1、颅外-颅内动脉旁路手术：历史、现状与展望EXTRACRANIAL-INTRACRANIAL BYPASS SURGERYPAST, 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 PLAInstitute of Neurosurg, Chinese PLA,Pioneers of Bypass Procedures Jacobson(1960)(Vermont) Reconstructed carotid arteries of dogs and rabbits, achieving
2、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 aske
3、d 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
4、 and Rasmussen advised him to contact prof. Donaghy 1965 Yasargil began his training in Donaghs 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 pe
5、rforming 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 occ
6、lusion 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
7、 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
8、 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-
9、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 an
10、d 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 inves
11、tigators 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 cen
12、ters 18 PET centers (20022010 ), 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 (20022010),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
13、,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 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
14、 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（级推荐，A级证据）, 颅内主要动脉狭窄50%以上，不推荐 旁路术 （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（
15、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 aba
16、ndonment, 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 病人，手术可能有益。 有限的应用加上着眼于未来的 进一步研究，而不是完全放弃。,Acute stroke Emergent cerebral revascula-rization is very rationalEncouraging results were reported. But others considered the acute ischemia a relative contraindicationConclusion: Only those patients with
17、 crescendo TIA or mild to moderate deficits 6 hrs with no infarction should be considered for EC/IC bypass,急性卒中 急诊脑血运重建合理，有报 告结果令人鼓舞 其他学者认为，急性缺血是 急诊重建的相对禁忌。,Crowell, Jafar(1986) 报告67例，27例改善，26例无变化，11例死亡,结论：EC/IC旁路术仅可用于渐进性TIA或轻至中度缺陷（ 4 seconds indicates a considerable mismatch volume (red contour on TTP images). The mismatch volumes were 473 cm3 for patient a and 199.7 cm3 for patient b. However, only patient b had a corresponding volume of penumbra (260 cm3).,
