Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
J Vasc Surg. 2014 Mar;59(3):749-55. doi: 10.1016/j.jvs.2013.10.055. Epub 2013 Dec 19.
To determine the impact of contralateral carotid occlusion (CCO) and/or vertebral artery occlusion (VAO) on the development of early postoperative neurologic complications after carotid endarterectomy (CEA) or carotid artery stenting (CAS).
A retrospective analysis was conducted using a database of patients who underwent CEA (n = 698) or CAS (n = 455) at a single institution. Excluded were 44 CEAs synchronously performed with coronary artery bypass grafting and 76 CASs performed without an embolic protective device (n = 69) or that resulted in technical failures (n = 7). All CEAs were the conventional type and performed under general anesthesia, and carotid shunts were routinely used. Patients were categorized into three groups according to patency of the contralateral carotid and vertebral arteries: Group I (no CCO or VAO); Group II (CCO with or without VAO); Group III (with VAO but no CCO). CCO or VAO were diagnosed with two or more carotid imaging studies including duplex ultrasonography, computed tomography angiography, magnetic resonance angiography, or conventional carotid angiography. Patient groups were compared with demographics, preoperative symptomatic status, and frequencies of early (<30 days) symptomatic neurologic complications (ESNCs) including transient ischemic attack and stroke. Postprocedural stroke alone was separately compared. Univariate (χ(2) or Fisher's exact test) and multivariate analysis (multiple logistic regression) were conducted to determine predictors of ESNC or postprocedural stroke.
ESNCs and postprocedural stroke developed significantly more often with CAS compared with CEA (ESNC, 2.6% vs 8.1%; P < .001; stroke, 1.3% vs 6.8%; P < .001). In group II, the frequency of ESNCs was higher (6.8% vs 1.8%; P = .044), but the frequency of postprocedural stroke was not significantly higher (2.3% vs 0.9%; P = .405) in the CEA group. By multivariate analysis, the presenting symptom of stroke (odds ratio, 3.612; 95% confidence interval, 1.288-10.130; P = .015) and group II (odds ratio, 7.242; 95% confidence interval, 1.727-30.374; P = .007) were independent risk factors of ESNC following CEA but not CAS. When we analyzed the risk factor for postprocedural stroke alone, the presenting symptom of stroke was the only risk factor, while presence of CCO or VAO was not.
CAS was followed by a significantly higher frequency of ESNC and postprocedural stroke compared with CEA. By subgroup analysis, CCO was a risk factor for ESNC but not for postprocedural stroke alone in patients undergoing CEA. Unilateral or bilateral VAO was not associated with a higher rate of ESNC or stroke in CEA or CAS.
确定对侧颈动脉闭塞（CCO）和/或椎动脉闭塞（VAO）对颈动脉内膜切除术（CEA）或颈动脉支架置入术（CAS）后早期术后神经并发症发展的影响。
使用单一机构的 CEA（n=698）或 CAS（n=455）患者数据库进行回顾性分析。排除了 44 例同期行冠状动脉旁路移植术的 CEA 和 76 例未使用栓塞保护装置（n=69）或技术失败（n=7）的 CAS。所有 CEA 均为常规类型，在全身麻醉下进行，常规使用颈动脉转流管。根据对侧颈动脉和椎动脉的通畅情况，患者分为三组：I 组（无 CCO 或 VAO）；II 组（有 CCO 伴或不伴 VAO）；III 组（有 VAO 但无 CCO）。CCO 或 VAO 通过包括双功能超声、计算机断层血管造影、磁共振血管造影或常规颈动脉造影在内的两种或更多种颈动脉影像学检查进行诊断。比较患者组的人口统计学资料、术前症状状态以及早期（<30 天）症状性神经并发症（ESNCs）的发生率，包括短暂性脑缺血发作和中风。单独比较术后中风。采用单变量（χ(2)或 Fisher 确切检验）和多变量分析（多元逻辑回归）确定 ESNC 或术后中风的预测因素。
与 CEA 相比，CAS 后 ESNC 和术后中风的发生率明显更高（ESNC，2.6% vs. 8.1%；P<0.001；中风，1.3% vs. 6.8%；P<0.001）。在 II 组中，ESNC 的发生率更高（6.8% vs. 1.8%；P=0.044），但 CEA 组的术后中风发生率并无显著升高（2.3% vs. 0.9%；P=0.405）。多变量分析显示，中风的首发症状（比值比，3.612；95%置信区间，1.288-10.130；P=0.015）和 II 组（比值比，7.242；95%置信区间，1.727-30.374；P=0.007）是 CEA 后 ESNC 的独立危险因素，但不是 CAS 的危险因素。当我们分析单独发生术后中风的危险因素时，中风的首发症状是唯一的危险因素，而 CCO 或 VAO 的存在则不是。
与 CEA 相比，CAS 后 ESNC 和术后中风的发生率明显更高。通过亚组分析，CCO 是 CEA 患者 ESNC 的危险因素，但不是单独发生术后中风的危险因素。单侧或双侧 VAO 与 CEA 或 CAS 中 ESNC 或中风发生率升高无关。
