両側内頸動脈高度狭窄あるいは閉塞病変の治療方針  [in Japanese] Treatment Strategy for Patients with Bilateral Internal Carotid Severe Stenosis or Occlusion  [in Japanese]

Carotid endarterectomy(CEA) is surgical treatment for cervical carotid stenosis according to medical evidence. Indications of STA-MCA anastomosis has been established recently based on the Japanese EC-IC Bypass Trial(JET Study). However, surgical management of multiple stenosis and/or occlusion of the internal carotid artery(ICA) remains controversial. In the present study, we investigated the surgical indication and order for the bilateral lesions. Bilateral ICA stenotic and/or occlusive lesions were divided into 2 groups: ICA occlusion and contralateral severe stenosis(Group I) and bilateral ICA occlusion except moyamoya disease(Group 2). Nine patients in Group 1 and 6 patients in Group 2 were treated between March 2002 and February 2006 in our institute. In Group 1, in principle, we performed STA-MCA anastomosis on the occlusion side first, followed by separate contralateral CEA. In case of repeated stroke caused by the carotid stenosis, CEA was the first treatment, followed by STA-MCA anastomosis on the contralateral side. In Group 2, we gave priority of surgical treatment(STA-MCA anastomosis) over a symptomatic side. Based on these treatment strategies, all of the cases in both groups had a good outcome without postoperative complications. However, we needed to control blood pressure strictly in some cases because of contralateral un-treated lesions, particularly in cases with hyperperfusion after the first surgical treatment. Treatment guidelines should be established for the multiple ICA lesions, which have various and complicated pathological conditions. Patients with these lesions can be treated safely by adequate perioperative management.