Arko F R, Buckley C J, Lee S D, Manning L G, Patterson D E
Division of Vascular Surgery, Texas A&M University Health Science Center, Scott & White Clinic, Temple 76508, USA.
J Cardiovasc Surg (Torino). 2000 Oct;41(5):737-42.
Carotid endarterectomy (CEA) is the standard of care for patients with high-grade carotid artery stenosis who are acceptable surgical candidates. Focal occlusive lesions of the origin of aortic arch vessels can be effectively and safely treated with balloon angioplasty and primary stenting. The purpose of this study was to retrospectively review results of carotid endarterectomy for high-grade carotid bifurcation stenosis combined with intraoperative retrograde transluminal angioplasty and primary stenting of a hemodynamically significant stenosis at the origin of a proximal ipsilateral aortic arch vessel.
Between October 1994 and August 1998, 592 patients underwent CEA. Six patients were found to have hemodynamically significant tandem lesions affecting one of the aortic arch vessels and the ipsilateral ICA for an overall incidence of 1%. Age ranged from 63 to 78 years (mean 74.7). Four of 6 (67%) patients had asymptomatic lesions, and 2 of 6 (33%) had symptoms of cerebral ischemia. Five patients had tandem lesions affecting the proximal left common carotid artery and the left ICA. One patient had a tandem lesion affecting the innominate artery and the right ICA. Carotid duplex imaging and arch and cerebral arteriography was performed in all six patients. Arteriography confirmed high-grade stenoses in both the ICA and ipsilateral proximal aortic arch vessel. The range of stenoses in the ICA was 70 to 95% (mean 80.8%) measured arteriographically. The range of stenoses at the origin of the aortic arch vessels was 75-90% (mean 79.2%). All six patients underwent combined retrograde transluminal balloon angioplasty and primary stenting of the ipsilateral CCA or innominate artery with temporary occlusion of the ICA for cerebral protection. The endovascular procedure was then followed with standard surgical endarterectomy using an inline shunt.
All six procedures were successfully completed. There were no periprocedural strokes or other morbidities. Follow-up ranged from 6 to 43 months (mean 23.6) and showed no evidence of recurrent stenosis by carotid duplex imaging. No TIAs or strokes related to the surgically corrected lesions were noted during the follow-up period. One patient suffered a right hemispheric stroke secondary to a high-grade right carotid stenosis which occurred two months after her procedure surgically correcting tandem lesions on the opposite side.
Carotid endarterectomy with balloon angioplasty and primary stenting of an ipsilateral hemodynamically significant aortic arch trunk vessel stenosis can be safely and successfully accomplished and avoids the need for an intra/extrathoracic bypass procedure.
对于符合手术条件的重度颈动脉狭窄患者，颈动脉内膜切除术（CEA）是标准的治疗方法。主动脉弓血管起始部的局灶性闭塞性病变可通过球囊血管成形术和初次支架置入术进行有效且安全的治疗。本研究的目的是回顾性分析重度颈动脉分叉狭窄合并术中逆行腔内血管成形术以及对同侧近端主动脉弓血管起始部具有血流动力学意义的狭窄进行初次支架置入术的颈动脉内膜切除术的结果。
1994年10月至1998年8月期间，592例患者接受了CEA。发现6例患者存在影响主动脉弓血管之一和同侧颈内动脉（ICA）的具有血流动力学意义的串联病变，总体发生率为1%。年龄范围为63至78岁（平均74.7岁）。6例患者中有4例（67%）为无症状性病变，6例中有2例（33%）有脑缺血症状。5例患者的串联病变影响左颈总动脉近端和左ICA。1例患者的串联病变影响无名动脉和右ICA。所有6例患者均进行了颈动脉双功超声成像以及主动脉弓和脑血管造影。血管造影证实ICA和同侧近端主动脉弓血管均存在重度狭窄。血管造影测量显示，ICA的狭窄范围为70%至95%（平均80.8%）。主动脉弓血管起始部的狭窄范围为75% - 90%（平均79.2%）。所有6例患者均接受了同侧颈总动脉（CCA）或无名动脉的逆行腔内球囊血管成形术和初次支架置入术，并临时阻断ICA以保护脑功能。然后在血管内操作之后，采用内置分流器进行标准的外科内膜切除术。
所有6例手术均成功完成。围手术期无卒中或其他并发症。随访时间为6至43个月（平均23.6个月），颈动脉双功超声成像显示无再狭窄迹象。随访期间未发现与手术矫正病变相关的短暂性脑缺血发作（TIA）或卒中。1例患者在手术矫正对侧串联病变两个月后，因右侧重度颈动脉狭窄继发右半球卒中。
颈动脉内膜切除术联合球囊血管成形术以及对同侧具有血流动力学意义的主动脉弓主干血管狭窄进行初次支架置入术可安全、成功地完成，且无需进行胸内/胸外旁路手术。
