Cunningham E J, Bond R, Mehta Z, Mayberg M R, Warlow C P, Rothwell P M
Stroke Prevention Research Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, UK.
Stroke. 2002 Nov;33(11):2658-63. doi: 10.1161/01.str.0000034397.72390.d3.
Carotid endarterectomy (CEA) reduces the risk of stroke ipsilateral to recently symptomatic severe carotid stenosis. Other techniques such as percutaneous transluminal angioplasty with stenting are currently being compared with CEA. Thus far, case series and several small, randomized, controlled trials of CEA versus percutaneous transluminal angioplasty (with and without stenting) have focused primarily on the 30-day procedural risks of stroke and death. However, long-term durability is also important. To determine the long-term risk of stroke after CEA and to identify risk factors, we studied patients in the European Carotid Study Trial (ECST), the largest published cohort with long-term follow-up by physicians after CEA.
Risks of ipsilateral carotid territory ischemic stroke were calculated by Kaplan-Meier analysis starting on the 30th day after CEA in 1728 patients who underwent trial surgery. Risk factors were determined by Cox regression. For comparison, we also determined the "background" risk of stroke on medical treatment in the ECST in the territory of 558 previously asymptomatic contralateral carotid arteries with <30% angiographic stenosis (ECST method) at randomization.
The risks of disabling ipsilateral ischemic stroke and any ipsilateral ischemic stroke were constant after CEA, reaching 4.4% [95% confidence interval (CI), 3.0 to 5.8] and 9.7% (95% CI, 7.6 to 11.7), respectively, by 10 years. The equivalent ischemic stroke risks distal to contralateral <30% asymptomatic carotid stenoses were 1.9% (95% CI, 0.8 to 3.2) and 4.5% (95% CI, 1.5 to 7.4). Presentation with cerebral symptoms, diabetes, elevated systolic blood pressure, smoking, male sex, increasing age, and a lesser severity of preoperative stenosis were associated with an increased risk of late stroke after CEA, but plaque morphology and patch grafting were not.
Although the risk of late ipsilateral ischemic stroke after CEA for symptomatic stenosis is approximately double the background risk in the territory of <30% asymptomatic stenosis, it is still only approximately 1% per year and remains low for at least 10 years after CEA. This is the standard against which alternative treatments should be judged. Several risk factors may be useful in identifying patients at particularly high risk of late postoperative stroke.
颈动脉内膜切除术（CEA）可降低近期有症状的严重颈动脉狭窄同侧发生卒中的风险。目前正在将其他技术，如经皮腔内血管成形术加支架置入术与CEA进行比较。到目前为止，关于CEA与经皮腔内血管成形术（有无支架置入）的病例系列研究以及几项小型随机对照试验主要关注的是30天内手术相关的卒中和死亡风险。然而，长期疗效也很重要。为了确定CEA术后发生卒中的长期风险并识别危险因素，我们对欧洲颈动脉研究试验（ECST）中的患者进行了研究，该试验是已发表的CEA术后由医生进行长期随访的最大队列研究。
对1728例接受试验性手术的患者，从CEA术后第30天开始，采用Kaplan-Meier分析计算同侧颈动脉区域缺血性卒中的风险。通过Cox回归确定危险因素。为作比较，我们还确定了ECST中558条术前无症状的对侧颈动脉造影狭窄<30%（ECST法）区域内接受药物治疗时卒中的“背景”风险。
CEA术后致残性同侧缺血性卒中和任何同侧缺血性卒中的风险保持稳定，到10年时分别达到4.4%[95%置信区间（CI），3.0至5.8]和9.7%（95%CI，7.6至11.7）。对侧无症状颈动脉狭窄<30%区域内等效的缺血性卒中风险分别为1.9%（95%CI，0.8至3.2）和4.5%（95%CI，1.5至7.4）。出现脑部症状、糖尿病、收缩压升高、吸烟、男性、年龄增加以及术前狭窄程度较轻与CEA术后晚期卒中风险增加相关，但斑块形态和补片移植与晚期卒中风险无关。
虽然有症状性狭窄的患者CEA术后晚期同侧缺血性卒中的风险约为无症状狭窄<30%区域背景风险的两倍，但每年仍仅约为1%，且在CEA术后至少10年内仍较低。这是评判其他替代治疗方法的标准。几个危险因素可能有助于识别术后晚期卒中特别高危的患者。
