Fletcher E, Kabeer M, Sathianathan J, Muir I, Williams D, Lim C
NHS Dumfries and Galloway, Dumfries and Galloway Royal Infirmary, Dumfries, UK.
EJVES Short Rep. 2016 Apr 16;31:12-15. doi: 10.1016/j.ejvssr.2016.03.003. eCollection 2016.
Carotid artery endarterectomy (CEA) is a common procedure undertaken by vascular surgeons with over 5,000 procedures performed annually worldwide. Published rates of perioperative stroke range from 1.3% to 6.3%.
A case is presented in which on-table intra-cranial angiography and catheter directed thrombolysis were used for a thromboembolic occlusion of the distal internal carotid artery (ICA) and proximal middle cerebral artery (MCA). An 83-year-old lady developed a dense right hemiparesis while undergoing a CEA under local anaesthetic (LA). Immediate re-exploration of the endarterectomy did not reveal technical error. Intraoperative duplex scanning of the internal carotid artery revealed no detectable diastolic flow. On-table angiogram showed complete occlusion of the distal ICA and proximal MCA. Catheter directed administration of TPA was undertaken. The entire ICA and MCA were completely clear on a completion angiogram. The patient made a full neurological recovery.
Prompt diagnosis and treatment with intraoperative catheter directed thrombolysis can resolve thromboembolic occlusion of the ICA/MCA. It is argued that performing CEA under LA is useful for immediate recognition of perioperative stroke. Furthermore, the advantage is highlighted of vascular surgeons having both the resources and skillset to perform on-table angiography and thrombolysis.
颈动脉内膜切除术（CEA）是血管外科医生常做的一种手术，全球每年进行超过5000例。已公布的围手术期卒中发生率在1.3%至6.3%之间。
本文介绍了一例在手术台上进行颅内血管造影和导管定向溶栓治疗颈内动脉（ICA）远端和大脑中动脉（MCA）近端血栓栓塞性闭塞的病例。一名83岁女性在局部麻醉下接受CEA手术时出现严重右侧偏瘫。立即对内膜切除术进行再次探查未发现技术失误。术中对颈内动脉进行双功扫描未发现可检测到的舒张期血流。手术台上的血管造影显示颈内动脉远端和大脑中动脉近端完全闭塞。进行了导管定向注射组织型纤溶酶原激活剂（TPA）。在完成血管造影时，整个颈内动脉和大脑中动脉完全通畅。患者神经功能完全恢复。
术中导管定向溶栓的及时诊断和治疗可解决颈内动脉/大脑中动脉的血栓栓塞性闭塞。有人认为在局部麻醉下进行CEA有助于立即识别围手术期卒中。此外，强调了血管外科医生具备进行手术台上血管造影和溶栓的资源和技能的优势。
