Shin Susanna H, Stout Christopher L, Richardson Albert I, DeMasi Richard J, Shah Rasesh M, Panneton Jean M
Division of Vascular Surgery, Eastern Virginia Medical School, Norfolk, VA 23507, USA.
J Vasc Surg. 2009 Oct;50(4):762-7; discussion 767-8. doi: 10.1016/j.jvs.2009.04.066.
Carotid angioplasty and stenting (CAS) is used in patients considered high-risk for carotid endarterectomy (CEA). Patients qualify as high-risk because of medical comorbid conditions or for anatomic considerations (previous CEA, radical neck dissection, radiation). We compared the technical feasibility and durability of CAS in medically high-risk patients (MED) vs anatomically high-risk patients (ANAT).
A retrospective review was performed of all consecutive patients undergoing CAS by a single vascular surgery group. All patients were high risk and evaluated with duplex ultrasound imaging and angiography. Primary end points were technical success, 30-day stroke, myocardial infarction (MI), death, and in-stent restenosis. Standard statistical analysis included Kaplan-Meier life tables.
From January 2003 to December 2007, 230 CAS (98 ANAT, 132 MED) procedures were attempted. The ANAT cohort comprised 84 patients with a single anatomic risk factor: 71 with a previous ipsilateral CEA, 6 high lesions, 6 history of neck radiation, and 1 with a tracheostomy. Ten patients had two or three anatomic risk factors: nine with radical neck dissection and radiation and one with neck radiation and ipsilateral CEA. The mean age was 71.1 years for ANAT vs 73.9 years for MED (P = .021). Technical success rates were 98% in ANAT and 98.5% in MED (P = .76). Thirty-day stroke rate was 1.0% in ANAT and 5.3% in MED (P = .14); the mortality rate was 2.0% in ANAT and 0.8% in MED (P = .79). The 2-year survival free from stroke was MED, 93.6% and ANAT, 98.9% (P = .118); and from restenosis was MED, 91.9%; and ANAT, 91.0% (P = .98). Two-year overall survival was significantly better in ANAT (84.6%) vs MED (70.1%; P = .026). Four of the seven restenoses in the ANAT group occurred in patients with previous neck radiation. The restenosis rate for radiation-induced (RAD) stenosis treated with CAS was significantly higher at 22.2% (4 of 18) compared with 3.8% (3 of 78) in ANAT group patients without a history of radiation (non-RAD; P = .028). The 2-year restenosis-free survival was 72.7% in the RAD group vs 95.9% in the non-RAD group (P = .017).
CAS is as technically feasible, safe, and durable in anatomically high-risk patients as in medically high-risk patients, with similar rates of periprocedural stroke and death and late restenosis. However, patients with radiation-induced stenosis appear to be at an increased risk for restenosis.
颈动脉血管成形术及支架置入术（CAS）用于那些被认为行颈动脉内膜切除术（CEA）存在高风险的患者。这些患者因合并内科疾病或解剖因素（既往CEA、根治性颈部清扫术、放疗）而被认定为高风险。我们比较了内科高风险患者（MED）与解剖学高风险患者（ANAT）行CAS的技术可行性及耐用性。
对由单一血管外科团队连续进行CAS手术的所有患者进行回顾性研究。所有患者均为高风险，通过双功超声成像及血管造影进行评估。主要终点为技术成功、30天内的卒中、心肌梗死（MI）、死亡及支架内再狭窄。标准统计分析包括Kaplan-Meier生存表。
2003年1月至2007年12月，共尝试进行230例CAS手术（98例ANAT，132例MED）。ANAT队列包括84例具有单一解剖学风险因素的患者：71例既往同侧有CEA，6例高位病变，6例有颈部放疗史，1例有气管切开术。10例患者有两个或三个解剖学风险因素：9例有根治性颈部清扫术及放疗史，1例有颈部放疗及同侧CEA史。ANAT组的平均年龄为71.1岁，MED组为73.9岁（P = 0.021）。ANAT组的技术成功率为98%，MED组为98.5%（P = 0.76）。ANAT组30天内的卒中率为1.0%，MED组为5.3%（P = 0.14）；死亡率ANAT组为2.0%，MED组为0.8%（P = 0.79）。MED组无卒中的2年生存率为93.6%，ANAT组为98.9%（P = 0.118）；无再狭窄的生存率MED组为91.9%，ANAT组为91.0%（P = 0.98）。ANAT组的2年总生存率（84.6%）显著高于MED组（70.1%；P = 0.026）。ANAT组7例再狭窄中有4例发生在既往有颈部放疗的患者中。与无放疗史的ANAT组患者（非RAD；3/78，3.8%）相比，CAS治疗放疗诱导（RAD）狭窄的再狭窄率显著更高，为22.2%（4/18）（P = 0.028）。RAD组无再狭窄的2年生存率为72.7%，非RAD组为95.9%（P = 0.017）。
在解剖学高风险患者中，CAS与在内科高风险患者中一样，在技术上可行、安全且耐用，围手术期卒中、死亡及晚期再狭窄发生率相似。然而，放疗诱导狭窄的患者似乎再狭窄风险增加。
