CEA手术室篇.pptx

手术室中的颈动脉内膜切除术Carotid Endarterectomy(CEA),日照市人民医院神经外科张玉海,第一页，共六十一页。,国家远程卒中中心、脑防委CEA培训基地、北京市脑血管病中心,第二页，共六十一页。,外科治疗相关问题,麻醉方式GALA trial术式介绍-标准CEA传统CEA-翻转式CEA护士协作并发症的预防,第三页，共六十一页。,Operation room team position during CEA.S Surgeon,aS assisting surgeon,Ne neurophysiologist；A anaesthesiologist；N nurse；M microscope,团队配置及体位,第四页，共六十一页。,Supine position;Head up:to reduce cervical venous pressure;Head is placed on a ring,with a sandbag under the shoulders;Exposing the full length of the sternomastoid muscle;,手术体位要求,第五页，共六十一页。,手术切口,第六页，共六十一页。,麻醉篇,麻醉平稳及适时调整血压至关重要,第七页，共六十一页。,麻醉方式,全麻：-General anaesthesia has several advantages,including easier surgical manoeuvres,handling of complications and easier patient monitoring.局麻：-local/regional anaesthesia decreases the number of medical complicationsat the expense of neurological complications.,第八页，共六十一页。,General anaesthesia versus local anaesthesia for carotid surgery(GALA):a multicentre,randomised controlled trial,Method:a parallel group,multicentre,randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries.-general(n=1753)or local(n=1773)anaesthesia;-stroke(including retinal infarction),myocardial infarction,or death between randomisation and 30 days after surgery;Conclusion:The two groups did not significantly differ for quality of life,length of hospital stay,or the primary outcome in the prespecified subgroups of age,contralateral carotid occlusion,and baseline surgical risk.两个组在生活质量、住院时间、预设不同年龄组的结果、双侧颈动脉闭塞和手术风险等方面均无显著差异。,第九页，共六十一页。,麻醉的不可替代性,掌握术前有无心脏疾病，缺血性尤为重要术前的根底血压，要明确麻醉平稳后开始手术前的血压，记录定标临时阻断后可能需要短时升压至要求值动脉缝合完毕后需要尽快降压结合TCCD定出出室后的血压平安控制范围,第十页，共六十一页。,麻醉深度监测,麻醉深度电极,脑氧监测,第十一页，共六十一页。,麻醉协助TCCD术前定标,第十二页，共六十一页。,术中阻断后短时升压血流再通后积极降压，不建议用硝普钠,第十三页，共六十一页。,术后麻醉与TCCD定控制范围,麻醉机,第十四页，共六十一页。,TCCD监测术中指导意义大,术前麻醉平稳后定标主要参考。脑血流峰值、平均值、收缩期、舒张期,第十五页，共六十一页。,Baseline(before induction)Pre-clamp(at heparin injection)Clamping,shunt insertion(if required)Post-clamping(15 min after clamping)Clamp release 5-min post-release 10-min post-release,术中监测,第十六页，共六十一页。,手术护理篇,熟悉流程能减少动脉阻断时间器械准备要求高巡回护士及时调整双极电凝阻断前静脉给肝素腔内操作持续肝素盐水冲洗术中冲洗准备两套吸引装置,第十七页，共六十一页。,操作流程,别离暴露动脉鞘显微操作阶段：切开剥离斑块、缝合动脉关闭动脉鞘、分层缝合。,第十八页，共六十一页。,显微操作前器械,第十九页，共六十一页。,显微操作前器械,第二十页，共六十一页。,显微操作中器械,第二十一页，共六十一页。,显微操作中器械,第二十二页，共六十一页。,显微操作中器械,第二十三页，共六十一页。,术中特别注意的问题,术中对血管的保护尤为重要。器械对缝合线的损伤隐患最大。无损伤器械使用。肝素盐水的高频率冲洗1ml含10u肝素。肝素：Dose of 5000 units of heparin or 30 u/kg body weight of intravenous heparin;CEA视频剪辑.mp4,第二十四页，共六十一页。,粥样斑块粥糜样物,狭窄处的真腔缝隙,狭窄真腔,第二十五页，共六十一页。,不稳定斑块,第二十六页，共六十一页。