颅外段颈动脉狭窄的治疗策略

目的：探讨颅外段颈动脉粥样硬化性狭窄的治疗方法。方法回顾性分析上海中山医院血管外科2012年1～6月51例颅外段颈动脉粥样硬化性狭窄患者的临床资料,16例行颈动脉内膜剥脱术（carotid endarterectomy,CEA）,35例行颈动脉支架置入术（ carotid artery stenting ,CAS）。结果51例手术均获成功,1例CAS术后即刻脑卒中,1例CEA术后第3天短暂性脑缺血发作（transient ischemic attack,TIA）,1例CAS术后颈动脉窦压迫。全组术后随访9～15个月,平均13．6月,复查颈动脉B超,无严重再狭窄。结论根据颅外段颈动脉粥样硬化性狭窄患者的相关医学资料,对于有下列情况之一的患者我们倾向于行CEA：①6个月内1次或多次TIA,且颈动脉狭窄度≥70％;②6个月内1次或多次轻度非致残性卒中发作,症状或体征持续超过24小时且颈动脉狭窄度≥70％;③对于经颈部血管CTA和颈动脉全脑血管造影发现的颈动脉狭窄段≥2 cm。对于有下列情况之一的患者我们倾向于行CAS：①无症状性颈动脉狭窄度≥70％;②有症状性狭窄度范围50％～69％;③无症状性颈动脉狭窄度＜70％,但血管造影或其他检查提示狭窄病变处于不稳定状态。     

颈动脉内膜剥脱术与颈动脉支架置入术治疗颅外颈动脉狭窄的临床疗效比较

目的比较颈动脉内膜剥脱术(carotid endarterectomy,CEA)与颈动脉支架置入术(carotid stenting,CAS)治疗颅外颈动脉狭窄的临床疗效,为颅外颈动脉狭窄的CEA和CAS治疗提供更丰富的临床循证医学证据。方法将40例有手术指征的颈动脉狭窄患者按治疗方法的不同分为CEA组和CAS组。2组患者均行相应手术治疗,观察、比较其临床疗效。结果 2组患者围术期并发症发生率、术后3个月2组患者的心血管并发症、脑卒中及死亡等主要终点事件发生率的差异均无统计学意义(P0.05);随访12个月,2组术侧颈动脉再狭窄、致残或致死性卒中发生率比较差异也无统计学意义(P0.05)。结论对于具有手术指征的颅外颈动脉狭窄患者,CEA与CAS具有同样的临床疗效,且安全性均较高;但仍需要大样本多中心长期循证医学证据支持。     

双侧颈动脉粥样硬化性狭窄的处理策略

目的:探讨双侧颈动脉粥样硬化性狭窄患者的手术适应证、时机和策略.方法:1987年2月至2007年12月共收治74例双侧颈动脉粥样硬化性狭窄患者,其中34例患者症状限于一侧,均施行了一侧颈动脉内膜切除(CEA),其中8例对侧因狭窄>70%或粥样硬化斑块不稳定而行CEA或支架成形(CAS).38例双侧均有症状,15例双侧先后施行CEA;3例一侧行CEA,对侧行CAS;20例仅行单侧CEA.另外2例双侧无症状,均因狭窄>70%而行单侧CEA,其中1例还行对侧CAS.结果:本组74例患者共行93侧CEA,68例术后顺利,2例神经功能障碍加重,2例出现心肌缺血,1例脑出血,1例声音嘶哑.67例患者平均随访4.9年,63例无与术侧颈动脉相关的脑缺血事件发生.结论:颈动脉粥样硬化性狭窄患者只要指征明确,无论对侧颈动脉正常、狭窄甚至闭塞,均应施行CEA.双侧狭窄患者的治疗时机和策略因人而异.CEA术中主要依据电生理监测结果决定是否采用转流.     

