颅外颅内旁路手术2013-03-25.

颅外-颅内动脉旁路手术：历史、现状与展望EXTRACRANIAL-INTRACRANIALBYPASSSURGERYPAST,PRESENTANDFUTURE解放军总医院神经外科全军神经外科研究所DeptofNeurosurg,GeneralHospitalofPLAInstituteofNeurosurg,ChinesePLAPioneersofBypassProcedures●Jacobson(1960)(Vermont)Reconstructedcarotidarteriesofdogsandrabbits,achievinga100%patencyrate●Donaghy(Vermont)Establishedmicrosurgicallab,reconstructedvessels1mmindiameter旁路手术的先驱●Jacobson(1960)(佛蒙得）重建犬和兔颈动脉，100%通畅●Donaghy(佛蒙得）建立显微神经外科实验室，重建直径1mm的血管HISTORYOFBYPASSPROCEDURES旁路手术历史M.G.Yasargil&HisContributions●Interestwasstimulatedwhenhewasaskedtoperformanembolectomyofacorticalartery,notyetmastered.●Enthusiasmtocerebralrevas-cularizationincreasedafterthereportofanEC-ICbypassM.G.Yasargil及其贡献●其兴趣因一例皮层动脉取栓术（尚未掌握该技术）激发●Woringer(1963)EC/IC旁路手术论文的发表进一步引起其热情●1964InternationalCongressofNeuroradiologistsDrs.SweetandRasmussenadvisedhimtocontactprof.Donaghy1965YasargilbeganhistraininginDonagh’slab.1964年，国际神经放射大会，Sweet和Rasmussen建议其与Donaghy联系。1965年，开始在Donaghy实验室训练。●InitialattemptstointerposeafemoralvasculargraftfromCCAtoMCA.Thegraftwouldprogresstothrombosis.TheideaofperformingSTA-MCAbypasswasthenborn.●Bytheendof1966morethan30STA-MCAbypassindogshadbeenperformed●初始时，作CCA-股部血管移植物-MCA术，但移植血管内血栓形成。产生STA-MCA旁路术设想●至1966年底完成30余例犬STA-MCA旁路术Oct.30,1967YasargilperformedthefirstSTA-MCAbypass,inapatientwithMarfansyndromeandcompleteocclusionofMCAAmajorstepwasmadeintothefieldofreconstructiveintracranialvascularmicroneurosurgery.1967年，Yasargil为一例Marfan综合征伴大脑中动脉闭塞者成功施行首例STA-MCA旁路术颅内血管重建的重要进展！●CerebralIschemia●Since1967STA-MCAbypasshadbeenwideaccepted,althoughtheindicationsremainedcontroversialbytheendof1960’.Dr.ZangrenheperformedthefirstcaseofSTA-MCAbypassinChina(1976).脑缺血●1967年后，STA-MCA被广泛应用，尽管到六十年代末，其适应证仍有争议。臧人和教授于1976年在国内首先开展STA-MCA旁路术。INDICATIONSFORBYPASS旁路手术应用●1977NorthAmericanEC-ICBypassStudy(byDr.HenryBarnett)●1977年开始的北美EC-IC旁路研究内科治疗组714例0.6%STA-MCA+内科663例2.5%30天死亡和致残、卒中率Conclusion:STA-MCAwasineffectiveinpreventingcerebralischemia结论：STA-MCA不能防止脑缺血●Failureofextracranial-intra-cranialarterialbypasstoreducetheriskofischemicstroke.Resultsofaninter-nationalrandomizedtrial.TheEC/ICBypassStudyGroup.NEnglJMed313:1191-1200,1985●MarkeddecreaseinthenumberofSTA-MCAbypassperformedforcerebralischemia●颅内-外动脉旁路术不能降低缺血性卒中的风险。国际随机试验结果。