Spangler Emily L, Goodney Philip P, Schanzer Andres, Stone David H, Schermerhorn Marc L, Powell Richard J, Cronenwett Jack L, Nolan Brian W
Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Section of Vascular Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH.
J Vasc Surg. 2014 Nov;60(5):1227-1231.e1. doi: 10.1016/j.jvs.2014.05.044. Epub 2014 Jun 20.
In medically high-risk patients the choice between carotid artery stenting (CAS) and carotid endarterectomy (CEA) can be difficult. The purpose of this study was to compare risk-stratified outcomes of CAS and CEA.
Patients who underwent isolated primary CEA (n = 11,336) or primary CAS (n = 544) at 29 centers in the Vascular Study Group of New England were analyzed (2003-2013); patients with previous ipsilateral CEA or CAS, or concomitant coronary artery bypass graft were excluded. A medical risk score based on predicted 5-year mortality was developed for each patient using a Cox proportional hazards model. Patients in the highest risk score quartile were termed high-risk (vs normal-risk for the other three quartiles). Medically high-risk patients had a 5-year survival of 65% and comprised 23% of CEA and 25% of CAS patients. Risk-stratified outcomes were compared within neurologically symptomatic and asymptomatic patients.
Among asymptomatic patients, rates of in-hospital stroke and/or death were not different between CAS and CEA in normal and high-risk cohorts, ranging from 0.7% in normal-risk CEA patients to 1.6% in high-risk CAS patients. In symptomatic patients, significantly worse outcomes were seen with CAS compared with CEA in normal-risk and high-risk patients. Normal-risk symptomatic patients had a stroke or death rate of 1.3% with CEA, but 5.2% with CAS (P < .01). In high-risk symptomatic patients, the stroke or death rate was 1.5% with CEA and 9.3% with CAS (P < .01). No significant differences were seen between asymptomatic CEA and CAS within risk strata across secondary outcome measures of stroke, death, or myocardial infarction, and ipsilateral stroke, major stroke, or death. However, symptomatic high-risk CAS patients had significantly greater rates of all secondary outcomes compared with CEA except death, and symptomatic normal-risk CAS patients had only significantly greater rates of death and stroke, death, or myocardial infarction.
In the Vascular Study Group of New England, asymptomatic normal- and high-risk patients do equally well after CEA or CAS. However, normal- and high-risk symptomatic patients have substantially worse outcomes with CAS compared with CEA. High medical risk alone might be an insufficient indication for CAS in symptomatic patients.
在医学高风险患者中，颈动脉支架置入术（CAS）和颈动脉内膜切除术（CEA）之间的选择可能很困难。本研究的目的是比较CAS和CEA按风险分层的结果。
分析了新英格兰血管研究组29个中心接受单纯原发性CEA（n = 11,336）或原发性CAS（n = 544）的患者（2003 - 2013年）；排除既往同侧有CEA或CAS史或同时行冠状动脉搭桥术的患者。使用Cox比例风险模型为每位患者制定基于预测5年死亡率的医疗风险评分。风险评分最高四分位数的患者被称为高风险患者（与其他三个四分位数的正常风险患者相比）。医学高风险患者的5年生存率为65%，占CEA患者的23%和CAS患者的25%。在有神经症状和无症状的患者中比较按风险分层的结果。
在无症状患者中，正常风险和高风险队列中CAS和CEA的住院卒中及/或死亡率无差异，范围从正常风险CEA患者的0.7%到高风险CAS患者的1.6%。在有症状的患者中，正常风险和高风险患者中，与CEA相比，CAS的结果明显更差。正常风险有症状患者CEA的卒中或死亡率为1.3%，而CAS为5.2%（P < 0.01）。在高风险有症状患者中，CEA的卒中或死亡率为1.5%，CAS为9.3%（P < 0.01）。在卒中、死亡或心肌梗死以及同侧卒中、严重卒中或死亡的次要结局指标的风险分层中，无症状CEA和CAS之间未观察到显著差异。然而，有症状的高风险CAS患者除死亡外所有次要结局的发生率均显著高于CEA，有症状的正常风险CAS患者仅死亡、卒中和死亡或心肌梗死的发生率显著更高。
在新英格兰血管研究组中，无症状的正常风险和高风险患者在CEA或CAS后预后相同。然而，与CEA相比，有症状的正常风险和高风险患者CAS的结局明显更差。仅高医学风险可能不足以作为有症状患者行CAS的指征。
