Powell Richard J, Schermerhorn Marc, Nolan Brian, Lenz James, Rzuidlo Eva, Fillinger Mark, Walsh Daniel, Wyers Mark, Zwolak Robert, Cronenwett Jack L
Division of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA.
J Vasc Surg. 2004 Jun;39(6):1193-9. doi: 10.1016/j.jvs.2003.12.038.
The purpose of this study was to review the initial results of carotid artery angioplasty with stenting (CAS) performed by vascular surgeons to treat bifurcation occlusive disease. Most patients were selected for CAS if they had indications for endarterectomy (CEA) but were considered at high risk for surgery.
Since December 2000, 74 carotid arteries in 69 patients underwent CAS, with distal balloon embolization protection in 96%. Mean patient age was 72 years; 82% of patients were men. Indications for CAS included asymptomatic disease (62%), transient ischemic attack (TIA; 23%), and cerebrovascular accident (15%). Mean internal carotid artery diameter stenosis was 82%. CAS was chosen over CEA because of cardiac (49%) or pulmonary (4%) comorbid conditions, hostile neck (25%), distal extent of disease (6%), and contralateral cranial nerve injury (1%). CAS was performed in 15% patients who were good surgical candidates, because of patient preference. Pathologic conditions were primary atherosclerosis (81%), recurrent carotid stenosis (18%), and dissection (1%). Procedures were transfemoral in 95% of cases and transcarotid in 5%. In 30% of cases the contralateral carotid artery had 80% or greater stenosis or was completely occluded.
Technical success was achieved in 96% of cases. There were no deaths, no major strokes, one minor stroke (National Institutes of Health Stroke Scale, 3), and one TIA (neurologic event rate, 2.6%). The single minor stroke resolved completely by 1 month. One patient (1.3%) had a perioperative myocardial infarction. Transient neurologic changes occurred in 8% of patients during the protection balloon inflation, and all resolved with deflation. Bradyarrhythmia requiring pharmacologic treatment occurred in 14% of patients. At mean follow-up of 6 months there have been two instances of recurrent stenosis greater than 50% as noted at duplex scanning. During the same period, 266 carotid CEAs were performed, with a neurologic event rate of 0.8% (major stroke, 0.4%; no minor strokes; TIA, 0.4%) and a myocardial infarction rate of 3%. Combined stroke and death rate was 1.3% in patients who underwent CAS and 0.5% in patients who underwent CEA.
CAS with cerebral protection can be performed safely in patients at high surgical risk, with low perioperative morbidity and mortality. The durability of the procedure must be determined with longer follow-up.
本研究旨在回顾血管外科医生进行颈动脉血管成形术加支架置入术（CAS）治疗分叉处闭塞性疾病的初步结果。大多数有内膜切除术（CEA）指征但被认为手术风险高的患者被选来进行CAS。
自2000年12月以来，69例患者的74条颈动脉接受了CAS，其中96%使用了远端球囊栓塞保护装置。患者平均年龄为72岁；82%为男性。CAS的指征包括无症状疾病（62%）、短暂性脑缺血发作（TIA；23%）和脑血管意外（15%）。颈内动脉平均直径狭窄率为82%。由于心脏（49%）或肺部（4%）合并症、颈部解剖结构复杂（25%）、病变远端范围（6%）和对侧颅神经损伤（1%），选择CAS而非CEA。15%适合手术的患者因个人偏好接受了CAS。病理情况为原发性动脉粥样硬化（81%）、复发性颈动脉狭窄（18%）和夹层（1%）。95%的病例采用经股动脉途径，5%采用经颈动脉途径。30%的病例中，对侧颈动脉狭窄80%或更高或完全闭塞。
96%的病例技术成功。无死亡病例，无重大卒中，1例轻度卒中（美国国立卫生研究院卒中量表评分为3分），1例TIA（神经事件发生率为2.6%）。这例轻度卒中在1个月内完全恢复。1例患者（1.3%）发生围手术期心肌梗死。8%的患者在保护球囊充气时出现短暂性神经功能改变，球囊放气后均恢复。14%的患者发生需要药物治疗的缓慢性心律失常。平均随访6个月时，经双功超声扫描发现2例再狭窄大于50%。同期进行了266例颈动脉CEA，神经事件发生率为0.8%（重大卒中0.4%；无轻度卒中；TIA 0.4%）；心肌梗死发生率为3%。接受CAS的患者中，卒中与死亡率合并为1.3%，接受CEA的患者中为0.5%。
对于手术风险高的患者，采用脑保护的CAS可以安全进行，围手术期发病率和死亡率较低。该手术的耐久性必须通过更长时间的随访来确定。
