区域麻醉下颈动脉内膜切除术中的颈动脉交叉钳位不耐受
- 作者: Majd P.1, Galkin P.1, Tayeh M.1, Herzmann T.1, Gores M.1, Kalmykov E.1, Ahmad W.2
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隶属关系:
- Evangelical Hospital Bergisch Gladbach
- University Hospital of Cologne
- 期: 卷 29, 编号 1 (2021)
- 页面: 66-72
- 栏目: Original study
- URL: https://bakhtiniada.ru/pavlovj/article/view/60620
- DOI: https://doi.org/10.23888/PAVLOVJ202129166-72
- ID: 60620
如何引用文章
详细
在外科动脉内膜切除术中,需要颈动脉交叉夹持以进行动脉切开和斑块清除。颈动脉阻断减少了流向Willis环的血流量,一些患者对颈内动脉(ICA)暂时性闭塞表现出不耐受。
目的。本研究论证了颈动脉交叉钳位不耐受(CCI)患者局部麻醉的安全性以及预测这种情况的危险因素。
材料和方法。回顾性分析发现,2019年1月至2020年12月期间接受颈动脉内膜切除术的所有患者(n=53,29名男性,年龄56-90岁(中位数78)),手术适应症为70%-99%的ICA狭窄或症状性狭窄。
外科手术。在胸锁乳突肌的前缘做一个切口。颈总动脉(CCA)从周围组织中分离出来,并向分叉处延伸。之后,分离颈内动脉和颈外动脉。静脉注射肝素(5000U),收缩压升高并保持在160mm Hg以上。接着,进行交叉钳位耐受性试验60s。使用夹钳期间,对患者的神经系统进行仔细观察。若出现颈动脉交叉钳位不耐受(CCI),插入临时分流器并继续手术。动脉切开术从颈总动脉开始,持续到颈内动脉。完全清除斑块,用补片覆盖动脉切开处。在完成缝合之前,夹钳被部分移除,利用血流冲洗碎屑后可松开外动脉和总动脉。最后移除颈内动脉钳。
结果。8例接受交叉钳夹耐受试验的患者表现为不耐受。所有这些病例的手术均通过分流继续进行。进一步的手术过程并不复杂。院内死亡率为零,仅1例发生短暂性脑缺血发作。冠状动脉疾病(CAD)[优势比(OR)12.65,95% 置信区间(CI)1.43–112.50]、脑血管事件史[OR 10.50,95% CI 1.83–60.30]、对侧狭窄70%或以上[OR 26.66,95% CI 2.29–304.37]与CCI和分流的必要性有显著关联。其余因素与不耐症无明显关联。
结论。区域麻醉是鉴别CCI患者和安全手术的安全方法。对侧ICA狭窄和脑血管事件史是预测CCI的重要因素。
作者简介
Payman Majd
Evangelical Hospital Bergisch Gladbach
Email: mir.majd@uk-koeln.de
ORCID iD: 0000-0002-5835-8318
Chief physician, Specialist in surgery, Specialist in vascular surgery, Endovascular surgeon
德国, Bergisch Gladbach North Rhine-Westphalia, GermanyPeter Galkin
Evangelical Hospital Bergisch Gladbach
Email: p.galkin@uk-koeln.de
ORCID iD: 0000-0003-2666-5337
Senior physician Dr. Med., Specialist in vascular surgery
德国, Bergisch Gladbach North Rhine-Westphalia, GermanyMahmoud Tayeh
Evangelical Hospital Bergisch Gladbach
Email: m.tayeh@uk-koeln.de
ORCID iD: 0000-0001-5460-8562
Assistant Doctor
德国, Bergisch Gladbach North Rhine-Westphalia, GermanyThomas Herzmann
Evangelical Hospital Bergisch Gladbach
Email: t.herzmann@uk-koeln.de
ORCID iD: 0000-0002-7442-9825
Michael Gores
Evangelical Hospital Bergisch Gladbach
Email: m.gores@uk-koeln.de
ORCID iD: 0000-0002-1015-3698
Egan Kalmykov
Evangelical Hospital Bergisch Gladbach
编辑信件的主要联系方式.
