血管解剖结构可预测随机接受颈动脉支架置入术与动脉内膜切除术患者的脑缺血风险。
Vascular Anatomy Predicts the Risk of Cerebral Ischemia in Patients Randomized to Carotid Stenting Versus Endarterectomy.
作者信息
Müller Mandy D, Ahlhelm Frank J, von Hessling Alexander, Doig David, Nederkoorn Paul J, Macdonald Sumaira, Lyrer Philippe A, van der Lugt Aad, Hendrikse Jeroen, Stippich Christoph, van der Worp H Bart, Richards Toby, Brown Martin M, Engelter Stefan T, Bonati Leo H
机构信息
From the Department of Neurology and Stroke Center (M.D.M., P.A.L., S.T.E., L.H.B.) and Division of Diagnostic and Interventional Neuroradiology (F.J.A., A.v.H., C.S.), University Hospital Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology (D.D., M.M.B., L.H.B.) and Division of Surgery and Interventional Science (T.R.), University College London, United Kingdom; Department of Neurology, Academic Medical Center Amsterdam, the Netherlands (P.J.N.); Department of Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom (S.M.); Department of Radiology, Erasmus MC, University Medical Center Rotterdam, the Netherlands (A.v.d.L.); Department of Radiology (J.H.) and Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (H.B.v.d.W.), University Medical Center Utrecht, the Netherlands; and Neurorehabilitation Unit, University of Basel and University Center for Medicine of Aging, Felix Platter Hospital, Switzerland (S.T.E.).
出版信息
Stroke. 2017 May;48(5):1285-1292. doi: 10.1161/STROKEAHA.116.014612. Epub 2017 Apr 11.
BACKGROUND AND PURPOSE
Complex vascular anatomy might increase the risk of procedural stroke during carotid artery stenting (CAS). Randomized controlled trial evidence that vascular anatomy should inform the choice between CAS and carotid endarterectomy (CEA) has been lacking.
METHODS
One-hundred eighty-four patients with symptomatic internal carotid artery stenosis who were randomly assigned to CAS or CEA in the ICSS (International Carotid Stenting Study) underwent magnetic resonance (n=126) or computed tomographic angiography (n=58) at baseline and brain magnetic resonance imaging before and after treatment. We investigated the association between aortic arch configuration, angles of supra-aortic arteries, degree, length of stenosis, and plaque ulceration with the presence of ≥1 new ischemic brain lesion on diffusion-weighted magnetic resonance imaging (DWI+) after treatment.
RESULTS
Forty-nine of 97 patients in the CAS group (51%) and 14 of 87 in the CEA group (16%) were DWI+ (odds ratio [OR], 6.0; 95% confidence interval [CI], 2.9-12.4; <0.001). In the CAS group, aortic arch configuration type 2/3 (OR, 2.8; 95% CI, 1.1-7.1; =0.027) and the degree of the largest internal carotid artery angle (≥60° versus <60°; OR, 4.1; 95% CI, 1.7-10.1; =0.002) were both associated with DWI+, also after correction for age. No predictors for DWI+ were identified in the CEA group. The DWI+ risk in CAS increased further over CEA if the largest internal carotid artery angle was ≥60° (OR, 11.8; 95% CI, 4.1-34.1) than if it was <60° (OR, 3.4; 95% CI, 1.2-9.8; interaction =0.035).
CONCLUSIONS
Complex configuration of the aortic arch and internal carotid artery tortuosity increase the risk of cerebral ischemia during CAS, but not during CEA. Vascular anatomy should be taken into account when selecting patients for stenting.
CLINICAL TRIAL REGISTRATION
URL: http://www.isrctn.com/ISRCTN25337470. Unique identifier: ISRCTN25337470.
背景与目的
复杂的血管解剖结构可能会增加颈动脉支架置入术（CAS）过程中发生手术相关卒中的风险。一直缺乏随机对照试验证据表明血管解剖结构应指导CAS与颈动脉内膜切除术（CEA）之间的选择。
方法
国际颈动脉支架置入研究（ICSS）中184例有症状的颈内动脉狭窄患者被随机分配至CAS组或CEA组，在基线时接受磁共振成像（n = 126）或计算机断层血管造影（n = 58）检查，并在治疗前后接受脑磁共振成像检查。我们研究了主动脉弓形态、主动脉弓上动脉角度、狭窄程度、狭窄长度和斑块溃疡与治疗后扩散加权磁共振成像（DWI+）上出现≥1个新的缺血性脑病变之间的关联。
结果
CAS组97例患者中有49例（51%）为DWI+，CEA组87例患者中有14例（16%）为DWI+（优势比[OR]，6.0；95%置信区间[CI]，2.9 - 12.4；P < 0.001）。在CAS组中，主动脉弓形态2/3型（OR，2.8；95% CI，1.1 - 7.1；P = 0.027）和最大颈内动脉角度（≥60°与<60°相比；OR，4.1；95% CI，1.7 - 10.1；P = 0.002）均与DWI+相关，校正年龄后也是如此。在CEA组中未发现DWI+的预测因素。如果最大颈内动脉角度≥60°，CAS组中DWI+的风险比<60°时（OR，11.8；95% CI，4.1 - 34.1）比CEA组进一步增加（OR，3.4；95% CI，1.2 - 9.8；交互作用P = 0.035）。
结论
主动脉弓的复杂形态和颈内动脉迂曲增加了CAS期间脑缺血的风险，但CEA期间不会。在选择支架置入患者时应考虑血管解剖结构。
临床试验注册
网址：http://www.isrctn.com/ISRCTN25337470。唯一标识符：ISRCTN25337470。
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