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1、手術(shù)室中的頸動脈內(nèi)膜切除術(shù)Carotid Endarterectomy(CEA)日照市人民醫(yī)院神經(jīng)外科張玉海 國家遠程卒中中心、腦防委CEA培訓基地、北京市腦血管病中心 外科治療相關(guān)問題麻醉方式（GALA trial）術(shù)式介紹-標準CEA（傳統(tǒng)CEA）-翻轉(zhuǎn)式CEA護士協(xié)作并發(fā)癥的預防 Operation room team position during CEA. S Surgeon, aS assisting surgeon, Ne neurophysiologist；A anaesthesiologist； N nurse；M microscope團隊配置及體位 I. Supine po
2、sition;II. Head up: to reduce cervical venous pressure;III. Head is placed on a ring, with a sandbag under the shoulders;IV. Exposing the full length of the sternomastoid muscle;手術(shù)體位要求 手術(shù)切口 麻醉篇麻醉平穩(wěn)及適時調(diào)整血壓至關(guān)重要 麻醉方式全麻：-General anaesthesia has several advantages, including easier surgical manoeuvres, h
3、andling of complications and easier patient monitoring.局麻：-local/regional anaesthesia decreases the number of medical complicationsat the expense of neurological complications. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trialMethod:
4、a parallel group, multicentre, randomised controlled trial of 3 5 2 6 patients with symptomatic or asymptomatic carotid stenosis from 9 5 centres in 2 4 countries.-general (n=1 7 5 3 ) or local (n=1 7 7 3 ) anaesthesia;-stroke (including retinal infarction), myocardial infarction, or death between r
5、andomisation and 3 0 days after surgery;Conclusion: The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk.兩個組在生活質(zhì)量、住院時間、預設(shè)不同年齡組的結(jié)果、雙側(cè)頸動脈閉塞和手術(shù)風險
6、等方面均無顯著差異。 麻醉的不可替代性掌握術(shù)前有無心臟疾病，缺血性尤為重要術(shù)前的基礎(chǔ)血壓，要明確麻醉平穩(wěn)后開始手術(shù)前的血壓，記錄定標臨時阻斷后可能需要短時升壓至要求值動脈縫合完畢后需要盡快降壓結(jié)合TCCD定出出室后的血壓安全控制范圍 麻醉深度監(jiān)測麻醉深度電極腦氧監(jiān)測 麻醉協(xié)助TCCD術(shù)前定標 術(shù)中阻斷后短時升壓血流再通后積極降壓，不建議用硝普鈉 術(shù)后麻醉與TCCD定控制范圍麻醉機 TCCD監(jiān)測術(shù)中指導意義大術(shù)前麻醉平穩(wěn)后定標主要參考。腦血流峰值、平均值、收縮期、舒張期 Baseline (before induction) Pre-clamp (at heparin injection) Cl
7、amping, shunt insertion (if required) Post-clamping (1 5 min after clamping) Clamp release 5 -min post-release 1 0 -min post-release 術(shù)中監(jiān)測 手術(shù)護理篇熟悉流程能減少動脈阻斷時間器械準備要求高巡回護士及時調(diào)整雙極電凝阻斷前靜脈給肝素腔內(nèi)操作持續(xù)肝素鹽水沖洗術(shù)中沖洗準備兩套吸引裝置 操作流程分離暴露動脈鞘顯微操作階段：切開剝離斑塊、縫合動脈關(guān)閉動脈鞘、分層縫合。 顯微操作前器械 顯微操作前器械 顯微操作中器械 顯微操作中器械 顯微操作中器械 術(shù)中特別注意的問題術(shù)中
8、對血管的保護尤為重要。器械對縫合線的損傷隱患最大。無損傷器械使用。肝素鹽水的高頻率沖洗（1 ml含1 0 u肝素）。肝素：Dose of 5 0 0 0 units of heparin or 3 0 u/kg body weight of intravenous heparin; CEA視頻剪輯.mp4 粥樣斑塊（粥糜樣物）狹窄處的真腔縫隙狹窄真腔 不穩(wěn)定斑塊 術(shù)式標準CEA翻轉(zhuǎn)式CEA Standard CEA technique. P Plaque, T superior thyroid artery, L longitudinal arteriotomyCEA technique wi
9、th intraluminal shunt. IS Intraluminal shunt, R rubber band aroundthe CCA, C window aneurysm clip at the ICA, P plaque, T superior thyroid artery Selective shunting with eversion carotid endarterectomy Modified Eversion Carotid Endarterectomy Ann Vasc Surg 2 0 1 3 ; 2 7 : 1 7 8 1 8 5 手術(shù)涉及的解剖結(jié)構(gòu)耳大神經(jīng)、頸
10、外靜脈頸闊肌、胸鎖乳突肌頸內(nèi)靜脈、面靜脈頸內(nèi)動脈頸總動脈頸袢、舌下神經(jīng)、迷走神經(jīng)、喉上神經(jīng)、面神經(jīng) 頸闊肌External jugular vein: vein is ligated and divided; Arteria branch of the great auricular nerve;Great auricular nerve（耳大神經(jīng)）External jugular vein 頸動脈鞘The jugular vein is not dissected free; it is merely identifi ed and left untouched.觸及CCA，分離方向：向頭端
