Université Paris Descartes, INSERM UMR 894, Department of Neurology, Hôpital Sainte-Anne, 75014 Paris, France.
Stroke. 2011 Feb;42(2):380-8. doi: 10.1161/STROKEAHA.110.588772. Epub 2010 Dec 23.
The purposes of this study were to assess the relationships between anatomic and technical factors and the 30-day risk of stroke or death after carotid angioplasty and stenting in the Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial and to perform a systematic review of the literature.
We included patients from EVA-3S in whom carotid stenting was attempted irrespective of allocated treatment. Two radiologists blinded to clinical data independently assessed the aortic arch and carotid arteries on procedural angiograms. In addition, we performed a systematic review of studies that reported 30-day risk of stroke or death in relation with arterial anatomy and technique. Outcomes were stroke or death and stroke occurring within 30 days of the carotid angioplasty and stenting procedure.
Two hundred sixty-two patients from EVA-3S fulfilled the inclusion criteria (including 1 initially allocated to surgery and 13 in whom stent insertion failed).Within 30 days after the procedure, 25 (9.5%) patients had a stroke or had died. The risk of stroke or death was higher in patients with internal carotid artery-common carotid artery angulation ≥60° (relative risk, 4.96; 2.29 to 10.74) and lower in those treated with cerebral protection devices (relative risk [RR], 0.38; 0.17 to 0.85). In the systematic review (56 studies; 34 398 patients), the risk of stroke or death was higher in patients with left-sided carotid angioplasty and stenting (RR, 1.29; 1.05 to 1.58), increased internal carotid artery-common carotid artery angulation (RR, 3.41; 1.52 to 7.63), and when the target internal carotid artery stenosis was >10 mm (RR, 2.36; 1.28 to 3.38). There was no significant increase in risk of stroke or death in patients with Type III aortic arch, aortic arch calcification, or with ostial involvement, calcification, ulceration or degree of stenosis of the target internal carotid artery stenosis. The use of a cerebral protection device was associated with a lower risk of stroke or death (RR, 0.55; 0.41 to 0.73). Risk was not related with stent or cerebral protection device type.
Our results strongly suggest that some technical and anatomic factors, especially extreme angulation of the carotid artery, have an impact on the risks of carotid angioplasty and stenting.
本研究旨在评估颈动脉血管成形术和支架置入术（EVA-3S 试验）后 30 天内发生卒中或死亡的风险与解剖和技术因素之间的关系，并对文献进行系统回顾。
我们纳入了 EVA-3S 试验中接受颈动脉支架置入术的患者，无论分配的治疗方式如何。两名对临床数据不知情的放射科医生独立评估了手术过程中的主动脉弓和颈动脉。此外，我们还对报道了 30 天内卒中或死亡风险与动脉解剖和技术之间关系的研究进行了系统回顾。结局为卒中或死亡，以及颈动脉血管成形术和支架置入术后 30 天内发生的卒中。
EVA-3S 试验中有 262 名患者符合纳入标准（包括最初分配至手术组的 1 例患者和 13 例支架置入失败的患者）。术后 30 天内，有 25 例（9.5%）患者发生卒中或死亡。颈内动脉-颈总动脉夹角≥60°的患者发生卒中或死亡的风险较高（相对风险，4.96；2.29 至 10.74），使用脑保护装置的患者风险较低（相对风险[RR]，0.38；0.17 至 0.85）。在系统回顾（56 项研究；34398 例患者）中，左侧颈动脉血管成形术和支架置入术患者的卒中或死亡风险较高（RR，1.29；1.05 至 1.58），颈内动脉-颈总动脉夹角增加（RR，3.41；1.52 至 7.63），目标颈内动脉狭窄程度＞10mm（RR，2.36；1.28 至 3.38）。主动脉弓 III 型、主动脉弓钙化或动脉开口受累、钙化、溃疡或目标颈内动脉狭窄程度的狭窄程度与卒中或死亡风险的增加无关。使用脑保护装置与卒中或死亡风险降低相关（RR，0.55；0.41 至 0.73）。风险与支架或脑保护装置类型无关。
我们的研究结果强烈提示，一些技术和解剖因素，尤其是颈动脉的极度成角，对颈动脉血管成形术和支架置入术的风险有影响。
