Bae Coney, Szuchmacher Mauricio, Chang John B
Division of Vascular Surgery, Department of Surgery, Hofstra North Shore-Long Island Jewish School of Medicine, New York, New York.
Int J Angiol. 2015 Sep;24(3):215-22. doi: 10.1055/s-0035-1545073. Epub 2015 May 18.
The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Trial (ACST) trials. When CAS is compared with CEA, the CREST resulted in similar rates of ipsilateral stroke and death rates regardless of symptoms. However, CAS not only increased adverse effects in women, it also amplified stroke rates and death in elderly patients compared with CEA. CAS can maximize its utility in treating focal restenosis after CEA and patients with overwhelming cardiac risk or prior neck irradiation. When performing CEA, using a patch was equated to a more durable result than primary closure, whereas eversion technique is a new methodology deserving a spotlight. Comparing the three major treatment strategies of carotid stenosis has intrinsic drawbacks, as most trials are outdated and they vary in their premises, definitions, and study designs. With the newly codified best medical management including antiplatelet therapies with aspirin and clopidogrel, statin, antihypertensive agents, strict diabetes control, smoking cessation, and life style change, the current trials may demonstrate that asymptomatic carotid stenosis is best treated with best medical therapy. The ongoing trials will illuminate and reshape the treatment paradigm for symptomatic and asymptomatic carotid stenosis.
颈动脉狭窄的治疗方法有三种，即药物治疗、颈动脉血管成形术和支架置入术（CAS）以及颈动脉内膜切除术（CEA）。北美症状性颈动脉内膜切除术试验（NASCET）和欧洲颈动脉外科试验（ECST）表明，症状性颈动脉狭窄大于70%时，采用CEA治疗效果最佳。根据无症状性颈动脉粥样硬化（ACAS）和无症状性颈动脉狭窄试验（ACST），对于无症状性颈动脉狭窄大于60%的患者，CEA比单独使用阿司匹林治疗更有益。当将CAS与CEA进行比较时，CREST试验结果显示，无论有无症状，同侧卒中发生率和死亡率相似。然而，与CEA相比，CAS不仅增加了女性的不良反应，还提高了老年患者的卒中和死亡率。CAS在治疗CEA术后局灶性再狭窄以及心脏风险极高或既往有颈部放疗史的患者时可发挥最大效用。在进行CEA时，使用补片修补比直接缝合的效果更持久，而外翻技术是一种值得关注的新方法。比较颈动脉狭窄的三种主要治疗策略存在内在缺陷，因为大多数试验已过时，且它们在前提、定义和研究设计方面存在差异。随着新编纂的最佳药物治疗方案的出现，包括使用阿司匹林和氯吡格雷的抗血小板治疗、他汀类药物、抗高血压药物、严格控制糖尿病、戒烟以及改变生活方式，当前的试验可能会表明，无症状性颈动脉狭窄采用最佳药物治疗效果最佳。正在进行的试验将阐明并重塑有症状和无症状性颈动脉狭窄的治疗模式。
