手术室中的颈动脉内膜切除术Carotid Endarterectomy(CEA)日照市人民医院神经外科张玉海国家远程卒中中心、脑防委CEA培训基地、北京市脑血管病中心外科治疗相关问题麻醉方式（GALA trial）术式介绍-标准CEA（传统CEA）-翻转式CEA护士协作并发症的预防Operation room team position during CEA. S Surgeon, aS assisting surgeon, Ne neurophysiologist；A anaesthesiologist； N nurse；M microscope团队配置及体位团队配置及体位I.Supine position;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;手术体位要求手术体位要求手术切口麻醉篇麻醉平稳及适时调整血压至关重要麻醉方式全麻：-General anaesthesia has several advantages, including easier surgical manoeuvres, handling 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: a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries.-general (n=1753) or local (n=1773) anaesthesia;-stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 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.两个组在生活质量、住院时间、预设不同年龄组的结果、双侧颈动脉闭塞和手术风险等方面均无显著差异。麻醉的不可替代性掌握术前有无心脏疾病，缺血性尤为重要术前的基础血压，要明确麻醉平稳后开始手术前的血压，记录定标临时阻断后可能需要短时升压至要求值动脉缝合完毕后需要尽快降压结合TCCD定出出室后的血压安全控制范围麻醉深度监测麻醉深度电极脑氧监测麻醉协助TCCD术前定标术中阻断后短时升压血流再通后积极降压，不建议用硝普钠术后麻醉与TCCD定控制范围麻醉机麻醉机TCCD监测术中指导意义大术前麻醉平稳后定标主要参考。脑血流峰值、平均值、收缩期、舒张期 Baseline (before induction) Pre-clamp (at heparin injection) Clamping, shunt insertion (if required) Post-clamping (15 min after clamping) Clamp release 5-min post-release 10-min post-release术中监测术中监测手术护理篇熟悉流程能减少动脉阻断时间器械准备要求高巡回护士及时调整双极电凝阻断前静脉给肝素腔内操作持续肝素盐水冲洗术中冲洗准备两套吸引装置操作流程分离暴露动脉鞘显微操作阶段：切开剥离斑块、缝合动脉关闭动脉鞘、分层缝合。显微操作前器械显微操作前器械显微操作中器械显微操作中器械显微操作中器械术中特别注意的问题术中对血管的保护尤为重要。器械对缝合线的损伤隐患最大。无损伤器械使用。肝素盐水的高频率冲洗（1ml含10u肝素）。肝素：Dose of 5000 units of heparin or 30 u/kg body weight of intravenous heparin;CEA视频剪辑.mp4粥样斑块（粥糜样物）粥样斑块（粥糜样物）狭窄处的真腔缝隙狭窄处的真腔缝隙狭窄真腔狭窄真腔不稳定斑块术式标准CEA翻转式CEAStandard CEA technique. P Plaque, T superior thyroid artery, L longitudinal arteriotomyCEA technique with intraluminal shunt. IS Intraluminal shunt, R rubber band aroundthe CCA, C window aneurysm clip at the ICA, P plaque, T superior thyroid arterySelective shunting with eversion carotid endarterectomyModified Eversion Carotid EndarterectomyAnn Vasc Surg 2013; 27: 178185手术涉及的解剖结构耳大神经、颈外静脉颈阔肌、胸锁乳突肌颈内静脉、面静脉颈内动脉颈总动脉颈袢、舌下神经、迷走神经、喉上神经、面神经颈阔肌颈阔肌External jugular vein: vein is ligated and divided; Arteria branch of the great auricular nerve;Great auricular nerve（耳大神经）External jugular vein颈动脉鞘The jugular vein is not dissected free; it is merely identifi ed and left untouched.触及CCA，分离方向：向头端，由CCA, ICA, ECA, superior thyroid arteries；向上：Posterior belly of the digastric muscle（二腹肌）;向下：Further exposure: Inferiorly the middle thyroid vein（甲状腺中静脉） may require ligation and the omohyoid muscle（肩胛舌骨肌）;需耐心处理的：淋巴结淋巴结需注意的：观察心率，必要时应用局麻药物；不要急于升压提升心率Posterior belly of the digastric muscle;Hypoglossal nerve 重要标记：The hypoglossal nerve: crosses the internal and external carotid arteries;颈袢：Ansa cervicalis;调整方向及深度：Self-retaining retractor；此过程轻提血管外膜，分离过程尽量不触及分叉部或斑块处；减少斑块脱落的风险；分离是为临时阻断做准备，不要过分游离血管；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，而是前后关系时，则需将分叉部尽可能分离；肝素：Dose of 5000 units of heparin or 30 u/kg body weight of intravenous heparin;阻断顺序：-The first clip is applied to the ICA, then one each to the ECA and the superior thyroid artery and finally to the CCA.（试阻断）-Clamps were applied sequentially to the superior thyroid artery, the common carotid artery, internal carotid artery, and the external carotid artery.