Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions.
Impact of external carotid artery occlusion at declamping of the external and common carotid arteries during carotid endarterectomy on development of new postoperative ischemic cerebral lesions.
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颈动脉内膜切除术中颈外动脉和颈总动脉松开时颈外动脉闭塞对术后新的缺血性脑病变发展的影响。
DOI：
10.1016/j.jvs.2018.03.437
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发表时间：
2019
期刊：
影响因子：
--
通讯作者：
Ogasawara K.
中科院分区：
文献类型：
--
作者：
Kobayashi M.;Yoshida K.;Kojima D.;Oshida S.;Fujiwara S.;Kubo Y.;Ogasawara K.
颈外动脉（ECA）在颈动脉内膜切除术（CEA）中意外闭塞。ECA闭塞的重要性已被强调为颅外至颅内侧支循环的损失、慢性栓塞的来源或伤口闭合期间延长血栓形成的部位。本研究旨在确定在动脉内膜切除术期间意外发生的ECA闭塞以及在所有颈动脉开放后使用ECA的血流测量最终检测到的ECA闭塞是否是在ECA和颈总动脉（CCA）开放时夹闭颈内动脉（ICA）时发生新的术后缺血性病变的风险因素。本研究的目的还在于确定是否术中经颅多普勒（TCD）监测预测的风险，发展这样的insulines.MethodsThis是一个前瞻性的观察性研究，包括患者接受CEA严重狭窄（≥70%）的颈部伊卡。当使用电磁流量计测量的通过ECA的血流量在用于动脉内膜切除术的颈动脉夹持之前仅夹持ECA时迅速降低，并且在动脉内膜切除术后颈动脉解除夹持之后仅夹持ECA没有改变时，确定患者已经发展为ECA闭塞。这些患者因ECA接受了额外的动脉内膜切除术。在整个手术过程中还进行了同侧大脑中动脉的TCD监测，以识别微栓塞信号（MES）。脑磁共振弥散加权成像（DWI）进行手术前后。ResultsThere是104例患者参加了这项研究。8例患者在手术过程中发生ECA闭塞。在ECA和CCA开放阶段，无MES患者的术中ECA闭塞发生率（8/12 [67%]）显著高于MES患者（0/92 [0%];P< .0001）。6例患者在DWI上显示新的术后缺血性病变。术中ECA闭塞的发生率（P<0.0001）和ICA夹闭时ECA和CCA开放时无MES（P<0.001）。0001）在DWI上出现新的术后缺血性病变的患者中显著高于未出现的患者。敏感性和特异性的MES在declamping的ECA和CCA的情况下，而夹紧伊卡预测新的术后缺血性病变的发展DWI分别为100%（6/6）和94%（92/98），分别为。术中TCD监测可准确预测此类病变发生的风险。
ObjectiveThe external carotid artery (ECA) is inadvertently occluded during carotid endarterectomy (CEA). The importance of ECA occlusion has been emphasized as a loss of extracranial to intracranial collaterals, a source of chronic embolization, or a site for extended thrombosis during wound closure. This study aimed to determine whether ECA occlusion that inadvertently developed during endarterectomy and that was eventually detected using blood flow measurement of the ECA after declamping of all carotid arteries is a risk factor for development of new postoperative ischemic lesions at declamping of the ECA and common carotid artery (CCA) while clamping the internal carotid artery (ICA). This study also aimed to determine whether intraoperative transcranial Doppler (TCD) monitoring predicts the risk for development of such lesions.MethodsThis was a prospective observational study that included patients undergoing CEA for severe stenosis (≥70%) of the cervical ICA. When blood flow through the ECA measured using an electromagnetic flow meter decreased rapidly on clamping of only the ECA before carotid clamping for endarterectomy and was not changed by clamping of only the ECA after carotid declamping following endarterectomy, the patient was determined to have developed ECA occlusion. These patients underwent additional endarterectomy for the ECA. TCD monitoring in the ipsilateral middle cerebral artery was also performed throughout surgery to identify microembolic signals (MESs). Brain magnetic resonance diffusion-weighted imaging (DWI) was performed before and after surgery.ResultsThere were 104 patients enrolled in the study. Eight patients developed ECA occlusion during surgery. The incidence of intraoperative ECA occlusion was significantly higher in patients without MESs at the phase of ECA and CCA declamping (8/12 [67%]) than in those with MESs (0/92 [0%];P< .0001). Six patients exhibited new postoperative ischemic lesions on DWI. The incidence of intraoperative ECA occlusion (P< .0001) and the absence of MESs at declamping of the ECA and CCA while clamping the ICA (P<. 0001) were significantly higher in patients with development of new postoperative ischemic lesions on DWI than in those without. Sensitivity and specificity for the absence of MESs at declamping of the ECA and CCA while clamping the ICA for predicting development of new postoperative ischemic lesions on DWI were 100% (6/6) and 94% (92/98), respectively.ConclusionsECA occlusion at declamping of the ECA and CCA while clamping the ICA during CEA is a risk factor for development of new postoperative ischemic lesions. Intraoperative TCD monitoring accurately predicts the risk for development of such lesions.