同期显微手术治疗颈动脉合并冠状动脉重度狭窄的临床疗效

Clinical efficacy of synchronous carotid endarterectomy combined with coronary artery bypass grafting in patients with severe carotid and coronary stenosis

目的:观察同期行颈动脉内膜切除术(CEA)联合冠状动脉旁路移植术(CABG)治疗颈动脉重度狭窄合并冠状动脉重度狭窄患者的疗效。方法:前瞻性研究2014年9月至2019年9月北京大学第三医院神经外科联合心脏外科同期行CEA+CABG的颈动脉重度狭窄合并冠状动脉重度狭窄患者的临床资料,共30例。观察围手术期并发症,随访患者的疗效。结果:30例患者中,围手术期新发脑干梗死1例(3.3%),因手术牵拉喉返神经引起声嘶1例(3.3%),MRI显示3例(10.0%)有新发梗死灶(均为无症状者,术后1~3个月梗死灶消失)。术后1~3个月头颈部和冠状动脉血管造影均行检查者21例,均未见颈动脉再狭窄和冠状动脉桥血管狭窄、闭塞。30例患者的中位随访时间为44.7(6.0~67.2)个月,1例(3.3%)因肺部感染发生呼吸功能衰竭,术后6个月死于多器官功能衰竭。29例存活者中,术后随访满1年者26例,其中25例行影像学随访,无一例发生再狭窄;满2年者22例,其中1例术前为支架内重度狭窄者,手术剥离了斑块和支架,术后18个月复查发现无症状再狭窄,再次行支架置入术,术后2年复查未见明显狭窄;满5年者1例。至随访末期均未出现新发心脑血管意外事件;部分患者心功能改善,末次随访时心功能分级Ⅰ级者9例,Ⅱ级者19例,因呼吸功能衰竭及脑干梗死无法评价者2例。结论:同期行CEA+CABG手术治疗颈动脉重度狭窄合并冠状动脉重度狭窄安全、有效。

Objective To evaluate the efficacy of synchronous carotid endarterectomy(CEA)combined with coronary artery bypass grafting(CABG)for patients with concomitant severe carotid and coronary stenosis.Methods The clinical data of 30 patients who underwent CEA+CABG surgeries from September 2014 to September 2019 at Department of Neurosurgery and Department of Cardiac Surgery,Peking University Third Hospital were prospectively analyzed.We documented the perioperative complications and followed up the therapeutic effects in those cases.Results Among 30 cases,brain stem infarction occurred perioperatively in 1 patient(3.3%),hoarseness occurred in 1 patient(3.3%)due to the stretching of laryngeal recurrent nerve,and MRI revealed new infarction lesions in 3 patients(10.0%),which were all asymptomatic and completely disappeared after 1-3 months.Twenty-one patients underwent head and neck angiography at 1-3 months post surgery,and no carotid restenosis or coronary artery bridge restenosis was reported.The median follow-up time of 30 patients was 44.7(6.0-67.2)months.Respiratory failure due to lung infection occurred in 1 patient(3.3%)who died of multiple organ failure after 6 months.Among the remaining 29 survivors,26 had been followed up for 1 year after surgery,and 25 underwent imaging follow-up showing no restenosis.Twenty-two patients had been followed up for 2 years.One patient was diagnosed as severe in-stent stenosis before synchronous operations,for whom the stent and carotid plaque were removed during CEA.At 18 months post operation,asymptomatic restenosis was reported in that patient who underwent carotid artery stenting(CAS)again,and no obvious stenosis was found at 2-year follow-up.One patient had been followed up for 5 years.No new cardio-cerebral vascular accidents occurred at the end of follow-up.Some patients showed improvement of cardiac function.By the end of the latest follow-up,the patient’s heart function was graded as classⅠin 9 cases,classⅡin 19 cases,and could not be evaluated because of respiratory failure and brain stem infarction in 2 cases.Conclusion Synchronous CEA and CABG surgeries are safe and effective for patients with concomitant severe carotid and coronary stenosis.