Aleksic M, Luebke T, Brunkwall J
Department of Vascular Surgery, University Clinic Cologne, Cologne, Germany.
Vasa. 2009 Aug;38(3):225-33. doi: 10.1024/0301-1526.38.3.225.
In the present study the perioperative complication rate is compared between high- and low-risk patients when carotid endarterectomy (CEA) is routinely performed under local anaesthesia (LA).
From January 2000 through June 2008 1220 consecutive patients underwent CEA under LA. High-risk patients fulfilled at least one of the following characteristics: ASA 4 classification, "hostile neck", recurrent ICA stenosis, contralateral ICA occlusion, age > or = 80 years. The combined complication rate comprised any new neurological deficit (TIA or stroke), myocardial infarction or death within 30 days after CEA, which was compared between patient groups.
Overall 309 patients (25%) were attributed to the high-risk group, which differed significantly regarding sex distribution (more males: 70% vs. 63%, p = 0.011), neurological presentation (more asymptomatic: 72% vs. 62%, p = 0.001) and shunt necessity (33% vs. 14%, p < 0.001). In 32 patients 17 TIAs and 15 strokes were observed. In 3 patients a myocardial infarction occurred. Death occurred in one patient following a stroke and in another patient following myocardial infarction, leading to a combined complication rate of 2.9% (35/1220). In the multivariate analysis only previous neurological symptomatology (OR 2.85, 95% CI 1.38-5.91) and intraoperative shunting (OR 5.57, 95% CI 2.69-11.55) were identified as independent risk factors for an increased combined complication rate.
With the routine use of LA, CEA was not associated with worse outcome in high-risk patients. Considering the data reported in the literature, it does not appear justified to refer high-risk patients principally to carotid angioplasty and stenting (CAS) when LA can be chosen to perform CEA.
在本研究中，比较了在局部麻醉（LA）下常规进行颈动脉内膜切除术（CEA）时高风险和低风险患者的围手术期并发症发生率。
从2000年1月至2008年6月，1220例连续患者在LA下接受了CEA。高风险患者至少具备以下特征之一：美国麻醉医师协会（ASA）4级分类、“颈部情况不佳”、颈内动脉（ICA）复发狭窄、对侧ICA闭塞、年龄≥80岁。联合并发症发生率包括CEA后30天内出现的任何新发神经功能缺损（短暂性脑缺血发作或中风）、心肌梗死或死亡，并在患者组之间进行比较。
总体而言，309例患者（25%）被归为高风险组，该组在性别分布（男性更多：70%对63%，p = 0.011）、神经学表现（无症状者更多：72%对62%，p = 0.001）和分流必要性（33%对14%，p < 0.001）方面存在显著差异。在32例患者中观察到17次短暂性脑缺血发作和15次中风。3例患者发生心肌梗死。1例患者在中风后死亡，另1例患者在心肌梗死后死亡，导致联合并发症发生率为2.9%（35/1220）。在多变量分析中，仅既往神经症状（比值比[OR] 2.85，95%置信区间[CI] 1.38 - 5.91）和术中分流（OR 5.57，95% CI 2.69 - 11.55）被确定为联合并发症发生率增加的独立危险因素。
常规使用LA时，CEA在高风险患者中并未导致更差的结果。考虑到文献报道的数据，当可以选择LA进行CEA时，将高风险患者主要转诊至颈动脉血管成形术和支架置入术（CAS）似乎没有道理。
