高龄病人颈动脉内膜切除术的围手术期处理

Perioperative management of carotid endarterectomy for advanced-age patients

目的探讨高龄（≥75岁）病人接受颈动脉内膜切除术（carotid endarterectomy，CEA）的围手术期处理策略。方法回顾性分析59例75岁以上因颈动脉重度狭窄而行CEA的病例资料。术前均行颈部血管多普勒超声、经颅多普勒超声（TCD）、头颈部CT血管造影（CTA）等检查，证实存在颅外段颈内动脉重度狭窄（狭窄率70％～99％）。评估颅内外血流交通情况和心脏功能，监控血压、血糖，术前持续服用阿司匹林及阿托伐他汀钙。术中采用TCD、体感诱发电位、脑电图、有创动脉血压等监测手段．保证血压平稳，严格把握转流管使用指征．尽量减少术中阻断时间，应用肝素，手术操作轻柔、保护神经。术后留置皮下引流管、压迫切口，监控血压，清除自由基，复查TCD，继续口服阿司匹林及阿托伐他汀钙，保持血容量充足。结果59例病人均成功实施CEA．其中术后出现手术对侧肢体偏瘫1例，脑高灌注1例，声音嘶哑2例，低血压2例，高血压1例。术后随访3-36个月，上述并发症均逐渐好转，均未出现术侧颈动脉再狭窄。结论对高龄病人施行CEA，应在围手术期进行严密评估与监测，可有效预防术后并发症发生，对降低病死率、提高生存质量和延长生命具有重要意义。

Objective To discuss the perioperative management strategy for carotid endarterectomy （CEA） in advanced-age patients. Methods Clinical data of 59 advanced-age patients with carotid severe stenosis undergoing CEA were analyzed retrospectively. Severe carotid artery stenosis （stenosis rate 70% to 99%） was diagnosed by neck vascular Doppler ultrasound, intracranial Doppler ultrasonography （TCD）, head and neck CT angiography （CTA）. The communication of intracranial and extracranial blood flows and heart function were assessed, blood pressure and blood sugar were monitored, aspirin and atorvastatin calcium were taken before operation. Stable blood pressure was guaranteed by TCD, somatosensory evoked potential monitoring, electroencephalography and invasive arterial. The indication of shunt tube placement was controlled strictly and blocking time was minimized. Heparin was used. All of the operations were done softly to protect the nerve. The drainage tube was placed, incision oppressed, blood pressure monitored, free radicals were scavenged, TCD was reperformed, aspirin and atorvastatin calcium were sequentially given to patients, and adequate blood volume was maintained after the operation. ResultS The CEA was performed successfully in 59 patients. After the operation, contralateral extremity hemiplegia occurred in 1 patient, cerebral hyperperfusion in 1, hoarseness in 2, hypotension in 2 and hypertension in 1. The follow-up was performed for 3-36 months in all patients, and the quality of life was improved without restenosis postoperation. Conclusions The advanced-age patients should be closely estimated and monitored during the perioperative management of CEA for preventing complications, which is important for reducing mortality, improving the life quality and prolonging the life-span of the patients.