Naylor A R
Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, UK.
Eur J Vasc Endovasc Surg. 2009 Oct;38(4):397-401. doi: 10.1016/j.ejvs.2009.07.007. Epub 2009 Aug 4.
The International Carotid Stenting Study (ICSS) and an amalgamated 'super' Registry of 'high risk for surgery' patients undergoing carotid artery stenting (CAS) have issued seemingly contradictory conclusions following release of their 30-day procedural risks. This paper evaluates the impact of the two trials, regarding the current status of CAS, and concludes that there are still more questions than answers. The available evidence supports CAS in the treatment of selected 'high risk for CEA' non-octogenarian symptomatic patients, provided certain caveats are met (maintenance of acceptable procedural risk, rapid intervention). There is, however, no level I evidence supporting the routine use of CAS in 'standard risk' symptomatic patients and this Cochrane recommendation will not change once the ICSS data are included. It is anticipated, however, that following meta-analyses of individual patient data from 5000 patients recruited into the four large, randomised trials (SPACE, EVA-3S, ICSS, CREST), selected patient subgroups will be identified who will benefit by being treated by CAS. In the meantime, the majority of standard risk, symptomatic patients should probably undergo expedited CEA. However, established (or less experienced) practitioners who intend to continue offering CAS to this category of patient (because it is already approved practice in their health system) must ensure that their audited 30-day risks of death/stroke remain <6% and that they offer patients access to expedited intervention (ie within 2 weeks) wherever possible. Delaying intervention in order to reduce the procedural risk may improve the reputation of the surgeon/interventionist, but it confers little overall benefit to the patient.
国际颈动脉支架置入研究（ICSS）以及一个合并的“超级”登记系统（纳入了接受颈动脉支架置入术（CAS）的“手术高风险”患者）在公布其30天手术风险后得出了看似矛盾的结论。本文评估了这两项试验对CAS现状的影响，并得出结论：问题仍多于答案。现有证据支持在满足某些条件（维持可接受的手术风险、快速干预）的情况下，对特定的“CEA高风险”非八旬有症状患者采用CAS治疗。然而，没有一级证据支持在“标准风险”有症状患者中常规使用CAS，一旦纳入ICSS数据，这一Cochrane推荐将不会改变。不过，预计在对来自四项大型随机试验（SPACE、EVA - 3S、ICSS、CREST）招募的5000名患者的个体患者数据进行荟萃分析后，将确定能从CAS治疗中获益的特定患者亚组。与此同时，大多数标准风险的有症状患者可能应接受快速CEA治疗。然而，打算继续为这类患者提供CAS治疗（因为在其医疗系统中这已是获批的做法）的成熟（或经验较少）从业者必须确保其经审核的30天死亡/中风风险保持在<6%，并尽可能为患者提供快速干预（即两周内）。为降低手术风险而延迟干预可能会提升外科医生/介入医生的声誉，但对患者总体益处不大。
