Tayama Eiki, Mori Ryusuke, Ueda Tomohiro, Imasaka Ken-Ichi, Tomita Yukihiro, Morita Shigeki
Department of Cardiovascular Surgery, Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
J Cardiothorac Surg. 2019 Jul 23;14(1):141. doi: 10.1186/s13019-019-0961-4.
Severe carotid and intracranial artery stenosis disease (CIAD) is major risk for perioperative stroke in coronary artery bypass grafting. Then, preoperative risk assessment is quite important.
A 58-years old Japanese woman with bilateral carotid stenosis and bilateral middle cerebral artery occlusion was suffered from worsening effort angina due to severe three coronary vessel disease. Magnetic resonance imaging angiography demonstrated severe carotid and intracranial vessel stenosis. Selective carotid/cerebral angiography also showed severe stenosis and delayed filling of the right internal carotid artery and moderate stenosis of the left internal carotid artery, with occlusion of the bilateral middle cerebral arteries. However, quantitative evaluation with brain perfusion, single-photon emission computed tomography (SPECT) with acetazolamide showed depleted cerebral perfusion volume and vascular responses, particularly in the left middle cerebral artery area. However, both sides of MCA reserve cerebral blood flow was maintained at > 34 ml/100 g/min. So, we finally considered that her cerebral perfusion reserve was maintained a certain level and could tolerate open heart surgery. Then, she underwent off-pump coronary artery grafting. Before sternotomy, prophylactic intra-aortic balloon pump support was used to minimize possible perioperative stroke. As a result, hemodynamic status and brain regional oxygen saturation were stable throughout the operation, and recovered uneventfully.
Preoperative quantitative evaluation using brain perfusion SPECT with acetazolamide is useful in assessing hemodynamic cerebrovascular risk in patients with severe obstructive CIAD. Off pump coronary artery bypass grafting with intra aortic balloon pump assist is a good option for prevention of cerebrovascular morbidity in ischemic heart disease with severe CIAD.
严重的颈动脉和颅内动脉狭窄疾病（CIAD）是冠状动脉搭桥手术围手术期发生中风的主要风险因素。因此，术前风险评估非常重要。
一名58岁的日本女性，患有双侧颈动脉狭窄和双侧大脑中动脉闭塞，因严重的三支冠状动脉疾病导致劳力性心绞痛加重。磁共振血管造影显示严重的颈动脉和颅内血管狭窄。选择性颈动脉/脑血管造影也显示右侧颈内动脉严重狭窄和延迟充盈，左侧颈内动脉中度狭窄，双侧大脑中动脉闭塞。然而，使用乙酰唑胺进行脑灌注的定量评估、单光子发射计算机断层扫描（SPECT）显示脑灌注量减少和血管反应减弱，尤其是在左侧大脑中动脉区域。然而，双侧大脑中动脉储备脑血流量维持在>34 ml/100 g/min。因此，我们最终认为她的脑灌注储备维持在一定水平，能够耐受心脏直视手术。然后，她接受了非体外循环冠状动脉搭桥术。在开胸手术前，使用预防性主动脉内球囊泵支持以尽量减少围手术期可能发生的中风。结果，整个手术过程中血流动力学状态和脑局部氧饱和度稳定，术后恢复顺利。
使用乙酰唑胺进行脑灌注SPECT的术前定量评估有助于评估严重阻塞性CIAD患者的血流动力学脑血管风险。非体外循环冠状动脉搭桥术联合主动脉内球囊泵辅助是预防严重CIAD缺血性心脏病患者脑血管并发症的一个好选择。
