Marrocco-Trischitta Massimiliano M, Melissano Germano, Kahlberg Andrea, Setacci Francesco, Abeni Damiano, Chiesa Roberto
Chair of Vascular Surgery, San Raffaele Scientific Institute, Università Vita-Salute San Raffaele, Milan and Rome, Italy.
J Vasc Surg. 2006 Jun;43(6):1155-61. doi: 10.1016/j.jvs.2006.02.028.
The aim of our study was to assess the influence of previous contralateral carotid endarterectomy (CEA) and of the timing of the procedures on cerebral clamping ischemia during the second operation in patients undergoing staged bilateral CEA.
We reviewed the 251 patients who presented with bilateral carotid stenosis of > or =70% at the time of the first admission and underwent staged bilateral CEA between January 2001 and December 2004. Surgery was performed under locoregional anesthesia. Cerebral perfusion was monitored with mental status and contralateral motor function evaluation in awake patients. Selective carotid shunting was performed for patients who manifested neurologic deficits. Univariate and multivariate analyses were performed for the variables of interest.
Twenty-two patients (8.8%) required carotid shunting during the first procedure and 28 (11.1%) during the second one. Nine of the latter also had shunts during the first CEA, whereas 19 tolerated cross-clamping during the first operation. Among the patients who underwent contralateral CEA < or =30 days, 23 of 146 required carotid shunting; between 31 and 60 days, 4 of 73; and after 61 days, 1 of 32 (P = .023; univariate analysis). The chi2 for trend was statistically significant (P = .009). Patients operated on the second side < or =30 days had a nearly fourfold risk of shunting during the second procedure compared with patients operated on > or =31 days. The highest risk was observed in patients with a shunt during the first operation who underwent the second CEA < or =30 days. Multivariate analysis also identified the time intervals between CEAs and the need of shunting during the first procedure as independent risk factors (P = .042 and P < .001).
These data show an increased incidence of cerebral clamping ischemia during contralateral endarterectomy performed < or =30 days; whereas after longer intervals between CEAs, the need for shunting is significantly reduced.
我们研究的目的是评估既往对侧颈动脉内膜切除术（CEA）以及手术时机对分期双侧CEA患者第二次手术期间脑钳夹缺血的影响。
我们回顾了2001年1月至2004年12月期间首次入院时双侧颈动脉狭窄≥70%并接受分期双侧CEA的251例患者。手术在局部麻醉下进行。在清醒患者中通过精神状态和对侧运动功能评估来监测脑灌注。对出现神经功能缺损的患者进行选择性颈动脉分流。对感兴趣的变量进行单因素和多因素分析。
22例患者（8.8%）在第一次手术期间需要颈动脉分流，28例（11.1%）在第二次手术期间需要。后者中有9例在第一次CEA期间也进行了分流，而19例在第一次手术期间耐受了交叉钳夹。在对侧CEA在≤30天内进行的患者中，146例中有23例需要颈动脉分流；在31至60天之间，73例中有4例；在61天之后，32例中有1例（P = 0.023；单因素分析）。趋势的卡方检验具有统计学意义（P = 0.009）。与在≥31天进行手术的患者相比，在≤30天对第二侧进行手术的患者在第二次手术期间进行分流的风险几乎高四倍。在第一次手术期间进行分流且在≤30天进行第二次CEA的患者中观察到最高风险。多因素分析还确定了CEA之间的时间间隔以及第一次手术期间分流的需求是独立的危险因素（P = 0.042和P < 0.001）。
这些数据表明，在≤30天进行对侧内膜切除术期间，脑钳夹缺血的发生率增加；而在CEA之间间隔较长时间后，分流的需求显著降低。
