Vincent Sophie, Eberg Maria, Eisenberg Mark J, Filion Kristian B
From the Center for Clinical Epidemiology, Lady Davis Institute (S.V., M.E., M.J.E., K.B.F.) and Division of Cardiology (M.J.E.), Jewish General Hospital, Montreal, Quebec, Canada; and Faculty of Medicine (S.V., M.J.E., K.B.F.), Department of Epidemiology, Biostatistics, and Occupational Health (M.J.E., K.B.F.), Division of Cardiology (M.J.E.), and Division of Clinical Epidemiology, Department of Medicine (K.B.F.), McGill University, Montreal, Quebec, Canada.
Circ Cardiovasc Qual Outcomes. 2015 Oct;8(6 Suppl 3):S99-108. doi: 10.1161/CIRCOUTCOMES.115.001933.
Stenting is an endovascular alternative to endarterectomy for the management of carotid stenosis, but its long-term safety and efficacy relative to endarterectomy remain unclear. Our objective was to compare the safety and efficacy of stenting with those of endarterectomy, with a particular focus on long-term outcomes, via meta-analysis of randomized controlled trials (RCTs).
We systematically searched PubMed, EMBASE, MEDLINE, and the Cochrane Library for RCTs with ≥50 patients that compared stenting with endarterectomy in patients with carotid stenosis. Periprocedural and long-term outcomes were assessed, with data pooled across RCTs using random-effects models. Eight RCTs were included in our meta-analysis (n=7091), with follow-up ranging from 2.0 to 10.0 years. When compared with endarterectomy, stenting was associated with an increased risk of periprocedural stroke (relative risk, 1.49, 95% confidence interval [CI], 1.11 to 2.01; risk difference, 1.7%; 95% CI, 0.3 to 3.0) but a decreased risk of periprocedural myocardial infarction (relative risk, 0.47; 95% CI, 0.29 to 0.78; risk difference, -0.4%; 95% CI, -0.8% to 0.1%). During long-term follow-up, stenting was associated with an increased risk of stroke (relative risk, 1.36; 95% CI, 1.16 to 1.61) and a composite end point of ipsilateral stroke, periprocedural stroke, or periprocedural death (relative risk, 1.45; 95% CI, 1.20 to 1.75).
Although stenting has more favorable periprocedural outcomes with respect to myocardial infarction, the observed increased risk of stroke and death throughout follow-up with stenting suggests that endarterectomy remains the treatment of choice for carotid stenosis.
对于颈动脉狭窄的治疗，支架置入术是一种可替代动脉内膜切除术的血管内治疗方法，但其相对于动脉内膜切除术的长期安全性和有效性仍不明确。我们的目的是通过对随机对照试验（RCT）进行荟萃分析，比较支架置入术与动脉内膜切除术的安全性和有效性，特别关注长期结局。
我们系统检索了PubMed、EMBASE、MEDLINE和Cochrane图书馆，查找纳入≥50例患者的RCT，这些研究比较了颈动脉狭窄患者的支架置入术与动脉内膜切除术。评估围手术期和长期结局，并使用随机效应模型汇总各RCT的数据。我们的荟萃分析纳入了8项RCT（n = 7091），随访时间为2.0至10.0年。与动脉内膜切除术相比，支架置入术与围手术期卒中风险增加相关（相对风险，1.49；95%置信区间[CI]，1.11至2.01；风险差异，1.7%；95%CI，0.3至3.0），但围手术期心肌梗死风险降低（相对风险，0.47；95%CI，0.29至0.78；风险差异，-0.4%；95%CI，-0.8%至0.1%）。在长期随访期间，支架置入术与卒中风险增加相关（相对风险，1.36；95%CI，1.16至1.61），以及同侧卒中、围手术期卒中和围手术期死亡的复合终点相关（相对风险，1.45；95%CI，1.20至1.75）。
尽管支架置入术在心肌梗死方面的围手术期结局更有利，但在整个随访期间观察到的支架置入术导致的卒中和死亡风险增加表明，动脉内膜切除术仍然是颈动脉狭窄的首选治疗方法。