颈动脉重度和极重度狭窄的治疗策略和并发症分析

目的 :比较重度颈动脉狭窄重度(70%～90%)和极重度(90%以上)病人行颈动脉内膜切除术(carotid endarterectomy, CEA)与颈动脉支架置入术(carotid artery stenting, CAS)的治疗效果和并发症发生情况。方法:回顾性分析2015年1月至2017年12月长海医院收治的463例重度颈动脉狭窄病人接受手术治疗的临床资料。结果:重度颈动脉狭窄的病人202例。CEA组62例与CAS组140例术后再发卒中的差异(3.2%比6.7%)无统计学意义(P=0.181)。CAS组术后再狭窄2.2%,CEA组无再狭窄,差异无统计学意义(P=0.240)。CEA组术后舌偏位、言语不清的发生率4.8%和3.2%,CAS术后无此两种并发症(P=0.009和0.033)。极重度颈动脉狭窄病人261例。CEA组95例和CAS组166例术后再发卒中发生率差异(1.1%比4.5%)无统计学意义(P=0.135),但CAS组较多。CAS术后再狭窄的发生率5.7%,而CEA术后无再狭窄(P=0.017)。CEA组术后发生舌偏位和言语不清4.2%与3.2%,同样CAS组无该并发症(P=0.008和0.021)。结论:CEA与CAS应用于颈动脉重度狭窄病人的治疗效果差异无统计学意义,但CAS术后无神经系统并发症。颈动脉极重度狭窄病人行CEA的治疗效果明显优于CAS。     

分期行冠状动脉旁路移植术和颈动脉支架植入术对术前脑卒中患者的临床预后研究

目的 分析分期行冠状动脉旁路移植术（coronary artery bypass grafting,CABG）和颈动脉支架植入术（carotid artery stenting,CAS）相较单独行CABG对术前有脑卒中史且合并颈动脉狭窄的冠状动脉粥样硬化性心脏病（冠心病）患者的近期和远期疗效。方法 回顾性分析2008—2017年复旦大学附属中山医院心脏外科55例术前有脑卒中史且合并颈动脉狭窄的分期行CABG+CAS和单独行CABG冠心病患者的临床资料,其中男48例、女7例,年龄（67.62±7.06）岁。分期CABG+CAS组有13例患者,单独CABG组有42例患者。比较两组患者在围手术期不良事件发生率和长期生存中的差异,并进行单因素和多因素分析以确定长期不良事件发生的独立危险因素。结果 分期CABG+CAS组1例（7.69%）患者发生围手术期不良事件,而单独CABG组有4例（9.52%）患者（P=0.84）。平均随访时间（67.84±37.99）个月,在随访期间,分期CABG+CAS组患者的长期生存率明显高于单独CABG组（P=0.02）,分期CABG+CAS术的长期不良事件发生风险...     

颈动脉支架置入术在合并无症状颈动脉重度狭窄的冠状动脉旁路移植术中的应用北大核心CSCD

目的对比分析颈动脉支架置入术(carotid artery stenting,CAS)联合冠状动脉旁路移植术(coronary artery bypass grafting,CABG)和单纯CABG两种术式治疗冠心病合并无症状重度颈动脉狭窄患者的围手术期情况及随访资料,评估CAS-CABG联合手术的安全性和有效性。方法回顾性分析2018年1月至2022年12月在北京安贞医院、北京朝阳医院、北京天坛医院行CABG治疗的700例冠心病合并无症状颈动脉重度狭窄患者的病历资料。根据是否进行CAS处理,分为CAS-CABG组(116例)和单纯CABG组(584例)。CAS-CABG组平均(64.8±7.3)岁,均仅行单侧CAS手术;单纯CABG组平均(65.5±7.6)岁。比较两组患者术后30天及中位24个月随访的主要结果。应用logistic回归法行单因素和多因素分析。结果CAS-CABG组患者术后早期卒中发生率显著降低(2.6%对9.1%,P=0.02),CAS联合CABG手术并未增加随访期间病死率和不良事件发生率。亚组分析发现,两种术式治疗无症状单侧颈动脉重度狭窄的卒中发生率差异无统计学意义,高龄、房颤史和卒中史是无症状单侧颈动脉重度狭窄CABG术后早期卒中的独立危险因素。结论CAS联合CABG治疗冠心病合并无症状颈动脉狭窄安全有效,可降低患者术后早期卒中发生率。应合理筛选合并无症状颈动脉狭窄的CABG患者,进行预防性CAS以降低此类患者术后卒中风险。     

颈动脉狭窄血管内支架植入和内膜切除术治疗的临床选择

目的 探讨在不同条件下如何合理选择颈动脉狭窄的治疗方式.方法 回顾性分析经颈动脉血管内支架植入术(CAS)和颈动脉内膜切除术(CEA)治疗的133例颈动脉狭窄患者的临床资料.其中46例患者行CAS,87例行CEA.观察两组患者的住院天数和治疗前后的美国国立卫生研究院卒中评分量表(NIHSS)评分、前向血流,治疗前和治疗后1-24个月狭窄处收缩期血流速度峰值及狭窄程度,以及治疗后死亡、脑卒中或心肌梗死等终点事件的发生率.结果 两组住院天数和治疗后NIHSS评分>20层次时差异有统计学意义(P<0.05);两组治疗前后的前向血流评定差异无统计学意义(P>0.05);多普勒频谱测定两组治疗前后颈动脉狭窄程度有显著性差异(P<0.05);两组治疗后30 d内,终点事件的累计发生率差异有统计学意义(P<0.05);31 d～2年终点事件的累计发生率差异无统计学意义(P>0.05);6个月后再狭窄发生率CAS组高于CEA组.结论 CAS和CEA对颈动脉狭窄的效果无显著差异,狭窄的部位、原因及对侧病变是选择CAS和CEA的重要因素.     

