患者不同危险分层患者新型药物的应用CEA+药物vs.CAS+药物CEAvs.CASvs.药物合并心脏疾病的处理更大范围的国际间、多中心合作研究国外动态AtosAlvesdeSausa1977-2003:2110CasesPreoperativeImagingMethodDuplex+MRA/Duplex+CTA:95%DSA:5%AnesthesiaGeneralAnesthesia:1330casesRegionalAnesthesia:780casesRestenosis10yrs:10%SmokingFemaleYoungIntimalFlap-DistalICArestenosisAtos-CranialInjuryCranialInjuryLiterature:3-48%NASCET:7.6%SUN:1.2-34.8%MinorandTemporaryVagousNervePossibleReasonandResolvationRetractionStretchingClampingTransectionAtos–RegionalAnesthesiaGeneralvs.RegionalRegional

2003-2003:167casesComplicationGA(%)RA(%)WoundHematoma1.53.612thnervepalsy1.60.0Infection0.70.9ParotidFistula0.10.0Total6.96.3ComplicationRAStroke1.0(0.6%)Death1.0(0.6%)Total2.0(1.2%)LoftusJapan2007JCAS:JapanCarotidAtheroslerosisStudyJapan2007InNeurologicalSurgery2003CEA2395+CAS1851=42462004CEA2662+CAS2353=50152005CEA2707+CAS2870=55772006CEA2693+CAS3803=6496