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Neurological Surgery No Shinkei Geka Volume 44, Issue 1 （January 2016）

Neurological Surgery 脳神経外科 44巻1号（2016年1月発行）

Japanese English

研究

頚動脈狭窄症に対する包括的治療戦略—「越中八策」の初期成績 Comprehensive Hybrid Strategy for Carotid Artery Stenosis with 8 Rules “Toyama Carotid 8” 秋岡直樹 ¹ , 柏崎大奈 ¹ , 高正圭 ¹ , 桑山直也 ¹ , 田中耕太郎 ² , 黒田敏 ¹ Naoki AKIOKA ¹ , Daina KASHIWAZAKI ¹ , Masaki KOH ¹ , Naoya KUWAYAMA ¹ , Kortaro TANAKA ² , Satoshi KURODA ¹ ¹富山大学大学院医学薬学研究部脳神経外科 ²富山大学大学院医学薬学研究部神経内科 ¹Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama ²Department of Neurology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama キーワード： carotid stenosis , carotid endarterectomy , carotid artery stenting , in-hospital rule Keyword: carotid stenosis , carotid endarterectomy , carotid artery stenting , in-hospital rule pp.31-38

発行日 2016年1月10日 Published Date 2016/1/10

DOI https://doi.org/10.11477/mf.1436203204

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Ⅰ．緒　　言

　近年の頚動脈内膜剝離術（carotid endarterectomy：CEA）および頚動脈ステント留置術（carotid artery stenting：CAS）の技術・周術期管理の向上は，頚動脈狭窄症を有する患者の予後の改善に大きく寄与している．近年もInternational Carotid Stenting Study（ICSS）やCarotid Revascularization Endarterectomy versus Stenting Trial（CREST）など，多数のランダム化臨床試験に基づいたエビデンスが提供されている^2,3)．しかし，欧米で実施された臨床試験の知見をわが国の臨床現場に画一的に外挿するのは危険で，術者・施設の経験や技量，各症例の臨床データ，数多くの相反するエビデンスを総合的に考慮して治療方針を決定すべきである．われわれは富山大学における現状を踏まえた上で，頚動脈狭窄症治療の原則を「越中八策」として成文化した．今回，この「越中八策」に則って実施した頚動脈狭窄症の治療の初期成績を報告する．

　In this paper, the preliminary results of carotid endarterectomy（CEA）and carotid artery stenting（CAS）for patients with carotid artery stenosis based on the 8 Rules “Toyama Carotid 8” are reported. This study included 104 patients who underwent CEA or CAS for carotid artery stenosis between March 2012 and January 2015. Toyama 8 Rules primarily recommend CEA and CAS for symptomatic and asymptomatic lesions, respectively. However, crossover of therapeutic options can be performed in patients at high surgical risk associated with CEA or CAS. Monitoring of platelet function is important prior to CAS. Internal shunting and near infrared spectroscopy monitoring are essential in CEA. Temporary cardiac pacing is essential in CAS. The choice of protection device and stent depends on the results of MR plaque imaging. Cerebral blood flow measurement is mandatory before and after CEA/CAS. Fifty-two CEAs and 52 CASs were performed for 55 symptomatic and 49 asymptomatic lesions. Crossover of therapeutic options was performed in 10（18%）of 55 symptomatic lesions and 7（14%）of 49 asymptomatic lesions. The 30-day morbidity rate was 1.9% in CEA and 1.9% in CAS. Postoperative diffusion-weighted magnetic resonance imaging showed fresh ischemic lesions in 5 patients who underwent CEA（10%）and 9 who underwent CAS（17%). Hyperperfusion syndrome occurred in one patient（1.0%). A management protocol for carotid artery stenosis needs to be established in hospitals to allow sharing of information and improvement in the short-term results of CEA / CAS for carotid artery stenosis. Further studies are warranted to evaluate the long-term outcome.