CEA手术室篇培训

手术室中的颈动脉内膜切除术

CarotidEndarterectomy〔CEA〕国家远程卒中中心、脑防委CEA培训基地、北京市脑血管病中心外科治疗相关问题麻醉方式〔GALAtrial〕术式介绍----标准CEA〔传统CEA〕----翻转式CEA护士协作并发症的预防OperationroomteampositionduringCEA.SSurgeon,aSassistingsurgeon,Neneurophysiologist；Aanaesthesiologist；Nnurse；Mmicroscope团队配置及体位Supineposition;Headup:toreducecervicalvenouspressure;Headisplacedonaring,withasandbagundertheshoulders;Exposingthefulllengthofthesternomastoidmuscle;手术体位要求手术切口麻醉篇麻醉平稳及适时调整血压至关重要麻醉方式全麻：----Generalanaesthesiahasseveraladvantages,includingeasiersurgicalmanoeuvres,handlingofplicationsandeasierpatientmonitoring.局麻：----local/regionalanaesthesiadecreasesthenumberofmedicalplicationsattheexpenseofneurologicalplications.Generalanaesthesiaversuslocalanaesthesiaforcarotidsurgery〔GALA〕:amulticentre,randomisedcontrolledtrialMethod:aparallelgroup,multicentre,randomisedcontrolledtrialof3526patientswithsymptomaticorasymptomaticcarotidstenosisfrom95centresin24countries.----general〔n=1753〕orlocal〔n=1773〕anaesthesia;----stroke〔includingretinalinfarction〕,myocardialinfarction,ordeathbetweenrandomisationand30daysaftersurgery;Conclusion:Thetwogroupsdidnotsignificantlydifferforqualityoflife,lengthofhospitalstay,ortheprimaryouteintheprespecifiedsubgroupsofage,contralateralcarotidocclusion,andbaselinesurgicalrisk.两个组在生活质量、住院时间、预设不同年龄组的结果、双侧颈动脉闭塞和手术风险等方面均无显著差异。麻醉的不可替代性掌握术前有无心脏疾病，缺血性尤为重要术前的基础血压，要明确麻醉平稳后开始手术前的血压，记录定标临时阻断后可能需要短时升压至要求值动脉缝合完毕后需要尽快降压结合TCCD定出出室后的血压安全控制范围麻醉深度监测麻醉深度电极脑氧监测麻醉协助TCCD术前定标术中阻断后短时升压血流再通后积极降压，不建议用硝普钠术后麻醉与TCCD定控制范围麻醉机TCCD监测术中指导意义大术前麻醉平稳后定标主要参考。脑血流峰值、平均值、收缩期、舒张期•Baseline〔beforeinduction〕•Pre-clamp〔atheparininjection〕•Clamping,shuntinsertion〔ifrequired〕•Post-clamping〔15minafterclamping〕•Clamprelease•5-minpost-release•10-minpost-release术中监测手术护理篇熟悉流程能减少动脉阻断时间器械准备要求高巡回护士及时调整双极电凝阻断前静脉给肝素腔内操作持续肝素盐水冲洗术中冲洗准备两套吸引装置操作流程别离暴露动脉鞘显微操作阶段：切开剥离斑块、缝合动脉关闭动脉鞘、分层缝合。显微操作前器械显微操作前器械显微操作中器械显微操作中器械显微操作中器械术中特别注意的问题术中对血管的保护尤为重要。器械对缝合线的损伤隐患最大。无损伤器械使用。肝素盐水的高频率冲洗〔1ml含10u肝素〕。肝素：Doseof5000unitsofheparinor30u/kgbodyweightofintravenousheparin;CEA视频剪辑.mp4粥样斑块〔粥糜样物〕狭窄处的真腔缝隙狭窄真腔不稳定斑块术式标准CEA翻转式CEAStandardCEAtechnique.

PPlaque,Tsuperiorthyroidartery,LlongitudinalarteriotomyCEAtechniquewithintraluminalshunt.ISIntraluminalshunt,RrubberbandaroundtheCCA,CwindowaneurysmclipattheICA,Pplaque,TsuperiorthyroidarterySelectiveshuntingwitheversioncarotidendarterectomyModifiedEversionCarotidEndarterectomyAnnVascSurg2013;27:178–185手术涉及的解剖结构耳大神经、颈外静脉颈阔肌、胸锁乳突肌颈内静脉、面静脉颈内动脉颈总动脉颈袢、舌下神经、迷走神经、喉上神经、面神经颈阔肌Externaljugularvein:veinisligatedanddivided;Arteriabranchofthegreatauricularnerve;Greatauricularnerve〔耳大神经〕Externaljugularvein颈动脉鞘Thejugularveinisnotdissectedfree;itismerelyidentifiedandleftuntouched.触及CCA，别离方向：向头端，由CCA,ICA,ECA,superiorthyroidarteries；向上：Posteriorbellyofthedigastricmuscle〔二腹肌〕;向下：Furtherexposure:Inferiorlythemiddlethyroidvein〔甲状腺中静脉〕mayrequireligationandtheomohyoidmuscle〔肩胛舌骨肌〕;需耐心处理的：淋巴结需注意的：观察心率，必要时应用局麻药物；不要急于升压提升心率Posteriorbellyofthedigastricmuscle;Hypoglossalnerve重要标记：Thehypoglossalnerve:crossestheinternalandexternalcarotidarteries;颈袢：Ansacervicalis;调整方向及深度：Self-retainingretractor；此过程轻提血管外膜，别离过程尽量不触及分叉部或斑块处；减少斑块脱落的风险；别离是为临时阻断做准备，不要过分游离血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后关系时，则需将分叉部尽可能别离；肝素：Doseof5000unitsofheparinor30u/kgbodyweightofintravenousheparin;阻断顺序：----ThefirstclipisappliedtotheICA,thenoneeachtotheECAandthesuperiorthyroidarteryandfinallytotheCCA.〔试阻断〕----Clampswereappliedsequentiallytothesuperiorthyroidartery,themoncarotidartery,internalcarotidartery,andtheexternalcarotidartery.〔持续阻断〕----返血：分别提起ECA，ICA阻断带；或源于咽升A，使用较大的阻断夹完全阻断ECA；重要标记：Thehypoglossalnerve:crossestheinternalandexternalcarotidarteries;颈袢：Ansacervicalis;调整方向及深度：Self-retainingretractor；此过程轻提血管外膜，别离过程尽量不触及分叉部或斑块处；减少斑块脱落的风险；别离是为临时阻断做准备，不要过分游离血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后关系时，则需将分叉部尽可能别离；动脉切开：longitudinalarteriotomy

