過去13年間の経年的手術件数の推移からみた脳血行再建術の動向と課題

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We analyzed the change of annual number of extracranial/intracranial (EC/IC) bypass surgeries and carotid endarterectomies (CEAs) in the past 13 years (1986-1998) to clarify the trends and issues of cerebrovascular reconstructive surgery in the near future. Since 1986, hemodynamic cerebral ischemia has been evaluated by cerebral blood flow (CBF) measurements using single photon emission CT (SPECT). The severity of hemodynamic cerebral ischemia was defined qualitatively using both resting and acetazolamide-activated N-isopropyl-[^<123>I]-iodoamphetamin (IMP) SPECT in 1986-1994, and stratified quantitatively using both IMP-Autoradiography (ARG) method in 1995-1998. EC/IC bypass surgery was performed on patients who had severe hemodynamic cerebral ischemia. In the quantitative assessment of hemodynamic cerebral ischemia, Stage II ischemia [i.e. resting rCBFSS 34 ml/100 g/min (80% of mean CBF of normal volunteer) and vascular reserve (acetazolamide-activated CBF / resting CBF-1) X 100% ≦ +10%] was selected for EC/IC bypass, and postoperative changes of resting rCBF and vascular reserve in Stage II ischemia were investigated for establishing the hemodynamic efficacy of surgical revascularization. Otherwise, CEA was performed on patients who had symptomatic or asymptomatic high-grade carotid stenosis (> 70%) confirmed by angiogram. Since 1993, percutaneous transluminal angioplasty (PTA) with or without stenting has been used with some patients with symptomatic high-grade carotid stenosis. In the past 13 years, 432 EC/IC bypass surgery and 146 CEAs were performed. The annual number of EC/IC bypass surgeries decreased gradually since 1988, due to an improvement in determining the severity of hemodynamic cerebral ischemia with the use of CBF-SPECT. In 20 patients with Stage II ischemia, an improvement of both resting rCBF and vascular reserve after EC/IC bypass (STAMCA anastomosis) was confirmed by IMP-ARG method. The annual number of CEAs was stable in 1986-1997, and increased steeply in 1998. CEAs for asymptomatic carotid lesion has increased in recent years. PTA for symptomatic carotid lesion has gradually increased since 1993 (a total of 27 procedures), but no alternative to CEA has emerged. Quantitative assessment of hemodynamic cerebral ischemia may show that EC/IC bypass surgery for ischemic stroke is not indicated, but prospective randomized trials concerning Stage II ischemia should be conducted to verify the roles to reduce the risk of stroke relapse. Candidates of CEA or PTA for high-grade carotid stenosis could increase persistently in the near future. Therefore, standard procedures, methods for risk control, and guidelines of CEA, and patient selection and longterm outcome of PTA should be investigated to determine the role of both procedures.
日本脳卒中の外科学会の論文
2000-09-30

過去13年間の経年的手術件数の推移からみた脳血行再建術の動向と課題

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