Durand Daniel J, Perler Bruce A, Roseborough Glen S, Grega Maura A, Borowicz Louis M, Baumgartner William A, Yuh David D
Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins University, Baltimore, Maryland 21287, USA.
Ann Thorac Surg. 2004 Jul;78(1):159-66; discussion 159-66. doi: 10.1016/j.athoracsur.2004.02.024.
Extracranial internal carotid artery stenosis is a risk factor for perioperative stroke in coronary artery bypass (CAB) surgery. Although both selective and nonselective methods of preoperative carotid screening have been advocated, it is unclear which approach is most clinically efficacious.
Hospital records for 1421 consecutive CAB patients from January 2000 through April 2002 were reviewed. Univariate and multivariate analyses were performed across selected parameters to identify risk factors for significant carotid stenosis (> or = 70%). Patients were retrospectively stratified into high- or low-risk groups based on risk factors common to carotid stenosis and perioperative stroke. The prevalence of carotid stenosis, surgical management, and perioperative stroke rates were determined for each group.
One-thousand one-hundred thirty-eight patients out of 1421 patients (80.1%) underwent preoperative carotid screening. The prevalence of significant carotid stenosis was 13.4%. Univariate risk factors for stenosis included an age of more than 65 years, peripheral vascular disease, prior cerebrovascular accident, history of cerebrovascular disease, left main coronary disease, carotid bruit, female gender, and hypertension. Carotid stenosis was a risk factor for stroke, neurologic injury, in-hospital mortality, and longer hospitalization. Prevalence of carotid stenosis was greater in high-risk patients (17.8%, N = 708) versus low-risk patients (6.1%, N = 426). Concomitant or staged carotid endarterectomy (CEA)/CAB was more commonly performed in the high-risk group (5.8% vs. 1%, p < 0.001). All nine patients with significant carotid stenosis who suffered perioperative strokes were in the high-risk group (9 out of 708 vs 0 out of 426, p = 0.016).
In our cohort, selectively screening only patients with either an age of more than 65, carotid bruit, or cerebrovascular disease would have reduced the screening load by nearly 40% with negligible impact on surgical management or neurologic outcomes.
颅外颈内动脉狭窄是冠状动脉搭桥（CAB）手术围手术期发生中风的一个危险因素。尽管术前颈动脉筛查的选择性和非选择性方法均已得到提倡，但目前尚不清楚哪种方法在临床上最有效。
回顾了2000年1月至2002年4月期间1421例连续CAB患者的医院记录。对选定参数进行单因素和多因素分析，以确定显著颈动脉狭窄（≥70%）的危险因素。根据颈动脉狭窄和围手术期中风的常见危险因素，将患者回顾性地分为高危或低危组。确定每组的颈动脉狭窄患病率、手术治疗情况和围手术期中风发生率。
1421例患者中有1138例（80.1%）接受了术前颈动脉筛查。显著颈动脉狭窄的患病率为13.4%。狭窄的单因素危险因素包括年龄超过65岁、外周血管疾病、既往脑血管意外、脑血管疾病史、左主干冠状动脉疾病、颈动脉杂音、女性和高血压。颈动脉狭窄是中风、神经损伤、住院死亡率和住院时间延长的危险因素。高危患者（17.8%，N = 708）的颈动脉狭窄患病率高于低危患者（6.1%，N = 426）。高危组更常进行同期或分期颈动脉内膜切除术（CEA）/CAB（5.8%对1%，p < 0.001）。所有9例患有显著颈动脉狭窄且发生围手术期中风的患者均在高危组（708例中有9例，而426例中无1例，p = 0.016）。
在我们的队列中，仅选择性地筛查年龄超过65岁、有颈动脉杂音或患有脑血管疾病的患者，将使筛查量减少近40%，而对外科治疗或神经学结局的影响可忽略不计。
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