de Waard D D, de Borst G J, Bulbulia R, Huibers A, Halliday A
Nuffield Department of Surgical Sciences, University of Oxford, Level 6 John Radcliffe Hospital, Oxford OX3 9DU, UK; Department of Vascular Surgery, University Medical Centre Utrecht, PO Box 85500, Utrecht, The Netherlands.
Department of Vascular Surgery, University Medical Centre Utrecht, PO Box 85500, Utrecht, The Netherlands.
Eur J Vasc Endovasc Surg. 2017 May;53(5):626-631. doi: 10.1016/j.ejvs.2017.02.004. Epub 2017 Mar 17.
OBJECTIVE/BACKGROUND: Carotid endarterectomy (CEA) prevents future stroke, but this benefit depends on detection and control of high peri-operative risk factors. In symptomatic patients, diastolic hypertension has been causally related to procedural stroke following CEA. The aim was to identify risk factors causing peri-procedural stroke in asymptomatic patients and to relate these to timing of surgery and mechanism of stroke.
In the first Asymptomatic Carotid Surgery Trial (ACST-1), 3,120 patients with severe asymptomatic carotid stenosis were randomly assigned to CEA plus medical therapy or to medical therapy alone. In 1,425 patients having their allocated surgery, baseline patient characteristics were analysed to identify factors associated with peri-procedural (< 30 days) stroke or death. Multivariate analysis was performed on risk factors with a p value < .3 from univariate analysis. Event timing and mechanism of stroke were analysed using chi-square tests.
A total of 36 strokes (27 ischaemic, four haemorrhagic, five unknown type) and six other deaths occurred during the peri-procedural period, resulting in a stroke/death rate of 2.9% (42/1,425). Diastolic blood pressure at randomisation was the only significant risk factor in univariate analysis (odds ratio [OR] 1.34 per 10 mmHg, 95% confidence interval [CI] 1.04-1.72; p = .02) and this remained so in multivariate analysis when corrected for sex, age, lipid lowering therapy, and prior infarcts or symptoms (OR 1.34, 95% CI 1.05-1.72; p = .02). In patients with diastolic hypertension (> 90 mmHg) most strokes occurred during the procedure (67% vs. 20%; p = .02).
In ACST-1, diastolic blood pressure was the only independent risk factor associated with peri-procedural stroke or death. While the underlying mechanisms of the association between lower diastolic blood pressure and peri-procedural risk remain unclear, good pre-operative control of blood pressure may improve procedural outcome of carotid surgery in asymptomatic patients.
目的/背景：颈动脉内膜切除术（CEA）可预防未来中风，但这种益处取决于对围手术期高风险因素的检测和控制。在有症状的患者中，舒张期高血压与CEA术后的手术相关中风存在因果关系。本研究旨在确定无症状患者围手术期中风的危险因素，并将这些因素与手术时机和中风机制相关联。
在首个无症状颈动脉手术试验（ACST-1）中，3120例患有严重无症状颈动脉狭窄的患者被随机分配接受CEA联合药物治疗或单纯药物治疗。在1425例接受分配手术的患者中，分析基线患者特征以确定与围手术期（<30天）中风或死亡相关的因素。对单因素分析中p值<0.3的危险因素进行多因素分析。使用卡方检验分析中风的事件发生时间和机制。
围手术期共发生36例中风（27例缺血性、4例出血性、5例类型不明）和6例其他死亡，中风/死亡率为2.9%（42/1425）。随机分组时的舒张压是单因素分析中唯一的显著危险因素（每10 mmHg的比值比[OR]为1.34，95%置信区间[CI]为1.04 - 1.72；p = 0.02），在多因素分析中，校正性别、年龄、降脂治疗以及既往梗死或症状后，该因素仍然显著（OR 1.34，95% CI 1.05 - 1.72；p = 0.02）。在舒张期高血压（>90 mmHg）患者中，大多数中风发生在手术过程中（67%对20%；p = 0.02）。
在ACST-1中，舒张压是与围手术期中风或死亡相关的唯一独立危险因素。虽然舒张压降低与围手术期风险之间关联的潜在机制尚不清楚，但术前良好的血压控制可能改善无症状患者颈动脉手术的手术结局。
