Department of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.
Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.
Eur J Vasc Endovasc Surg. 2020 Apr;59(4):526-534. doi: 10.1016/j.ejvs.2020.01.007. Epub 2020 Feb 5.
Intra-operative haemodynamic instability during carotid endarterectomy (CEA) has been associated with an increased risk of procedural stroke. Diffusion weighted imaging (DWI) lesions have been proposed as a surrogate marker for peri-operative silent cerebral ischaemia. This study aimed to investigate the relationship between peri-operative blood pressure (BP) and presence of post-operative DWI lesions in patients undergoing CEA.
A retrospective analysis was performed based on patients with symptomatic CEA included in the MRI substudy of the International Carotid Stenting Study. Relative intra-operative hypotension was defined as a decrease of intra-operative systolic BP ≥ 20% compared with pre-operative ('baseline') BP, absolute hypotension was defined as a drop in systolic BP < 80 mmHg. The primary endpoint was the presence of any new DWI lesions on post-operative MRI (DWI positive). The occurrence and duration of intra-operative hypotension was compared between DWI positive and DWI negative patients as was the magnitude of the difference between pre- and intra-operative BP.
Fifty-five patients with symptomatic CEA were included, of whom eight were DWI positive. DWI positive patients had a significantly higher baseline systolic (186 ± 31 vs. 158 ± 27 mmHg, p = .011) and diastolic BP (95 ± 15 vs. 84 ± 13 mmHg, p = .046) compared with DWI negative patients. Other pre-operative characteristics did not differ. Relative intra-operative hypotension compared with baseline occurred in 53/55 patients (median duration 34 min; range 0-174). Duration of hypotension did not differ significantly between the groups (p = .088). Mean systolic intra-operative BP compared with baseline revealed a larger drop in BP (-37 ± 29 mmHg) in DWI positive compared with DWI negative patients (-14 ± 26 mmHg, p = .024). Absolute intra-operative systolic BP values did not differ between the groups.
In this exploratory study, high pre-operative BP and a larger drop of intra-operative BP were associated with peri-procedural cerebral ischaemia as documented with DWI. These results call for confirmation in an adequately sized prospective study, as they suggest important consequences for peri-operative haemodynamic management in carotid revascularisation.
颈动脉内膜切除术（CEA）过程中出现的术中血流动力学不稳定与手术过程中中风的风险增加有关。弥散加权成像（DWI）病变已被提议作为围手术期无症状性脑缺血的替代标志物。本研究旨在探讨接受 CEA 的患者围手术期血压（BP）与术后 DWI 病变之间的关系。
对国际颈动脉支架研究的 MRI 子研究中纳入的有症状性 CEA 患者进行回顾性分析。术中相对低血压定义为术中收缩压与术前（“基线”）BP 相比下降≥20%，绝对低血压定义为收缩压下降<80mmHg。主要终点是术后 MRI 上是否存在任何新的 DWI 病变（DWI 阳性）。比较 DWI 阳性和 DWI 阴性患者术中低血压的发生和持续时间，以及术前和术中 BP 差值的大小。
共纳入 55 例有症状性 CEA 患者，其中 8 例为 DWI 阳性。与 DWI 阴性患者相比，DWI 阳性患者的基线收缩压（186±31 与 158±27mmHg，p=0.011）和舒张压（95±15 与 84±13mmHg，p=0.046）明显更高。其他术前特征无差异。与基线相比，55 例患者中有 53 例发生术中相对低血压（中位持续时间 34 分钟；范围 0-174 分钟）。两组间低血压的持续时间无显著差异（p=0.088）。与基线相比，DWI 阳性患者术中收缩压平均下降幅度较大（-37±29mmHg），而 DWI 阴性患者下降幅度较小（-14±26mmHg，p=0.024）。两组间术中收缩压绝对值无差异。
在这项探索性研究中，高术前 BP 和术中 BP 下降幅度较大与 DWI 记录的围手术期脑缺血有关。这些结果需要在适当大小的前瞻性研究中得到证实，因为它们提示了颈动脉血运重建术围手术期血流动力学管理的重要后果。
