Department of Surgery, West Virginia University, Charleston, WV.
Department of Surgery, West Virginia University, Charleston, WV.
J Vasc Surg. 2021 Mar;73(3):968-974. doi: 10.1016/j.jvs.2020.03.058. Epub 2020 Apr 29.
Concomitant carotid endarterectomy (CEA; for severe internal carotid artery stenosis) with carotid-subclavian bypass grafting (CSBG; for proximal common carotid artery or subclavian artery occlusion) is rarely used. Only a few studies have been reported. This report analyzed early and late clinical outcomes of the largest study to date of the combined procedures in our institution.
Electronic medical records of patients who had concomitant CEA with CSBG during three decades were analyzed. Indications for surgery were arm ischemia, neurologic events, and clinical subclavian steal. Early (30 days) perioperative complications (stroke, death, and others) and late complications (stroke, death) were recorded. Kaplan-Meier analysis was used to estimate late graft/CEA primary patency, freedom from stroke, and stroke-free survival rates. Graft patency was determined clinically and confirmed using duplex ultrasound. Outcomes were compared with previously published data on isolated CSBG by the same group.
There were 37 combined procedures analyzed. Mean age was 64 years (range, 45-81 years). Indications for surgery were arm ischemia in 12 (32%), hemispheric transient ischemic attack or stroke in 15 (41%), vertebrobasilar insufficiency in 4 (11%), symptomatic subclavian steal in 10 (27%), and asymptomatic common carotid artery occlusion with severe internal carotid artery stenosis in 6 (16%). The 30-day perioperative (stroke and death) rate was 5.4% (one stroke and one death). Immediate symptom relief was noted in 100%, with 2.7% (transient ischemic attack) symptom recurrence. The crude patency rate of both CEA and CSBG was 92%. At 1 year, 2 years, 3 years, 4 years, and 5 years, respectively, primary patency rates were 100%, 96%, 96%, 96%, and 85%; freedom from stroke rates were 97%, 97%, 97%, 97%, and 97%; and stroke-free survival rates were 94%, 94%, 87%, 82%, and 78%. When these outcomes were compared with the isolated CSBG group alone (28 patients), there was no difference in perioperative stroke (2.7% for concomitant CEA/CSBG vs 0% for isolated CSBG), perioperative death (2.7% vs 2.8%), or late patency rates (92% vs 96%).
Concomitant CEA/CSBG is safe and durable. There was no significant difference in perioperative stroke/death or late patency rates compared with isolated CSBG.
同时进行颈动脉内膜切除术（CEA；用于严重的颈内动脉狭窄）和颈动脉-锁骨下旁路移植术（CSBG；用于近端颈总动脉或锁骨下动脉闭塞）的情况很少见。仅有少数研究进行了报道。本报告分析了我们机构迄今为止最大规模的联合手术的最新临床结果。
对过去 30 年间同时进行 CEA 和 CSBG 的患者的电子病历进行了分析。手术指征为手臂缺血、神经事件和临床锁骨下盗血。记录了早期（30 天）围手术期并发症（卒中、死亡和其他）和晚期并发症（卒中、死亡）。采用 Kaplan-Meier 分析估计晚期移植/CEA 的通畅率、免于卒中的情况和无卒中生存率。通过临床检查和双功能超声确认移植通畅情况。通过与同一组发表的单独 CSBG 的先前数据进行比较，评估了手术结果。
共分析了 37 例联合手术。平均年龄为 64 岁（范围，45-81 岁）。手术指征为手臂缺血 12 例（32%）、半球性短暂性脑缺血发作或卒中 15 例（41%）、椎基底动脉供血不足 4 例（11%）、症状性锁骨下盗血 10 例（27%）和无症状性颈总动脉闭塞伴严重颈内动脉狭窄 6 例（16%）。30 天围手术期（卒中和死亡）发生率为 5.4%（1 例卒中，1 例死亡）。100%的患者即刻症状缓解，2.7%（短暂性脑缺血发作）的患者症状复发。CEA 和 CSBG 的总通畅率为 92%。1 年、2 年、3 年、4 年和 5 年的原发通畅率分别为 100%、96%、96%、96%和 85%；免于卒中的比例分别为 97%、97%、97%、97%和 97%；无卒中生存率分别为 94%、94%、87%、82%和 78%。将这些结果与单独的 CSBG 组（28 例）进行比较，围手术期卒中（联合 CEA/CSBG 组为 2.7%，单独 CSBG 组为 0%）、围手术期死亡（联合 CEA/CSBG 组为 2.7%，单独 CSBG 组为 2.8%）或晚期通畅率（联合 CEA/CSBG 组为 92%，单独 CSBG 组为 96%）均无显著差异。
同时进行 CEA/CSBG 是安全且持久的。与单独进行 CSBG 相比，围手术期卒中/死亡或晚期通畅率无显著差异。
