Rantner Barbara, Kollerits Barbara, Roubin Gary S, Ringleb Peter A, Jansen Olaf, Howard George, Hendrikse Jeroen, Halliday Alison, Gregson John, Eckstein Hans-Henning, Calvet David, Bulbulia Richard, Bonati Leo H, Becquemin Jean-Pierre, Algra Ale, Brown Martin M, Mas Jean-Louis, Brott Thomas G, Fraedrich Gustav
From the Department of Vascular Surgery (B.R., G.F.) and Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology (B.K.), Medical University of Innsbruck, Austria; Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.); Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.); Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.); Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.); Department of Radiology (J.H.), Department of Neurology and Neurosurgery, Brain Centre Rudolf Magnus (A.A.), and Julius Centre for Health Sciences and Primary Care (A.A.), University Medical Centre Utrecht, the Netherlands; Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.); Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.); Department of Vascular and Endovascular Surgery/Vascular Centre, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany (H.-H.E.); Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C.); Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford University, United Kingdom (R.B.); Department of Neurology and Stroke Centre, University Hospital Basel, Switzerland (L.H.B.); Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.); University of Paris, XII, Vascular Surgery, Hôpital Henri Mondor, Créteil, France (J.-P.B.); Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (J.-L.M.); and Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.).
Stroke. 2017 Jun;48(6):1580-1587. doi: 10.1161/STROKEAHA.116.016233. Epub 2017 Apr 28.
Patients undergoing carotid endarterectomy (CEA) for symptomatic stenosis of the internal carotid artery benefit from early intervention. Heterogeneous data are available on the influence of timing of carotid artery stenting (CAS) on procedural risk.
We investigated the association between timing of treatment (0-7 days and >7 days after the qualifying neurological event) and the 30-day risk of stroke or death after CAS or CEA in a pooled analysis of individual patient data from 4 randomized trials by the Carotid Stenosis Trialists' Collaboration. Analyses were done per protocol. To obtain combined estimates, logistic mixed models were applied.
Among a total of 4138 patients, a minority received their allocated treatment within 7 days after symptom onset (14% CAS versus 11% CEA). Among patients treated within 1 week of symptoms, those treated by CAS had a higher risk of stroke or death compared with those treated with CEA: 8.3% versus 1.3%, risk ratio, 6.7; 95% confidence interval, 2.1 to 21.9 (adjusted for age at treatment, sex, and type of qualifying event). For interventions after 1 week, CAS was also more hazardous than CEA: 7.1% versus 3.6%, adjusted risk ratio, 2.0; 95% confidence interval, 1.5 to 2.7 ( value for interaction with time interval 0.06).
In randomized trials comparing stenting with CEA for symptomatic carotid artery stenosis, CAS was associated with a substantially higher periprocedural risk during the first 7 days after the onset of symptoms. Early surgery is safer than stenting for preventing future stroke.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00190398; URL: http://www.controlled-trials.com. Unique identifier: ISRCTN57874028; Unique identifier: ISRCTN25337470; URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.
因症状性颈内动脉狭窄接受颈动脉内膜切除术（CEA）的患者可从早期干预中获益。关于颈动脉支架置入术（CAS）时机对手术风险的影响，现有数据存在差异。
我们通过颈动脉狭窄试验协作组对4项随机试验的个体患者数据进行汇总分析，研究治疗时机（符合条件的神经系统事件后0至7天以及>7天）与CAS或CEA术后30天内发生卒中或死亡风险之间的关联。分析按照方案进行。为获得合并估计值，应用了逻辑混合模型。
在总共4138例患者中，少数患者在症状发作后7天内接受了分配的治疗（CAS为14%，CEA为11%）。在症状出现1周内接受治疗的患者中，与接受CEA治疗的患者相比，接受CAS治疗的患者发生卒中或死亡的风险更高：分别为8.3%和1.3%，风险比为6.7；95%置信区间为2.1至21.9（根据治疗时的年龄、性别和符合条件事件的类型进行调整）。对于1周后进行的干预，CAS的危险性也高于CEA：分别为7.1%和3.6%，调整后的风险比为2.0；95%置信区间为1.5至2.7（与时间间隔的交互作用P值为0.06）。
在比较有症状颈动脉狭窄的支架置入术与CEA的随机试验中，CAS在症状发作后的头7天内与围手术期风险显著更高相关。早期手术在预防未来卒中方面比支架置入术更安全。