颈动脉狭窄患者内膜剥脱术与支架植入术1年疗效Meta分析

目的利用Meta分析法探讨颈动脉内膜剥脱术（CEA）与颈动脉支架植入术（CAS）对颈动脉狭窄治疗1年内死亡和卒中、死亡、卒中、重度再狭窄及闭塞事件发生情况并进行评价。方法制定原始文献的纳入标准、排除标准及检索策略,搜索关于CEA及CAS治疗对颈动脉狭窄的对照研究。应用RevMan4.2.2软件对纳入文献进行定量评价。以优势比（OR值）及双侧95%可信区间（CI）作为效应尺度进行分析。结果纳入本研究的文献共6篇,1037例患者接受CAS治疗,1681例接受CEA治疗,将发生死亡和卒中、死亡、卒中事件统计数据合并;累计1586例接受CAS治疗,2196例接受CEA治疗,进行再狭窄及闭塞的统计数据合并。术后1年内CAS与CEA患者死亡和卒中、死亡、卒中事件发生差异无统计学意义,其OR值分别为0.81（95%CI0.56～1.18）、0.75（95%CI0.47～1.19）、0.78（95%CI0.53～1.16）。CAS患者再狭窄率高于CEA患者[OR=1.99（95%CI1.44～2.74）,P〈0.05）。结论对于颈动脉狭窄患者,CEA与CAS的1年死亡和卒中、死亡、卒中事件发生无明显差异,CAS术后重度再狭窄及闭塞率为CEA术的1.99倍。由于在缺乏足够数量的随机对照试验的情况下,纳入部分非随机对照试验的Meta分析,使论证强度受到一定的限制,有待更多大样本高质量随机对照试验对本研究结果进一步验证。     

颈动脉内膜剥脱术及颈动脉支架置入术治疗颅外颈动脉硬化狭窄术后早期并发症比较

目的比较颈动脉内膜剥脱术(carotid endarterectomy,CEA)及颈动脉支架置入术(carotid stenting,CAS)治疗颅外颈动脉硬化狭窄后早期并发症发生情况,为临床治疗方法的选择提供理论依据。方法 2005年1月-2007年12月,分别采用CEA(CEA组,36例)和CAS(CAS组,27例)治疗63例颅外颈动脉狭窄患者。男42例,女21例;年龄52～79岁,平均67.5岁。左侧28例,右侧35例。颈动脉狭窄度为60%～95%,平均79%。主要临床症状为中风和短暂性脑缺血发作。头颅CT检查:24例有陈旧性脑梗死(cerebral infarction,CI),22例见多发性腔隙性CI,余17例未见明显异常。分析两种术式治疗后7 d内脑部、心血管及局部并发症发生情况。结果术后7 d内CEA组3例(8.3%)出现脑部并发症,2例(5.6%)出现心血管并发症,5例(13.9%)出现局部并发症;CAS组8例(29.6%)出现脑部并发症,1例(3.7%)出现心血管并发症,3例(11.1%)出现局部并发症;CAS组患者脑部并发症发生率明显高于CEA组,差异有统计学意义(χ2=4.855,P=0.028);但两组心血管、局部并发症发生率以及总并发症发生率比较,差异均无统计学意义(P>0.05)。结论对于颅外颈动脉硬化狭窄患者,CEA是首选治疗方式。     

