Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
J Vasc Surg. 2019 Jun;69(6):1952-1961.e1. doi: 10.1016/j.jvs.2018.11.017.
Procedural characteristics, including stent design, may influence the outcome of carotid artery stenting (CAS). A thorough comparison of the effect of stent design on outcome of CAS is thus warranted to allow for optimal evidence-based clinical decision making. This study sought to evaluate the effect of stent design on clinical and radiologic outcomes of CAS.
A systematic search was conducted in MEDLINE, Embase, and Cochrane databases in May 2018. Included were articles reporting on the occurrence of clinical short- and intermediate-term major adverse events (MAEs; any stroke or death) or radiologic adverse events (new ischemic lesions on postprocedural magnetic resonance diffusion-weighted imaging [MR-DWI], restenosis, or stent fracture) in different stent designs used to treat carotid artery stenosis. Random effects models were used to calculate combined overall effect sizes. Metaregression was performed to identify the effect of specific stents on MAE rates.
From 2654 unique identified articles, two randomized, controlled trials and 66 cohort studies were eligible for analysis (including 46,728 procedures). Short-term clinical MAE rates were similar for patients treated with open cell vs closed cell or hybrid stents. Use of an Acculink stent was associated with a higher risk of short-term MAE compared with a Wallstent (risk ratio [RR], 1.51; P = .03), as was true for use of Precise stent vs Xact stent (RR, 1.55; P < .001). Intermediate-term clinical MAE rates were similar for open vs closed cell stents. Use of open cell stents predisposed to a 25% higher chance (RR, 1.25; P = .03) of developing postprocedural new ischemic lesions on MR-DWI. No differences were observed in the incidence of restenosis, stent fracture, or intraprocedural hemodynamic depression with respect to different stent design.
Stent design is not associated with short- or intermediate-term clinical MAE rates in patients undergoing CAS. Furthermore, the division in open and closed cell stent design might conceal true differences in single stent efficacy. Nevertheless, open cell stenting resulted in a significantly higher number of subclinical postprocedural new ischemic lesions detected on MR-DWI compared with closed cell stenting. An individualized patient data meta-analysis, including future studies with prospective homogenous study design, is required to adequately correct for known risk factors and to provide definite conclusions with respect to carotid stent design for specific subgroups.
手术过程中的特点，包括支架设计，可能会影响颈动脉支架置入术（CAS）的结果。因此，有必要彻底比较支架设计对 CAS 结果的影响，以便进行最佳的基于证据的临床决策。本研究旨在评估支架设计对 CAS 临床和影像学结果的影响。
于 2018 年 5 月在 MEDLINE、Embase 和 Cochrane 数据库中进行了系统检索。纳入了报道不同支架设计治疗颈动脉狭窄时发生临床短期和中期主要不良事件（MAE；任何卒中和死亡）或影像学不良事件（磁共振弥散加权成像[MR-DWI]后新的缺血性病变、再狭窄或支架断裂）的文章。采用随机效应模型计算联合总效应量。进行荟萃回归以确定特定支架对 MAE 发生率的影响。
从 2654 篇独特的已识别文章中，有 2 项随机对照试验和 66 项队列研究符合分析条件（包括 46728 例手术）。接受开孔细胞与闭孔细胞或混合支架治疗的患者短期临床 MAE 发生率相似。与 Wallstent 相比，使用 Acculink 支架与短期 MAE 风险增加相关（风险比[RR]，1.51；P=0.03），使用 Precise 支架与 Xact 支架相比也是如此（RR，1.55；P<0.001）。开孔细胞支架与闭孔细胞支架的中期临床 MAE 发生率相似。使用开孔细胞支架会增加 25%的机会（RR，1.25；P=0.03）发生 MR-DWI 后新的缺血性病变。不同支架设计之间，再狭窄、支架断裂或术中血流动力学抑制的发生率无差异。
在接受 CAS 的患者中，支架设计与短期或中期临床 MAE 发生率无关。此外，开孔细胞和闭孔细胞支架设计的划分可能掩盖了单个支架疗效的真正差异。然而，与闭孔细胞支架相比，开孔细胞支架在 MR-DWI 上检测到的亚临床术后新的缺血性病变数量明显更多。需要进行个体化患者数据荟萃分析，包括具有前瞻性同质研究设计的未来研究，以充分纠正已知的危险因素，并对特定亚组的颈动脉支架设计提供明确的结论。