11、，由CCA, ICA, ECA, superior thyroid arteries；向上：Posterior belly of the digastric muscle（二腹?。?向下：Further exposure: Inferiorly the middle thyroid vein（甲狀腺中靜脈） may require ligation and the omohyoid muscle（肩胛舌骨?。?需耐心處理的：淋巴結(jié)需注意的：觀察心率，必要時應用局麻藥物；不要急于升壓提升心率Posterior belly of the digastric muscle;Hypoglossal n
12、erve 重要標記：The hypoglossal nerve: crosses the internal and external carotid arteries;頸袢：Ansa cervicalis;調(diào)整方向及深度：Self-retaining retractor；此過程輕提血管外膜，分離過程盡量不觸及分叉部或斑塊處；減少斑塊脫落的風險；分離是為臨時阻斷做準備，不要過分游離血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后關(guān)系時，則需將分叉部盡可能分離； 肝素：Dose of 5 0 0 0 units of heparin or 3 0 u/kg b
13、ody weight of intravenous heparin;阻斷順序：-The first clip is applied to the ICA, then one each to the ECA and the superior thyroid artery and finally to the CCA.（試阻斷）-Clamps were applied sequentially to the superior thyroid artery, the common carotid artery, internal carotid artery, and the external ca
14、rotid artery.（持續(xù)阻斷）-返血：分別提起ECA，ICA阻斷帶；或源于咽升A，使用較大的阻斷夾完全阻斷ECA； 重要標記：The hypoglossal nerve: crosses the internal and external carotid arteries;頸袢：Ansa cervicalis;調(diào)整方向及深度：Self-retaining retractor；此過程輕提血管外膜，分離過程盡量不觸及分叉部或斑塊處；減少斑塊脫落的風險；分離是為臨時阻斷做準備，不要過分游離血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后關(guān)系時，則需將分叉
15、部盡可能分離； 動脈切開：longitudinal arteriotomy注意刀片方向：Cutting edge outwards so that once the lumen is entered, the blade can be drawn outwards to commence a longitudinal arteriotomy.技巧：切開動脈壁時：可標記切口，以確保方向； The arteriotomy is slightly lateral to the midline (from the surgeons point of vision); especially at the
16、 bifurcation it runs some 3 mm lateral from the upper aspect of the bifurcation; Potts angle scissors近端: the vessel is palpated to find a target area of lesser disease where the endarterectomy can be stopped;遠端: the arteriotomy on the anterolateral aspect of the internal carotid is taken beyond the
17、severe disease, this being usually within 1 2 centimeters of its origin; Dissector（剝離子的使用）The inner is a thickened, irregular longitudinal length of atheroma with the intima that may be ulcerated and covered with thrombus.The outer layer is yellow and uniform in thickness: it is a layer of thickened
18、 intimomedial fibers that may peel off easily as a circular strip, but which can also be left in situif firmly adherent to the wall. 特殊斑塊處理 Care is necessary when dissecting hard, calcified plaques. Firmer attachments to the outer vessel layers;處置方式：Cut through the plaque to the lumen, cutting it lo
19、ngitudinally until the healthy ICA is reached; The inner core of atheroma is gently mobilized along its length until an end point is reached in the internal carotid artery;It thins down to a transparent thin layer of intima無殘渣：without residual frills.移形處的處理： clean end point must be seen；PIN；The abse
20、nce of any residual frills is tested by flushing and careful excision. Proximally, obtaining a satisfactory end point may be more difficult.Distally, it is advisable to follow the atheroma until it reaches its thin end point;斑塊切斷順序： -The plaque is transversally cut in the most caudal aspect of the a
21、rteriotomy.- the arteriotomy proceeds cranially stepwise always after the segment of the plaque is dissected free. 頸外動脈斑塊處理：-Atheromatous core extends into the external carotid artery, usually for 5 1 0 mm.-Y型切開： ICA斑塊殘端的處理：Technique to secure the distal end of the plaque. In case it is not possible