,术式,标准CEA翻转式CEA,第二十七页，共六十一页。,Standard CEA technique.P Plaque,T superior thyroid artery,L longitudinal arteriotomy,CEA technique with intraluminal shunt.IS Intraluminal shunt,R rubber band aroundthe CCA,C window aneurysm clip at the ICA,P plaque,T superior thyroid artery,第二十八页，共六十一页。,Selective shunting with eversion carotid endarterectomy,第二十九页，共六十一页。,Modified Eversion Carotid Endarterectomy,Ann Vasc Surg 2022;27:178185,第三十页，共六十一页。,第三十一页，共六十一页。,第三十二页，共六十一页。,手术涉及的解剖结构,耳大神经、颈外静脉颈阔肌、胸锁乳突肌颈内静脉、面静脉颈内动脉颈总动脉颈袢、舌下神经、迷走神经、喉上神经、面神经,第三十三页，共六十一页。,颈阔肌External jugular vein:vein is ligated and divided;Arteria branch of the great auricular nerve;,Great auricular nerve耳大神经,External jugular vein,第三十四页，共六十一页。,颈动脉鞘The jugular vein is not dissected free;it is merely identifi ed and left untouched.触及CCA，别离方向：向头端，由CCA,ICA,ECA,superior thyroid arteries；向上：Posterior belly of the digastric muscle二腹肌;向下：Further exposure:Inferiorly the middle thyroid vein甲状腺中静脉 may require ligation and the omohyoid muscle肩胛舌骨肌;需耐心处理的：淋巴结需注意的：观察心率，必要时应用局麻药物；不要急于升压提升心率,Posterior belly of the digastric muscle;,Hypoglossal nerve,第三十五页，共六十一页。,重要标记：The hypoglossal nerve:crosses the internal and external carotid arteries;颈袢：Ansa cervicalis;调整方向及深度：Self-retaining retractor；此过程轻提血管外膜，别离过程尽量不触及分叉部或斑块处；减少斑块脱落的风险；别离是为临时阻断做准备，不要过分游离血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后关系时，那么需将分叉部尽可能别离；,第三十六页，共六十一页。,肝素：Dose of 5000 units of heparin or 30 u/kg body weight of intravenous heparin;阻断顺序：-The first clip is applied to the ICA,then one each to the ECA and the superior thyroid artery and finally to the CCA.试阻断-Clamps were applied sequentially to the superior thyroid artery,the common carotid artery,internal carotid artery,and the external carotid artery.持续阻断-返血：分别提起ECA，ICA阻断带；或源于咽升A，使用较大的阻断夹完全阻断ECA；,第三十七页，共六十一页。,重要标记：The hypoglossal nerve:crosses the internal and external carotid arteries;颈袢：Ansa cervicalis;调整方向及深度：Self-retaining retractor；此过程轻提血管外膜，别离过程尽量不触及分叉部或斑块处；减少斑块脱落的风险；别离是为临时阻断做准备，不要过分游离血管；鞘的固定：可起到提起血管的作用，利于操作；特例：ECA、ICA并非平行，而是前后关系时，那么需将分叉部尽可能别离；,第三十八页，共六十一页。,动脉切开：longitudinal arteriotomy注意刀片方向：Cutting edge outwards so that once the lumen is entered,the blade can be drawn outwards to commence a longitudinal arteriotomy.技巧：切开动脉壁时：可标记切口，以确保方向；The arteriotomy is slightly lateral to the midline(from the surgeons point of vision);especially at the bifurcation it runs some 3 mm lateral from the upper aspect of the bifurcation;,第三十九页，共六十一页。,Potts angle scissors近端:the vessel is palpated to find a