endarterectomy

As early as the early 1950s, Spence (1951) in the United States first performed endarterectomy. In 1953, DeBakey successfully reconstructed blood flow for endoscopic resection of the complete occlusion of the internal arteries. For half a century, especially after the multi-center large-scale randomized trial results of the Symptoms Endarterectomy Association (NASCET) and the European Association of Arterial Surgery Trials (ECST) were published in 1991, the endarterectomy method was published. There is no doubt about the status of the United States, the annual amount of surgery is as high as 100,000 cases. Treatment of diseases: systemic idiopathic telangiectasia hereditary hemorrhagic telangiectasia Indication Applicable to the internal carotid artery stenosis more than 50% of the original diameter. The patient can be presented as: 1 author of transient cerebral ischemia (TIA); 2 complete stroke; 3 audible vascular murmur; 4 carotid ultrasound examination with stenosis. Those with clinical manifestations, complete cerebral angiography or magnetic resonance angiography (MRA) confirmed that the internal carotid artery stenosis is feasible. Patients with bilateral internal carotid artery stenosis should first do the side that causes the symptoms. Preoperative preparation 1. Carotid ultrasound examination showed cerebral angiography when carotid artery stenosis. 2. Cerebral angiography should include the beginning of the internal carotid artery and whole brain angiography to understand the collateral circulation. 3. Regular CT and MRI examinations to understand the extent of cerebral infarction and brain atrophy. 4. A viable radionuclide brain scan to understand the area of cerebral ischemia in patients with cerebral infarction. 5. Evaluation of heart, lung, kidney function and control of hypertension. 6. Do blood biochemical tests to understand electrolytes and blood lipid levels. Surgical procedure 1. Anesthesia for general anesthesia to keep blood pressure stable. 2. The position is lying flat, the head is turned to the healthy side, the head is fully exposed to the neck, and the head can be raised to an angle of 15° to 20° with the bed surface. 3. Three kinds of incision selection (1) Straight incision: along the sternocleidomastoid muscle, up to the thyroid cartilage, down to the mandibular angle. (2) transverse incision: centered on the sternocleidomastoid muscle. (3) "S"-shaped incision: up to the mastoid, turn forward to the anterior border of the sternocleidomastoid muscle, down to the upper edge of the sternal notch 1~2 fingers. 4. Exposure to the total neck, internal and external carotid arteries, attention to the ligation, shearing and separation of the vagus nerve. Local anesthetics were injected into the carotid sinus to reduce the impact on heart rate and blood pressure. Try to expose the internal carotid artery upwards, pay attention to the separation and protection of the hypoglossal nerve. Temporary blockage of the total neck, internal and external carotid arteries, and 5,000 U of heparin should be given before occlusion of the internal carotid artery. The superior thyroid artery can be clipped with an aneurysm clip. Keep blood pressure normal or high during this process. 5. Insert the shunt tube longitudinally to open the internal carotid artery and the common carotid artery. The incision should expose the atherosclerotic plaque and show it to the normal internal carotid artery. If necessary, insert the proximal end of the shunt tube into the proximal end of the internal carotid artery. The distal end of the shunt should be inserted into the common carotid artery. The movement should be gentle to prevent the arteriosclerotic plaque from falling off, and if necessary, remove it. It usually takes 2~3 minutes from intubation to blood flow through the shunt. 6. Under the operating microscope, the atherosclerotic plaque removal and endarterectomy remove the arteriosclerotic plaque from the side of the inner wall of the artery, remove it under the shunt, and the arterial plaque at the external carotid artery should be removed together until See the normal arterial intima. When suturing the internal carotid artery, a large saphenous vein can be used to repair the carotid artery in order to prevent stenosis. Before the suture is completed, the shunt tube is taken out, and the air bubbles in the artery are discharged, and the total neck, the external neck, and the internal carotid artery are sequentially blocked. Sewing layer by layer. Heparinization can be relieved with 30-50 g of protamine (protamine sulfate). complication 1. Postoperative blood pressure rises. 2. Postoperative stroke. 3. Postoperative hematoma and rupture of the carotid suture. 4. Internal carotid artery stenosis recurrence.