Bellosta Raffaello, Luzzani Luca, Carugati Claudio, Talarico Matteo, Sarcina Antonio
Vascular Surgery Division, Poliambulanza Hospital, Brescia, Italy.
Ann Vasc Surg. 2006 Jul;20(4):482-7. doi: 10.1007/s10016-006-9037-8. Epub 2006 Apr 26.
The purpose of this report is to describe the perioperative and long-term outcomes of standard carotid endarterectomy (CEA) with general anesthesia, routine shunting, and patching and to show that routine shunting is a safe and reliable method of cerebral protection. Between January 1998 and December 2004, 700 patients attending our Department of Vascular Surgery underwent 786 CEAs performed using a standardized technique. Forty-four patients were excluded from the analysis because they underwent combined CEA and coronary artery bypass grafting, so the analysis is based on the results of 742 CEAs in 656 patients (86 bilateral CEAs). The strict surgical protocol included general anesthesia and standard carotid bifurcation endarterectomy with routine shunting (Javid's shunt) and Dacron patching. The Javid shunts were easily inserted in 738 cases (99.4%) but could not be used in four cases (0.5%) because of the presence of a very small internal carotid artery. The mean ischemic time required to insert the shunt and complete the suture was 4.7 min (+/-1.15), and the mean time to perform the endarterectomy was 34.3 min (+/-6.7). The mean follow-up was 24.4 months (+/-17.3). Overall 30-day mortality was 0.1% (one patient) due to a contralateral major stroke. The 1-month perioperative neurological complication rate was 0.7%, with three major and two minor strokes. The cumulative stroke and death rate was 0.8%. Preoperative symptoms such as hypertension, contralateral occlusion, or an age of more than 80 years were not independent risk factors for perioperative stroke. In the long-term follow-up, Kaplan-Meier analysis indicated an estimated 5-year stroke-free rate of 98.0%. There were eight cases (1%) of >70% restenosis (four cases) or thrombosis (four cases) of the operated internal carotid artery during the follow-up in asymptomatic patients: in four cases, carotid stenting due to >70% restenosis led to good results. The Kaplan-Meier estimate of the restenosis-free rate was 97.8%. The combined stroke and mortality rate of 0.8%, and the restenosis rate of 1% support the argument that standard CEA performed with routine shunting as brain protection leads to excellent early and long-term results.
本报告的目的是描述采用全身麻醉、常规分流和补片技术进行标准颈动脉内膜切除术（CEA）的围手术期及长期结果，并表明常规分流是一种安全可靠的脑保护方法。1998年1月至2004年12月期间，我院血管外科的700例患者接受了786次采用标准化技术的CEA手术。44例患者因同时接受了CEA和冠状动脉旁路移植术而被排除在分析之外，因此分析基于656例患者（86例双侧CEA）的742次CEA结果。严格的手术方案包括全身麻醉、标准颈动脉分叉内膜切除术、常规分流（贾维德分流）和涤纶补片。贾维德分流在738例（99.4%）中易于插入，但4例（0.5%）因颈内动脉非常细小而无法使用。插入分流并完成缝合所需的平均缺血时间为4.7分钟（±1.15），进行内膜切除术的平均时间为34.3分钟（±6.7）。平均随访时间为24.4个月（±17.3）。总体30天死亡率为0.1%（1例患者），原因是对侧严重中风。1个月围手术期神经并发症发生率为0.7%，有3例严重中风和2例轻微中风。累积中风和死亡率为0.8%。术前症状如高血压、对侧闭塞或年龄超过80岁并非围手术期中风的独立危险因素。在长期随访中，Kaplan-Meier分析表明估计5年无中风率为98.0%。在无症状患者的随访期间，有8例（1%）手术侧颈内动脉出现＞70%再狭窄（4例）或血栓形成（4例）：4例因＞70%再狭窄行颈动脉支架置入术，效果良好。Kaplan-Meier估计的无再狭窄率为97.8%。0.8%的中风和死亡率以及1%的再狭窄率支持了这样的观点，即采用常规分流作为脑保护措施进行的标准CEA可带来优异的早期和长期结果。
