泛血管医学时代“脑心同治”手术与展望

doi:10.3969/j.issn.1672-6731.2024.01.003

中国现代神经疾病杂志 ›› 2024, Vol. 24 ›› Issue (1): 8-16. doi: 10.3969/j.issn.1672-6731.2024.01.003

• 泛血管医学时代“脑心同治”手术 • 上一篇下一篇

2 泛血管医学时代“脑心同治”手术与展望

尚彦国¹, 王轩¹^,*(), 佟小光¹, 施铭岗¹, 李春海², 王联群³

1. 300350 天津市环湖医院(天津市脑系科中心医院)神经外科复合脑血管外科病区天津市神经外科研究所显微神经外科实验室天津医科大学神经内外科及神经康复临床学院天津市脑血管与神经变性重点实验室天津市脑血流重建与头颈神经肿瘤新技术转化重点实验室
2. 300350 天津市环湖医院(天津市脑系科中心医院)内科
3. 300222 天津大学胸科医院心血管外科天津市心血管病研究所天津市心血管急危重症重点实验室

收稿日期:2023-12-29 出版日期:2024-01-25 发布日期:2024-01-30
通讯作者: 王轩
基金资助:
天津市“131”创新型人才团队计划项目; 天津市科技计划项目(18ZXDBSY00180); 天津市青年医学新锐计划项目; 天津市卫生健康委员会科技项目(TJWJ2021MS031); 天津市医学重点学科（专科）建设项目(TJYXZDXK-022A); 天津市医学重点学科（专科）建设项目(TJYXZDXK-052B); 天津市海河医学学者计划项目(TJSHHYXXZ-D2-007)

Synchronous surgical treatment for brain and heart in the era of pan-vascular medicine

Yan-guo SHANG¹, Xuan WANG¹^,*(), Xiao-guang TONG¹, Ming-gang SHI¹, Chun-hai LI², Lian-qun WANG³

1. Hybrid Cerebrovascular Surgery Ward, Department of Neurosurgery; Laboratory of Microneurosurgery, Tianjin Neurosurgical Institute; Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University; Tianjin Key Laboratory of Cerebrovascular and Neural Degenerative Diseases; Tianjin Key Laboratory of Cerebral Revascularization and Head and Neck Neuro-Oncology for Technology Transformation, Tianjin 300350, China
2. Department of Internal Medicine, Tianjin Huanhu Hospital (Tianjin Central Hospital for Neurosurgery and Neurology), Tianjin 300350, China
3. Department of Cardiovascular Surgery, Tianjin Institute of Cardiovascular Disease; Tianjin Key Laboratory of Cardiovascular Emergency and Critical Care, Chest Hospital, Tianjin University, Tianjin 300222, China

Received:2023-12-29 Online:2024-01-25 Published:2024-01-30
Contact: Xuan WANG
Supported by:
Tianjin "131" Innovative Talents Group Project; Science and Technology Project of Tianjin(18ZXDBSY00180); Tianjin Young Medical Experts Project; Science and Technology Project of Tianjin Health Commission(TJWJ2021MS031); Tianjin Key Medical Discipline (Specialty) Construction Project(TJYXZDXK-022A); Tianjin Key Medical Discipline (Specialty) Construction Project(TJYXZDXK-052B); Tianjin Haihe Medical Scholar Project(TJSHHYXXZ-D2-007)

摘要/Abstract

摘要：

“脑心共病”逐渐受到国内外神经外科和心血管内外科医师的重视，并着手开展“脑心同治”手术互为保障，“泛血管医学”概念提出多学科交叉、跨学科整合的研究模式和发展理念。泛血管医学思想对“脑心同治”手术具有重要指导意义，“脑心同治”手术又使“泛血管医学”概念更加完整与深化。现阶段坚持以动脉粥样硬化性疾病为基础进行手术实施设计，“脑心同治”手术将在未来突破传统的颈动脉与冠状动脉同期手术范畴，过渡到以血管重建为中心的发展方向，从外科手术角度扩大“泛血管医学”概念的内涵。

关键词: 脑血管障碍, 心血管疾病, 外科手术, 脑心同治(非MeSH词), 泛血管医学(非MeSH词), 血管重建(非MeSH词), 综述

Abstract:

