CABG术前颈动脉重度狭窄亚满意血管成形术有效性和安全性分析

Effectiveness and safety of submaximal angioplasty and stenting for patients with severe carotid artery stenosis before CABG

目的探讨分析CABG术前症状性颈动脉重度狭窄的亚满意球囊扩张和小直径支架置入术的有效性和安全性。方法回顾性纳入2016年1月至2019年12月期间首都医科大学附属北京安贞医院神经介入科连续30例冠状动脉粥样硬化性心脏病(冠心病)左主干或冠状动脉三支病变合并颈内动脉重度狭窄(≥70%)患者,行小球囊亚满意扩张及小直径支架置入术,收集患者一般资料、临床和影像资料等。30例中冠心病左主干病变6例,三支病变24例。既往同侧颈动脉狭窄伴脑梗塞24例,短暂性脑缺血发作6例。技术成功定义为颈内动脉支架成形术后前向血流mTICI3级,且残余狭窄<50%。围手术期并发症定义为颈动脉支架置入术和CABG术后30天内出现急性缺血性或出血性卒中、急性冠状动脉综合征和全因性死亡。亚满意成形定义为球囊扩张和支架成形至靶血管管腔直径的80%。结果全组手术成功29例(96.7%,29/30)。出现围手术期并发症1例,为颈动脉支架置入术后急性冠状动脉综合征。术后随访30天,短暂性脑缺血发作和脑梗塞各1例,无心脏相关并发症。结论CABG术前接受亚满意球囊扩张和小直径支架置入术安全可行,可减少颈动脉狭窄介入术中迷走反射所致急性冠状动脉综合征不良事件和CABG围手术期低灌注致急性缺血性卒中发生。

Objective To investigate the feasibility and safety of submaximal balloon dilation and to perform small-diameter stent for symptomatic carotid artery severely stenosis before coronary artery bypass grafting(CABG).Methods From January 2016 to December 2019,30 patients of the Department of Neurointervention in Beijing Anzhen Hospital with symptomatic carotid artery stenosis(≥70%)and the left main trunk or triple-vessel of coronary artery disease were analyzed retrospectively.General information,clinical characteristics,and imaging data of all cases were collected.All patients underwent submaximal balloon dilation and small-diameter stent implantation.Preoperative comorbidities or risk factors included hypertension 23 cases(76.7%),diabetes 10 cases(33.3%),hyperglycemia 14 cases(46.7%),moking 13 cases(43.3%).Left main trunk disease 6 cases(20.0%),three-vessels disease 24 cases(80.0%),mitral regurgitation 1 case(3.3%),stable angina 25 cases(83.3%),myocardial infarction 8 cases(26.7%),cerebral infarction 24 cases(80.0%)and transient ischemia attack(TIA)6 cases(20.0%)caused by ipsilateral carotid artery stenosis.The median National Institutes of Health Stroke Scale(NIHSS)score was 2(0-3),and the median modified Rankin Scale(mRS)score was 1(0-1)before the operation.The mean interval between carotid artery intervention and CABG was(23.4±8.2)days.Results 29 cases(96.7%,29/30)underwent CAS-CABG operation successfully.In one case of carotid artery extreme tortuosity,the emboli protective device could not place the distal carotid artery.In the operative procedure,27 cases(90.0%,27/30)underwent with 3mm diameter balloon,only 3 cases(10.0%)with 3 mm balloon after pre-dilatation with 2 mm diameter balloon because of severely high-grade stenosis(99%).25 cases(83.3%)with 7mm diameter stents and 5 cases(16.7%)with 6 mm diameter stents,including 22 cases(73.3%)with a closed-cell stent and 8 cases(26.7%)with an open-cell stent.In the perioperative period,the heart rate of two patients was lower than 50 BPM during operation and returned to normal after using atropine immediately.Another patient presented with chest tightness during interventional therapy.TNI elevation was examined urgently.After oxygen inhalation and intravenous infusion of Nitroglycerin,the patient's symptoms improved rapidly.No cardiac and cerebrovascular complications occurred during the perioperative period of CABG,no cardiac-related complications occurred within 30 days of follow-up,one case of TIA and 1 case of cerebral infarction.After intensive anti-platelet aggregation and lipid-lowering treatment,two patient's symptoms improved.There were no death cases in all patients during carotid artery interventional therapy,perioperative CABG and 30-day follow-up.Thirty days later,we performed a clinical follow-up of 23 cases,median 4.5(3.0-7.9)months,mRS Score Median 1(0-1).One patient presented with TIA,any patient had no symptoms of the cardiac or nervous system.Image follow-up of 17 cases,median 3.5(2.8-4.5)months,carotid artery ultrasound showed in-stent restenosis(stenosis rate>50%)in 1 case,the patient was asymptomatic restenosis,continue treatment of aggressive anti-platelet and lipid-lowering drugs.Conclusion Submaximal balloon dilation and performing small-diameter stent for symptomatic carotid artery severely stenosis before CABG is safe and feasible,which could not only reduce the incidence of vagus reflex resulted in acute coronary syndrome during carotid artery stenosis intervention but also morbidity of acute ischemic stroke events during CABG.