van der Vaart Michiel G, Meerwaldt Robbert, Reijnen Michel M P J, Tio René A, Zeebregts Clark J
Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands.
Am J Surg. 2008 Feb;195(2):259-69. doi: 10.1016/j.amjsurg.2007.07.022.
Carotid endarterectomy (CEA) is still considered the "gold-standard" of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endovascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis. This review presents the development of CAS according to early reports, results of recent randomized trials, and future perspectives regarding CAS.
A literature search using the PubMed and Cochrane databases identified articles focusing on the key issues of CEA and CAS.
Early nonrandomized reports of CAS showed variable results, and the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy trial led to United States Food and Drug Administration approval of CAS for the treatment of patients with symptomatic carotid stenosis. In contrast, recent trials, such as the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial and the Endarterectomy Versus Stenting in Patients with Symptomatic Severe Carotid Stenosis trial, (re)fuelled the debate between CAS and CEA. In the Stent-Protected Angioplasty Versus Carotid Endarterectomy trial, the complication rate of ipsilateral stroke or death at 30 days was 6.8% for CAS versus 6.3% for CEA and showed that CAS failed the noninferiority test. Analysis of the Endarterectomy Versus Stenting in Patients With Symptomatic Severe Carotid Stenosis trial showed a significant higher risk for death or any stroke at 30 days for endovascular treatment (9.6%) compared with CEA (3.9%). Other aspects-such as evolving best medical treatment, timely intervention, interventionalists' experience, and analysis of plaque composition-may have important influences on the future treatment of patients with carotid artery stenosis.
CAS performed with or without embolic-protection devices can be an effective treatment for patients with carotid artery stenosis. However, presently there is no evidence that CAS provides better results in the prevention of stroke compared with CEA.
颈动脉内膜切除术（CEA）仍然被认为是治疗重度颈动脉狭窄患者的“金标准”，并且在过去几十年中已证明其价值。然而，血管内技术最近一直在发展。颈动脉支架置入术（CAS）正在挑战CEA成为治疗颈动脉狭窄患者的最佳方法。本综述根据早期报告、近期随机试验结果以及关于CAS的未来展望介绍了CAS的发展情况。
使用PubMed和Cochrane数据库进行文献检索，确定关注CEA和CAS关键问题的文章。
CAS的早期非随机报告显示结果不一，而“高危内膜切除术患者的支架置入与血管成形术保护”试验促使美国食品药品监督管理局批准CAS用于治疗有症状的颈动脉狭窄患者。相比之下，近期的试验，如“支架保护血管成形术与颈动脉内膜切除术”试验和“有症状严重颈动脉狭窄患者的内膜切除术与支架置入术”试验，再次引发了CAS与CEA之间的争论。在“支架保护血管成形术与颈动脉内膜切除术”试验中，CAS组30天同侧卒中或死亡的并发症发生率为6.8%，而CEA组为6.3%，表明CAS未通过非劣效性检验。对“有症状严重颈动脉狭窄患者的内膜切除术与支架置入术”试验的分析显示，与CEA（3.9%）相比，血管内治疗30天死亡或任何卒中的风险显著更高（9.6%）。其他方面，如不断发展的最佳药物治疗、及时干预、介入医生的经验以及斑块成分分析，可能对未来颈动脉狭窄患者的治疗有重要影响。
无论是否使用栓子保护装置进行的CAS都可以是治疗颈动脉狭窄患者的有效方法。然而，目前没有证据表明与CEA相比，CAS在预防卒中方面能提供更好的结果。
