頸部内頸動脈狭窄症に対する頸動脈内膜剥離術―安全な手術を目指して工夫していること―

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We will outline our surgical techniques and treatment strategies of CEA to prevent peri-operative complications. Between 1997 and 2006, 234 CEAs were performed on 205 patients, 128 of which were symptomatic, while 106 were asymptomatic. Prior to surgery, all patients were screened by cardiologists to elucidate congestive and/or ischemic heart disease (IHD). If coronary artery stenosis was present, it was treated before surgery. CEA was performed under general anesthesia using a “hitch-up” maneuver and with or without shunting according to a number of intraoperative parameters. For high-risk cases with higher carotid bifurcation, we prepared a special mouthpiece to achieve mandibular subluxation and expose the distal ICA for easy access. For patients with long-segmental lesions or contralateral ICA occlusion, and for those who seemed to be intolerant to intraoperative temporary occlusion of the ICA, we used an extracorporeal circulation technique. Postoperative management was as follows: 1) Overnight sedation with intubation to avoid postoperative bleeding and airway obstruction, and 2) SPECT on postoperative days (POD) 1 and 4 to predict hyperperfusion syndrome. Among 128 symptomatic cases, perioperative stroke occurred in 5 (minor stroke in 3 and cerebral hemorrhage in 2 cases), making surgical morbidity and the mortality rate within 1 month of the CEAs 1.7% and 0.4%, respectively. Cranial nerve palsies were seen in 8 cases (6.2%), but all recovered within 1 month. Conversely, 106 asymptomatic cases had no surgical morbidity or mortality except for temporary cranial nerve palsies (6 cases: 5.7%). During the long-term follow-up of 32 months, minor stroke occurred in 2 patients (1.0%), and 12 patients (5.1%) died of causes other than stroke, including 1 myocardial infarction. As for high-risk cases (92 cases), cumulative incidence of adverse events (death, stroke, or myocardial infarction) at 30 days and 1 year after CEAs were 3.2% and 5.4%, respectively, which seemed to be acceptable compared with other clinical trials. CEA prevents strokes (even for high-risk patients) quite effectively if carried out with consistent treatment strategies and appropriate technical devices.