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抄録
反対側頚動脈強度狭窄・閉塞の症例のうち,術前バルーン閉塞試験で5分以内に脳虚血由来の症状が出現する場合は,通常の内シャント挿入でも虚血性合併症をきたす可能性があると考えている.当科では,このような症例に対して体外循環シャントを使用し,術中の遮断時間をゼロにするような工夫をしてきた.現在は狭窄病変が長く,通常の内シャント挿入までに時間を要するような症例や,頚動脈遮断下に頚動脈剥離を行ったほうが安全な頚動脈偽性動脈瘤といった症例にも応用している.全例で体外循環シャントを形成,維持することが可能であり,安全に手術を行うことができた.周術期合併症を認めた症例もなく,より安全に頚動脈手術を行うためのdeviceになりうると思われた.
Carotid endarterectomy (CEA) is a well established procedure for the prevention of cerebral infarction secondary to carotid artery stenosis, but the use of intraluminal shunt during CEA remains controversial. We have used intraluminal shunt selectively if the collateral blood supply is insufficient during cross clamping. The ischemic tolerance is investigated by carotid artery balloon test occlusion before insertion of the intraluminal shunt during CEA for patients with contralateral carotid severe stenosis or occlusion. If ischemic symptoms, such as paralysis, develop within 5 minutes after the test occlusion, we think that insertion of the intraluminal shunt carries the risk of ischemic complication. Therefore, we use femoral-internal carotid extraluminal shunt instead of intraluminal shunt, which allows us to perform CEA without interrupting the blood flow to the brain. In addition, the extraluminal shunt can supply blood to the brain without relying on blood pressure, because the blood flow is supplied by a roller pump. We have also applied this technique to patients with long segment common carotid stenosis who require more time to insert the intraluminal shunt than usual, and patients with carotid pseudoaneurysm who require carotid cross clamping during CEA. The femoral-internal carotid extraluminal shunt could be placed in all cases without problems, and CEAs were performed without complications. Femoral-internal carotid extraluminal shunt can reduce perioperative complications in patients who have potential risks associated with insertion of an intraluminal shunt.
