Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN.
Department of Surgery, University of Tennessee College of Medicine, Chattanooga, Chattanooga, TN.
J Am Coll Surg. 2014 Apr;218(4):760-6. doi: 10.1016/j.jamcollsurg.2013.12.029. Epub 2014 Jan 5.
Carotid endarterectomy (CEA) is often completed with general anesthesia and routine shunting; however, shunting is only required in a small group of at-risk patients to maintain adequate cerebral perfusion. Selective shunting during CEA is performed to normalize cerebral hemodynamics for patients determined to be at risk. Eversion CEA with selective shunting for neurologic dysfunction in patients that are awake/sedated is described, as well as routine use of permissive hypertension (PH), which uses standard cardiovascular medications to recruit the cerebral collateral network and reduce the need for shunting.
A retrospective review of all CEA procedures performed from July 2006 to April 2013 was conducted. Procedures were divided into 3 groups: pre-PH phase (group A), PH-test phase (group B), and routine PH phase (group C). Operative reports and anesthesia documentation were reviewed for clamp time, need for shunting, and mean hemodynamics during each case.
During the study period, 232 CEAs met inclusion criteria and were divided into 3 groups: group A (n = 75) was predominate reactionary shunting, group B (n = 41) was predominate reactionary blood pressure augmentation, and group C (n = 116) was pre-emptive PH. When combining groups A and B, the at-risk group consisted of 21 of 116 (18.1%) patients who had a neurologic compromise develop after clamping the internal carotid artery and required a shunt or altered blood pressure hemodynamics. In comparison with group C, routine use of PH pre-emptively before clamping as a standard intraoperative technique led to need for shunting in 1 of 116 (0.86%) (p ≤ 0.001) and significantly reduced operative time (p ≤ 0.0001).
Routine use of PH during clamp time can recruit the cerebral collateral network and substantially reduce the at-risk group and need for shunting in awake/sedated patients.
颈动脉内膜切除术（CEA）通常在全身麻醉和常规分流的情况下完成；然而，分流仅在一小部分高危患者中需要，以维持足够的脑灌注。选择性分流术在有风险的患者中进行，以维持正常的脑血流动力学。描述了在清醒/镇静患者中，通过外翻颈动脉内膜切除术和选择性分流术治疗神经功能障碍，以及常规使用允许性高血压（PH），该方法使用标准心血管药物募集脑侧支网络，减少分流的需求。
对 2006 年 7 月至 2013 年 4 月期间进行的所有 CEA 手术进行了回顾性研究。手术分为 3 组：PH 前阶段（A 组）、PH 试验阶段（B 组）和常规 PH 阶段（C 组）。查阅手术报告和麻醉记录，了解每个病例的夹闭时间、分流需求和平均血流动力学。
在研究期间，232 例 CEA 符合纳入标准，并分为 3 组：A 组（n = 75）主要为反应性分流，B 组（n = 41）主要为反应性血压增强，C 组（n = 116）为预防性 PH。将 A 组和 B 组合并后，高危组包括 116 例患者中的 21 例（18.1%），这些患者在夹闭颈内动脉后出现神经功能障碍，需要分流或改变血压血流动力学。与 C 组相比，在夹闭前常规预防性使用 PH 作为标准术中技术，116 例患者中有 1 例（0.86%）需要分流（p ≤ 0.001），手术时间明显缩短（p ≤ 0.0001）。
在夹闭期间常规使用 PH 可以募集脑侧支网络，显著减少高危组和清醒/镇静患者的分流需求。