The concomitant of brain and heart diseases has progressively garnered the attention of neurosurgeons and cardiovascular surgeons, who have initiated synchronous surgical treatment for brain and heart. The concept of "pan-vascular medicine" advocates a research model and development philosophy that fosters interdisciplinary collaboration and integration. The principles of "pan-vascular medicine" serve as a crucial guiding force for the synchronous surgical treatment for brain and heart, while the latter enhances the completeness and depth of the former's theoretical framework. Presently, we persist in designing specific surgical interventions based on atherosclerosis diseases. In the future, synchronous surgical treatment for brain and heart will transcend the conventional boundaries of concurrent carotid and coronary artery surgery, and evolve towards a development axis centered on vascular reconstruction. This will thereby expand the scope of the "pan-vascular medicine" concept from a surgical standpoint.

Key words: Cerebrovascular disorders, Cardiovascular diseases, Surgical procedures, operative, Synchronous surgical treatment for brain and heart (not in MeSH), Pan-vascular medicine (not in MeSH), Vascular reconstruction (not in MeSH), Review

尚彦国, 王轩, 佟小光, 施铭岗, 李春海, 王联群. 泛血管医学时代“脑心同治”手术与展望[J]. 中国现代神经疾病杂志, 2024, 24(1): 8-16.

Yan-guo SHANG, Xuan WANG, Xiao-guang TONG, Ming-gang SHI, Chun-hai LI, Lian-qun WANG. Synchronous surgical treatment for brain and heart in the era of pan-vascular medicine[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(1): 8-16.

http://journal11.magtechjournal.com/cjcnn/CN/Y2024/V24/I1/8

图/表 4

图 1 介入“同治”手术病例：男性，58岁，行经皮冠状动脉介入术联合颈动脉支架成形术，手术在神经介入手术室完成 1a 颈部CTA显示双侧颈内动脉起始部重度狭窄，以右侧为著 1b 冠状动脉CTA显示同时合并冠状动脉单支狭窄，无明显钙化 1c 术中先行经皮冠状动脉介入术，冠状动脉造影显示术后冠状动脉狭窄解除 1d 经皮冠状动脉介入术完成后即刻行颈动脉支架成形术，DSA显示术后左颈内动脉狭窄解除 1e DSA显示颈动脉支架成形术后左颈动脉颅内供血明显改善，拟二期行右颈动脉内膜切除术

Figure 1 An interventional synchronous surgery was performed in a 58 - year - old male patient who underwent a combination of PCI and CAS. The surgery was performed in the neurovascular intervention operating room. CTA showed severe stenosis at proximal segments of bilateral ICA, with more significant stenosis on the right side (Panel 1a). CTA showed single - vessel stenosis of the coronary arteries, with no significant calcification (Panel 1b). Intraoperatively, PCI was performed firstly to relieve the coronary artery stenosis (Panel 1c). Immediately following PCI completion, CAS was performed to relieve the stenosis of the left ICA (Panel 1d). DSA showed significant improvement in cerebral blood supply from the left carotid artery, with plans for a secondary CEA on the right side (Panel 1e).

图 2 开放“同治”手术病例：男性，66岁，行颈动脉内膜切除术联合冠状动脉旁路移植术，手术在心脏复合手术室完成 2a 头颈部CTA显示右颈内动脉起始部重度狭窄且斑块钙化严重，远端管腔明显变细，颈动脉支架成形术后血管欠通畅或再狭窄风险高，须行颈动脉内膜切除术 2b 冠状动脉CTA显示冠状动脉3支狭窄伴严重钙化，难以行经皮冠状动脉介入术，需行冠状动脉旁路移植术 2c 术中3组医师同时手术，神经外科医师行颈动脉内膜切除术的同时，由两组心血管外科医师分别完成大隐静脉留取与开胸准备 2d 随后心血管外科医师进行冠状动脉吻合 2e 术后即刻DSA显示右颈内动脉与冠状动脉血运重建通畅