Email: info@helios-international.com
ORCID iD: 0000-0001-6784-2243
MD, PhD
德国, Bergisch Gladbach North Rhine-Westphalia, GermanyWael Ahmad
University Hospital of Cologne
Email: wael.ahmad@uk-koeln.de
ORCID iD: 0000-0001-5090-3468
参考
- Bagan P, Vidal R, Martinod E, et al. Cerebral ischemia during carotid artery cross-clamping: predictive value of phase-contrast magnetic resonance imaging. Annals of Vascular Surgery. 2006;20(6): 747-52. doi: 10.1007/s10016-006-9126-8
- ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/ CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive summary. Catheterization & Cardiovascular Interventions. 2013;81(1):E76-123. doi: 10.1002/ccd.22983
- Naylor AR, Ricco JB, de Borst GJ, et al. Editor's Choice – Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). European Journal of Vascular and Endovascular Surgery. 2018;55(1):3-81. doi:10.1016/ j.ejvs.2017.06.021
- Kalmykov EL, Matoussevitch V, Brunkwall J. Letter to editor. Longitudinal and transverse access for carotid endarterectomy. Commentary and invitation to discussion. Russian Journal of Operative Surgery and Clinical Anatomy. 2019;3(2):34-6. doi:10.17116/ operhirurg2019302134
- Paraskevas KI, Kalmykov EL, Naylor AR. Stroke/ Death Rates Following Carotid Artery Stenting and Carotid Endarterectomy in Contemporary Admin-istrative Dataset Registries: A Systematic Review. European Journal of Vascular and Endovascular Surgery. 2016;51(1):3-12. doi: 10.1016/j.ejvs.2015.07.032
- Ahmad W, Deeb H, Otto C, et al. Long-term out-comes of open and endovascular treatment of recurrent carotid artery stenosis – a 16-year retrospective single centre case series. Vasa. 2020;49(1):23-9. doi: 10.1024/0301-1526/a000824
- Piffaretti G, Tarallo A, Franchin M, et al. Out-come Analysis of Carotid Cross-Clamp Intolerance during Carotid Endarterectomy under Locoregional Anesthesia. Annals of Vascular Surgery. 2017; 43:249-57. doi: 10.1016/j.avsg.2016.11.024
- Montisci R, Sanfilippo R, Bura R, et al. Status of the circle of Willis and intolerance to carotid cross-clamping during carotid endarterectomy. European Journal of Vascular and Endovascular Surgery. 2013;45(2):107-12. doi: 10.1016/j.ejvs.2012.11.012
- Myrcha P, Lewczuk A, Jakuciński M, et al. The Anatomy of the Circle of Willis Is Not a Strong Enough Predictive Factor for the Prognosis of Cross-Clamping Intolerance during Carotid Endarterectomy. Journal of Clinical Medicine. 2020;9(12): 3913. doi: 10.3390/jcm9123913
- Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351(9113):1379-87.
- Lutz H-J, Michael R, Gahl B, et al. Local versus general anaesthesia for carotid endarterectomy – improving the gold standard? European Journal of Vascular and Endovascular Surgery. 2008;36(2): 145-9;
- discussion 150-1. doi: 10.1016/j.ejvs.2008.03.009
- Harky A, Chan JSK, Kot TKM, et al. General Anesthesia Versus Local Anesthesia in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. Journal of Cardiothoracic and Vascular Anesthesia. 2020;34(1):219-34. doi: 10.1053/j.jvca. 2019.03.029
- Kretz B, Abello N, Astruc K, et al. Influence of the contralateral carotid artery on carotid surgery out-come. Annals of Vascular Surgery. 2012;26(6):766-74. doi: 10.1016/j.avsg.2011.12.009
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