Neurological Surgery 脳神経外科41巻12号

2013年12月発行

連載 合併症のシステマティック・レビュー―適切なInformed Consentのために

（11）STA-MCAバイパス術

著者： 千田光平¹ 小笠原邦昭¹

所属機関： ¹岩手医科大学脳神経外科

ページ範囲：P.1111 - P.1118

Ⅰ．はじめに

　Extracranial-intracranial（EC-IC）バイパス術は1969年にYaşargilによって導入され，1970年代に入って多くの施設で内頚動脈あるいは中大脳動脈の慢性閉塞性病変に対し行われるようになった⁵¹⁾．しかし，その適応および効果に関しては不明であったため，1977年から1982年にかけ，世界的規模で多施設参加によるprospective randomization studyが行われた⁴⁴⁾．そして1985年に，EC-ICバイパス術には内科的治療に勝る脳梗塞再発予防効果はないとする結果が発表された⁴⁴⁾．しかし，この研究は，患者選択に際し貧困灌流の概念が導入されていないなどといった欠点があった．

　1990年代になりpositron emission tomography（PET），single photon emission CT（SPECT），あるいはtranscranial Doppler（TCD）などの普及により，脳循環代謝の測定が一般臨床でも可能となった．これに伴い，EC-ICバイパス術が有効となり得る可能性を示唆する研究がなされ^13,29,41,50)，Japanese EC-IC Bypass Trial（JET study）によって中等度以上の血行力学的脳虚血に対して，脳梗塞の予防効果が初めて示された²²⁾．しかし，近年米国で行われたThe Carotid Occlusion Surgery Study（COSS）randomized trialでは，アテローム血栓性の症候性内頚動脈閉塞患者のうちPETで酸素摂取率（oxygen extraction fraction：OEF）の上昇（対側比で1.13倍以上）を認めた症例において，2年以内の同側の虚血性脳卒中の発症は，EC-ICバイパス群と内科治療群で差がみられなかった³⁸⁾．

　一方で，もやもや病に対する直接血行再建術の有効性に関しては，エビデンスの構築が難しい領域ではあるが，多くのcase control研究がなされてきた²⁰⁾．治療困難な脳動脈瘤に対するEC-ICバイパス術も，近年盛んに行われている⁴⁶⁾．血管内治療の普及が著しい一方で，バイパス術に替わる技術は開発されていない．

　このようにEC-ICバイパス術は，予防あるいは治療の補助として用いられるため，合併症を低く抑える必要がある．本稿ではEC-ICバイパス術のうち，STA-MCAバイパス術における周術期合併症についての論文を可能な限り抽出し，系統的に整理した．

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