颈部动脉血流重建治疗重症多发性大动脉炎导致脑缺血

Treatment of severe cerebral ischemia in Takayasu＇s disease with arterial reconstruction

目的观察多发性大动脉炎导致的重度脑缺血外科治疗的效果，并评估经颅多普勒超声（TCD）在手术中的作用。方法2003年3月至2008年2月，共治疗16例多发性大动脉炎患者，男性4例，女性12例；平均年龄32岁，平均病程7．5年。临床表现主要为头晕、头痛、眩晕和眼部视力障碍等。DSA和血管彩色多普勒超声显示多数患者的颈动脉和椎动脉有不同程度的病变。8例患者行升主动脉（主动脉弓）-双腋（肱）／锁骨下动脉人工血管旁路移植术；3例行升主动脉-双腋（肱）／锁骨下动脉人工血管旁路移植-单侧颈内动脉自体大隐静脉旁路移植术；3例行升主动脉-一侧锁骨下动脉和颈动脉人工血管旁路移植术；2例单纯行升主动脉-右颈内动脉自体大隐静脉旁路移植术，其中1例同时行升主动脉-一侧颈内动脉和冠状动脉旁路移植术。有4例在原来接受升主动脉．双腋动脉人工血管旁路移植的基础上，又行一侧人工血管-一侧颈内动脉自体大隐静脉旁路移植术。14例患者术中采用TCD监测双侧大脑中动脉血流，2例尝试分别经一侧锁骨下穿刺和一侧股动脉穿刺与颈动脉穿刺临时转流。结果手术成功率为100％，无死亡病例。手术后出现伸舌歪斜3例，术后2周缓解。脑部缺血症状与体征均有不同程度的改善，总的有效率为100％。全部患者获得随访，平均随访时间2．2年。所有患者未出现症状复发。2例患者术后4年内出现吻合口处动脉瘤，1例为双侧。结论颈部动脉血流重建是治疗多发性大动脉炎导致脑缺血的有效方法。术中TCD监测大脑中动脉的血流变化，并据此调整血压，对于预防脑缺血后的过度灌注有重要作用。

Objective To evaluate the effect of surgical bypass and to explore the role of transeranial doppler （TCD） during the bypass operation. Methods From March 2003 to February 2008, sixteen patients （4 male and 12 female） with mean age of 32 years old and mean disease course of 7. 5 years were treated by surgical procedures. The main clinical presentations were dizziness, headache, vertigo, and visional dysfunction. Variated degree of artery stenoses in the 4 arteries （bilateral carotid and vertebral arteries） were revealed by color doppler ultrasonography and DSA. Eight patients underwent aorto- bisubclaivian arteries prosthetic graft bypass. Three patients underwent aorto-bisubclaivian artery prosthetic graft bypass and graft-unilateral caroticd artery bypass with autologous great saphenous vein. Three patients underwent aorta-unilateral subclavian artery-unilateral carotid artery prosthetic graft bypass. Two patients underwent aortocarotid artery bypass with autologous great saphenous vein, of which one patient underwent aortocoranary artery bypass simultaneously. Cerebral blood supply was monitored in 14 patients with transcranial doppler. Unilateral subclaviocarotid and femrocarotid artery shunt was used respectively to avoid cerebral ischemia during operation in 2 patients. Results Symptoms and signs of cerebral ischemia improved in all patients with effective rate of 100% apart from deflected tongue-protrusion in 3 patients which recovered in 2 weeks after operation. All patients survived and no symptoms recurred at the end of a 2. 2 year＇s follow-up. Unfortunately, two patients developed aneurysm at the anastomosis within 4 years after operation. Condusions Arterial reconstruction is an effective method for Takayasu＇s disease with severe cerebral ischemia. TCD monitoring plays an important role during the bypass operation. It can help to determine the revision of blood pressure and prevent postoperative brain reperfusion injury.