颈动脉内膜剥脱术和颈动脉支架的前瞻性随机对照研究

目的 评价颈动脉内膜剥脱术和颈动脉支架治疗颈动脉狭窄的近期和中期临床效果.方法 前瞻性单中心随机对照研究,自2004年5月至2006年12月,将同意入组的40例有症状(狭窄程度>50%)和无症状(狭窄程度>70%)颈动脉狭窄患者随机分为两组,即颈动脉内膜剥脱术组(CEA)和颈动脉支架组(CAS).一期观察终点是术后30 d内出现严重脑梗死或死亡;二期观察终点是各种手术并发症、急性脑缺血发作、偏瘫、急性心肌梗死和术后18个月内的脑卒中、死亡和再狭窄等,同时回顾性分析两组总的住院费用.结果 CEA和CAS两组患者术前一般资料、临床症状、伴随疾病等因素均无差异.CEA组20例23支颈动脉手术(3例分别行双侧CEA),术中应用转流管9条(39.1%),颈动脉补片12条(52.2%);CAS组20例23支颈动脉支架(3例行双侧CAS),应用脑保护装置21个(91.3%).CEA和CAS两组术后30 d内神经系统并发症(4.3%对8.7%,P=0.46)、急性心肌梗死(4.3%对0,P=0.31)和伤口血肿(8.7%对0,P=0.14)等差异均无统计学意义,至术后18个月无短暂性脑缺血发作和再狭窄病例.CEA和CAS两组平均住院费用分别为(16 450.95±6188.76)和(70 130.15±11 999.02)元人民币,差异有统计学意义(P<0.01).结论 CEA和CAS术后30 d和术后18个月的并发症、病死率和临床疗效无明显差异,但CAS的住院花费明显高于CEA.     

Carotid Endarterectomy Versus Carotid Stenting: an Updated Review of Randomized Trials and Subgroup Analyses

Atherosclerotic disease of the carotid arteries is responsible for a significant portion of ischemic strokes. Carotid endarterectomy (CEA) is currently the accepted standard of treatment for patients with severe symptomatic carotid stenosis. In the past few years, however, carotid angioplasty and stenting (CAS) has emerged as a potential alternative endovascular treatment strategy for this disorder. In fact, spurred by the positive results of single center studies and small, pivotal randomized trials, some even consider CAS as the treatment modality of choice, especially in presumably surgical high-risk patients. Yet, randomized trials directly comparing CAS with CEA are sparse and have produced conflicting results.

The aim of this article is to review the current trial data on this issue and to define the role of these techniques for the management of two important subgroups of patients.

An updated meta-analysis of seven randomized trials comparing CEA with CAS demonstrates that CAS is associated with a significantly increased risk of any stroke or death within 30 days (OR. 1.41, 95% CI 1.07-1.87, p<0.05). Focusing on patients with a symptomatic carotid stenosis, there was also a significant difference in the odds of treatment-related stroke and death between CAS and CEA (OR, 1.41; CI 1.05 to 1.88, p < 0.05). Data on all disabling strokes and deaths within 30 days was available from five trials. The odds of disabling stroke or death at 30 days were similar in the endovascular and surgical group (OR, 1.33, 95% CI 0.89 to 1.98).

Overall, these data do not justify a blind enthusiasm for CAS and a widespread use of this procedure for the treatment of carotid artery stenosis. On the other hand, a closer inspection of the current literature on elderly patients and those with a contralateral carotid occlusion clearly indicates that CAS and CEA already now have a complementary role. While elderly patients should preferentially be treated with CEA, CAS appears to be the treatment of choice in patients with a symptomatic carotid artery stenosis and a contralateral carotid occlusion in experienced centers.     

颈动脉内膜剥脱术治疗高龄颈动脉狭窄患者的安全性和有效性分析

目的分析颈动脉内膜剥脱术（cEA）治疗高龄（≥75岁）颅外段颈动脉狭窄患者的疗效及安全性。方法回顾性分析北京协和医院血管外科2009年10月至2012年10月期间行CEA治疗的312例颈动脉狭窄患者的临床资料,分析CEA治疗高龄颈动脉狭窄患者的危险因素,探讨围手术期并发症的预防措施。结果本研究共纳入39例患者,所有手术过程顺利,随访时间为（22．18±8．71）个月。其中男33例（84．6％）,女6例（15．4％）;中位年龄77岁（75～82岁）;双侧病变患者11例（28．2％）,无症状患者7例（17．9％）;共施行39例次CEA,22例次（56．4％）采用颈动脉补片;16例次（41．0％）使用转流管;住院时间（17．38±5．39）d。1例患者（2．6％）术后第2天出现脑过度灌注综合征,1例患者（2．6％）术后15个月出现手术侧再狭窄,无围手术期死亡病例。结论在严格掌握手术适应证情况下,CEA是治疗高龄颈动脉狭窄患者安全而有效的方法。     

A comparison of carotid artery stenting with neuroprotection versus carotid endarterectomy under local anesthesia

