颈动脉体瘤切除术中颈内动脉破裂的高危因素分析

Risk factors of rupture of internal carotid artery during surgical resection of carotid body tumor

目的探讨颈动脉体瘤切除术中颈内动脉破裂的高危因素并总结处理经验。方法回顾性分析1991至2016年间在中山大学附属第一医院行颈动脉体瘤切除术过程中发生颈内动脉破裂的27例患者（28侧病变）的临床和随访资料。针对同时期所有接受颈动脉体瘤切除患者，使用Logistic回归分析探讨术中颈内动脉破裂的高危因素。结果28例病变中，瘤体直径≥5 cm有15例（53.6%），Shamblin Ⅲ型病变有20例（71.4%）。术中使用转流管8例（28.6%），行颈外动脉结扎13例（46.4%），行颅神经切除2例（7.1%）。术中使用直接缝补/补片修复16例、自体血管修复10例及人工血管修复2例。术后出现脑梗死4例（14.3%），颅神经损伤15例（53.6%）。中位随访时间36（14～125）个月，仍有颅神经损伤表现者5例（20%）。影像学检查提示治疗血管闭塞3例（10.7%）。无新发脑梗死病例。回归分析中，女性（OR＝3.650，P＝0.012）、年龄≤25岁（OR＝3.710，P＝0.013）及Shamblin Ⅲ型病变（OR＝4.631, P＝0.008）增加术中颈内动脉破裂的风险。结论Shamblin Ⅲ型病变是术中颈内动脉破裂的高危因素。阻断颈内动脉过程中，适当诱导性升压、肝素化、针对脑侧支循环不良者使用转流管，可望减少脑梗死的发生。

ObjectiveTo investigate risk factors of rupture of internal carotid artery resection during carotid body tumor resection and to summarize our treatment experience.MethodsDuring the period from 1991 to 2016, rupture of internal carotid artery occurred in 27 patients （28 tumors） during surgical resection of carotid body tumor in the First Affiliated Hospital of Sun Yat-sen University. Their clinical and follow-up data were retrospectively collected and analyzed. For all patients underwent surgical resection during this period, Logistic regression analysis was used to investigate the risk factors of intraoperative rupture of internal carotid artery.ResultsOf these 28 tumors, there were 15 （53.6%） tumors with diameter≥5 cm and 20 （71.4%） Shamblin Ⅲ tumors. Intraoperatively, shunt was applied for 8 （28.6%） cases. Thirteen （46.4%） patients underwent ligation of external carotid artery, while 2 （7.1%） patients accepted resection of cranial nerves. Direct closure/patchplasty, autologous vessels or graft reconstruction was used in 16, 10 and 2 cases, respectively. Postoperatively, stroke occurred in 4（14.3%） cases and cranial nerve deficit in 15 （53.6%） cases. During a median length of 36 （14-125） months, cranial nerve deficit persisted in 5 cases. Follow-up radiologic examination indicated 3 （10.7%） cases of targeted vessel occlusion. However, no new-onset stroke was identified. Among all patients underwent surgical resection of carotid body tumor, female （OR=3.650, P=0.012）, age≤25 years old （OR=3.710, P=0.013） and Shamblin Ⅲ tumor （OR=4.631, P=0.008） increase the risks of intraoperative carotid artery rupture.ConclusionsShamblin Ⅲ tumor is the predictor of rupture of internal carotid artery. Intraoperative, properly increased blood pressure, intraoperative heparinization and use of shunt for those cases without well-compensated cranial collateral arteries are likely to decreasing the incidence of stroke.