AbuRahma Ali F, Mousa Albeir Y, Stone Patrick A, Hass Stephen M, Dean L Scott, Keiffer Tammi
Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA.
Ann Vasc Surg. 2011 Aug;25(6):830-6. doi: 10.1016/j.avsg.2011.04.002. Epub 2011 Jun 15.
The optimal method for predicting when carotid shunting is not necessary during carotid endarterectomy (CEA) is controversial. This study will analyze the correlation of collateral perfusion pressure and the status of contralateral carotid/cerebral collaterals and determine whether preoperative duplex ultrasound/cerebral angiography can predict when CEA can be done without shunting.
Ninety-eight patients were randomized into routine shunting and 102 into selective shunting when the collateral perfusion pressure (systolic carotid stump pressure) was <40 mm Hg during CEA. All patients had preoperative carotid duplex ultrasound and 87 had angiography, the results of which were evaluated for the presence of collateral flow from the contralateral carotid artery or posterior circulation through the anterior and/or posterior communicating arteries.
The perioperative stroke rate was 1.5% for the entire group. There was no correlation between preoperative symptoms and the status of the contralateral carotid artery (normal, stenosed, or occluded). The mean collateral perfusion pressure was inversely related to the severity of the contralateral carotid stenosis: 60, 57, 55, 56, and 38 mm Hg for normal, <50% stenosed, 50-69% stenosed, 70-99% stenosed, and occluded arteries, respectively (p = 0.005). There was a direct relation between the number of patients with a collateral perfusion pressure of <40 mm Hg (shunted group) and the severity of the contralateral carotid stenosis: 6 of 62 (10%) for normal carotid, 7 of 43 (16%) for <50% stenosis (OR = 1.82), 12 of 69 (17%) for 50-69% stenosis (OR = 1.97), 3 of 10 (30%) for 70-99% stenosis (OR = 4, CI = 0.81-19.68), and 9 of 13 (70%) for occlusion (OR = 21, CI = 4.98-89.32) (p < 0.0001). None of the patients (0/56) with normal to <70% contralateral carotid stenosis with cross-filling had a collateral perfusion pressure of <40 mm Hg (no shunting was necessary). However, 9 of 17 (47%) patients with <70% contralateral carotid stenosis and no cross-filling had a collateral perfusion pressure of <40 mm Hg (p < 0.0001), whereas 6 of 7 (86%) patients with ≥70% contralateral carotid stenosis and cross-filling versus 2 of 7 (29%) with ≥70% contralateral carotid stenosis and no cross-filling had a collateral perfusion stump pressure of >40 mm Hg (p = 0.1026). Overall, 62 of 63 (98.4%) patients with cross-filling versus 10 of 24 (42%) without cross-filling had a collateral perfusion pressure of ≥40 mm Hg (p < 0.0001).
There was an inverse correlation between collateral perfusion pressure and severity of contralateral carotid stenosis, and patients with severe contralateral carotid stenosis/occlusion were more likely to be shunted. The presence of cross-filling with normal to <70% contralateral carotid stenosis was associated with a collateral perfusion stump pressure of ≥40 mm Hg in 100% of patients for whom shunting was not carried out in our series.
在颈动脉内膜切除术（CEA）期间，预测何时无需进行颈动脉分流的最佳方法存在争议。本研究将分析侧支灌注压与对侧颈动脉/脑侧支状态之间的相关性，并确定术前双功超声/脑血管造影能否预测何时可以在不进行分流的情况下进行CEA。
98例患者在CEA期间侧支灌注压（收缩期颈动脉残端压）<40 mmHg时被随机分为常规分流组，102例被分为选择性分流组。所有患者术前均进行了颈动脉双功超声检查，87例进行了血管造影，评估结果以确定是否存在来自对侧颈动脉或后循环通过前和/或后交通动脉的侧支血流。
整个组的围手术期卒中率为1.5%。术前症状与对侧颈动脉状态（正常、狭窄或闭塞）之间无相关性。平均侧支灌注压与对侧颈动脉狭窄的严重程度呈负相关：正常、<50%狭窄、50 - 69%狭窄、70 - 99%狭窄和闭塞动脉的平均侧支灌注压分别为60、57、55、56和38 mmHg（p = 0.005）。侧支灌注压<40 mmHg的患者数量（分流组）与对侧颈动脉狭窄的严重程度呈正相关：正常颈动脉的62例中有6例（10%），<50%狭窄的43例中有7例（16%）（OR = 1.82），50 - 69%狭窄的69例中有12例（17%）（OR = 1.97），70 - 99%狭窄的10例中有3例（30%）（OR = 4，CI = 0.81 - 19.68），闭塞的13例中有9例（70%）（OR = 21，CI = 4.98 - 89.32）（p < 0.0001）。对侧颈动脉狭窄正常至<70%且有交叉充盈的患者中，无一例（0/56）侧支灌注压<40 mmHg（无需分流）。然而，对侧颈动脉狭窄<70%且无交叉充盈的17例患者中有9例（47%）侧支灌注压<40 mmHg（p < 0.0001），而对侧颈动脉狭窄≥70%且有交叉充盈的7例患者中有6例（86%），对侧颈动脉狭窄≥70%且无交叉充盈的7例患者中有