注意刀片方向：Cuttingedgeoutwardssothatoncethelumenisentered,thebladecanbedrawnoutwardstomencealongitudinalarteriotomy.技巧：切开动脉壁时：可标记切口，以确保方向；

Thearteriotomyisslightlylateraltothemidline〔fromthesurgeon’spointofvision〕;especiallyatthebifurcationitrunssome3mmlateralfromtheupperaspectofthebifurcation;Pottsanglescissors近端:thevesselispalpatedtofindatargetareaoflesserdiseasewheretheendarterectomycanbestopped;远端:thearteriotomyontheanterolateralaspectoftheinternalcarotidistakenbeyondtheseveredisease,thisbeingusuallywithin1–2centimetersofitsorigin;Dissector〔剥离子的使用〕Theinnerisathickened,irregularlongitudinallengthofatheromawiththeintimathatmaybeulceratedandcoveredwiththrombus.Theouterlayerisyellowanduniforminthickness:itisalayerofthickenedintimomedialfibersthatmaypeeloffeasilyasacircularstrip,butwhichcanalsobeleftinsituiffirmlyadherenttothewall.特殊斑块处理Careisnecessarywhendissectinghard,calcifiedplaques.Firmerattachmentstotheoutervessellayers;处置方式：Cutthroughtheplaquetothelumen,cuttingitlongitudinallyuntilthehealthyICAisreached;Theinnercoreofatheromaisgentlymobilizedalongitslengthuntilanendpointisreachedintheinternalcarotidartery;Itthinsdowntoatransparentthinlayerofintima无残渣：withoutresidualfrills.移形处的处理：cleanendpointmustbeseen；PIN；Theabsenceofanyresidualfrillsistestedbyflushingandcarefulexcision.Proximally,obtainingasatisfactoryendpointmaybemoredifficult.Distally,itisadvisabletofollowtheatheromauntilitreachesitsthinendpoint;斑块切断顺序：

----Theplaqueistransversallycutinthemostcaudalaspectofthearteriotomy.----thearteriotomyproceedscraniallystepwisealwaysafterthesegmentoftheplaqueisdissectedfree.颈外动脉斑块处理：----Atheromatouscoreextendsintotheexternalcarotidartery,usuallyfor5–10mm.----Y型切开：ICA斑块残端的处理：Techniquetosecurethedistalendoftheplaque.IncaseitisnotpossibletoremoveallremnantsofplaqueinthedistalendofICAandtheintimaisloose,tackingsuturesareused.Thestitchesarepositionedat6,9and12hours“lookingintoICAlumen〞.The4thfirmpointisthefirststitchstartingtheclosure〔at3hours〕.RPResidualplaque6/0tackingsutures缝合前的要求：----goodendpoints:allthreecarotidvessels;----Residualclotisflushedaway.Closurestarts:abovetheendarterectomyattheupperextremeoftheincision.6/0runningsuture;Beforeitspletion,theICAisshortlyopenedandflushed.Thearteryisflushedwithheparinsolution;Moreknotsareused–usually7–andtheendsofthestitchesarecutlonger,some5–6mmfromtheknots.肝素盐水冲洗：Asthesuturelineisalmostplete,furtherfloodingofthesegmentwithheparinizedsalinesolutionisundertakentoremoveanyresidualdebrisandtofillthesegmentwithfluid,removinganyairbubbles.短暂松开甲状腺上A：Theloopmaybereleasedaroundthesuperiorthyroidarterytoallowbloodtofillthesegment,flushingoutanyremainingbubbles.Theinternalcarotidarteryclampisremovedfirsttoensurethattherearenoleaks,thentheexternal.Afterthearteriotomyisclosed,theICAclipisbriefly〔1sec〕opened.TheclipsarethenremovedfromtheECA,thesuperiorthyroidarteryandtheCCA.ThelasttoremoveistheclipfromtheICA.Directdopplerometryisusedtocheckthepatencyanddiscloseanyirregularitiesinthevessels;临时阻断夹释放顺序Thearteriotomyusuallyleaksasmallamountandsometimesevenasmalljetofbloodmaybeencountered.----Addextrastitches?----Leakingarteriotomyiscoveredforsome3–5minbymuslinsoakedinwarmRingersolution;----Coveredbyasmallstripofoxycellulose;suctiondrainCarotidsheath;Closedintwolayers〔platysma,skin〕缝合后渗血的处理局部出血的观察Hemorrhage:dressing,neckswelling,withorwithouttrachealpression,andbloodcollectedinthedrainagebottleContinuedhemorrhageofgreaterthan100ml/hand/ortrachealpressionmayrequirereexploration,evacuationofthehematomaandsecu