受体动脉不同临时阻断策略在烟雾病颞浅动脉-大脑中动脉搭桥术中的应用比较

doi:10.3969/j.issn.1673-5765.2024.07.005

摘要/Abstract

摘要：

目的探讨颞浅动脉-大脑中动脉端侧吻合术中不同临时阻断技术的效果及可靠性。

方法回顾性分析2015年1月—2023年4月南方医科大学南方医院神经外科收治的接受直接搭桥术治疗的烟雾病患者资料，根据临时阻断策略的不同将患者分为3组：①有垫片、多阻断夹阻断组（multi-clips+rubber pad group，M+R组）；②无垫片、多阻断夹阻断组（multi-clips group，M组）；③无垫片、单阻断夹阻断组（single-clip group，S组）。比较组间临时阻断时间、受体动脉切开后有无渗血、术中穿支血管损伤以及术后新发脑梗死情况。

结果共355例患者、360个大脑半球纳入分析，按大脑半球统计患者360例，其中男性188例，女性172例，平均年龄为（43.8±0.7）岁。其中M+R组45例，M组191例，S组124例。3组平均阻断时间：M+R组为（37.9±9.8）min，M组为（20.9±9.0）min，S组为（11.0±3.5）min，组间差异有统计学意义（P＜0.001）。阻断后受体动脉管腔内渗血以及术中穿支血管损伤发生率：M+R组为8.89%（阻断后受体动脉渗血4例），M组为14.66%（阻断后受体动脉渗血19例，术中穿支血管损伤8例，临时阻断部位有血栓形成1例），S组为5.65%（阻断后受体动脉渗血7例），组间差异无统计学意义（P>0.05）。术后新发脑梗死发生率差异无统计学意义（P>0.05）。

结论单阻断夹阻断策略安全、有效，能显著缩短临时阻断时间，可以优先考虑作为颞浅动脉-大脑中动脉端侧吻合过程中的临时阻断策略。

文章导读： 与有垫片+多阻断夹阻断及无垫片、多阻断夹阻断策略相比，无垫片、单阻断夹阻断策略安全、有效，能显著缩短临时阻断时间，且不增加相关并发症发生率，可以优先考虑作为颞浅动脉-大脑中动脉端侧吻合过程中的临时阻断策略。

关键词: 烟雾病; 颞浅动脉-大脑中动脉; 端侧吻合; 临时阻断策略

Abstract:

Objective To investigate the effects and reliability of different temporary occlusion techniques in end-to-side anastomosis of the superficial temporal artery-middle cerebral artery.

Methods A retrospective analysis was conducted on the data of patients with Moyamoya disease who underwent direct bypass surgery in the Department of Neurosurgery, Nanfang Hospital, Southern Medical University, from January 2015 to April 2023. The patients were divided into three groups according to the different temporary occlusion strategies: ①multi-clips+rubber pad group (M+R group); ②multi-clips group (M group); and ③single-clip group (S group). Temporary occlusion time, presence of errhysis after recipient artery incision, intraoperative perforator vessel injury, and postoperative novel cerebral infarction were compared among the three groups.

Results A total of 355 patients and 360 cerebral hemispheres were included in the analysis, and 360 patients were counted according to the number of cerebral hemispheres, including 188 males and 172 females, with an average age of (43.8±0.7) years. There were 45 cases in the M+R group, 191 cases in the M group, and 124 cases in the S group. The average occlusion time were (37.9±9.8) minutes in the M+R group, (20.9±9.0) minutes in the M group, and (11.0±3.5) minutes in the S group, with significant differences between the groups (P<0.001). The incidence of intraluminal errhysis of the recipient artery after occlusion and intraoperative perforator vessel injury was 8.89% in the M+R group (4 cases of recipient artery errhysis after occlusion), 14.66% in the M group (19 cases of recipient artery errhysis after occlusion, 8 cases of intraoperative perforator vessel injury, and 1 case of thrombosis at the temporary occlusion site), and 5.65% in the S group (7 cases of recipient artery errhysis after occlusion), with no significant difference between the groups (P>0.05). There was no significant difference in the incidence of novel cerebral infarctions postoperatively (P>0.05).

Conclusions The single-clip occlusion strategy is safe and effective, which significantly shortens the temporary occlusion time, and should be prioritized as the temporary occlusion technique in end-to-side anastomosis of the superficial temporal artery-middle cerebral artery.

Key words: Moyamoya disease; Superficial temporal artery-middle cerebral artery; End-to-side anastomosis; Temporary occlusion strategy

中图分类号:

陈方舟, 龙廷翰, 陈俊达, 温运宇, 陈思源, 张国忠, 李明洲, 张世超, 康慧斌, 冯文峰, 漆松涛, 王刚.

受体动脉不同临时阻断策略在烟雾病颞浅动脉-大脑中动脉搭桥术中的应用比较 [J]. 中国卒中杂志, 2024, 19(7): 762-768.

CHEN Fangzhou, LONG Tinghan, CHEN Junda, WEN Yunyu, CHEN Siyuan, ZHANG Guozhong, LI Mingzhou, ZHANG Shichao, KANG Huibin, FENG Wenfeng, QI Songtao, WANG Gang.

Comparison of Different Temporary Occlusion Strategies for Recipient Arteries in the Application of Superficial Temporal Artery-Middle Cerebral Artery Bypass for Moyamoya Disease [J]. Chinese Journal of Stroke, 2024, 19(7): 762-768.

