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Neurological Surgery No Shinkei Geka Volume 47, Issue 11 （November 2019）

Neurological Surgery 脳神経外科 47巻11号（2019年11月発行）

Japanese English

研究

頚動脈内膜剝離術と頚動脈ステント留置術の優劣—二刀流の観点から Advantages and Disadvantages of Carotid Endarterectomy and Carotid Artery Stenting:Notes from a Hybrid Neurosurgeon 林健太郎 ¹ , 松永裕希 ¹ , 林之茂 ¹ , 白川靖 ¹ , 岩永充人 ¹ Kentaro HAYASHI ¹ , Yuki MATSUNAGA ¹ , Yukishige HAYASHI ¹ , Kiyoshi SHIRAKAWA ¹ , Mitsuto IWANAGA ¹ ¹佐世保市総合医療センター脳神経外科 ¹Department of Neurosurgery, Sasebo City General Hospital キーワード： carotid endarterectomy , carotid artery stenting , complication , hybrid neurosurgeon Keyword: carotid endarterectomy , carotid artery stenting , complication , hybrid neurosurgeon pp.1151-1156

発行日 2019年11月10日 Published Date 2019/11/10

DOI https://doi.org/10.11477/mf.1436204092

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Ⅰ．はじめに

　頚動脈起始部の狭窄は脳血流の低下を来したり，プラークの破綻や血栓形成により脳塞栓症の原因となる．食生活の欧米化や高齢化に伴い，本邦においても増加してきており，疾患の重要度は増してきている．頚動脈内膜剝離術（carotid endarterectomy：CEA）は欧米で大規模研究が行われ，その有効性が示され，広く実施されてきた^3,13)．近年，血管内治療の進歩は目覚ましいものがあり，頚動脈狭窄に対してもステント留置術（carotid artery stenting：CAS）が行われ，CEAと遜色ない結果もみられている¹⁾．本邦ではどちらの治療も主に脳神経外科医が担当しているという特徴があり，その観点からCEAとCASの現状や合併症について検討した．

　OBJECTIVE:Carotid endarterectomy（CEA）is well-established and performed for carotid artery stenosis all over the world. However, some severe complications and pitfalls have been reported. Carotid artery stenting（CAS）in high-surgical-risk patients is considered an effective alternative to CEA. We reviewed our clinical experience of CEA and CAS and discuss the advantages and disadvantages of each treatment.

　MATERIALS and METHODS:For 13 years, we performed CEA for 133 patients（135 lesions）and CAS for 127 patients with carotid artery stenosis（129 lesions). CAS is indicated for the CEA high-risk patients. Perioperative imaging studies and post-operative statuses were evaluated especially in cases with complications.

　RESULTS:In our CEA series, ischemic stroke occurred in 3 cases, myocardial infarction in 1, cranial nerve palsy in 2, internal carotid artery occlusion in 1, wound hematoma in 2, and hyperperfusion syndrome in 4. The procedure was halted in one case because of an internal shunt problem. All cases of CAS were successfully performed except for one case complicated with myocardial infarction. Ischemic stroke occurred in 7 cases, hyperperfusion syndrome in 2, stent occlusion in 2, and puncture site hematoma in 2. Restenosis appeared in CAS significantly more than in CEA.

　CONCLUSIONS:CEA is a first-line treatment for carotid artery stenosis. However, complications of CEA may result in severe situations. Recognizing pitfalls and careful perioperative management is required. The results of CAS are comparable to those of CEA. Radiological evaluation for the presence of plaque and appropriate selection of an embolus protection device are important.