2022年 · 第37卷第03期

carotid artery atherosclerotic stenosis (CAAS) is a common peripheral vascular disease. Severe carotid artery stenosis is one of the main causes of ischemic stroke, because it can be intervened and prevented by surgery, and has received widespread attention in recent years. Traditional indications for carotid artery surgery are mainly determined based on the degree of stenosis and symptoms of the patient. In recent years, with new diagnosis and treatment techniques being applied to this disease, this standard is being challenged. Evidence suggests that in addition to the degree of stenosis and symptoms, carotid plaque stability and intracranial compensation can also affect the benefits and risks of surgery. This article will briefly describe the new research achievements in surgical intervention of CAAS, in order to provide reference for rational treatment of this disease.

Stroke is the leading cause of death among urban and rural residents in China, and the number of reported patients has reached 13 million^［1］。 Studies suggest that 80% ~87% of cerebral strokes are ischemic strokes, and about 25% ~30% of ischemic strokes are related to carotid stenosis^［2］。 According to the results of many clinical studies, early intervention of carotid artery stenosis can effectively reduce the occurrence of ischemic stroke. carotid endarterectomy (CEA), carotid artery stenting (CAS), and optimal medical therapy (OMT) are the main treatments for carotid stenosis at present^［3］。 In recent years, evidence of clinical trials on the treatment of carotid artery stenosis has been emerging, and a series of controversies and consensus have emerged. This article will explain the current hot issues in the treatment of carotid artery stenosis.

A 40-year-old female was admitted with "intermittent right lower abdominal discomfort for 10 years and intermittent right upper abdominal discomfort for 1 month". Physical examination: positive for McMaher's point tenderness, positive for right upper abdominal tenderness, no rebound pain and muscle tension. Abdominal B-ultrasound: an anechoic area of about 20 mm ×18 mm was seen in the liver, with thin and smooth wall; The gallbladder is about 54 mm ×13 mm, the wall is rough, and there is a strong echogenic light mass about 10 mm ×5 mm in the dark area of the cystic cavity, accompanied by acoustic shadows, and the common bile duct is not dilated. Diagnosis: gallbladder stones with chronic cholecystitis, chronic appendicitis, hepatic cyst. Laparoscopic cholecystectomy and appendectomy assisted by magnetic anchor with reduced poke hole under general anesthesia. The magnetic anchor mating device is shown in Figure 1. Lie on your back and make a 1 cm arc incision under the umbilicus to place a puncture device, puncture to the right under the xiphoid process and place a poke card, insert a magnetic anchor built-in grasping forceps, and use a titanium alloy tissue forceps to clamp it to the ampulla of the gallbladder. An anchor magnet is placed outside the upper right abdominal wall of the patient. The anchor magnet attracts the target magnet of the built-in grasping forceps and lifts the gallbladder. Adjust the anchor magnet in an appropriate position to fully expose the gallbladder triangle. Open the surface serosa with an electric hook, and separate the cystic duct with a separation forceps (Figure 2). Clamp the cystic duct with a vascular clamp at 4 mm from the common bile duct, and use a titanium clamp to clamp the cystic duct near the gallbladder side. Cut the cystic duct between the two clamps, clamp the gallbladder artery with a vascular clamp, and separate the gallbladder artery with an electric hook. Clear cystic fluid can be seen flowing out when the liver cyst wall is opened with the electric hook, and the cyst cavity can be seen when the cyst wall is removed. The gallbladder is completely peeled off antegrade under the pull of the magnetic anchor device, the anchor magnet is removed, the built-in grasping forceps are removed and placed on the right lower abdomen, the gallbladder is loaded into the specimen bag, the gallbladder bed is checked for no bleeding or gallbladder leakage, the puncture device is removed, and the puncture opening is sutured with silk thread. Puncture and place a poke card 5 cm below the left of the patient's umbilicus, also clamp the internal grasper forceps in the middle of the appendix, place an anchor magnet outside the abdominal wall of the right lower abdomen, attract the target magnet of the internal grasper forceps and lift the appendix, open the serosa with the electric hook, separate the appendix and mesangium (Figure 3), adjust the position of the anchor magnet, maintain a good appendix pulling force, and successfully remove the appendix. Remove the anchor magnet, remove the magnetic anchor built-in gripper, load the appendix into the specimen bag, remove the appendix and gallbladder, and the operation is over. The position of the abdominal wall poke hole is shown in Figure 4. The patient was discharged on the 2nd postoperative day.

A 35-year-old male was admitted to the hospital with "ruptured right thigh hemangioma and huge hematoma" due to "sudden right thigh pain 1 d ago". Physical examination: heart rate 114 beats/min, blood pressure 96/62 mmHg, right thigh 40 cm hard mass, skin ecchymosis; Multiple nodules and milk spots on the skin throughout the body (Figure 1). X-ray examination revealed a huge soft tissue density focus in the middle and distal right thigh with unclear boundaries. CT examination showed a mixed density focus in the anterior part of the right thigh, considering the tumor with hematoma; Swelling and exudation of soft tissues of right psoas major, iliac muscle and right thigh; The right external iliac vein is considered as a neoplastic dilatation or aneurysm (Figures 2, 3). Routine blood test: hemoglobin 76 g/L. Consider the compensatory period of hemorrhagic shock. A blood clot of 1 500 ml was seen subcutaneously during emergency surgery, and the mass infiltrated the adipose tissue. Pathological examination: The maximum diameter of the tumor was 32 cm, the weight was 2.9 kg, and it was gray-yellow, solid in nature, with large bleeding (Figure 4). Under light microscope, the nucleus of tumor cells were comma-shaped, with few mitotic images and infiltrative growth; Interstitial vascularity was abundant with hemorrhage (Figures 5, 6). Immunohistochemical staining was positive for S-100 and SOX-10. The patient, his brother and mother all suffered from neurofibromatosis type I (NF1), and the pathological diagnosis was: (right thigh) soft tissue giant neurofibroma with hematoma. After 6 months follow-up, the wound and function of the affected limb recovered well.