参考文献

[1] MAKI Y，ENOMOTO T. Moyamoya disease[J]. Childs Nerv Syst，1988，4（4）：204-212.

[2] IHARA M，YAMAMOTO Y，HATTORI Y，et al. Moyamoya disease：diagnosis and interventions[J]. Lancet Neurol，2022，21（8）：747-758.

[3] ACKER G，FEKONJA L，VAJKOCZY P. Surgical management of Moyamoya disease[J]. Stroke，2018，49（2）：476-482.

[4] VELO M，GRASSO G，FUJIMURA M，et al. Cause，clinical manifestations，neuroradiologic features，and surgical management[J/OL]. World Neurosurg，2022，159：409-425[2024-01-01]. https://doi.org/10.1016/j.wneu.2021.11.026.

[5] 烟雾病治疗中国专家共识编写组. 烟雾病治疗中国专家共识[J]. 国际脑血管病杂志，2019，27（9）：645-650.

Writing Group for Chinese Expert Consensus Statement on the Diagnosis and Treatment of Moyamoya Disease. Chinese expert consensus statement on the diagnosis and treatment of Moyamoya disease[J]. Int J Cerebrovasc Dis，2019，27（9）：645-650.

[6] HERVé D，KOSSOROTOFF M，BRESSON D，et al. French clinical practice guidelines for Moyamoya angiopathy[J]. Rev Neurol（Paris），2018，174（5）：292-303.

[7] FUJIMURA M，TOMINAGA T，KURODA S，et al. 2021 Japanese guidelines for the management of Moyamoya disease：guidelines from the Research Committee on Moyamoya Disease and Japan Stroke Society[J]. Neurol Med Chir（Tokyo），2022，62（4）：165-170.

[8] GONZALEZ N R，AMIN-HANJANI S，BANG O Y，et al. Adult Moyamoya disease and syndrome：current perspectives and future directions：a scientific statement from the American Heart Association/American Stroke Association[J/OL]. Stroke，2023，54（10）：e465-e479[2024-01-01]. https://doi.org/10.1161/STR.0000000000000443.

[9] CHIBA T，SETTA K，SHIMADA Y，et al. Comparison of effects between clopidogrel and cilostazol on cerebral perfusion in nonsurgical adult patients with symptomatically ischemic Moyamoya disease：subanalysis of a prospective cohort[J]. J Stroke Cerebrovasc Dis，2018，27（11）：3373-3379.

[10] ZHANG X，XIAO W P，ZHANG Q，et al. Progression in Moyamoya disease：clinical features，neuroimaging evaluation，and treatment[J]. Curr Neuropharmacol，2022，20（2）：292-308.

[11] BERSANO A，KHAN N，FUENTES B，et al. European Stroke Organisation（ESO）guidelines on Moyamoya angiopathy endorsed by Vascular European Reference Network（VASCERN）[J]. Eur Stroke J，2023，8（1）：55-84.

[12] DING J Y，ZHOU D，PAUL COSKY E E，et al. Hemorrhagic Moyamoya disease treatment：a network meta-analysis[J/OL]. World Neurosurg，2018，117：e557-e562[2024-01-01]. https://doi.org/10.1016/j.wneu.2018.06.076.

[13] PARK H，HAN M，JANG D K，et al. Association of bypass surgery and mortality in Moyamoya disease[J/OL]. J Am Heart Assoc，2023，12（22）：e030834[2024-01-01]. https://doi.org/10.1161/JAHA.123.030834.

[14] WANG G Q，ZHANG X Y，FENG M Z，et al. Efficacy of surgical treatment on the recurrent stroke prevention for adult patients with hemorrhagic Moyamoya disease[J]. J Craniofac Surg，2017，28（8）：2113-2116.

[15] VILELA M D，NEWELL D W. Superficial temporal artery to middle cerebral artery bypass：past，present，and future[J/OL]. Neurosurg Focus，2008，24（2）：E2[2024-01-01]. https://doi.org/10.3171/FOC/2008/24/2/E2.

[16] POWERS W J，CLARKE W R，GRUBB R L，Jr，et al. Extracranial-intracranial bypass surgery for stroke prevention in hemodynamic cerebral ischemia：the carotid occlusion surgery study randomized trial[J]. JAMA，2011，306（18）：1983-1992.

[17] MA Y，WANG T，WANG H B，et al. Extracranial-intracranial bypass and risk of stroke and death in patients with symptomatic artery occlusion：the CMOSS randomized clinical trial[J]. JAMA，2023，330（8）：704-714.

[18] 张果，秦小宏，程荆，等. 烟雾病脑血管重建术围手术期管理[J]. 临床外科杂志，2023，31（11）：1104-1106.

ZHANG G，QIN X H，CHENG J，et al. Perioperative management of cerebral revascularization of Moyamoya disease[J]. J Clin Surg，2023，31（11）：1104-1106.

[19] CHO W S，KIM J E，KIM C H，et al. Long-term outcomes after combined revascularization surgery in adult Moyamoya disease[J]. Stroke，2014，45（10）：3025-3031.

[20] SASAKI T，KODAMA N，MATSUMOTO M，et al. Blood flow disturbance in perforating arteries attributable to aneurysm surgery[J]. J Neurosurg，2007，107（1）：60-67.

[21] HORIUCHI T，RAHMAH N N，YANAGAWA T，et al. Revisit of aneurysm clip closing forces：comparison of titanium versus cobalt alloy clip[J]. Neurosurg Rev，2013，36（1）：133-138.