头端动脉经皮腔内血管成形术的早期和晚期结果

Buszman Paweł, Debiński Marcin, Gruszka Agata, Janas Piotr, Król Marek, Kondys Marek, Iwiński Janusz, Kazibutowska-Zarańska Zofia, Cierpka Lech, Tendera Michał

Oddział Ostrych Zespołów Wieńcowych, Górnoślaskie Centrum Medyczne, Slaski Uniwersytet Medyczny, ul. Ziołowa 47, Katowice.

Kardiol Pol. 2008 Mar;66(3):233-42, discussion 243.

BACKGROUND

Efficacy of carotid endarterectomy (CEA) in prevention of stroke in patients with carotid artery stenosis has been confirmed in randomised trials. Carotid artery stenting (CAS) is a routine clinical practice and recent results of CAS are not worse than CEA. Moreover, percutaneous transluminal angioplasty (PTA) techniques allow other cephalad arteries to be dilated.

AIM

To assess early and long-term outcome of PTA of cephalad arteries and to determine risk factors of early and late major adverse cardiovascular and cerebral events (MACCE).

METHODS

The study group consisted of 223 consecutive patients (151 males, 67.7%, mean age 65.3+/-8.6) in whom 256 PTA procedures of cephalad arteries were performed. Two hundred and forty-two internal carotid, 7 common carotid and 15 vertebral arteries were dilated. Thirty-four patients underwent one-stage carotid and coronary procedures, while in 46 patients one-stage carotid and peripheral procedures were performed. Neuroprotection with a distal protection device was used in 51.5% of cases. The procedures were divided into two groups: with high (n=181) and low (n=75) risk of cardiovascular events. Early and late events were recorded and analysed subsequently.

RESULTS

In hospital 30-day MACCE occurred in 12 (4.6%) patients, including 7 (2.7%) strokes, 3 (1.1%) myocardial infarctions and two (0.8%) deaths. Transient ischaemic attacks were observed in 8 patients, pulmonary oedema in 3 cases, as well as a single episode of retinal artery embolisation and acute renal insufficiency. The incidence of 30-day MACCE was not significantly higher in the high-risk group (6.07 vs. 1.33%; NS), but the risk of any adverse event was significantly higher (p=0.03). There was no difference in stroke incidence between procedures with or without neuroprotection (2.27 vs. 3.22%; NS). There was no difference in risk of MACCE between angioplasty of cephalad artery and one-stage cephalad and coronary artery angioplasty procedure (3.6 vs. 5.5%; NS). During 50.3+/-20 months of follow-up there were 16 (7.1%) deaths, 9 (3.5%) strokes and 6 (2.3%) re-stenoses confirmed angiographically. One-year total survival and one-year MACCE-free survival rates according to the Kaplan-Meier analysis were 94.9% and 89.0%, showing a trend towards better outcome in the low-risk group (F-Cox=2.46; p=0.19 and F-Cox=2.17; p=0.09 respectively).

CONCLUSIONS

Percutaneous transluminal angioplasty of cephalad arteries is safe and feasible, with a low periprocedural complication rate and good late outcome. Carotid artery stenting is an alternative method to CEA.

背景

颈动脉内膜切除术（CEA）预防颈动脉狭窄患者中风的疗效已在随机试验中得到证实。颈动脉支架置入术（CAS）是一种常规临床操作，且CAS的近期结果并不比CEA差。此外，经皮腔内血管成形术（PTA）技术可用于扩张其他头端动脉。

目的

评估头端动脉PTA的早期和长期结果，并确定早期和晚期主要不良心血管和脑血管事件（MACCE）的危险因素。

方法

研究组由223例连续患者（151例男性，占67.7%，平均年龄65.3±8.6岁）组成，共进行了256次头端动脉PTA手术。扩张了242条颈内动脉、7条颈总动脉和15条椎动脉。34例患者接受了一期颈动脉和冠状动脉手术，46例患者接受了一期颈动脉和外周血管手术。51.5%的病例使用了远端保护装置进行神经保护。手术分为两组：心血管事件风险高（n=181）和低（n=75）的组。记录并随后分析早期和晚期事件。

结果

住院30天内，12例（4.6%）患者发生MACCE，包括7例（2.7%）中风、3例（1.1%）心肌梗死和2例（0.8%）死亡。8例患者出现短暂性脑缺血发作，3例出现肺水肿，以及1例视网膜动脉栓塞和1例急性肾功能不全。高危组30天MACCE的发生率并不显著高于低危组（6.07%对1.33%；无统计学差异），但任何不良事件的风险显著更高（p=0.03）。使用或未使用神经保护的手术之间中风发生率无差异（2.27%对3.22%；无统计学差异）。头端动脉血管成形术与一期头端动脉和冠状动脉血管成形术之间MACCE风险无差异（3.6%对5.5%；无统计学差异）。在50.3±20个月的随访期间，有16例（7.1%）死亡、9例（3.5%）中风和6例（2.3%）经血管造影证实的再狭窄。根据Kaplan-Meier分析，1年总生存率和1年无MACCE生存率分别为94.9%和89.0%，显示低危组有更好结局的趋势（F-Cox=2.46；p=0.19和F-Cox=2.17；p=0.09）。