1、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.S
2、upine 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 man
3、oeuvres,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 trial Me
4、thod: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
5、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
6、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 i
7、nsertion(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
8、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CEA Standard CEA technique.P Plaque,T superior thyroid artery,L longitudinal arteriotomy CEA techni
9、que with intraluminal shunt.IS Intraluminal shunt,R rubber band around the 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 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
10、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C
11、CA,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 nerv
12、e 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 weigh
13、t 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.
14、（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：lon
15、gitudinal 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 run
16、s 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 thro