EC/IC研究组，新英格兰医学313:1191,1985●STA-MCA旁路手术量明显减少●CriticismtoEC/ICBypassStudy▲Patientswerenotevaluatedpreoperativelycerebrovascularhemodynamicstatus▲Bothpatientandtherapistwerenotblined▲Onlyhalfofthepatientsreceivingantiplateletagents▲Alargepercentageofpatientshadnosymptomsbeforeentry▲Alargenumberofpatientsunderwentsurgeryoutsidethestudy●对EC/IC旁路研究的批评▲未评估病人术前的脑血流动力状态▲非双盲研究▲仅半数病人接受抗血小板治疗▲相当部分病人入组前无症状▲许多手术病人未纳入研究●Thestudyinvestigatorspointedoutthatrandomizedtrialsinvolveonlyasmallfractionofthepopulationatriskandthatthisfactordoesnotpreventastudyfrombe-ingvalid.●研究组人员回应承认该随机试验仅包括小部分卒中风险人群，但并不影响试验的可靠性●TheCarotidOcclusionSurgeryStudyRandomizedTrial(COSS)U.SandCanada,49clinicalcenters18PETcenters(2002~2010)●颈动脉闭塞手术随机研究（COSS）美国、加拿大49个临床中心18个PET中心(2002~2010)30天同侧卒中2年终点事件手术组（STA-MCA+内科治疗）97例14（14.4%）20（21.0%）内科组（抗栓+危险因素控制）98例2（2.0%）20（22.7%）Conclusion:EC-ICbypassdidnotreducetheriskofrecurrentipsilateralischemicstrokeat2years.JAMA,306:1983,2011结论：EC/IC旁路术不能降低同侧缺血性卒中的风险JAMA,306:1983,2011●Forpatientswithsymptomaticextracranialcarotidocclusion,EC/ICbypassisnotroutinelyrecommended(ClassⅢEvidenceA)●ForpatientswithstrokeorTIAdueto50%to99%stenosisofamajorintracranialartery,EC/ICbypassisnotrecommended(ClassⅢEvidenceB)AHA/ASAGuidelinesforthePreventionofstroke2011●症状性颅外颈动脉闭塞，通常不推荐旁路术（Ⅲ级推荐，A级证据）●颅内主要动脉狭窄50%以上，不推荐旁路术（Ⅲ级推荐，B级证据）美国心脏学会/卒中学会2011版卒中预防指南●Extracranial-IntracranialBypassforStroke—IsThistheEndoftheLineoraBumpintheRoad?Neurosurgery71:557,2012●颅内外旁路手术预防卒中—路到尽头，还是（又一）撞击？神经外科71:557,2012●AlthoughgeneralexpansionofEC/ICbypassusewouldnotbesupported,aselectsubsetofpatientswithmedicallyrefractoryhemodynamicsymptomsmaywellbenefitfromsurgery.●Limitedapplicationandfurtherstudywithaneyetofuturedevelopments,ratherthancompleteabandonment,iswarranted.●虽然不支持广泛开展，但对某些药物治疗无效的血动力学损害的病人，手术可能有益。●有限的应用加上着眼于未来的进一步研究，而不是完全放弃。Acutestroke●Emergentcerebralrevascula-rizationisveryrationalEncouragingresultswerereported.●ButothersconsideredtheacuteischemiaarelativecontraindicationConclusion:OnlythosepatientswithcrescendoTIAormildtomoderatedeficits6hrswithnoinfarctionshouldbeconsideredforEC/ICbypass急性卒中●急诊脑血运重建合理，有报告结果令人鼓舞●其他学者认为，急性缺血是急诊重建的相对禁忌。Crowell,Jafar(1986)报告67例，27例改善，26例无变化，11例死亡结论：EC/IC旁路术仅可用于渐进性TIA或轻至中度缺陷（6hrs）且无梗死者●Withtheadventofinterventionalneuroradiologyandthrombolytictherapies,emergentEC/ICbypassforacutestrokedecreased●介入神经放射和溶栓治疗的出现，使急性卒中的急诊旁路术减少。SAHandCerebralVasospasm●STA-MCAbypasshasbeenperformed●Thisindicationdidnotgainwideacceptance.Endovasculartechniquescombinedwith“3H”therapyassumedapivotalroleSAH与脑血管痉挛●曾采用STA-MCA旁路术Batjer,Samson(1986)报告11例，术后6例改善，2例稳定●未被广泛接受。主要采用血管内技术和“三高”疗法Forty-two-year-oldabuserwithSAHfromamycoticleftmiddlecerebralaneurysm.A,preoperativelateralcarotidinjectionshowsproximalcarotidspasm.B,lateralcommoncarotidangiogram2weeksafterbyp