冠状动脉合并颈动脉粥样硬化性狭窄患者同期血运重建七例临床分析

Clinical analysis of synchronous revascularization in treating concomitant coronary artery disease and carotid artery stenosis

目的探讨同期行颈动脉及冠状动脉血运重建治疗冠心病合并颈动脉粥样硬化性狭窄的临床经验,评估其安全性及可行性。方法回顾性分析2018年12月至2020年10月于首都医科大学宣武医院心脏外科与神经外科连续收治的7例冠心病合并颈动脉粥样硬化性狭窄患者,均同期行不停跳冠状动脉旁路移植术(CABG)和颈动脉内膜切除术(CEA)或颈动脉支架置入术(CAS)。7例患者中,男6例,女1例;年龄57~67岁,平均(62±4)岁;冠状动脉DSA示,4例为左主干+3支病变,2例为3支病变,1例为双支病变;颈动脉DSA示,1例为单侧颈动脉闭塞,6例存在双侧颈动脉粥样硬化性狭窄,双侧狭窄率≥50%且靶血管狭窄率≥80%,包括对侧中度狭窄(50%~69%)4例、重度狭窄(≥70%)1例。所有患者优先处理颈动脉病变,再行冠状动脉旁路移植术。收集并分析所有患者的人口学资料(性别、年龄)、危险因素(高血压病、糖尿病、高脂血症、吸烟史)及临床资料,临床资料包括病变特征(颈动脉责任病变侧别、冠状动脉病变部位及其狭窄程度)、围手术期及随访等情况。结果7例冠心病合并颈动脉粥样硬化性狭窄患者中,3例同期行CAS+不停跳CABG,3例同期行CEA+不停跳CABG,1例同期行CEA+CAS+不停跳CABG。术后住院期间2例患者出现低血压(收缩压<90 mmHg),1例患者出现短暂性脑缺血发作。围手术期无死亡,无新发心肌梗死以及脑梗死等并发症。术后随访患者7例,随访时间6~19个月,1例再发间断头晕症状入院就诊,为双侧颈动脉病变,拒绝再次手术;1例因胸闷症状入院,冠状动脉CTA示桥血管及吻合口显影良好;其余患者无主要心脑血管不良事件以及死亡发生。结论初步分析显示,同期行颈动脉及冠状动脉血运重建术可考虑作为冠心病合并颈动脉粥样硬化性狭窄患者的一种治疗选择,但需进一步验证。

Objective To evaluate the clinical feasibility and safety of simultaneous coronary and carotid artery revascularization in the treatment of coronary artery disease combined with carotid artery stenosis.Methods From December 2018 to October 2020,we retrospectively analyzed 7 cases who underwent synchronous off-pump coronary artery bypass grafting(CABG)and carotid endarterectomy(CEA)or carotid artery stenting(CAS)in the Department of cardiac surgery and the Department of Neurosurgery of Xuanwu Hospital,Capital Medical University.Among the 7 patients,6 were males and 1 was female.The average age was(62±4)years,ranging from 57 to 67 years old.Coronary artery DSA showed 4 cases of left main artery+3 vessel lesions,2 cases of 3 vessel lesions and 1 case of double vessel lesions.Carotid DSA showed that 1 case was unilateral carotid artery occlusion,6 cases had bilateral carotid atherosclerotic stenosis with stenosis rate≥50%and target vessel stenosis rate≥80%,including 4 cases of contralateral moderate stenosis(50%-69%)and 1 case of severe stenosis(≥70%).All patients were given priority to the treatment of carotid artery disease before coronary artery bypass grafting.Demographic data(gender,age),risk factors(hypertension,diabetes,hyperlipidemia,smoking history)and clinical data including lesion characteristics(responsible side of carotid artery,lesion site and stenosis degree of coronary artery),condition during perioperative period and follow-up were collected and analyzed.Results Among the 7 patients with coronary heart disease complicated with carotid atherosclerotic stenosis,3 patients underwent CAS+off-pump CABG,3 patients underwent CEA+off-pump CABG,and 1 patient underwent CEA+CAS+off-pump CABG.Two patients had hypotension(systolic blood pressure<90 mmHg)and one patient had transient ischemic attack.There was no death,new myocardial infarction and cerebral infarction.Seven patients were followed up for 6 to 19 months.One patient was re-admitted to hospital due to recurrent intermittent dizziness and bilateral carotid artery disease,but the patient refused to receive operation again.One patient was admitted to hospital due to chest tightness.Coronary CTA showed that the bridging vessels and anastomotic stoma were well developed;other patients had no major cardiovascular and cerebrovascular adverse events and death.Conclusion Preliminary analysis showing that simultaneous carotid and coronary revascularization can be considered as a treatment option for patients with coexisting coronary heart disease and carotid atherosclerotic stenosis,but further verification is needed.