頸動脈内膜剝離術の適応と手術手技 はじめに 頸動脈狭窄症に対する手術適応 第 49 回総会パネルディスカッション 2 頸動脈狭窄の治療をめぐって. 2 J Jpn Coll Angiol, 2010, 50:

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1 Online publication August 20, 2010 総 説 第 49 回総会パネルディスカッション 2 頸動脈狭窄の治療をめぐって 頸動脈内膜剝離術の適応と手術手技 1, 2 2 要旨 : randomized study J Jpn Coll Angiol, 2010, 50: Key words: carotid endarterectomy, surgical indication, surgical technique, surgical timing はじめに CEA randomized study CEA 頸動脈狭窄症に対する手術適応 1 Randomized study 3 class I prospective study prospective study 4, 5 Asymptomatic Carotid Atherosclerosis Study ACAS 1 60 medical 5.1 vs 11.0 / 5 years p= number needed to treat NNT 17 sub-analysis CEA CEA Asymptomatic Carotid Surgery Trial ACST immediate CEA deferral CEA CEA medication randomized 5 immediate CEA 6.4 deferral CEA 11.8 immediate CEA benefit ACAS ACST CEA CEA recommendation 6 5 CEA morbidity & mortality 3.3 Table CEA THE JOURNAL of JAPANESE COLLEGE of ANGIOLOGY Vol. 50,

2 Randomized study a stroke 8 JACS stroke 9 risk factor 10 best medication b irregularity stroke risk 10, 11 CEA B- 12 black blood MRI Screening MRA time of flight TOF 3D gradient-echo BB hyperintensity 13 T1 hyperintensity vulnerable plaque lipid necrotic core intraplaque hemorrhage 14, 15 2 NASCET 16 ECST study 70 medical CEA NASCET 70 CEA medical 2 17 NNT medical p=0.045 NNT CEA 18 ECST 70 CEA 70 CEA 17 CEA perioperative stroke and death NASCET 5.8 ECST 5.6 CEA 18, morbidity & mortality 4.2 Table 1 Surgical result in patients with asymptomatic and symptomatic carotid artery stenosis Table 1 near occlusion CEA 20 Near occlusion CEA Mortality Morbidity Total Asymptomatic (N=180) 2.2% 1.1% 3.3% Symptomatic (N=280) 1.7% 2.5% 4.2% N; number of patients CEA 1 6 ICA Level A 2 50 CEA Level A, CEA Level B 6 CEA 5 CEA 6 手術手技 21, S 8 10 cm Fig 脈管学 Vol. 50, 2010

3 1 Figure 1 Skin incision. S-shaped skin incision is performed along to the anterior margin of Sternocleidomastoid muscle. wandering vagus D-CTA 24 CEA 21, 22 5 mm Fig. 2 21, 22, 25 Figure 2 Dissection of the distal side of internal carotid artery in patients with high position stenosis. Occipital artery and Sternocleidomastoid artery are cut and Ansa cervicalis is also cut at the 5 mm distal side from hypoglossal nerve and hypoglossal nerve is elevated by pincette. Then distal side of internal carotid artery can be dissected. 1: common carotid artery, 2: internal carotid artery, 3: external carotid artery, 4: superior thyroid artery, 5: occipital artery (cut), 6: distal side of occipital artery (cut), 7: hypoglossal nerve, 8: Ansa cervicalis (cut), 9: vagus nerve, 10: digastric muscle, P: pincette CEA 2 CEA 25 somatosensory evoked potentials SEP transcranial Doppler TCD near infra-red spectoroscopy NIRS 5 cc 3 SEP TCD SEP amplitude 50 CEA 脈管学 Vol. 50,

4 intimal flap 7-0 stay suture CEA ACT , mm Table 2 Surgical result of CEA and CAS in patients with symptomatic carotid artery stenosis CEA (N=49) CAS (N=15) Mortality 0% 0% Morbidity 0% N; number of patients 6.7% (1/15) Cerebral infarction Table 3 Surgical result of CEA and CAS in patients with asymptomatic carotid artery stenosis CEA (N=32) Mortality 0% CAS (N=17) 5.9% (1/17) AAA rupture after CABG Morbidity 0% 0% N; number of patients, AAA; abdominal aortic aneurysm, CABG; coronary artery bypass grafting 手術の timing について 2004 Lancet 26 CEA 2 TIA nondisabling stroke 2 CEA benefit benefit 27 1 CEA 4 CEA vulnerable plaque LDL 28 CEA か CAS か? CEA high risk CAS CEA 29 CEA CAS randomized study CAS 30, 31 CEA high risk CEA CAS randomized study CEA CEA high risk CAS 5 CEA 81 CAS 32 Table 2,3 high risk CAS CEA mortality & morbidity 0 CAS high risk CEA CAS おわりに prospective randomized study CEA CEA 1 CEA 脈管学 Vol. 50, 2010

