不同转流标准对颈动脉内膜切除术后脑梗死的影响

Effect of different shunt strategies on cerebral infarction after carotid endarterectomy

目的:颈动脉内膜切除术(carotid endarterectomy,CEA)的麻醉管理要点是颈动脉阻断期间维持足够的颅脑灌注,放置转流管是外科常用方法之一,分析CEA手术不同转流标准对术后脑梗死的影响。方法:回顾收集2年内全身麻醉下接受CEA手术的443例患者,根据不同转流标准分为影像组(以术前影像学资料作为是否转流的依据)和残端压组(以术中残端压作为是否转流的依据)。分析患者术前人口学资料、既往病史、颈部血管狭窄程度、围术期各时间点血压情况、血管阻断时间、是否放置转流管、术后住院时间、住院期间脑梗死和其他不良事件,进行组间对比,在此基础上对组间差异有统计学意义的术前、术中情况进行倾向性评分匹配,分析不同转流标准对术后发生脑梗死的影响。结果:影像组患者268例、残端压组患者175例均接受全身麻醉下CEA手术,两组间基本情况和各时间点血压差异有统计学意义。经倾向性评分匹配后,匹配出影像组和残端压组各105例患者,两组患者的术前基本情况、各时间点血压差异无统计学意义。两组患者术后脑梗死发生率差异无统计学意义(1.9%vs.1.0%,P>0.999),影像组术中转流率明显低于残端压组(0 vs.22.9%,P<0.001),影像组患者术后住院时间8(7,8)d明显长于残端压组5(4,6)d(P<0.001)。结论:依据术前影像学检查决定是否转流的患者组中,术中转流管使用率低于依据术中残端压决定是否转流的患者组,两组患者术后住院期间脑梗死的发生率差异无统计学意义,不同转流标准对患者脑梗死的影响有待于进一步深入研究。

Objective:The key point of anesthesia management in carotid endarterectomy(CEA)is to maintain adequate cerebral perfusion during carotid artery occlusion.Placement of shunt is one of the common surgical methods.This study analyzed the effects of different shunt strategies on cerebral infarction after carotid endarterectomy.Methods:A total of 443 patients who underwent CEA under general anesthesia within 2 years were divided into imaging group(based on preoperative imaging data as the basis for shunt)and stump pressure group(based on intraoperative stump pressure as the basis for shunt).The preoperative demographic data,past medical history,degree of cervical vascular stenosis,blood pressure at each time point during the perioperative period,vascular blocking time,whether to place the shunt,postoperative hospital stay,cerebral infarction during hospitalization,and other adverse events were collected and compared between the two groups.On this basis,the preoperative and intraoperative conditions with significant differences were matched with propensity scores,and the influence of different shunt strategies on postoperative cerebral infarction was analyzed.Results:In the study,268 patients in the imaging group and 175 patients in the stump pressure group underwent CEA under general anesthesia.There were statistically significant differences in basic conditions and blood pressure at each time point between the two groups.After matching the propensity scores,105 patients in each of the two groups were matched.The basic conditions of the patients before surgery and the difference in blood pressure of the two groups at each time point were not statistically significant.There was no significant diffe-rence in the incidence of postoperative cerebral infarction between the two groups(1.9%vs.1.0%,P>0.999).The intraoperative shunt rate in the imaging group was lower than that in the stump pressure group(0 vs.22.9%,P<0.001).The postoperative hospital stay in the imaging group was 8(7,8)days,which was longer than the stump pressure group 5(4,6)days(P<0.001).Conclusion:The rate of the shunt was lower according to preoperative imaging examination than that according to the residual pressure in our hospital.There is no significant difference in the incidence of cerebral infarction during the postoperative hospital stay.The effect of different shunt strategies on cerebral infarction needs further study.