Gibello Lorenzo, Varetto Gianfranco, Spalla Flavia, Ferraris Andrea, Ripepi Matteo, Trevisan Alessandra, Bert Fabrizio, Fonio Paolo, Verzini Fabio, Rispoli Pietro
Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, San Giovanni Battista Hospital, Torino, Turin, Italy.
Division of Vascular Surgery, Department of Surgical Sciences, University of Turin, Città della Salute e della Scienza, San Giovanni Battista Hospital, Torino, Turin, Italy.
Ann Vasc Surg. 2019 Oct;60:229-235. doi: 10.1016/j.avsg.2019.02.020. Epub 2019 May 7.
One of the most critical phases of carotid endarterectomy (CEA) is the carotid cross-clamping test, which is a concrete evaluation of efficacy of collateral cerebral perfusion. Some studies revealed a strong correlation between tolerance to carotid cross-clamping and postoperative transient ischemic attack (TIA)/stroke complications. The aim of the study is to make a global analysis of supra-aortic trunks (SAT) and circle of Willis (CoW) patency to predict the tolerance to carotid cross-clamping preoperatively.
We observed retrospectively 503 patients who underwent CEA under local anesthesia between January 2012 and 2017. We analyzed single preoperative risk factors, drug therapy, and vessels patency of the group of patients who did or did not present neurological symptoms at carotid cross-clamping. Afterward, we created a cerebral perfusion score (P) to estimate the efficacy of collateral cerebral perfusion and we compared the results from both groups. The score ranges from 0 (hypothetical total occlusion of the SAT and CoW) to 0.65 in case of patency of all arterial districts. Moreover, we evaluated postoperative complication rates.
Patients with previous neurological symptoms, female gender, and diabetes correlate with a lower tolerance to carotid cross-clamping (odds ratio: 2.57, 2.78, and 2.57, respectively; P value < 0.05). The SAT and CoW score revealed that patients with score <0.2 more frequently did not tolerate carotid cross-clamping (P value 0.01). Patients who required an intraoperative shunt presented a higher risk of TIA/stroke within 30 days from surgery than those with a better neurological compensation (P value 0.03).
The efficacy of cerebral mechanisms of compensation during carotid cross-clamping reflects the capability of the brain to adapt to ischemic insults, and this also correlates with the postoperative risk of TIA/stroke. It is possible to identify preoperatively patients with a higher risk of neurological intolerance at carotid cross-clamping. This score could be a useful method to make a further stratification of risk of neurological complications and eventually to prefer a general anesthesia and the use of shunt for those with P < 0.2.
颈动脉内膜切除术（CEA）最关键的阶段之一是颈动脉夹闭试验，这是对脑侧支循环灌注效果的具体评估。一些研究表明，对颈动脉夹闭的耐受性与术后短暂性脑缺血发作（TIA）/中风并发症之间存在密切关联。本研究的目的是对主动脉弓上干（SAT）和 Willis 环（CoW）的通畅情况进行全面分析，以术前预测对颈动脉夹闭的耐受性。
我们回顾性观察了 2012 年 1 月至 2017 年期间在局部麻醉下接受 CEA 的 503 例患者。我们分析了术前单一危险因素、药物治疗以及在颈动脉夹闭时出现或未出现神经症状的患者组的血管通畅情况。之后，我们创建了一个脑灌注评分（P）来评估脑侧支循环灌注的效果，并比较了两组的结果。该评分范围从 0（假设 SAT 和 CoW 完全闭塞）到所有动脉区域通畅时的 0.65。此外，我们评估了术后并发症发生率。
既往有神经症状、女性和糖尿病患者对颈动脉夹闭的耐受性较低（比值比分别为 2.57、2.78 和 2.57；P 值<0.05）。SAT 和 CoW 评分显示，评分<0.2 的患者更常不能耐受颈动脉夹闭（P 值 0.01）。与神经代偿较好的患者相比，术中需要分流的患者在术后 30 天内发生 TIA/中风的风险更高（P 值 0.03）。
颈动脉夹闭期间脑代偿机制的效果反映了大脑适应缺血性损伤的能力，这也与术后 TIA/中风的风险相关。术前可以识别出在颈动脉夹闭时神经不耐受风险较高的患者。该评分可能是进一步分层神经并发症风险的有用方法，并最终为 P<0.2 的患者选择全身麻醉和使用分流术。