5 1 文献 1 Executive Committee for the Asymptomatic Carotid Atherosclerosis Study: Endarterectomy for asymptomatic carotid artery stenosis. JAMA, 1995, 273: Halliday A, Mansfield A, Marro J et al: Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet, 2004, 363: Hobson RW 2nd, Weiss DG, Fields WS et al: Efficacy of carotid endarterectomy for asymptomatic carotid stenosis. The Veterans Affairs Cooperative Study Group. N Engl J Med, 1993, 328: The CASANOVA Study Group: Carotid surgery versus medical therapy in asymptomatic carotid stenosis. Stroke, 1991, 22: Mayo Asymptomatic Carotid Endarterectomy Study Group: Results of a randomized controlled trial of carotid endarterectomy for asymptomatic carotid stenosis. Mayo Clin Proc, 1992, 67: Chaturvedi S, Bruno A, Feasby T et al: Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Carotid endarterectomy-an evidencebased review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 2005, 65: Liapis CD, Bell PR, Mikhailidis D, ESVS Guidelines Collaborators: ESVS guidelines. Invasive treatment for carotid stenosis: indications, techniques. Eur J Vasc Endovasc Surg, 2009, 37: Muluk SC, Muluk VS, Sugimot H et al: Progression of Asymptomatic carotid stenosis: a natural history study in 1004 patients. J Vasc Surg, 1999, 29: JCAS JCAS Fisher M, Paganini-Hill A, Martin A et al: Carotid plaque pathology: thrombosis, ulceration, and stroke pathogenesis. Stroke, 2005, 36: Jellyfish sign plaque Neurosonology Screening black-blood MRI No Shinkei Geka Saam T, Hatsukami TS, Takaya N et al: The vulnerable, or highrisk, atherosclerotic plaque: noninvasive MR imaging for characterization and assessment. Radiology, 2007, 244: Yoshida K, Narumi O, Chin M et al: Characterization of carotid atherosclerosis and detection of soft plaque with use of black-blood MR imaging. AJNR Am J Neuroradiol, 2008, 29: North American Symptomatic Carotid Endarterectomy Trial Collaborators: Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med, 1991, 325: European Carotid Surgery Trialists Collaborative Group, MRC European Carotid Surgery Trial: Interim results for symptomatic patients with severe (70-99%, or with mild (0-29%, carotid stenosis. Lancet, 1991, 337: Barnett HJ, Taylor DW, Eliasziw M et al: Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med, 1998, 339: Moore WS, Barnett HJ, Beebe HG et al: Guidelines for carotid endarterectomy, A multidisciplinary consensus statement from the Ad Hoc Committee, American Heart Association. Stroke, 1995, 26: Rothwell PM, Eliasziw M, Gutnikov SA et al: Carotid Endarterectomy Trialists Collaboration. Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet, 2003, 361: CEA XVII Carotid endarterectomy CEA Sundt TM: Surgical and functional anatomy of the carotid triangle. In Occlusive cerebrovascular disease. Diagnosis and surgical management. Sundt TM, Philadelphia, WB Saunders Co., 1987, Wei CJ, Chang FC, Chiou SY et al: Aberrant ascending pharyngeal artery mimicking a partially occluded internal carotid artery. J Neuroimaging, 2004, 14: CEA Rothwell PM, Eliasziw M, Gutnikov SA et al: Carotid Endart- 脈管学 Vol. 50,

6 erectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet, 2004, 363: Rothwell PM, Eliasziw M, Gutnikov SA et al: Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke, 2004, 35: Suzue A, Uno M, Kitazato TK et al: Comparison between early and late carotid endarterectomy for symptomatic carotid stenosis in relation to oxidized LDL and plaque vulnerability. J Vasc Surg, 2007, 46: Yadav JS, Wholey MH, Kuntz RE et al: Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy Investigators: Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med, 2004, 351: Mas JL, Chatellier G, Beyssen B et al, EVA-3S Investigators: Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. N Engl J Med, 2006, 355: SPACE Collaborative Group, Ringleb PA, Allenberg J, Brückmann H et al: 30 day results from the SPACE trial of stentprotected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet, 2006, 368: Surgical Indication and Technique for Patients with Carotid Artery Stenosis Masaaki Uno 1, 2 and Shinji Nagahiro 2 1 Deparment of Neurosurgery, Kawasaki Medical School, Okayama, Japan 2 Deparment of Neurosurgery, The University of Tokushima, Tokushima, Japan Key words: carotid endarterectomy, surgical indication, surgical technique, surgical timing Carotid endarterectomy (CEA) is recommended in symptomatic patients with > 50% stenosis if the perioperative stoke/death rate is < 6%, preferably within 2 weeks of the patient s last symptoms. CEA is also recommended in asymptomatic patients with > 60% stenosis if the perioperative stoke/death rate is < 3%. We provide an outline of CEA technique under the anatomical findings, including high position stenosis. Carotid patch angioplasty is preferable technique to primary closure. For the present, carotid artery stenting should be performed only in patients at high-risk for CEA. (J Jpn Coll Angiol, 2010, 50: ) Online publication August 20, 脈管学 Vol. 50, 2010