Figure 2 An open synchronous surgery was performed in a 66-year-old male patient who underwent a combination of CEA and CABG. The surgery was performed in the cardiovascular hybrid operating room. CTA showed severe stenosis and plaque calcification at the origin of the right ICA, with a significantly narrowed lumen distally. This high risk of restenosis or blockage after stenting necessitated CEA (Panel 2a). CTA showed three - vessel stenosis of the coronary arteries with significant calcification, making it difficult to perform PCI. This required CABG (Panel 2b). During the procedure, 3 groups of doctors operated simultaneously: while the neurosurgeon performed CEA, 2 groups of cardiovascular surgeons prepared for the great saphenous vein harvesting and thoracotomy (Panel 2c). After the above manipulations were completed, the cardiovascular surgeon performed coronary artery anastomosis (Panel 2d). Postoperatively, DSA showed that both right ICA and coronary artery revascularization were patent (Panel 2e).

图 3 椎动脉起始部血运重建病例：男性，65岁，行胸廓内动脉-大隐静脉-椎动脉V1段搭桥术，手术在神经外科复合手术室完成 3a 头颈部CTA显示右椎动脉为优势侧，其起始部重度狭窄，左椎动脉较细，向颅内供血止于左小脑后下动脉 3b 正位DSA显示右椎动脉起始部狭窄致颅内供血受限，椎基底动脉系统显影浅淡 3c 初拟行右椎动脉支架成形术，反复尝试微导丝通过狭窄段困难，遂终止手术 3d，3e 术后即刻正位和侧位DSA显示术后桥血管通畅，椎基底动脉系统供血明显改善 3f DSA双容积重建显示桥血管形态及毗邻关系 3g DSA双容积重建显示大隐静脉作为移植血管的位置（紫色区域所示）

Figure 3 A case of vascular reconstruction for the origin of the VA was a 65-year-old male patient who underwent a thoracic internal artery-great saphenous vein-V1 segment of the VA bypass. The surgery was performed in a neurosurgical hybrid operating room. CTA showed the right VA was the dominant side, with severe stenosis at its origin. The left VA terminated at the posterior inferior cerebellar artery (Panel 3a). DSA showed restricted intracranial blood supply from the right VA, resulting in obscure opacification of vertebro-basilar artery system (Panel 3b). Initially, CAS was planned for the right VA, but repeated attempts to pass the microcatheter through the stenosis site were unsuccessful, and the operation was terminated (Panel 3c). DSA showed patent bypass after surgery, with significantly improved blood supply to vertebro-basilar artery system in the frontal view (Panel 3d) and lateral view (Panel 3e). Dual volume reconstruction of DSA showed the bypass configuration and adjacent structures (Panel 3f). Dual volume reconstruction of DSA showed the great saphenous vein as interposition graft (purple areas indicate, Panel 3g).

图 4 颈总动脉闭塞血运重建病例：女性，67岁，双侧颈总动脉闭塞伴基底动脉顶端代偿性复杂动脉瘤，右颈动脉分叉低位，选择主动脉弓部大血管搭桥，左颈动脉分叉高位，选择颈部搭桥，手术在神经外科复合手术室完成 4a 头颈部CTA显示双侧颈总动脉闭塞 4b 一期采取右锁骨下动脉-大隐静脉-颈总动脉末端搭桥术，术后即刻DSA显示桥血管通畅 4c 二期采取左椎动脉V2段-桡动脉-颈内动脉搭桥术，术后即刻DSA显示桥血管通畅

Figure 4 A case of vascular reconstruction for the CCA occlusion was a 67-year-old female patient with bilateral CCA occlusion and a compensatory basilar apex aneurysm. The right carotid bifurcation was at a low position, and revascularized by the large branch vessel of the aorta, while the left carotid bifurcation rided a higher position, and the cervical bypass was selected at this side. Both surgeries were performed in a neurosurgical hybrid operating room. CTA showed bilateral CCA occlusion (Panel 4a). In the first stage, the right side was treated with a subclavian artery - great saphenous vein - CCA bypass, postoperative DSA showed a patent graft (Panel 4b). In the second stage, the left side was treated with a V2 segment of the VA-radial artery-ICA bypass, postoperative DSA showed a patent graft (Panel 4c).

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2 泛血管医学时代“脑心同治”手术与展望

Synchronous surgical treatment for brain and heart in the era of pan-vascular medicine

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