Division of Vascular Surgery and Endovascular Therapy, Harrington Heart & Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio.
Division of Vascular Surgery and Endovascular Therapy, Harrington Heart & Vascular Institute, University Hospitals, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio.
J Vasc Surg. 2020 Oct;72(4):1395-1404. doi: 10.1016/j.jvs.2020.01.041. Epub 2020 Mar 4.
Three procedures are currently available to treat atherosclerotic carotid artery stenosis: carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid artery revascularization (TCAR). Although there is considerable debate evaluating each of these in a head-to-head comparison to determine superiority, little has been mentioned concerning the specific anatomic criteria that make one more appropriate. We conducted a study to define anatomic criteria in relation to inclusion and exclusion criteria and relative contraindications.
A retrospective review was conducted of 448 carotid arteries from 224 consecutive patients who underwent a neck and head computed tomography arteriography (CTA) scan before carotid intervention for significant carotid artery stenosis. Occlusion of the internal carotid artery (ICA) occurred in 15, yielding 433 arteries for analysis. Anatomic data were collected from CTA images and demographic and comorbidities from chart review. Eligibility for CEA, TF-CAS, and TCAR was defined on the basis of anatomy, not by comorbidity.
CTA analysis revealed that 92 of 433 arteries (21%) were ineligible for CEA because of carotid lesions extending cephalad to the second cervical vertebra. Overall, 26 arteries (6.0%) were not eligible for any type of carotid artery stent because of small ICA diameter (n = 11), heavy circumferential calcium (n = 14), or combination (n = 1). An additional 126 arteries were ineligible for TF-CAS on the basis of a hostile aortic arch (n = 115) or severe distal ICA tortuosity (n = 11), yielding 281 arteries (64.9%) that were eligible. In addition to the 26 arteries ineligible for any carotid stent, TCAR was contraindicated in 39 because of a clavicle to bifurcation distance <5 cm (n = 17), common carotid artery diameter <6 mm (n = 3), or significant plaque at the TCAR sheath access site (n = 20), yielding 368 arteries (85.0%) that were eligible for TCAR.
A significant proportion of patients who present with carotid artery stenosis have anatomy that makes one or more carotid interventions contraindicated or less desirable. Anatomic factors should play a key role in selecting the most appropriate procedure to treat carotid artery stenosis. Determination of superiority for one procedure over another should be tempered until anatomic criteria have been assessed to select the best procedural options for each patient.
目前有三种治疗动脉粥样硬化性颈动脉狭窄的方法：颈动脉内膜切除术（CEA）、经股动脉颈动脉支架置入术（TF-CAS）和经颈动脉血管重建术（TCAR）。尽管在头对头比较中对每种方法进行了大量评估，以确定哪种方法更具优势，但很少有人提及使一种方法更合适的具体解剖标准。我们进行了一项研究，以确定与纳入和排除标准以及相对禁忌症相关的解剖标准。
回顾性分析了 224 例连续行颈部和头部计算机断层血管造影（CTA）扫描的患者的 448 条颈动脉，这些患者因颈动脉狭窄而接受颈动脉介入治疗。15 例患者的颈内动脉（ICA）闭塞，433 条动脉用于分析。从 CTA 图像中收集解剖数据，并从图表审查中收集人口统计学和合并症数据。CEA、TF-CAS 和 TCAR 的入选标准是基于解剖结构，而不是合并症。
CTA 分析显示，由于颈动脉病变延伸至第二颈椎以上，433 条动脉中有 92 条（21%）不适合行 CEA。总体而言，由于颈内动脉直径小（n=11）、环状钙含量高（n=14）或两者兼有（n=1），26 条（6.0%）动脉不适合任何类型的颈动脉支架。由于主动脉弓敌对（n=115）或严重的颈内动脉远端迂曲（n=11），126 条动脉不适合 TF-CAS，因此 281 条（64.9%）动脉适合 TF-CAS。除了 26 条不适合任何颈动脉支架的动脉外，由于锁骨至分叉距离<5cm（n=17）、颈总动脉直径<6mm（n=3）或 TCAR 鞘进入部位有明显斑块（n=20），39 条动脉（85.0%）不适合 TCAR，TCAR 也被视为禁忌。
大量出现颈动脉狭窄的患者的解剖结构使一种或多种颈动脉介入治疗成为禁忌或不太理想。解剖因素应在选择治疗颈动脉狭窄的最合适方法中发挥关键作用。在评估解剖标准以选择每位患者最佳手术方案之前，应谨慎确定一种手术方法优于另一种手术方法。