BACKGROUND: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce the risk of stroke in patients with high-grade carotid artery stenosis. Despite the known impact of type of anesthesia on outcome after CEA, none of the current studies comparing CEA with CAS addresses the effect of anesthetic choice on perioperative events. In this study, we compare our results of distally protected CAS versus CEA under local anesthesia. METHODS: Clinical data of 345 patients who underwent 372 procedures for carotid artery occlusive disease over a 36-month were retrospectively collected for this analysis. Distal embolic protection was used in CAS procedures. All procedures, both CEA (n = 221, 59%) and CAS (N = 152, 41%), were performed under local anesthesia. The primary outcome measure was aggregate 30-day major ipsilateral stroke and/or death. Follow-up serial Duplex ultrasound examinations were performed. RESULTS: Both patient cohorts were similar in terms of demographic and risk factors, with the exception of a higher incidence of coronary artery disease in the CAS group (59% versus 30%, P <.05). The 30-day stroke and death rates were 3.2% (CAS) and 3.7% (CEA) (P = not significant). Cranial nerve injury only occurred in the CEA patients (2.3%). Perioperative hemodynamic instability was more common among patients in the CAS group (11.9% versus 4.1%, P <.05). CONCLUSIONS: Percutaneous carotid stenting with neuroprotection provides comparable clinical success to CEA performed under local anesthetic. Further studies are warranted to validate the long-term efficacy of CAS and to elucidate patient selection criteria for endovascular carotid revascularization.     

Selecting an Appropriate Surgical Treatment Instead of Carotid Artery Stenting Alone According to the Patient’s Risk Factors Contributes to Reduced Perioperative Complications in Patients with Internal Carotid Stenosis: A Single Institutional Retrospective Analysis

This retrospective study was aimed to compare the perioperative complications for internal carotid artery stenosis (ICS) in a Japanese single institute between the use of carotid artery stenting (CAS) alone or the use of an appropriate individualized treatment method allowing either carotid endarterectomy (CEA) or CAS based on patient risk factors. Based on the policy at our hospital, only CAS was performed on patients (n = 33) between January 2005 and November 2009. From December 2009 to December 2012, either CEA or CAS (tailored treatment) was selected for patients (n = 61) based on individual patient risk factors. CEA was considered the first-line treatment in all cases. In high-risk CEA cases, CAS was performed instead (n = 11), whereas in low-risk CEA cases, CEA was performed (n = 19). Further, in moderate-risk CEA cases based on own criteria, CAS was considered first, whereas for high-risk CAS cases, CEA was performed (n = 17). For low-risk CAS cases, CAS was performed (n = 9). Perioperative clinical complications (any stroke, myocardial infarction, or death within 30 days) were compared between both periods. Significantly reduced perioperative complications were observed during the tailored period (4/61 sites, 6.6%) as compared with the CAS period (8/33 sites, 24.2%) [Fisher’s exact test p = 0.022; odds ratio, 4.56 (CAS/tailored); 95% confidence interval, 1.26–16.5]. Selecting an appropriate individualized treatment method according to patient risk factors, as opposed to adhering to a single treatment approach such as CAS, may contribute to improved overall outcomes in patients with ICS.     

Endarterectomy or carotid artery stenting: the quest continues

BACKGROUND: Carotid endarterectomy (CEA) is still considered the "gold-standard" of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endovascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis. This review presents the development of CAS according to early reports, results of recent randomized trials, and future perspectives regarding CAS. METHODS: A literature search using the PubMed and Cochrane databases identified articles focusing on the key issues of CEA and CAS. RESULTS: Early nonrandomized reports of CAS showed variable results, and the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy trial led to United States Food and Drug Administration approval of CAS for the treatment of patients with symptomatic carotid stenosis. In contrast, recent trials, such as the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial and the Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis trial, (re)fuelled the debate between CAS and CEA. In the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial, the complication rate of ipsilateral stroke or death at 30 days was 6.8% for CAS versus 6.3% for CEA and showed that CAS failed the noninferiority test. Analysis of the Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis trial showed a significant higher risk for death or any stroke at 30 days for endovascular treatment (9.6%) compared with CEA (3.9%). Other aspects-such as evolving best medical treatment, timely intervention, interventionalists' experience, and analysis of plaque composition-may have important influences on the future treatment of patients with carotid artery stenosis. CONCLUSIONS: CAS performed with or without embolic-protection devices can be an effective treatment for patients with carotid artery stenosis. However, presently there is no evidence that CAS provides better results in the prevention of stroke compared with CEA.