大動脈弁狭窄症および対側内頚動脈閉塞症を有する症候性内頚動脈高度狭窄症に対して一期的に頚動脈内膜剝離術と大動脈弁置換術を施行した1例

Concomitant Surgery for Symptomatic Severe Carotid Artery Stenosis and Aortic Valve Stenosis with Contralateral Internal Carotid Artery Occlusion:A Case Report

Ⅰ．はじめに

　心疾患をはじめとする頚動脈内膜剝離術（carotid endarterectomy：CEA）の危険因子を有する内頚動脈狭窄症では，頚動脈ステント留置術（carotid artery stenting：CAS）が施行されることが多い．しかし，未治療の大動脈弁狭窄症（aortic valve stenosis：AS）を合併する場合にはCASに伴う徐脈，低血圧により病態が悪化することが知られている¹⁰⁾．また，非心臓手術を要する重症ASでは，非心臓手術を中止するか大動脈弁治療を先行させることが望ましいと考えられている⁵⁾．しかし，内頚動脈高度狭窄症とASが合併した場合の治療方針に関しては，未だ統一した見解はない．今回われわれは，ASおよび対側内頚動脈閉塞症を合併した症候性内頚動脈高度狭窄症に対して，一期的にCEAと大動脈弁置換術（aortic valve replacement：AVR）を施行した1例を経験したので，文献的考察を加え報告する．

　We report a case of concomitant carotid endarterectomy（CEA）and aortic valve replacement（AVR）for symptomatic severe carotid artery and aortic valve stenosis（AS).

　A 77-year-old man, presented to our hospital with AS complicated by right internal carotid artery（ICA）stenosis and left ICA occlusion, seeking treatment for AS. He suffered from left hemiparesis, and diffusion-weighted magnetic resonance imaging（MRI）showed multiple ischemic lesions in the right cerebral hemisphere. He was admitted to our neurosurgical department and received treatment for acute cerebral infarction caused by severe right ICA stenosis. The symptomatic severe right ICA stenosis was an indication for surgical treatment, but simple carotid revascularization of the stenosed ICA was considered to be deteriorated the cardiac function due to untreated AS. Thus, we decided to perform concomitant carotid and valvular surgery. The patient underwent a combined CEA and AVR procedure with the introduction of an intraoperative intra-aortic balloon pump. His postoperative course was uneventful even 12 months after the surgery.

　Management and surgical strategies for patients with concomitant ICA stenosis and AS continue to be controversial subjects. Combined carotid and cardiac valve surgery is considered to be effective in such cases, and we discuss its implications and review of literature.