Bowser Andrew N, Bandyk Dennis F, Evans Avery, Novotney Michael, Leo Fabian, Back Martin R, Johnson Brad L, Shames Murray L
Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, Tampa, FL 33606, USA.
J Vasc Surg. 2003 Sep;38(3):432-8. doi: 10.1016/s0741-5214(03)00927-3.
We compared outcome and durability of carotid stent-assisted angioplasty (CAS) with open surgical repair (ie, repeat carotid endarterectomy [CEA]) to treat recurrent carotid stenosis (RCS).
A retrospective review of anatomic and neurologic outcomes was carried out after 27 repeat CEA procedures (1993-2002) and 52 CAS procedures (1997-2002) performed to treat high-grade internal carotid artery (ICA) RCS after CEA. The incidence of intervention because of symptomatic RCS was similar (repeat CEA, 63%; CAS, 60%), but the interval from primary CEA to repeat intervention was greater (P <.05) in the repeat CEA group (83 +/- 15 months) compared with the CAS group (50 +/- 8 months). In the CAS group, 17 of 52 arteries (33%) were judged not to be surgical candidates because of surgically inaccessible high lesions (n = 8), medical comorbid conditions (n = 4), neck irradiation (n = 3), or previous surgery with cranial nerve deficit or stroke (n = 2). Three patients who underwent repeat CEA had lesions not appropriate for treatment with CAS.
Overall 30-day morbidity was similar after CAS (12%; death due to ipsilateral intracranial hemorrhage, 1; nondisabling stroke, 1; reversible neurologic deficits or transient ischemic attack, 2; access site complication, 2). and repeat CEA (11%; no death; nondisabling stroke, 1; reversible cranial nerve injury, 1; cervical hematoma, 1). Combined stroke and death rate was 3.7% for repeat CEA and 5.7% for CAS (P >.1). All duplex ultrasound scans obtained within 3 months after CEA and CAS demonstrated patent ICA and velocity spectra of less than 50% stenosis. During follow-up, no repeat CEA (mean, 39 months) or CAS (mean, 26 months) repair demonstrated ICA occlusion, but two patients (8%) who underwent repeat CEA and 4 patients (8%) who underwent CAS required balloon or stent angioplasty because of 80% RCS. At last follow-up, no patient had ipsilateral stroke and all ICA remain patent. At duplex scanning, stenosis-free (<50% diameter reduction) ICA patency at 36 months was 75% after repeat CEA and 57% after CAS (P =.26, log-rank test).
Carotid angioplasty for treatment of high-grade stenotic ICA after CEA resulted in similar anatomic and neurologic outcomes compared with open surgical repair. Most lesions are amenable to endovascular therapy, and CAS enabled treatment in patients judged not to be suitable surgical candidates. Duplex scanning surveillance after repeat CEA or CAS is recommended, because stenosis can recur after either secondary procedure.
我们比较了颈动脉支架辅助血管成形术（CAS）与开放性手术修复（即再次颈动脉内膜切除术[CEA]）治疗复发性颈动脉狭窄（RCS）的疗效和持久性。
对1993年至2002年间进行的27例再次CEA手术和1997年至2002年间进行的52例CAS手术进行回顾性分析，这些手术用于治疗CEA术后的重度颈内动脉（ICA）RCS。因症状性RCS进行干预的发生率相似（再次CEA为63%，CAS为60%），但再次CEA组从初次CEA到再次干预的间隔时间更长（P<.05）（83±15个月），而CAS组为（50±8个月）。在CAS组中，52条动脉中有17条（33%）因手术难以到达的高位病变（n = 8）、内科合并症（n = 4）、颈部放疗（n = 3）或既往手术导致颅神经缺损或中风（n = 2）而被判定不适合手术。3例接受再次CEA的患者有不适合CAS治疗的病变。
CAS术后总体30天发病率相似（12%；因同侧颅内出血死亡1例；非致残性中风1例；可逆性神经功能缺损或短暂性脑缺血发作2例；穿刺部位并发症2例），再次CEA术后为11%（无死亡；非致残性中风1例；可逆性颅神经损伤1例；颈部血肿1例）。再次CEA的联合中风和死亡率为3.7%，CAS为5.7%（P>.1）。CEA和CAS术后3个月内进行的所有双功超声扫描均显示ICA通畅，狭窄速度频谱小于50%。在随访期间，没有再次CEA（平均39个月）或CAS（平均26个月）修复显示ICA闭塞，但2例接受再次CEA的患者（8%）和4例接受CAS的患者（8%）因80%的RCS需要球囊或支架血管成形术。在最后一次随访时，没有患者发生同侧中风，所有ICA均保持通畅。在双功扫描时，再次CEA后36个月无狭窄（直径缩小<50%）的ICA通畅率为75%，CAS后为57%（P =.26，对数秩检验）。
与开放性手术修复相比，CEA术后采用颈动脉血管成形术治疗重度狭窄性ICA的解剖学和神经学结果相似。大多数病变适合血管内治疗，CAS使那些被判定不适合手术的患者能够得到治疗。建议在再次CEA或CAS后进行双功超声扫描监测，因为这两种二次手术术后狭窄都可能复发。
