AbuRahma A F, Robinson P A, Saiedy S, Richmond B K, Khan J
Department of Surgery, Robert C. Byrd Health Sciences Center of West Virginia University, Charleston Area Medical Center, Charleston, WV, USA.
Stroke. 1999 Jun;30(6):1185-9. doi: 10.1161/01.str.30.6.1185.
Although several studies have compared the results of carotid endarterectomy (CEA) with primary closure (PC) versus patch closure, none have compared the outcome of bilateral CEAs with patch versus PC performed on the same patient. This prospective randomized study compares the clinical outcome and incidence of recurrent stenosis (>/=80%) for CEA with PC versus patch closure in patients with bilateral CEAs.
This study includes 74 patients with bilateral CEAs with PC on one side and patching on the other. Patients were randomized to sequential operative treatment of either patching/PC or PC/patching. Postoperative duplex ultrasounds and clinical follow-up were done at 1, 6, and 12 months and every year thereafter. A Kaplan-Meier analysis was used to estimate the risk of significant restenosis (>/=80%).
Demographic characteristics and the mean operative diameter of the internal carotid artery were similar for both PC and patching. The mean follow-up was 29 months (range, 6 to 65 months). The incidence of ipsilateral stroke was 4% for PC versus 0% for patching. PC had a significantly higher incidence of neurological complications (transient ischemic attacks and stroke combined) than patching (12% versus 1%; P=0.02). Operative mortality was 0%. PC had a higher incidence of recurrent stenosis (22% versus 1%; P<0.003) and total internal carotid artery occlusion (8% versus 0%; P=0.04) than patching. Restenoses necessitating a repeated CEA were also higher for PC (14%) than for patching (1%; P=0.01). The Kaplan-Meier analysis showed that patching had a significantly better cumulative patency rate than PC (P<0.01). This analysis also showed that freedom from recurrent stenosis at 24 months was 75% for PC and 98% for patching.
Patch closure is less likely than PC to cause ipsilateral stroke, transient ischemic attacks, and recurrent carotid stenosis. The higher rate of unilateral recurrent stenosis may suggest that local factors play a more significant role than systemic factors in the etiology of recurrent carotid stenosis.
尽管多项研究比较了颈动脉内膜切除术（CEA）采用一期缝合（PC）与补片修补的结果，但尚无研究比较同一患者双侧CEA采用补片修补与一期缝合的结局。这项前瞻性随机研究比较了双侧CEA患者中CEA采用PC与补片修补的临床结局及再狭窄（≥80%）发生率。
本研究纳入74例双侧CEA患者，一侧采用PC，另一侧采用补片修补。患者被随机分配接受补片修补/PC或PC/补片修补的序贯手术治疗。术后分别在1、6和12个月以及此后每年进行双功超声检查和临床随访。采用Kaplan-Meier分析评估严重再狭窄（≥80%）的风险。
PC组和补片修补组的人口统计学特征及颈内动脉平均手术直径相似。平均随访时间为29个月（范围6至65个月）。PC组同侧卒中发生率为4%，补片修补组为0%。PC组神经并发症（短暂性脑缺血发作和卒中合并）发生率显著高于补片修补组（12%对1%；P=0.02）。手术死亡率为0%。PC组再狭窄发生率（22%对1%；P<0.003）和颈内动脉完全闭塞发生率（8%对0%；P=0.04）高于补片修补组。因再狭窄需要再次行CEA的比例PC组（14%）也高于补片修补组（1%；P=0.01）。Kaplan-Meier分析显示，补片修补组的累积通畅率显著优于PC组（P<0.01）。该分析还显示，24个月时PC组无再狭窄的比例为75%，补片修补组为98%。
与PC相比，补片修补导致同侧卒中、短暂性脑缺血发作和颈动脉再狭窄的可能性较小。单侧再狭窄发生率较高可能表明，局部因素在颈动脉再狭窄病因中比全身因素发挥更重要的作用。