（持续阻断）-返血：分别提起ECA，ICA阻断带；或源于咽升A，使用较大的阻断夹完全阻断ECA；重要标记：The hypoglossal nerve: crosses the internal and external carotid arteries;颈袢：Ansa cervicalis;调整方向及深度：Self-retaining retractor；此过程轻提血管外膜，分离过程尽量不触及分叉部或斑块处；减少斑块脱落的风险；分离是为临时阻断做准备，不要过分游离血管；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，而是前后关系时，则需将分叉部尽可能分离；动脉切开：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：切开动脉壁时：可标记切口，以确保方向； The arteriotomy is slightly lateral to the midline (from the surgeons point of vision); especially at the 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;远端: the arteriotomy on the anterolateral aspect of the internal carotid is taken beyond the severe disease, this being usually within 12 centimeters of its origin;Dissector（剥离子的使用）（剥离子的使用）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 intimomedial fibers that may peel off easily as a circular strip, but which can also be left in situif firmly adherent to the wall.特殊斑块处理Care is necessary when dissecting hard, calcified plaques. Firmer attachments to the outer vessel layers;处置方式：Cut through the plaque to the lumen, cutting it longitudinally 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无残渣：无残渣：without residual frills.移形处的处理：移形处的处理： clean end point must be seen；PIN；The absence 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;斑块切断顺序：斑块切断顺序： -The plaque is transversally cut in the most caudal aspect of the arteriotomy.- the arteriotomy proceeds cranially stepwise always after the segment of the plaque is dissected free.颈外动脉斑块处理：颈外动脉斑块处理：-Atheromatous core extends into the external carotid artery, usually for 510 mm.-Y型切开：型切开：ICA斑块残端的处理：Technique to secure the distal end of the plaque. In case it is not possible 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 12 hours “looking into ICA lumen”. The 4th firm point is the first stitch starting the closure (at 3 hours). RP Residual plaque6/0 tacking sutures缝合前的要求：缝合前的要求：-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;IV.More knots are used usually 7 and the ends of the stitches are cut longer, some 56 mm from the knots.肝素盐水冲洗：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, removing any air bubbles.短暂松开甲状腺上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 closed, 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;临时阻断夹释放顺序临时阻断夹释放顺序The arteriotomy 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 35 min by muslin soaked in warm Ringer solution;-Covered by a small strip of oxycellulose;suction drainCarotid sheath; Closed in two layers (platysma, skin)缝合后渗血的处理缝合后渗血的处理局部出血的观察Hemorrhage: dressing, neck swelling, with or without tracheal compression, and blood collected in the drainage bottleContinued hemorrhage of greater than 100 ml/h and/or tracheal compression may require reexploration, evacuation of the hematoma and securing hemostasis.相关并发症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 embolisation, from the endarterectomised vessel.Hyperperfusion syndromeCranial nerve injury: XIIth, VIIth, recurrent nerveWound: wound haematoma and excessive wound swellingHOW TO AVOID COMPLICATIONSPATIENT SELECTIONANAESTHESIA (gentle and smooth anaesthesia)MONITORING (诸多方面：BP，术中转流的监测，血管缝合后的即刻监测，术后切口的观察等)DISSECTION AND ENDARTERECTOMYCROSS CLAMPING （ Proper sequence of clip application and removal decreases the risk of perioperative embolisation.）HAEMOSTASIS （ meticulous haemostasis）HEPARIN NON-REVERSALPOST-OPERATIVE CARE作为术者参与手术术中解剖演示术中解剖演示We areA TeamBelieve me, I can.We are sure, we can您的聆听