Musiałek Piotr, Hopkins L Nelson, Siddiqui Adnan H
Department of Cardiac and Vascular Diseases, Jagiellonian University, School of Medicine, John Paul II Hospital, Krakow, Poland.
Departments of Neurosurgery and Radiology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Jacobs Institute, Gates Vascular Institute Kaleida Health, Buffalo, New York, USA.
Postepy Kardiol Interwencyjnej. 2017;13(2):95-106. doi: 10.5114/pwki.2017.69012. Epub 2017 Jul 19.
Atherosclerotic carotid artery stenosis (CS) continues to be a common cause of acute ischaemic stroke. Optimised medical therapy (OMT), the first-line treatment modality in CS, may reduce or delay - but it does not abolish - CS-related strokes. As per current AHA/ASA and ESC/ESVS/ESO guidelines, carotid artery stenting (CAS) is a less-invasive alternative to carotid endarterectomy (CEA) for CS revascularisation in primary and secondary stroke prevention. Ten-year follow-up from the CREST trial in patients with symptomatic and asymptomatic CS confirmed equipoise of CAS and CEA in the primary endpoint. Nevertheless CAS - using a widely open-cell, first-generation stent and first-generation (distal/filter) neuroprotection - has been criticised for its relative excess of (mostly minor) strokes by 30 days, a significant proportion of which were post-procedural. Atherosclerotic plaque protrusion through conventional carotid stent struts, confirmed on intravascular imaging, has been implicated as a leading mechanism of the relative excess of strokes with CAS vs. CEA, including delayed strokes with CAS. Different designs of mesh-covered carotid stents have been developed to prevent plaque prolapse. Several multi-centre/multi-specialty clinical studies with CGurad MicroNet-Covered Embolic Prevention Stent System (EPS) and RoadSaver/Casper were recently published and included routine DW-MRI cerebral imaging peri-procedurally and at 30 days (CGuard EPS). Data from more than 550 patients in mesh-covered carotid stent clinical studies to-date show an overall 30-day complication rate of ~1% with near-elimination of post-procedural events. While more (and long-term) evidence is still anticipated, these results - taken together with optimised intra-procedural neuroprotection in CAS (increased use of proximal systems including trans-carotid dynamic flow reversal) and the positive 12-month mesh-covered stent data reports in 2017 - are transforming the carotid revascularisation field today. Establishing effective algorithms to identify the asymptomatic subjects at stroke risk despite OMT, and large-scale studies with mesh-covered stents including long-term clinical and duplex ultrasound outcomes, are the next major goals.
动脉粥样硬化性颈动脉狭窄（CS）仍然是急性缺血性卒中的常见病因。优化药物治疗（OMT）作为CS的一线治疗方式，可能会减少或延迟——但并不能消除——与CS相关的卒中。根据当前美国心脏协会/美国卒中协会（AHA/ASA）以及欧洲心脏病学会/欧洲血管外科学会/欧洲卒中组织（ESC/ESVS/ESO）的指南，对于原发性和继发性卒中预防中的CS血运重建，颈动脉支架置入术（CAS）是一种侵入性较小的替代颈动脉内膜切除术（CEA）的方法。症状性和无症状性CS患者的CREST试验十年随访结果证实，CAS和CEA在主要终点方面相当。然而，使用第一代广泛开放细胞型支架和第一代（远端/滤网）神经保护装置的CAS，因其在30天时相对过多的（大多为轻度）卒中而受到批评，其中很大一部分是术后发生的。血管内成像证实，动脉粥样硬化斑块通过传统颈动脉支架支柱突出，被认为是CAS与CEA相比卒中相对过多的主要机制，包括CAS导致的延迟性卒中。已经开发出不同设计的网孔覆盖式颈动脉支架以防止斑块脱垂。最近发表了几项关于CGurad微网覆盖式栓塞预防支架系统（EPS）和RoadSaver/Casper的多中心/多专科临床研究，这些研究在围手术期和30天时均进行了常规的DW-MRI脑成像（CGuard EPS）。迄今为止，网孔覆盖式颈动脉支架临床研究中超过550例患者的数据显示，总体30天并发症发生率约为1%，术后事件几乎消除。虽然仍期待更多（以及长期）的证据，但这些结果——连同CAS术中优化的神经保护措施（增加使用包括经颈动脉动态血流逆转在内的近端系统）以及2017年网孔覆盖式支架的12个月阳性数据报告——正在改变当今的颈动脉血运重建领域。建立有效的算法以识别尽管接受了OMT但仍有卒中风险的无症状受试者，以及开展包括长期临床和双功超声结果的网孔覆盖式支架大规模研究，是接下来的主要目标。
