叶志东:颈动脉狭窄合并冠心病的治疗策略

2020-12-31 《门诊》杂志 门诊新视野

动脉粥样硬化是一种全身性血管疾病,既可能发生在冠状动脉导致心肌缺血,也可能发生在颈动脉引起脑组织缺血,产生相应症状甚至导致脑卒中。

动脉粥样硬化是一种全身性血管疾病,既可能发生在冠状动脉导致心肌缺血,也可能发生在颈动脉引起脑组织缺血,产生相应症状甚至导致脑卒中。冠心病患者往往合并存在颈动脉狭窄,有6%~20.5%的冠心病患者合并颈动脉狭窄。近期在首届“乐真”血管论坛 2018会议上,来自中日友好医院心脏血管外科的叶志东教授分享了他在颈动脉狭窄合并冠心病诊疗方面的临床经验。

临床现状

在临床上经常会遇到冠心病合并颈动脉狭窄的患者。Hertzer教授等曾在《新英格兰医学杂志》上发表过一篇纳入506例患者的报道,其中需行颈动脉内膜剥脱术(carotid endarterectomy, CEA)且合并冠心病(Coronary Artery Disease, CAD)的患者比例高达65%。这些患者中,30%的患者CAD病变严重但仍处于代偿期病变,28%患者CAD病变严重但临床尚可以治疗,有7%患者CAD病变严重且无法彻底治疗。临床上,降低卒中发生率是除颈动脉狭窄治疗外,围手术期需要关注的热点问题。另外,多项研究表明颈动脉狭窄会影响冠状动脉旁路移植术(coronary artery bypass surgery, CABG)的治疗效果。

治疗手段

对于颈动脉狭窄的治疗,可以分为颈动脉内膜剥脱术(carotid endarterectomy, CEA)或者颈动脉支架置入术(carotid artery stenting, CAS),冠状动脉狭窄的治疗可以采用冠状动脉旁路移植术(coronary artery bypass surgery, CABG)或者经皮冠状动脉介入治疗(percutaneous transluminal coronary intervention, PCI)。所以临床治疗策略需考虑有效的血运重建、围手术期安全以及长期改善脏器血供后得出众多排列组合:同期手术(CEA+CABG)、分期手术(CEA/EEA-CABG)、同期介入(CAS+PCI)、同期杂交(CEA+PCI/CAS+CABG)、分期介入(CAS-PCI/PCI-CAS)以及分期杂交(CAS-CABG/CEA-PCI)。

对于合并两种疾病的患者,可以同期治疗或者分期治疗。如果同期手术,将会增加手术的复杂性、手术时间以及手术风险。而行分期手术,未处理的病变风险仍然存在,可能会引起卒中或者心肌梗死。那么该如何权衡呢?对此,研究者们进行了相关研究。

一项荟萃分析纳入12项研究,其中包括17,469例同期手术(CEA+CABG),7,552例分期手术。结果显示,两组患者围手术期卒中、心梗、死亡等发生率无明显差异。

克利夫兰医学中心的经验显示,分期CAS-OHS(open heart surgery,开放性心脏手术)与同期CEA+OHS在近期有着相似死亡率、中风和心肌梗死发生率。然而,一年以后,分期CAS-OHS组,上述风险显著降低。另外,分期CEA-OHS会增加治疗期间的心肌梗死发生率,所以应尽量避免。分期CAS-OHS和同期CEA+OHS的策略中,治疗期间的心肌梗死风险及围手术期中风也是需重点考虑的问题。
指南与经验分享

国外对这类患者的治疗,给出了相关的指南推荐(Table 1)。叶志东教授同样分享了中日友好医院的在处理这类患者上的临床经验(Figure 1)。

Table 1



心脏手术前颈动脉重建的指南

Figure 1

中日友好医院临床治疗策略

总 结

颈动脉狭窄临床治疗中,要重视冠心病的筛查

对有症状性颈动脉重度狭窄,合并不稳定心绞痛时,同期治疗可以作为治疗手段之一。

对无症状颈动脉狭窄,合并冠心病时,应先处理冠心病,然后处理颈动脉狭窄。

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