Department of Neurosurgery, Mount Sinai School of Medicine, New York, New York, USA.
Neurosurgery. 2010 Mar;66(3):448-53; discussion 453-4. doi: 10.1227/01.NEU.0000365008.17803.AD.
Carotid artery angioplasty and carotid artery stenting (CAS) offer a viable alternative to carotid endarterectomy for symptomatic and asymptomatic patients; however, the complication rates associated with CAS may be higher than previously documented. We evaluated the safety and efficacy of CAS in high surgical risk patients in a single neurovascular center retrospective review.
An institutional review board-approved retrospective review of the clinical variables and treatment outcomes of 101 consecutive patients (109 stents) from July 2001 to March 2007 with carotid stenosis were analyzed. Both symptomatic and asymptomatic stenoses were studied in high surgical risk patients as defined by the SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy) trial. Specifically, those patients with clinically significant cardiac disease (congestive heart failure, abnormal stress test, or need for open-heart surgery), severe pulmonary disease, contralateral carotid occlusion, contralateral laryngeal nerve palsy, recurrent stenosis after carotid endarterectomy, previous radical neck surgery, or radiation therapy to the neck, and an age older than 80.
Seventy-four percent of the patients were symptomatic (n = 81), and the mean stenosis in symptomatic patients was 83%. Reasons for stenting included cardiac/pulmonary/medical risk (60%), contralateral internal carotid artery occlusion (8%), recurrent stenosis after carotid endarterectomy (11%), carotid dissection (6%), age older than 80 (7%), previous radical neck surgery (7%), and previous neck radiation (1%). Stent deployment was achieved in 108 of 109 vessels (99%). Distal embolic protection devices were used in 72% of cases treated. The overall rate of in-hospital adverse events (transient ischemic attack, intracranial hemorrhage, minor stroke, major stroke, myocardial infarction, and death) was 8.3% (9 of 109). Of these events, 2 patients (1.8%) experienced a hemispheric transient ischemic attack (neurological symptoms that resolved within 24 hours), 2 others (1.8%) had transiently symptomatic acute reperfusion syndrome. The 30-day stroke/death/myocardial infarction risk was 4.6% (n = 5). Of these patients, 3 had minor strokes (2.7%) defined as a modified Rankin Scale score less than 3 at 1-year follow-up, 1 had a major stroke (0.9%) defined as a modified Rankin Scale score of 3 or more at 1-year follow-up, and 1 patient died after a periprocedural myocardial infarction (0.9%).
CAS can be performed with a low 30-day complication rate, even with a higher percentage of symptomatic lesions. The results support the use of CAS in high surgical risk patients with both significant symptomatic and asymptomatic carotid artery disease.
颈动脉血管成形术和颈动脉支架置入术（CAS）为有症状和无症状患者提供了一种可行的颈动脉内膜切除术替代方法；然而，CAS 相关的并发症发生率可能高于以前的记录。我们在一个单一的神经血管中心回顾性研究中评估了 CAS 在高手术风险患者中的安全性和疗效。
对 2001 年 7 月至 2007 年 3 月期间因颈动脉狭窄接受治疗的 101 例连续患者（109 个支架）的临床变量和治疗结果进行了机构审查委员会批准的回顾性分析。根据 SAPPHIRE（高风险颈动脉内膜切除术患者支架置入和血管成形术）试验，对高手术风险患者进行了有症状和无症状狭窄的研究。具体而言，这些患者患有临床显著的心脏病（充血性心力衰竭、异常应激试验或需要开胸手术）、严重的肺部疾病、对侧颈动脉闭塞、对侧喉返神经麻痹、颈动脉内膜切除术后再狭窄、先前的根治性颈部手术或颈部放疗以及年龄大于 80 岁。
74%的患者有症状（n=81），有症状患者的平均狭窄程度为 83%。支架置入的原因包括心脏/肺部/医学风险（60%）、对侧颈内动脉闭塞（8%）、颈动脉内膜切除术后再狭窄（11%）、颈动脉夹层（6%）、年龄大于 80 岁（7%）、先前的根治性颈部手术（7%）和先前的颈部放疗（1%）。109 个血管中的 108 个（99%）成功置入了支架。在 72%的治疗病例中使用了远端栓塞保护装置。住院期间不良事件（短暂性脑缺血发作、颅内出血、小卒、大卒、心肌梗死和死亡）的总发生率为 8.3%（9/109）。这些事件中，2 例患者（1.8%）发生半球性短暂性脑缺血发作（24 小时内缓解的神经症状），另外 2 例患者（1.8%）发生短暂症状性急性再灌注综合征。30 天卒中和/或死亡和心肌梗死的风险为 4.6%（n=5）。这些患者中，3 例发生小卒（2.7%），定义为 1 年随访时改良 Rankin 量表评分小于 3，1 例发生大卒（0.9%），定义为改良 Rankin 量表评分 3 分或更高，1 例患者死于围手术期心肌梗死（0.9%）。
即使有更高比例的有症状病变，CAS 也可以以较低的 30 天并发症发生率进行。结果支持在有明显有症状和无症状颈动脉疾病的高手术风险患者中使用 CAS。
