颈动脉内膜切除术与支架成形术治疗颈动脉粥样硬化狭窄

Experience on the management of extracranial carotid atherosclerotic stenosis with CEA and CAS

[目的]介绍应用CEA和CAS治疗颈内动脉粥样硬化狭窄的体会。[方法]收集32例症状性颈内动脉狭窄患者资料,其中,4例行颈动脉内膜切除术,28例行腔内成形、支架置入术,应用脑保护装置12例。初步结果评价以术后30 d狭窄同侧有否卒中发生或死亡,应用彩色超声随访观察。[结果]CAS 30 d内卒中和死亡发生率分别为14%和3.6%,CEA后并发症和死亡率分别为0%和25% (1/4)。CAS围手术期常见血液动力学不稳定,可见微栓子和冠心病发作。可能与刺激颈动脉窦后持续性低血压有关。应用脑保护装置者无1例发生神经系统并发症。[结论]与CEA比较,脑保护装置下的经皮血管内支架术,治疗颈动脉粥样硬化狭窄,同样具有安全性和有效性。在以后的研究中,进一步探讨CAS治疗的长期效果,阐明血管内治疗颈动脉狭窄病人的选择标准。

[Objective] To describe the experience on the treatment of severe symptomatic or asymptomatic atherosclerotic carotid artery stenosis with CEA and CAS. [Methods] CAS or CEA were performed on 32 patients suffering from extracranial atherosclerotic stenosis of the internal carotid artery （ 〉 80%, symptomatic or asymptomatic） of the 32 asymptomatic patients received CAS, 4 （12.5%） received CEA. Distal embolic protection was used for 12 patients in CAS procedures. The primary outcome was determined by the apperance of major ipsilateral stroke and/or death 30 d after operation. Duplex ultrasound examinations were performed during follow-up. [Results] Combined 30 d stroke and death rates after CAS were 14% and 3.6% （1/28） in patients. After CEA, these rates were 0% and 25% （1/4）, respectively. Perioperative hemodynamic instabihty was more common among patients in the CAS group. This included a minor stroke and a coronary artery disease in the same individual. Both events were attributed to sustained postprocedural hypotension probably induced by increased carotid sinus activity. Better protection was obtained with a cerebral protection device during CAS. [Conclusion] Percutaneous carotid stenting with neuroprotection provides comparable clinical success to CEA. Further studies are warranted to validate the long-term efficacy of CAS and to elucidate patient selection criteria for endovascular carotid revascularization.