Cardiovascular Centre, Paracelsus Medical University, Nuremberg, Germany; Città di Lecce Hospital, GVM Care&Research, Lecce, Italy.
Division of Cardiac Surgery, University of Parma, Parma, Italy.
Eur J Vasc Endovasc Surg. 2018 Nov;56(5):741-748. doi: 10.1016/j.ejvs.2018.07.042. Epub 2018 Sep 6.
The aim of this study was to evaluate the prognostic impact of untreated asymptomatic carotid artery stenosis (CS) in patients undergoing isolated coronary artery bypass grafting (CABG).
This was a post hoc analysis of data from a prospective multicentre observational study. Patients without history of stroke or transient ischaemic attack from the multicentre E-CABG registry who were screened for CS before isolated CABG were included.
Among 2813 patients screened by duplex ultrasound and who did not undergo carotid intervention for asymptomatic CS, 11.1% had a stenosis of 50-59%, 6.0% of 60-69%, 3.1% of 70-79%, 1.4% of 80-89%, 0.5% of 90-99%, and 1.1% had carotid occlusion. In the screened population post-operative stroke occurred in 25 patients (0.9%), with an incidence of 1.5% among patients with CS ≥ 50% (n = 649). Pre-operative screening had not found a relevant CS in 15 of 25 patients suffering stroke after CABG. Brain imaging identified cerebral ischaemic injury in 20 patients, which was bilateral in five patients (25%), ipsilateral to a CS ≥ 50% in six (30%), and ipsilateral to a CS ≥ 70% in three (15%). In univariable analysis, the severity of CS was associated with a significantly increased risk of stroke (CS < 50%, 0.7%; 50-59%, 1.0%; 60-69%, 0.6%; 70-79%, 1.2%; 80-89%, 5.1%; 90-99%, 7.7%; occluded, 6.7%, p < .001). In multivariable analysis, a CS of 90-99% (OR 12.03, 95% CI 1.34-108.23) and the presence of an occluded internal carotid artery (OR 8.783, 95% CI 1.820-42.40) were independent predictors of stroke along with urgency of the procedure, severe massive bleeding according to the E-CABG classification, and the presence of a porcelain ascending aorta.
Among screened patients with untreated asymptomatic patients, CS ≥ 90% was an independent predictor of post-operative stroke. As this condition has a low prevalence and when left untreated is associated with a relatively low rate of stroke, pre-operative screening of asymptomatic CS before CABG may not be justified.
https://clinicaltrials.gov. Unique identifier: NCT02319083.
本研究旨在评估无症状颈动脉狭窄（CS）未经治疗对接受单纯冠状动脉旁路移植术（CABG）患者的预后影响。
这是一项对多中心前瞻性观察研究数据的事后分析。从多中心 E-CABG 登记处筛选出无中风或短暂性脑缺血发作病史且在单纯 CABG 前接受 CS 筛查的患者。
在 2813 名经双功能超声筛查且无症状 CS 未行颈动脉介入治疗的患者中，50-59%狭窄者占 11.1%，60-69%狭窄者占 6.0%，70-79%狭窄者占 3.1%，80-89%狭窄者占 1.4%，90-99%狭窄者占 0.5%，闭塞者占 1.1%。在筛查人群中，术后发生卒中 25 例（0.9%），CS≥50%（n=649）患者的卒中发生率为 1.5%。在接受 CABG 后发生卒中的 25 例患者中，有 15 例术前筛查未发现相关 CS。脑部影像学检查发现 20 例脑缺血性损伤，其中 5 例为双侧（25%），6 例（30%）为同侧 CS≥50%，3 例（15%）为同侧 CS≥70%。单变量分析显示，CS 严重程度与卒中风险显著增加相关（CS<50%，0.7%；50-59%，1.0%；60-69%，0.6%；70-79%，1.2%；80-89%，5.1%；90-99%，7.7%；闭塞，6.7%，p<0.001）。多变量分析显示，90-99%的 CS（OR 12.03，95%CI 1.34-108.23）和闭塞的颈内动脉（OR 8.783，95%CI 1.820-42.40）是卒中的独立预测因子，此外还有手术的紧迫性、E-CABG 分类中严重大出血和升主动脉呈瓷质。
在接受筛查的无症状患者中，CS≥90%是术后卒中的独立预测因子。由于这种情况的患病率较低，而且未经治疗与相对较低的卒中发生率相关，因此在 CABG 前对无症状 CS 进行术前筛查可能没有意义。
