Coyle K A, Smith R B, Gray B C, Salam A A, Dodson T F, Chaikof E L, Lumsden A B
Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.
Ann Surg. 1995 May;221(5):517-21; discussion 521-4. doi: 10.1097/00000658-199505000-00009.
The authors determined whether carotid endarterectomy in patients with recurrent cerebrovascular disease poses a greater perioperative risk than for those individuals undergoing first-time carotid endarterectomy.
A percentage of patients undergoing carotid endarterectomy for atherosclerosis experience recurrent cerebrovascular disease. Reoperation may be difficult because of postoperative scarring of the soft tissues of the neck and the carotid artery itself. Such patients were believed to be at greater risk for perioperative morbidity than those undergoing first-time carotid endarterectomy.
To address this concern, the authors retrospectively reviewed their experience with 69 patients who underwent repeat carotid endarterectomies over a recent 10-year period of time. This subgroup represented 6.4% of 1072 total carotid endarterectomies performed during the same time period. The average extent of stenosis on the operated side was 81% and the time elapsed after previous endarterectomy averaged 83 months. Twelve patients (17.4%) had contralateral internal carotid occlusion, and 30 patients (43.5%) had undergone previous endarterectomies on the contralateral side.
Complications within 30 days of operation included two deaths (2.9%) and one stroke (1.4%), for a combined stroke and death rate of 4.3%. Six patients developed cervical hematomas requiring drainage; one of these had rupture of a saphenous vein patch. No patient had a significant cranial nerve injury in the reoperative group, whereas 2.0% of patients undergoing first-time carotid endarterectomy had cranial nerve injuries. Overall, these results compared favorably with a combined stroke and death rate of 4.0% among 1003 patients who underwent first-time carotid endarterectomy during the same period.
This review suggests that repeat carotid endarterectomy can be performed safely in individuals with severe recurrent carotid stenosis, with morbidity and mortality rates similar to those for patients undergoing first-time carotid endarterectomies. For this population, reoperative carotid endarterectomy represents a safe and important mechanism for the prevention of stroke.
作者旨在确定复发性脑血管疾病患者行颈动脉内膜切除术是否比首次行颈动脉内膜切除术的患者具有更高的围手术期风险。
一部分因动脉粥样硬化而行颈动脉内膜切除术的患者会出现复发性脑血管疾病。由于颈部软组织及颈动脉本身术后形成瘢痕，再次手术可能会很困难。人们认为这类患者围手术期发病风险高于首次行颈动脉内膜切除术的患者。
为解决这一问题，作者回顾性分析了近10年里69例行再次颈动脉内膜切除术患者的情况。该亚组占同期1072例颈动脉内膜切除术总数的6.4%。手术侧平均狭窄程度为81%，上次内膜切除术后平均间隔时间为83个月。12例患者（17.4%）对侧颈内动脉闭塞，30例患者（43.5%）对侧曾行内膜切除术。
术后30天内的并发症包括2例死亡（2.9%）和1例卒中（1.4%），卒中及死亡率合计为4.3%。6例患者出现颈部血肿需要引流；其中1例大隐静脉补片破裂。再次手术组无患者出现严重的脑神经损伤，而首次行颈动脉内膜切除术的患者中有2.0%出现脑神经损伤。总体而言，这些结果与同期1003例首次行颈动脉内膜切除术患者4.0%的卒中及死亡率相比更优。
本综述表明，对于严重复发性颈动脉狭窄患者，再次颈动脉内膜切除术可安全实施，其发病率和死亡率与首次行颈动脉内膜切除术的患者相似。对于这一人群，再次颈动脉内膜切除术是预防卒中的一种安全且重要的手段。
