Department of Vascular Surgery, Innsbruck Medical University, Innsbruck, Austria.
J Vasc Surg. 2013 Mar;57(3):619-626.e2; discussion 625-6. doi: 10.1016/j.jvs.2012.08.107. Epub 2012 Dec 11.
Among patients with symptomatic carotid artery stenosis, carotid artery stenting (CAS) is associated with a higher risk of periprocedural stroke or death than carotid endarterectomy (CEA). Uncertainty remains whether the balance of risk changes with time since the most recent ischemic event.
We investigated the association of time between the qualifying ischemic event and treatment (0-7 days, 8-14 days, and >14 days) with the risk of stroke or death within 30 days after CAS or CEA in a pooled analysis of data from individual patients randomized in the Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial, and the International Carotid Stenting Study (ICSS). Data were analyzed with a fixed-effect binomial regression model adjusted for source trial.
Information on time of qualifying event was available for 2839 patients. In the first 30 days after intervention, any stroke or death occurred significantly more often in the CAS group (110/1434 [7.7%]) compared with the CEA group (54/1405 [3.8%]; crude risk ratio, 2.0; 95% confidence interval, 1.5-2.7). Patients undergoing CEA within the first 7 days of the qualifying event had the lowest periprocedural stroke or death rate (3/106 [2.8%]). Patients treated with CAS in the same period had a 9.4% risk of periprocedural stroke or death (13/138; risk ratio CAS vs CEA: 3.4; 95% confidence interval, 1.01-11.8; adjusted for age, sex, and type of qualifying event). Patients treated between 8 and 14 days showed a periprocedural stroke or death rate of 3.4% (7/208) and 8.1% (19/234), respectively, for CEA and CAS. The latest treatment group had 4% complications in the CEA group (44/1091) and 7.3% in the CAS group (78/1062).
The increase in risk of CAS compared with CEA appears to be greatest in patients treated within 7 days of symptoms. Early surgery might remain most effective in stroke prevention in patients with symptomatic carotid artery stenosis.
在有症状性颈动脉狭窄的患者中，颈动脉支架置入术（CAS）与围手术期卒中或死亡风险高于颈动脉内膜切除术（CEA）相关。但最近的缺血性事件发生后时间的风险平衡是否会发生变化，目前仍存在不确定性。
我们对来自症状性严重颈动脉狭窄患者内膜切除术与血管成形术（EVA-3S）试验、支架保护血管成形术与颈动脉内膜切除术（SPACE）试验和国际颈动脉支架研究（ICSS）的随机患者个体数据进行了汇总分析，研究了 qualifying 缺血性事件和治疗之间的时间（0-7 天、8-14 天和＞14 天）与 CAS 或 CEA 后 30 天内卒中或死亡风险之间的关系。数据分析采用调整源试验的固定效应二项式回归模型。
2839 例患者提供了 qualifying 事件时间的信息。在干预后的 30 天内，CAS 组（110/1434 [7.7%]）发生任何卒中或死亡的比例显著高于 CEA 组（54/1405 [3.8%]；粗风险比，2.0；95%置信区间，1.5-2.7）。在 qualifying 事件发生后 7 天内接受 CEA 治疗的患者围手术期卒中或死亡发生率最低（3/106 [2.8%]）。在此期间接受 CAS 治疗的患者围手术期卒中或死亡风险为 9.4%（13/138；CAS 与 CEA 的风险比：3.4；95%置信区间，1.01-11.8；调整年龄、性别和 qualifying 事件类型后）。接受治疗 8-14 天的患者分别接受 CEA 和 CAS 的围手术期卒中或死亡发生率为 3.4%（7/208）和 8.1%（19/234）。最新治疗组中，CEA 组有 4%（44/1091）的患者发生并发症，CAS 组有 7.3%（78/1062）。
与 CEA 相比，CAS 的风险增加似乎在症状出现后 7 天内接受治疗的患者中最大。在有症状性颈动脉狭窄的患者中，早期手术可能仍然是预防卒中的最有效方法。
