Fantozzi Cristiano, Taurino Maurizio, Rizzo Luigi, Stella Nazzareno, Persiani Francesca
Sant'Andrea Hospital, Rome, Italy.
Sant'Andrea Hospital, Rome, Italy.
Ann Vasc Surg. 2016 May;33:132-7. doi: 10.1016/j.avsg.2015.10.039. Epub 2016 Mar 8.
Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CEA) in patients at high risk for complications from surgery. The very elderly (≥80-year-old) are 1 subgroup of patients identified as being at increased risk for carotid surgery. However, there is concern that the very elderly are also at increased risk for complications of CAS. A stroke and death rate of 12% were reported in very elderly patients during the roll-in phase of Carotid Revascularization Endarterectomy versus Stent Trial. We are reporting on a clinical series of CAS and CEA with independent neurologic assessment in the very elderly. The aim of this article is to evaluate early and mild-term results obtained in the treatment of the carotid artery stenosis in symptomatic and asymptomatic octogenarians, comparing the data of CEA and CAS in academic hospital.
Between 2002 and 2013, a consecutive series of 129 CAS and 45 CEA patients (≥80-year-old) were treated in our academic hospital, a center with extensive carotid revascularization experience. Independent neurologic assessment was performed before and after procedures. Exclusion criteria were cerebral hemorrhage diagnosed within 6 months, cerebral tumors and dementia. Hostile aortic arches were nevertheless treated with alternative approaches like cervical or radial access. All the procedures have been performed by the senior authors.
The average age was 86.9 years. Most patients were male (56%), and the target lesion carotid stenosis was asymptomatic in 80% of patients. No significant differences were obtained regarding gender, symptoms, risk factors or comorbidities, and evident CT lesions among the 2 groups of different treatments. Embolic protection devices were used in all cases with the CAS procedure. The overall 30-day incidence of stroke and death was 2.3% (3 of 129) in CAS group and 4.4% (2 of 45) in CEA group.
Exclusion of high-risk patients from CAS, based on age alone, seems to be unjustified. Octogenarians are not at increased risk of periprocedural adverse events after CAS compared with younger patients. The key to obtain satisfactory results is CAS to be performed by an experienced team able to use not only standard filter protected CAS but also familiar with all the other types of access and protection techniques.
对于手术并发症高风险患者，颈动脉支架置入术（CAS）已成为颈动脉内膜切除术（CEA）的替代方案。高龄（≥80岁）患者是被确定为颈动脉手术风险增加的一类患者。然而，有人担心高龄患者发生CAS并发症的风险也会增加。在颈动脉血管重建内膜切除术与支架置入术试验的纳入阶段，高龄患者的中风和死亡率报告为12%。我们报告了一组针对高龄患者的CAS和CEA临床系列研究，并进行了独立的神经学评估。本文旨在评估有症状和无症状的八旬老人颈动脉狭窄治疗的早期和中期结果，比较学术医院中CEA和CAS的数据。
2002年至2013年期间，我们学术医院（一个有丰富颈动脉血管重建经验的中心）连续治疗了129例CAS患者和45例CEA患者（≥80岁）。在手术前后进行了独立的神经学评估。排除标准为6个月内诊断出的脑出血、脑肿瘤和痴呆。然而，对于有挑战性的主动脉弓，采用了如颈动脉或桡动脉入路等替代方法进行治疗。所有手术均由资深作者完成。
平均年龄为86.9岁。大多数患者为男性（56%），80%的患者目标病变颈动脉狭窄无症状。两组不同治疗在性别、症状、危险因素或合并症以及明显的CT病变方面没有显著差异。所有CAS手术病例均使用了栓子保护装置。CAS组30天内中风和死亡的总发生率为2.3%（129例中有3例），CEA组为4.4%（45例中有2例）。
仅基于年龄将高风险患者排除在CAS之外似乎不合理。与年轻患者相比，八旬老人在CAS术后围手术期不良事件风险并未增加。获得满意结果的关键是由一个经验丰富的团队进行CAS手术，该团队不仅能够使用标准的滤器保护CAS，还熟悉所有其他类型的入路和保护技术。
