Ricco J B, Marchand C, Neau J P, Marchand E, Cau J, Fébrer G
Vascular Surgery Department, Jean Bernard University Hospital, 86021, Poitiers, France.
Eur J Vasc Endovasc Surg. 2009 Mar;37(3):272-8. doi: 10.1016/j.ejvs.2008.11.012. Epub 2008 Dec 25.
Carotid endarterectomy (CEA) is the standard treatment for atherosclerotic lesions involving the carotid bifurcation. However, CEA can be challenging under some conditions. The goal of this study was to determine the outcome and durability of prosthetic carotid bypass grafting (PCB) with polytetrafluoroethylene (PTFE) grafts as an alternative to CEA.
This is a prospective series of 198 consecutive patients with PCB, representing 12.4% of 1595 patients with a carotid reconstruction procedure performed in our department between September 1986 and December 2006. Qualifying event was stroke in 67 patients (34%) and transient ischaemic attack (TIA) in 45 (23%), and 86 patients (43%) were asymptomatic. Primary indications for PCB were extensive atherosclerotic lesions (n=71; 36%), carotid stenosis associated with kinking (n=49; 25%), recurrent stenosis (n=47; 23%), stenosis after radiation therapy (n=18; 9%) and technical failure of CEA (n=13; 7%), with excessive arterial wall thinning and perforation after endarterectomy (n=10) or intimal flap on completion digital angiography (n=3).
The combined stroke and death rate at 30 days were 0.5% (one stroke). Median follow-up was 9.5 years (interquartile range (IQR): 6.2-18.3 years). At 10 years, primary patency was 97.9+/-3.4%. Six PCBs (3.0%) became occluded during follow-up; one patient had a restenosis greater than 50% and 18 patients (9.1%) had a restenosis of less than 50%. Five patients had an ipsilateral stroke (one postoperative stroke, one at 103 days with a patent PCB and three related to occlusion of the PCB at 4, 13 and 15 years after the procedure). At 10 years, cumulative stroke-free survival was 98.4+/-3.2%, and cumulative survival was 78.8+/-7.0%.
PCB is a safe surgical alternative and is durable, with a low incidence of graft restenosis, when CEA seems hazardous.
颈动脉内膜切除术（CEA）是治疗累及颈动脉分叉处动脉粥样硬化病变的标准方法。然而，在某些情况下，CEA具有挑战性。本研究的目的是确定使用聚四氟乙烯（PTFE）移植物的人工血管颈动脉旁路移植术（PCB）作为CEA替代方法的疗效和耐用性。
这是一项前瞻性研究，连续纳入198例接受PCB的患者，占1986年9月至2006年12月间在我科进行颈动脉重建手术的1595例患者的12.4%。符合条件的事件包括67例（34%）发生卒中，45例（23%）发生短暂性脑缺血发作（TIA），86例（43%）无症状。PCB的主要适应证包括广泛动脉粥样硬化病变（n = 71；36%）、合并血管扭曲的颈动脉狭窄（n = 49；25%）、复发性狭窄（n = 47；23%）、放疗后狭窄（n = 18；9%）以及CEA技术失败（n = 13；7%），其中包括内膜切除术后动脉壁过度变薄和穿孔（n = 10）或数字减影血管造影完成时出现内膜瓣（n = 3）。
30天时的卒中与死亡率合并为0.5%（1例卒中）。中位随访时间为九年半（四分位间距（IQR）：6.2 - 18.3年）。10年时，初始通畅率为97.9%±3.4%。随访期间6例PCB（3.0%）闭塞；1例患者再狭窄大于50%，18例患者（9.1%）再狭窄小于50%。5例患者发生同侧卒中（1例术后卒中，1例在术后103天发生，此时PCB通畅，3例与术后4、13和15年时PCB闭塞相关）。10年时，无卒中累积生存率为98.4%±3.2%，累积生存率为78.8%±7.0%。
当CEA似乎具有风险时，PCB是一种安全的手术替代方法，耐用性好，移植物再狭窄发生率低。
