对侧颈动脉闭塞患者无症状性颈动脉狭窄≥60%的自然病程。
Natural history of > or =60% asymptomatic carotid stenosis in patients with contralateral carotid occlusion.
作者信息
AbuRahma Ali F, Metz Matthew J, Robinson Patrick A
机构信息
Department of Surgery, Robert C. Byrd Health Sciences Center, Of West Virginia University, Charleston Area Medical Center, Charleston, WV 25304, USA.
出版信息
Ann Surg. 2003 Oct;238(4):551-61; discussion 561-2. doi: 10.1097/01.sla.0000089856.64262.66.
OBJECTIVE
Although the Asymptomatic Carotid Atherosclerosis Study (ACAS) reported that carotid endarterectomy (CEA) is beneficial for patients with asymptomatic > or =60% carotid stenosis (ACS), several other studies have reported mixed results. Our prospective study analyzed the natural history of > or =60% ACS in patients with contralateral carotid occlusion (CCO).
PATIENT POPULATION AND METHODS
During a 10-year period, patients with 60-<70% ACS with CCO were entered into a protocol of clinical examination and duplex surveillance every 6 months. All patients underwent maximum medical therapy. Late CEAs were considered if lesions became symptomatic or progressed to > or =70% stenosis. A Kaplan-Meier lifetable analysis was performed to estimate the freedom from both ipsilateral strokes and all strokes.
RESULTS
Eighty-two patients were enrolled with a mean follow-up of 59.5 months (range, 7-141 months). Late strokes were noted in 27 of 82 patients (33%); 19 (23%) were ipsilateral and 8 (10%) were contralateral (side of CCO). Late transient ischemic attacks (TIAs) were noted in 22 of 82 (27%, 7 ipsilateral and 15 contralateral). The combined neurologic event (TIA/stroke) rate was 60% (49 of 82, 32% ipsilateral and 28% contralateral). Kaplan-Meier lifetable analysis showed that the rates of freedom from ipsilateral strokes, all strokes, and progression to > or =70% stenosis at 1, 2, 3, 4, and 5 years were 94%, 90%, 85%, 80%, 73%; 94%, 89%, 84%, 77%, 67%; and 99%, 96%, 92%, 86%, and 82%, respectively. The ipsilateral stroke-free survival rates at l, 2, 3, 4, and 5 years were 94%, 88%, 78%, 70%, and 63%. Twenty-one late CEAs were performed with no perioperative stroke/deaths (5 for ipsilateral TIAs, 9 for ipsilateral strokes, and 7 for > or =70% ACS). Overall, 20 (24%, 11 with symptoms and 9 asymptomatic) progressed to > or =70% stenosis.
CONCLUSIONS
Patients with 60-<70% ACS and CCO with maximal medical therapy carry a higher incidence of ipsilateral strokes and all strokes than what was reported by the ACAS study; therefore, prophylactic CEA may be justified in these patients.
目的
尽管无症状性颈动脉粥样硬化研究（ACAS）报告称，颈动脉内膜切除术（CEA）对无症状性颈动脉狭窄（ACS）≥60%的患者有益，但其他一些研究报告的结果却各不相同。我们的前瞻性研究分析了对侧颈动脉闭塞（CCO）患者中≥60% ACS的自然病程。
患者群体与方法
在10年期间，将患有60% - <70% ACS且伴有CCO的患者纳入每6个月进行一次临床检查和双功超声监测的方案。所有患者均接受了最大程度的药物治疗。如果病变出现症状或进展至≥70%狭窄，则考虑进行晚期CEA。进行Kaplan-Meier生存表分析以估计同侧卒中及所有卒中的无事件生存率。
结果
共纳入82例患者，平均随访59.5个月（范围7 - 141个月）。82例患者中有27例（33%）发生晚期卒中；19例（23%）为同侧卒中，8例（10%）为对侧（CCO侧）卒中。82例中有22例（27%）发生晚期短暂性脑缺血发作（TIA）；7例为同侧，15例为对侧。神经学事件（TIA/卒中）的综合发生率为60%（82例中的49例，同侧为32%，对侧为28%）。Kaplan-Meier生存表分析显示，1年、2年、3年、4年和5年时同侧卒中、所有卒中以及进展至≥70%狭窄的无事件生存率分别为94%、90%、85%、80%、73%；94%、89%、84%、77%、67%；99%、96%、92%、86%、82%。1年、2年、3年、4年和5年时同侧无卒中生存率分别为94%、88%、78%、70%、63%。共进行了21例晚期CEA，无围手术期卒中/死亡（5例因同侧TIA，9例因同侧卒中，7例因≥70% ACS）。总体而言，20例（24%，11例有症状，9例无症状）进展至≥70%狭窄。
结论
接受最大程度药物治疗的60% - <70% ACS且伴有CCO的患者，其同侧卒中和所有卒中的发生率高于ACAS研究报告的发生率；因此，对这些患者进行预防性CEA可能是合理的。
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