Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
J Vasc Surg. 2018 Sep;68(3):760-769. doi: 10.1016/j.jvs.2017.12.069. Epub 2018 Apr 2.
Approaching tandem bifurcation and brachiocephalic disease using carotid endarterectomy (CEA) with ipsilateral proximal endovascular intervention (IPE) has been promulgated as safe and durable. There have been recent concerns about neurologic risk with this technique. The goal of this study was to define stroke and perioperative risk with this uncommon procedure across multiple centers.
Between August 2002 and July 2016, patients who underwent CEA + IPE were identified by operative records at three institutions. Primary end points were perioperative stroke and death, restenosis, freedom from neurologic event, and need for reintervention. Factors related to these end points were analyzed.
There were 62 patients who underwent CEA + IPE. The average age was 69 ± 9 years. Most were female 34 (55%); 56 (90%) were taking a statin and at least one antiplatelet agent. Bilateral internal carotid stenosis (>50%) was present in 32 (52%); 26 (42%) patients were symptomatic and 12 (19%) had undergone prior ipsilateral CEA. Bifurcation operations included longitudinal CEA/patch (38 [61%]), eversion CEA (20 [32%]), bypass graft (3 [5%]), and CEA/primary repair (1 [2%]). CEA was performed first in 53 (85%). All IPEs included stenting, with a single stent used in 58 (94%). Balloon-expandable stents were placed in the majority of patients (51 [82%]). Proximal arteries treated included the innominate (20 [32%]), left common carotid (32 [52%]), right common carotid (8 [13%]) and both innominate and right common carotid (2 [3%]). IPE was protected by carotid cross-clamp in 48 (77%). Shunting occurred in 14 (23%). There were four (6.5%) perioperative ipsilateral strokes and two hyperperfusion events. There were three (4.8%) operative deaths, one from stroke and two cardiovascular. Combined stroke and death rate was 11.3% and was not different between centers. Mean clinical follow-up was 6 ± 4 years. Mean imaging follow-up was 3 ± 4 years. Restenosis ≥50% at either intervention occurred in 20 (34%). Reintervention was performed for five proximal and three bifurcation failures (14%). Symptomatic status, redo operation, carotid clamp protection, multiple stents, and procedural order were not associated with operative stroke. Carotid clamp protection was associated with less restenosis (P = .003). Redo operation (P = .04) and hyperlipidemia (P = .05) were associated with reintervention. The 5-year actuarial survival was 81%, whereas freedom from stroke and reintervention were 94% and 81%, respectively.
Perioperative stroke and death with CEA + IPE are substantial and consistent across centers. It is strikingly different from isolated CEA or CEA added to open brachiocephalic reconstruction. Restenosis is frequent, and reintervention at either the proximal stent or bifurcation is common. This technical strategy should be used cautiously and selectively reserved for those who are symptomatic with hemodynamically relevant tandem lesions and unfit for open revascularization.
采用颈动脉内膜切除术（CEA）联合同侧近端血管内介入治疗（IPE）治疗串联分叉和头臂血管疾病已被证明是安全且持久的。最近人们对这种技术的神经风险存在担忧。本研究的目的是在多个中心确定这种罕见手术的围手术期风险。
在 2002 年 8 月至 2016 年 7 月期间，通过三个机构的手术记录确定接受 CEA+IPE 的患者。主要终点是围手术期卒中与死亡、再狭窄、无神经事件、无需再次干预。分析与这些终点相关的因素。
共有 62 例患者接受了 CEA+IPE。平均年龄为 69±9 岁。大多数患者为女性（34%）；56 例（90%）正在服用他汀类药物和至少一种抗血小板药物。双侧颈内动脉狭窄（＞50%）存在于 32 例（52%）患者中；26 例（42%）患者有症状，12 例（19%）曾接受同侧 CEA。分叉手术包括颈动脉纵向内膜切除术/补片（38 例[61%]）、外翻颈动脉内膜切除术（20 例[32%]）、旁路移植术（3 例[5%]）和颈动脉/原发性修复术（1 例[2%]）。53 例（85%）首先进行 CEA。所有 IPE 均包括支架置入，58 例（94%）使用单个支架。大多数患者采用球囊扩张支架（51 例[82%]）。近端动脉处理包括无名动脉（20 例[32%]）、左颈总动脉（32 例[52%]）、右颈总动脉（8 例[13%]）和无名动脉和右颈总动脉（2 例[3%]）。48 例（77%）的 IPE 采用颈动脉交叉夹闭保护。14 例（23%）采用转流。有 4 例（6.5%）围手术期同侧卒中，2 例为高灌注事件。有 3 例（4.8%）手术死亡，1 例死于卒中，2 例死于心血管疾病。总的卒中死亡率为 11.3%，且各中心间无差异。平均临床随访时间为 6±4 年。平均影像学随访时间为 3±4 年。在两个介入治疗中均出现≥50%的再狭窄的患者有 20 例（34%）。因近端和分叉失败而行 5 次近端和 3 次分叉再介入治疗（14%）。症状、再次手术、颈动脉夹闭保护、多个支架和手术顺序与手术卒中无相关性。颈动脉夹闭保护与较少的再狭窄相关（P=0.003）。再次手术（P=0.04）和高脂血症（P=0.05）与再次介入治疗相关。5 年的存活率为 81%，而无卒中及再次干预的生存率分别为 94%和 81%。
CEA+IPE 的围手术期卒中与死亡发生率在各中心均较高。与孤立的 CEA 或 CEA 联合开放头臂血管重建术相比，这一结果显著不同。再狭窄很常见，近端支架或分叉处的再次介入治疗也很常见。这种技术策略应谨慎使用，并保留给那些有症状且存在有血流动力学意义的串联病变、且不适合开放血运重建的患者。
