血管搭桥手术的时代过去了吗？(英文).pptVIP

IstheageoftheCerebralBypassGone?JonathanWhite,M.D.AssociateProfessorofNeurosurgeryUTSouthwesternMedicalCenterDallas,Texas

HistoricalIndicationsForBypass:Vascularreplacement:ComplexaneurysmsTumorsIschemiaMoyaMoyadiseaseAtherosclerosis

Historicaluseofbypass?Fukushima1986-2006100patients,SaphenousveinAneurysm,Menigioma,carotidbody,glomus,otherThreetypesofbypassPetroustoparaclinoidCervicalexternaltopetrousCervicalexternaltoM2

ThingsChange

Traditionalwaysnolongerneeded:

BetterTechnology?

Aneurysms?BettermicroscopeBetterclipsIntra-operativeangiographyAnesthesiaBettersurgeons?Bettersurgicaltraining

Aneurysms:CoilsandStents

WhataboutIschemia?

ResultsofBypassStudies:

BypassdoesnotworkNEnglJMed.313(19):1191-2000,1985,Nov7.714Medicaland663STA-MCAbypasspatientsFollowed56monthsNodifferenceoverallbetweengroupsSomesurgicalsubgroupdidworse:MCAstenosis,carotidocclusionwithTIA

AngioplastyandStent

Doesnewtechnologyandinformationeliminatetheneedfortraditionaltechniques?

GammaKnife?

GammakniferesultsPoorcontrolwithlargevolumetumorsRiskofvascularinjury

AneurysmCoiling?UTSouthwestern2002-200695aneurysmsgreaterthen2.0CM17weretreatedbyprimaryendovascular Only9(53%)completelyoccluded 12(71%)requiredre-treatment

Ischemicdisease:

FlawsofpreviousbypasstrialsPre–operativestrokesconsideredsurgicalfailureSelectionbias–goodsurgicalcandidatesnotrandomizedMedicalfailurecasesdidnotcrossNotenoughpowertoidentifysubgroupswhichmaybenefitfrombypass

Ischemia:NeedtomeasureatrisktissueYonas,JNSG1993XeCT;compared5%vs50%dropinflowwithdiamox68patientsfor24months4.4%vs36%strokeriskinlowflowPtsGrubb,JAMA1998PETevidenceofhighoxygenextraction,31month11/39(28%)vs2/42(5%)ipislateralstrokerisk

STA-MCAbypassforischemia:

STA-MCAbypass

STA-MCAbypass

STA-MCAbypass

STA-MCABypass

STA-MCAresultsJa