Division of Neurosurgery, University of Vermont, Burlington, Vermont 05401, USA.
J Neurosurg. 2012 Jun;116(6):1251-7. doi: 10.3171/2012.3.JNS111320. Epub 2012 Apr 6.
Several randomized trials have emerged with conflicting data on the overall safety of carotid artery stenting (CAS) in comparison with carotid endarterectomy (CEA). The authors hypothesize that changes in national trends correspond to publication of randomized trials, including an increase in utilization of CAS after publication of trials favorable to CAS (for example, Carotid and Vertebral Artery Transluminal Angioplasty Study [CAVATAS] and Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy [SAPPHIRE]) and decrease in utilization of CAS after publication of trials favorable to CEA (for example, Endarterectomy versus Stenting in Patients with Symptomatic Severe Carotid Stenosis [EVA3-S] and Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy [SPACE]).
The Nationwide Inpatient Sample was obtained for the years 1998-2008. Individual cases were isolated for principal diagnosis of unilateral or bilateral carotid artery stenosis or occlusion undergoing CEA or CAS. The percentage of CAS for all carotid revascularization procedures was calculated for each year. Perioperative inpatient morbidity, including stroke or death, were calculated and compared.
The percentage of patients undergoing CAS increased yearly from the start of the observed period to the end, with the exception of a decrease in 2007. The peak utilization of CAS for carotid artery revascularization procedures was 15% of all cases in 2006. The stroke or death rate was consistent at 5% among all patients undergoing CEA for all years, while the incidence of stroke or death decreased among patients undergoing CAS from 9% in 1998 to 5% in 2008.
The practice of CAS in the US is expanding, from less than 3% of all carotid artery revascularization procedures to 13% in 2008. The utilization of CAS was seen to correlate with publication of randomized trials. Utilization nearly doubled in 2005 after publication of the CAS-favorable SAPPHIRE in 2004, and decreased by 22% after publication of the CEA-favorable EVA-3S and SPACE in 2007. With the publication of Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), the authors predict a resultant increase in the rate of CAS for carotid artery disease in the upcoming years.
几项随机试验的结果相互矛盾，数据显示颈动脉支架置入术（CAS）的总体安全性与颈动脉内膜切除术（CEA）相比。作者假设，全国趋势的变化与随机试验的发表相对应，包括在有利于 CAS 的试验发表后（例如，颈动脉和椎动脉经皮血管成形术研究[CAVATAS]和高危颈动脉内膜切除术患者支架置入和血管成形术[ SAPPHIRE]），CAS 的使用率增加，以及在有利于 CEA 的试验发表后（例如，症状性严重颈动脉狭窄患者的内膜切除术与支架置入术[EVA3-S]和颈动脉支架置入术与内膜切除术[SPACE]），CAS 的使用率降低。
获取了 1998 年至 2008 年全国住院患者样本。对接受 CEA 或 CAS 的单侧或双侧颈动脉狭窄或闭塞的主要诊断进行了个体病例隔离。计算了每年所有颈动脉血运重建手术中 CAS 的比例。计算并比较了围手术期住院患者的发病率，包括中风或死亡。
从观察期开始到结束，每年接受 CAS 的患者比例逐年增加，2007 年除外。2006 年，CAS 用于颈动脉血运重建手术的比例达到了所有病例的 15%。所有接受 CEA 的患者中风或死亡率均保持在 5%左右，而接受 CAS 的患者中风或死亡率从 1998 年的 9%下降到 2008 年的 5%。
美国的 CAS 实践正在扩大，从不到所有颈动脉血运重建手术的 3%增加到 2008 年的 13%。CAS 的应用与随机试验的发表有关。2004 年发表有利于 CAS 的 SAPPHIRE 后，2005 年 CAS 的使用率几乎翻了一番，2007 年发表有利于 CEA 的 EVA-3S 和 SPACE 后，使用率下降了 22%。随着颈动脉血运重建内膜切除术与支架置入术试验（CREST）的发表，作者预计未来几年颈动脉疾病的 CAS 率将会增加。
