Kastrup Andreas, Gröschel Klaus, Schnaudigel Sonja, Nägele Thomas, Schmidt Friederike, Ernemann Ulrike
Department of Neurology, University of Göttingen, Robert-Koch-Strasse 40, Göttingen, Germany.
J Vasc Surg. 2008 Jan;47(1):88-95. doi: 10.1016/j.jvs.2007.09.045.
Although evidence is accumulating that advanced age is a risk factor for carotid angioplasty and stenting (CAS), the reason for this finding is incompletely understood. The aims of this study were to compare the prevalence of anatomic risk factors in patients <80 years with those in patients > or =80 years and to determine the effect of these risk factors on the incidence of new lesions seen on diffusion-weighted imaging (DWI) after protected CAS as surrogate markers for stroke.
Various potential anatomic risk factors for CAS were analyzed in 62 symptomatic patients (49 aged <80 years; 13 aged > or =80 years) by using preprocedural digital subtraction angiograms and extracranial contrast-enhanced magnetic resonance angiographies. DWI was performed immediately before and <or =48 hours after the procedure. Clinical outcome measures were stroke and death <or =30 days.
The octogenarians had a significantly higher incidence of severe aortic arch calcification (54% vs 14%, P < .01) and ulcerated stenoses (69% vs 22%, P < .01), but no statistically significant differences were found between treatment groups in elongation of the aortic arch, common or internal artery tortuousities, degree of stenosis, or length of the stenosis. Although the differences in clinical outcome between the treatment groups (4% aged <80 years vs 8% >or =80 years) were not significant, the proportion of patients with any new ipsilateral DWI lesions, as well as the total number of these lesions, was higher in octogenarians than in patients aged <80 years (85% vs 47%, P < .05), with a median of 2 (interquartile range [IQR], 1 to 5) vs 0 (IQR, 0 to 3; P = .07). Similarly, the proportion of patients with any new DWI lesions outside the vascular territory of the target vessel as well as the total number of these lesions was significantly higher in octogenarians compared with patients aged <80 years (54% vs 10%, P < .01), with a median of 1.5 (IQR, 0.25 to 10.75) vs 0 (IQR, 0 to 1; P < .05). The presence of an ulcerated lesion was an independent predictor of any new ipsilateral DWI lesion (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.06 to 17.1; P < .05), whereas a severe aortic arch calcification tended to be a predictor of new DWI lesions outside the territory of the treated artery (OR, 1.8; 95% CI, 0.99 to 3335; P = .05).
Increased prevalences of severe aortic arch calcifications and target lesion ulceration are associated with an increased risk for magnetic resonance DWI-detected embolic events during CAS. Because in our study arch calcification and target lesion ulceration were more prevalent in octogenarians, this association may explain the increased risk of CAS in the elderly.
尽管越来越多的证据表明高龄是颈动脉血管成形术和支架置入术（CAS）的一个危险因素，但这一发现的原因尚未完全明确。本研究的目的是比较80岁以下患者与80岁及以上患者解剖学危险因素的患病率，并确定这些危险因素对在保护性CAS术后弥散加权成像（DWI）上出现的新病变发生率的影响，将其作为卒中的替代标志物。
通过术前数字减影血管造影和颅外对比增强磁共振血管造影，对62例有症状患者（49例年龄<80岁；13例年龄≥80岁）的各种潜在CAS解剖学危险因素进行分析。在手术前及术后≤48小时进行DWI检查。临床结局指标为≤30天内的卒中和死亡。
八旬老人严重主动脉弓钙化（54%对14%，P<.01）和溃疡性狭窄（69%对22%，P<.01）的发生率显著更高，但治疗组在主动脉弓延长、颈总动脉或颈内动脉迂曲、狭窄程度或狭窄长度方面未发现统计学显著差异。尽管治疗组之间的临床结局差异（年龄<80岁者为4%，年龄≥80岁者为8%）不显著，但八旬老人中出现任何同侧新发DWI病变的患者比例及其病变总数均高于80岁以下患者（85%对47%，P<.05），中位数分别为2（四分位间距[IQR]，1至5）对0（IQR，0至3；P=.07）。同样，八旬老人中在目标血管血管区域外出现任何新发DWI病变的患者比例及其病变总数与80岁以下患者相比显著更高（54%对10%，P<.01），中位数分别为1.5（IQR，0.25至10.75）对0（IQR，0至1；P<.05）。溃疡性病变的存在是任何同侧新发DWI病变的独立预测因素（优势比[OR]，4.3；95%置信区间[CI]，1.06至17.1；P<.05），而严重主动脉弓钙化倾向于成为治疗动脉区域外新发DWI病变的预测因素（OR，1.8；95%CI，0.99至3335；P=.05）。
严重主动脉弓钙化和目标病变溃疡患病率的增加与CAS期间磁共振DWI检测到的栓塞事件风险增加相关。由于在我们的研究中，主动脉弓钙化和目标病变溃疡在八旬老人中更为普遍，这种关联可能解释了老年人CAS风险增加的原因。
