高齢者頸動脈狭窄病変に対する血行再建術の治療成績

Vascular Reconstructive Surgery for Elderly Patients with Internal Carotid Artery Stenosis at the Cervical Portion

Ⅰ．はじめに

　近年，平均余命の延長，並びに周術期管理・血行再建手技の進歩により，高齢者頸動脈狭窄病変に対する血行再建術の有益性が増し，その適応が拡大しつつある．70歳以上または75歳以上の高齢者は，高齢なだけで周術期合併症の危険因子との報告がある一方^7,8)，80歳以上でも，専門医との連携のもと慎重な周術期管理を行えば安全にcarotid endarterectomy（CEA）は行えるとの報告も多く出ている^1,3,11)．ただし，いまだ高齢者の定義が一致していないこともあり，今回われわれは年齢が頸動脈狭窄病変の病態・治療方法・その成績にどのような影響を与えているかを検討した．

Purpose　We encounted increasing numbers of elderly patients suffering from stenotic lesions of the cervical internal carotid artery. Most of them have been considered to indicate a need for carotid artery stenting. The purpose of this study was to clarify with regard to the modality of treatment and perioperative complications the effectiveness of vascular reconstruction procedure in elderly patients.

　Patients and methods　Ninety eight lesions in 91 patients with stenosis of the internal carotid artery were treated surgically. Eighty lesions received carotid endarterectomy (CEA),and 18 lesions received percutaneous transluminal angioplasty (PTA) with or without stent. Treatment with PTA-with-or-without-stent has been opted in cases of patient with such conditions as radiation-induced stenosis,re-stenosis after CEA,unfitness for general anesthesia,bilateral lesions both of which need to be reconstructed with in a short interval. We divided the patients into 4 groups according to their age; under 70-year-old group,70-to-74-year old group,75-to-79-year old group,and over 80-year-old group. Vasoreconstructive procedures were performed for 41 patients in the under 70-year-old group,for 31 in the 70-to-74-year old group,for 21 in the 75-to-79-year old group,and for 5 in the over 80-year-old group.

　Result　The overall surgical morbidity rate was 2％ (2 of 98 cases) and there was no mortality. Tweleve patients (12.2％) experienced transient neurological deficits. Two patients exhibited perioperative complications in gastrointestinal organs,but none of the patients experienced cardiac complications. Elderly patients tend to experience systemic complications such as gastrointestinal complications as well as transient neurological deficits,which appear as restlessness,possibly due to hyperperfusion syndrome. The perioperative complication rate in elderly patients (putting the patients of the 70-to-74-year old group,the 75-to-79-year old group,and the over 80-year-old group together) was,statistically,significantly higher than those in patients of under the 70-year-old group. However,when two treatment modalities,CEA and PTA-with-or-without stent,were compared,there was no significant difference in the perioperative complication rate.

　Conclusion　Careful patient selection and prudent perioperative management enabled us to perform vasoreconstructive surgery even for elderly patients with internal carotid artery stenosis in a relatively safe manner with an acceptable complication rate. Decision making in selecting treatment modality,CEA or PTA with or without stent,should not be based solely on aging.