Ross Charles B, Naslund Thomas C, Ranval Timothy J
Division of Vascular Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Am Surg. 2002 Nov;68(11):967-75; discussion 975-7.
Carotid artery angioplasty and stenting (CAS) has been accomplished in multiple centers with short-term and midterm results similar to carotid endarterectomy (CEA). Until completion of multicentered prospective evaluation of the benefit of CAS versus established therapy (CEA) clinical judgment must be used to determine whether an individual patient with unusual technical challenges and/or risks might be best suited for CEA or CAS. We report our experience with 41 CAS procedures in 39 patients treated from November 1996 through November 2001. Six patients had primary lesions (three symptomatic and three asymptomatic). Thirty-three patients had 35 procedures for recurrent carotid stenosis (11 symptomatic and 24 asymptomatic). Technical success was achieved in 40 of 41 procedures. No deaths occurred. The 30-day major stroke rate was one in 41 (2.4%), and the overall 30-day stroke/transient ischemic attack rate was three in 41 (7.3%). No recurrence or late neurologic events were seen in patients treated for primary carotid stenosis. A 23 per cent recurrence rate was observed in patients treated for recurrent carotid stenosis, after one or more CEAs, with mean follow-up of 18 +/- 14 months. Recurrence requiring operative correction with carotid resection and interposition grafts occurred in three patients treated with CAS in this group. Late deaths occurred in six patients; one of these was due to stroke. Overall freedom from late stroke and/or need for reintervention (by Kaplan-Meier analysis) was 64 +/- 13 per cent at 48 months in the group treated by CAS for post-CEA recurrence. CAS represents a technically simplistic means of providing carotid revascularization. However, its role remains undefined and benefits unproven. Surgical revascularization remains appropriate for patients with operable carotid lesions. However, surgical revascularization is not always an ideal option when we are faced with difficult carotid lesions and risks. For this reason we advocate that all surgeons who intend to remain specialists in the management of carotid disease should attain, master, and maintain the skills necessary for CAS.
颈动脉血管成形术和支架置入术（CAS）已在多个中心开展，其短期和中期结果与颈动脉内膜切除术（CEA）相似。在完成CAS与既定治疗方法（CEA）疗效的多中心前瞻性评估之前，必须运用临床判断来确定，对于面临特殊技术挑战和/或风险的个体患者，CEA或CAS哪种最为合适。我们报告了1996年11月至2001年11月期间对39例患者实施41例CAS手术的经验。6例患者有原发性病变（3例有症状，3例无症状）。33例患者因复发性颈动脉狭窄接受了35例手术（11例有症状，24例无症状）。41例手术中有40例获得技术成功。无死亡病例。30天内主要卒中发生率为41例中的1例（2.4%），30天内总体卒中/短暂性脑缺血发作发生率为41例中的3例（7.3%）。接受原发性颈动脉狭窄治疗的患者未出现复发或晚期神经事件。在接受复发性颈动脉狭窄治疗的患者中，经过一次或多次CEA后，平均随访18±14个月，观察到复发率为23%。该组中接受CAS治疗的3例患者出现复发，需要进行颈动脉切除和植入移植血管的手术矫正。6例患者出现晚期死亡；其中1例死于卒中。通过CAS治疗CEA后复发的患者组，在48个月时，根据Kaplan-Meier分析，总体无晚期卒中及/或无需再次干预的生存率为64±13%。CAS是一种技术上较为简单的颈动脉血运重建方法。然而，其作用仍不明确，益处也未得到证实。对于可手术治疗的颈动脉病变患者，手术血运重建仍然是合适的选择。然而，当我们面对困难的颈动脉病变和风险时，手术血运重建并不总是理想的选择。因此，我们主张所有打算继续成为颈动脉疾病治疗专家的外科医生都应掌握、精通并保持实施CAS所需的技能。