22、 to remove all remnants of plaque in the distal end of ICA and the intima is loose, tacking sutures are used. The stitches are positioned at 6 , 9 and 1 2 hours “l(fā)ooking into ICA lumen”. The 4 th firm point is the first stitch starting the closure (at 3 hours). RP Residual plaque6 /0 tacking sutures
23、 縫合前的要求：-good end points: all three carotid vessels; -Residual clot is flushed away. I. Closure starts: above the endarterectomy at the upper extreme of the incision.II. 6 /0 running suture;III. Before its completion, the ICA is shortly opened and flushed. The artery is flushed with heparin solution
24、;IV. More knots are used usually 7 and the ends of the stitches are cut longer, some 5 6 mm from the knots. 肝素鹽水沖洗：As the suture line is almost complete, further flooding of the segment with heparinized saline solution is undertaken to remove any residual debris and to fill the segment with fluid, r
25、emoving any air bubbles.短暫松開甲狀腺上A：The loop may be released around the superior thyroid artery to allow blood to fill thesegment, flushing out any remaining bubbles.The internal carotid artery clamp is removed first to ensure that there are no leaks, then the external. I. After the arteriotomy is clo
26、sed, the ICA clip is briefly (1 sec) opened. II. The clips are then removed from the ECA, the superior thyroid artery and the CCA. III. The last to remove is the clip from the ICA. IV. Direct dopplerometry is used to check the patency and disclose any irregularities in the vessels;臨時阻斷夾釋放順序 The arte
27、riotomy usually leaks a small amount and sometimes even a small jet of blood may be encountered.-Add extra stitches?-Leaking arteriotomy is covered for some 3 5 min by muslin soaked in warm Ringer solution;-Covered by a small strip of oxycellulose; suction drain Carotid sheath; Closed in two layers
28、(platysma, skin)縫合后滲血的處理 局部出血的觀察 Hemorrhage: dressing, neck swelling, with or without tracheal compression, and blood collected in the drainage bottle Continued hemorrhage of greater than 1 0 0 ml/h and/or tracheal compression may require reexploration, evacuation of the hematoma and securing hemost
29、asis. 相關(guān)并發(fā)癥 Carrdiac issues: The two possible serious complications likely to occur are myocardial infarction or cardiac failure during the perioperative period and a decrease in blood pressure during the perioperative period. Ipsilateral stroke: drop in blood pressure, vessel thrombosis or by embol
30、isation, from the endarterectomised vessel. Hyperperfusion syndrome Cranial nerve injury: XIIth, VIIth, recurrent nerve Wound: wound haematoma and excessive wound swelling HOW TO AVOID COMPLICATIONS PATIENT SELECTION ANAESTHESIA (gentle and smooth anaesthesia) MONITORING (諸多方面：BP，術(shù)中轉(zhuǎn)流的監(jiān)測，血管縫合后的即刻監(jiān)測，
31、術(shù)后切口的觀察等) DISSECTION AND ENDARTERECTOMY CROSS CLAMPING （ Proper sequence of clip application and removal decreases the risk of perioperative embolisation.） HAEMOSTASIS （ meticulous haemostasis） HEPARIN NON-REVERSAL POST-OPERATIVE CARE 作為術(shù)者參與手術(shù) 術(shù)中解剖演示 術(shù)中解剖演示 We areA Team Believe me, I can. We are sure, we can 您 的 聆 聽
《cea手術(shù)室篇》PPT課件
