Bourke V C, Bourke B M, Beiles C B
Department of Vascular Surgery, Central Coast Area Health Service, Gosford, NSW 2250, Australia.
Department of Vascular Surgery, Central Coast Area Health Service, Gosford, NSW 2250, Australia.
Eur J Vasc Endovasc Surg. 2016 Feb;51(2):167-73. doi: 10.1016/j.ejvs.2015.08.022. Epub 2015 Oct 1.
The aim was to analyse a prospective, consecutive series of awake carotid endarterectomy (CEA) patients undergoing, when possible, pre- and postoperative diffusion-weighted magnetic resonance imaging brain scans (DWI).
All CEA patients from June 23, 2006, to January 13, 2012, were prospectively entered in the study. CEA was performed under regional cervical block. Only patients demonstrating shunt dependence were shunted. Before August 7, 2008, all longitudinal endarterectomy had been performed with a vein patch. From that date all CEA were eversions without a patch, except shunted patients who were vein patched. DWI was performed 2 days before and 5 days after (3 Tesla). Scans were reported by MRI-trained radiologists. Logistic regression analysis (LRA) identified predictive variables for MRI changes using backward stepwise elimination of variables with p > .05.
There was a total of 295 consecutive CEA. There were no deaths but four clinical strokes (1.4 %); 89 excluded from DWI leaving 206; of these 27 (13%) developed new DWI lesions including four of 57 (7%) in the asymptomatic group and 23 of 149 (15%) symptomatic patients. Nineteen of the 206 (9.2%) were shunted. LRA showed that shunt dependence was highly associated with new DWI lesions: odds ratio (OR) 6.43; 95% confidence interval (CI) 2.3-17.9; p < .001. Both the vein patched, non-shunted group (OR .25; CI 0.09-0.72; p = .010) and the eversion (all non-shunted and all non-patched) group (OR 0.05; CI 0.01-0.22; p < .001) were associated with a low risk of new lesions, with the eversion group a lower risk than the patched group.
One in every eight CEA patients developed new DWI lesions (rate doubled in symptomatic patients). Shunt dependence in conscious CEA patients is highly associated with the development of new DWI lesions compared with non-shunted patients. For non-shunted patients the new lesion risk is low, and in those patients the risk in the eversion group is lower than in the patched group.
本研究旨在分析一系列连续的清醒状态下行颈动脉内膜切除术（CEA）的患者，尽可能对其术前行弥散加权磁共振成像（DWI）脑部扫描，并在术后进行复查。
2006年6月23日至2012年1月13日期间所有接受CEA手术的患者均纳入本前瞻性研究。CEA手术在颈部区域阻滞麻醉下进行。只有显示分流依赖的患者才进行分流。2008年8月7日前，所有纵向内膜切除术均使用静脉补片。自该日期起，除接受分流且使用静脉补片的患者外，所有CEA手术均采用外翻术且不使用补片。分别在术前2天和术后5天进行DWI扫描（3特斯拉）。扫描结果由经过MRI培训的放射科医生报告。采用逻辑回归分析（LRA），通过向后逐步排除p>0.05的变量来确定MRI变化的预测变量。
共有295例连续的CEA手术患者。无死亡病例，但有4例发生临床卒中（1.4%）；89例患者被排除在DWI扫描之外，剩余206例；其中27例（13%）出现新的DWI病变，包括无症状组57例中的4例（7%）和有症状患者149例中的23例（15%）。206例患者中有19例（9.2%）接受了分流。LRA显示，分流依赖与新的DWI病变高度相关：优势比（OR）为6.43；95%置信区间（CI）为2.3 - 17.9；p < 0.001。使用静脉补片的非分流组（OR 0.25；CI 0.09 - 0.72；p = 0.010）和外翻术组（所有非分流且未使用补片的患者，OR 0.05；CI 0.01 - 0.22；p < 0.001）发生新病变的风险较低，外翻术组的风险低于使用补片组。
每八例CEA患者中有一例出现新的DWI病变（有症状患者的发生率翻倍）。与未分流的患者相比，清醒状态下接受CEA手术且有分流依赖的患者发生新的DWI病变的可能性更高。对于未分流的患者，发生新病变的风险较低，且外翻术组患者的风险低于使用补片组。
