内膜剥脱联合腔内技术治疗慢性症状性长段颈内动脉闭塞的疗效分析

Efficacy analysis of carotid endarterectomy combined with endovascular technique in treatment of long-segment chronic symptomatic internal carotid artery occlusion

背景与目的:对于慢性症状性长段颈内动脉闭塞(ICAO),内膜剥脱术(CEA)与腔内介入手术均有各自的局限性,但两者联合使用的复合手术治疗的效果研究仍较少。因此,本研究探讨CEA联合腔内技术治疗慢性症状性ICAO的安全性和有效性。方法:回顾性分析2017年3月—2019年6月我科37例行复合手术治疗的长段慢性ICAO(至少累及岩段及以上)患者临床资料。所有患者闭塞起始于颈段(C1段),闭塞远端位于海绵窦段(C4段)及以下者共20例(近端组),闭塞远端位于床突段(C5段)及以上者17例(远端组)。分析患者手术前后临床症状的变化、手术前后改良Rankin量表(mRS)及术后3~6个月复查CTA情况。结果:37例患者均接受复合手术治疗,其中30例成功开通闭塞段血管,手术成功率为81.1%。近端组的总体开通率为95.0%(19/20),其中C2段、C3段开通率均为100%,C4段开通率为87.5%(7/8);远端组的总体开通率为64.7%(11/17),其中C5段开通率为66.7%(6/9),C6段开通率为57.1%(4/7),C7段开通率为100%(1/1)。近端组总体开通率高于远端组(P=0.033)。开通患者的临床症状较术前不同程度的减轻,术后复查的CTA显示颈内动脉通畅,术后1周复查PWI显示颅内灌注血流动力学指标均较术前明显改善。30例开通患者获随访6~17个月,靶血管通畅率为90.0%(27/30),其中近端组94.7%(18/19),远端组为81.8%(9/11),两组差异无统计学意义(P=0.543);术后6个月患者mRS评分较术前明显好转(t=6.238,P<0.01)。结论:CEA联合腔内技术治疗慢性症状性ICAO是一种安全、可行的治疗方法,且颈内动脉闭塞远端至海绵窦段及以下的患者其开通成功率较高。

Background and Aims:For long-segment chronic symptomatic internal carotid artery occlusion(ICAO),either carotid endarterectomy(CEA)or endovascular surgery has its respective limitations.However,the reports on the efficacy of their combined surgery are still not enough.Therefore,this study was conducted to investigate the safety and effectiveness of CEA combined with endovascular technique in the treatment of chronic symptomatic ICAO.Methods:The clinical data of 37 patients with long-segment chronic ICAO(involving at least the petrous or more distal segments)undergoing combined surgery from March 2017 to June 2019 were retrospectively analyzed.The proximal occlusion lesion located at the cervical segment(C1 segment)in all patients,the distal occlusion lesion extended to the cavernous segment(C4 segment)or more proximal segments in 20 patients(proximal group),and the distal occlusion lesion extended to clinoid segment or more distal segments in 17 patients(distal group).The changes in clinical symptoms,the scores of the modified Rankin scale(mRS)before and after operation as well the CTA reviewed 3 to 6 months after operation of the patients were analyzed.Results:All 37 patients with received combined surgical treatment,of whom,the occluded segment in 30 cases were successfully recanalized,and the surgical success rate was 81.1%.In proximal group,the overall recanalization rate was 95.0%(19/20),in which,the recanalization rate for either C2 or C3 segment was 100%,and for C4 segment was 66.7%(6/9);in distal group,the overall recanalization rate was 64.7%(11/17),in which,the recanalization rate for C5 segment was 66.7%(6/9),C6 segment was 57.1%(4/7)and C7 segment was 100%(1/1).The overall recanalization rate in proximal group was significantly higher than that in distal group(P=0.033).The clinical symptoms were improved to different extents in the recanalized patients,the postoperative CTA demonstrated a patent right internal carotid artery,and the PWI images at 1 week after operation showed that the intracranial perfusion hemodynamic indicators were significantly improved compared with their preoperative conditions.Follow-up was conducted for 6 to 17 months in the 30 recanalized patients,the patency rate of the target vessel was 90.0%(27/30),which was 94.7%(18/19)in proximal group and 81.8%(9/11)in distal group,and the difference was no significant between the two groups(P=0.543).The mRS score of the patients at 6 months after operation was significantly better than that before operation(t=6.238,P<0.01).Conclusion:CEA combined with endovascular technique is a safe and feasible method for the treatment of chronic symptomatic ICAO,and the recanalization rate is higher in patients with distal ICA occlusion at the cavernous more proximal segments.