颅外颅内旁路手术2013年.ppt

颅外-颅内动脉旁路手术：历史、现状与展望 EXTRACRANIAL-INTRACRANIAL BYPASS SURGERY PAST, PRESENT AND FUTURE,解放军总医院神经外科 全军神经外科研究所 Dept of Neurosurg, General Hospital of PLA Institute of Neurosurg, Chinese PLA,Pioneers of Bypass Procedures ● Jacobson(1960)(Vermont) Reconstructed carotid arteries of dogs and rabbits, achieving a 100% patency rate ● Donaghy (Vermont) Established microsurgical lab, reconstructed vessels 1mm in diameter,旁路手术的先驱 ● Jacobson(1960)(佛蒙得） 重建犬和兔颈动脉，100% 通畅 ● Donaghy (佛蒙得） 建立显微神经外科实验室， 重建直径1mm的血管,HISTORY OF BYPASS PROCEDURES,旁路手术历史,M.G. Yasargil & His Contributions ● Interest was stimulated when he was asked to perform an embolectomy of a cortical artery, not yet mastered. ● Enthusiasm to cerebral revas- cularization increased after the report of an EC-IC bypass,M.G.Yasargil及其贡献 ● 其兴趣因一例皮层动脉取栓 术（尚未掌握该技术）激发 ● Woringer(1963) EC/IC 旁路手术论文的发表进一步 引起其热情,● 1964 International Congress of Neuroradiologists Drs. Sweet and Rasmussen advised him to contact prof. Donaghy 1965 Yasargil began his training in Donagh’s lab. 1964年，国际神经放射大会，Sweet 和Rasmussen 建议其与 Donaghy联 系。

1965年，开始在Donaghy实验室 训练● Initial attempts to interpose a femoral vascular graft from CCA to MCA. The graft would progress to thrombosis. The idea of performing STA-MCA bypass was then born. ● By the end of 1966 more than 30 STA-MCA bypass in dogs had been performed,● 初始时，作CCA-股部血管 移植物-MCA术，但移植血 管内血栓形成 产生STA-MCA旁路术设想 ● 至1966年底完成30余例犬 STA-MCA旁路术,Oct. 30, 1967 Yasargil performed the first STA-MCA bypass, in a patient with Marfan syndrome and complete occlusion of MCA A major step was made into the field of reconstructive intracranial vascular microneurosurgery. 1967年，Yasargil为一例Marfan综合征伴大脑中动脉闭塞者成功施行首例STA-MCA旁路术 颅内血管重建的重要进展！,●,Cerebral Ischemia ● Since 1967 STA-MCA bypass had been wide accepted, although the indications remained controversial by the end of 1960’. Dr.Zang renhe performed the first case of STA-MCA bypass in China(1976).,脑缺血 ● 1967年后，STA-MCA被广泛应 用，尽管到六十年代末，其适应 证仍有争议。

臧人和教授于1976年在国内首先开展STA-MCA旁路术INDICATIONS FOR BYPASS,,旁路手术应用,● 1977 North American EC-IC Bypass Study (by Dr. Henry Barnett),● 1977年开始的北美EC-IC旁路研究,内科治疗组 714例 0.6% STA-MCA+内科 663例 2.5%,30天死亡和致残、卒中率,Conclusion: STA-MCA was ineffective in preventing cerebral ischemia,结论：STA-MCA不能防止脑缺血,● Failure of extracranial-intra- cranial arterial bypass to reduce the risk of ischemic stroke. Results of an inter- national randomized trial. The EC/IC Bypass Study Group. N Engl J Med 313:1191-1200, 1985 ● Marked decrease in the number of STA-MCA bypass performed for cerebral ischemia,● 颅内-外动脉旁路术不能降 低缺血性卒中的风险。

国际 随机试验结果EC/IC研究 组，新英格兰医学313:1191, 1985 ● STA-MCA旁路手术量明显 减少,● Criticism to EC/IC Bypass Study ▲ Patients were not evaluated preoperatively cerebrovascular hemodynamic status ▲ Both patient and therapist were not blined ▲ Only half of the patients receiving antiplatelet agents ▲ A large percentage of patients had no symptoms before entry ▲ A large number of patients underwent surgery outside the study,● 对EC/IC旁路研究的批评 ▲ 未评估病人术前的脑血流动力 状态 ▲ 非双盲研究 ▲仅半数病人接受抗血小板治疗 ▲ 相当部分病人入组前无症状 ▲许多手术病人未纳入研究,● The study investigators pointed out that randomized trials involve only a small fraction of the population at risk and that this factor does not prevent a study from be- ing valid.,● 研究组人员回应 承认该随机试验仅包括小部 分卒中风险人群，但并不影 响试验的可靠性,● The Carotid Occlusion Surgery Study Randomized Trial(COSS) U.S and Canada, 49 clinical centers 18 PET centers (2002~2010 ),● 颈动脉闭塞手术随机研究（COSS） 美国、加拿大 49 个临床中心 18个PET中心 (2002~2010),30天同侧卒中 2年终点事件 手术组（STA-MCA+内科治疗） 97例 14（14.4%） 20（21.0%） 内科组（抗栓+危险因素控制） 98例 2（2.0%） 20（22.7%）,Conclusion: EC-IC bypass did not reduce the risk of recurrent ipsilateral ischemic stroke at 2 years. JAMA,306:1983,2011,结论：EC/IC旁路术不能降低同 侧缺血性卒中的风险 JAMA,306:1983,2011,● For patients with symptomatic extracranial carotid occlusion, EC/IC bypass is not routinely recommended ( Class Ⅲ Evidence A) ● For patients with stroke or TIA due to 50% to 99%stenosis of a major intracranial artery, EC/IC bypass is not recommended (Class Ⅲ Evidence B) AHA/ASA Guidelines for the Prevention of stroke 2011,● 症状性颅外颈动脉闭塞，通常不推荐 旁路术（Ⅲ级推荐，A级证据）,● 颅内主要动脉狭窄50%以上，不推荐 旁路术 （Ⅲ级推荐，B级证据） 美国心脏学会/卒中学会 2011版卒中 预防指南,● Extracranial-Intracranial Bypass for Stroke — Is This the End of the Line or a Bump in the Road? Neurosurgery 71:557,2012,● 颅内外旁路手术预防卒中— 路 到尽头，还是（又一）撞击？ 神经外科 71:557,2012,● Although general expansion of EC/IC bypass use would not be supported, a select subset of patients with medically refractory hemodynamic symptoms may well benefit from surgery. ● Limited application and further study with an eye to future developments, rather than complete abandonment, is warranted.,● 虽然不支持广泛开展，但对某些 药物治疗无效的血动力学损害的 病。