Lam Russell C, Lin Stephanie C, DeRubertis Brian, Hynecek Robert, Kent K Craig, Faries Peter L
Division of Vascular Surgery, New York Presbyterian Hospital, Cornell University, Weill Medical School and Columbia University, College of Physicians and Surgeons, New York, NY 10021, USA.
J Vasc Surg. 2007 May;45(5):875-80. doi: 10.1016/j.jvs.2006.12.059.
Current evaluations of carotid artery angioplasty and stenting (CAS) have suggested equivalency compared with carotid endarterectomy (CEA). However, the incidence of stroke and death with CAS may be higher in elderly patients. We assessed the anatomic characteristics of patients undergoing CAS and compared them based on age older or younger than 80 years. The impact of age on the incidence of postoperative complications was also determined.
From February 2003 to August 2005, 135 CAS procedures were performed in 133 patients. Digital subtraction angiograms for each patient were evaluated by two independent observers blinded to patient identifiers. Anatomic characteristics that impact the performance of CAS were assessed as either favorable or unfavorable. These included aortic arch elongation, arch calcification, arch vessel origin stenosis, common and internal carotid artery tortuosity, and treated lesion stenosis, calcification, and length. Postoperative events were defined as myocardial infarction, stroke, and death. Fisher's exact test and chi(2) tests were used to determine statistical significance (P < .05).
Of the 133 patients treated, 87 (65%) were men and 46 (35%) were women; and 37 (28%) were >or=80 years of age. The cohort >or=80 years old had an increased incidence of unfavorable arch elongation (P = .008), arch calcification (P = .003), common carotid or innominate artery origin stenosis (P = .006), common carotid artery tortuosity (P = .0009), internal carotid artery tortuosity (P = .019), and treated lesion stenosis (P = .007). No significant difference was found for treated lesion calcification or length. Perioperative cerebral vascular accidents occurred in four patients (3.0%, 3 with no residual deficit, 1 with residual deficit), myocardial infarction in three (2.2%), and one patient (0.8%) died secondary to a hemorrhagic stroke. The combined stroke, myocardial infarction, and death rate for the entire population was 3.7%. The rate was significantly increased in patients aged >or=80 years old (10.8%) compared with those aged <80 years old (1%, P = .012).
Elderly patients, defined as those aged >80 years, have a higher incidence of anatomy that increases the technical difficulty of performing CAS. This increase in unfavorable anatomy may be associated with complications during CAS. Although the small number of perioperative events does not allow for determination of a direct relationship with specific anatomic characteristics, the presence of unfavorable anatomy does warrant serious consideration during evaluation for CAS in elderly patients.
目前对颈动脉血管成形术和支架置入术（CAS）的评估表明，其与颈动脉内膜切除术（CEA）疗效相当。然而，老年患者接受CAS后发生卒中及死亡的发生率可能更高。我们评估了接受CAS患者的解剖学特征，并根据年龄是否大于80岁进行比较。同时还确定了年龄对术后并发症发生率的影响。
2003年2月至2005年8月，对133例患者实施了135例CAS手术。两名独立观察者在不知道患者身份标识的情况下对每位患者的数字减影血管造影进行评估。将影响CAS操作的解剖学特征评估为有利或不利。这些特征包括主动脉弓延长、弓部钙化、弓部血管起源狭窄、颈总动脉和颈内动脉迂曲，以及治疗病变的狭窄、钙化和长度。术后事件定义为心肌梗死、卒中和死亡。采用Fisher精确检验和卡方检验确定统计学意义（P <.05）。
在接受治疗的133例患者中，87例（65%）为男性，46例（35%）为女性；37例（28%）年龄≥80岁。年龄≥80岁的队列中，不利的弓部延长发生率增加（P =.008）、弓部钙化（P =.003）、颈总动脉或无名动脉起源狭窄（P =.006）、颈总动脉迂曲（P =.0009）、颈内动脉迂曲（P =.019）以及治疗病变狭窄（P =.007）。治疗病变的钙化或长度未发现显著差异。围手术期发生脑血管意外4例（3.0%，3例无残留神经功能缺损，1例有残留神经功能缺损），心肌梗死3例（2.2%），1例患者（0.8%）因出血性卒中死亡。整个队列的卒中、心肌梗死和死亡率为3.7%。年龄≥80岁患者的发生率（10.8%）显著高于年龄<80岁的患者（1%，P =.012）。
定义为年龄>80岁的老年患者，其增加CAS技术难度的解剖学特征发生率更高。这种不利解剖结构的增加可能与CAS术中并发症相关。虽然围手术期事件数量较少，无法确定与特定解剖学特征的直接关系，但在评估老年患者是否适合CAS时，不利解剖结构的存在确实值得认真考虑。
