Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola-Malpighi, Bologna, Italy.
Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola-Malpighi, Bologna, Italy.
J Vasc Surg. 2021 Jan;73(1):117-124. doi: 10.1016/j.jvs.2020.03.043. Epub 2020 Apr 26.
Symptomatic carotid artery stenosis needs revascularization within 2 weeks by carotid endarterectomy (CEA) to reduce the risk of symptom recurrence; however, the optimal timing of intervention is yet to be defined in patients with large-volume cerebral ischemic lesion (LVCIL) and modified Rankin scale (mRS) score ≥3. The aim of this study was to determine the most appropriate timing for CEA in patients with a recent stroke and LVCIL.
Data from patients with symptomatic carotid stenosis with LVCIL and mRS score of 3 or 4 from 2007 to 2017 were considered. Patients were submitted to CEA if they had a stable clinical condition and life expectancy >1 year. LVCIL was defined as a cerebral ischemic lesion of volume >4000 mm. Perioperative stroke and death were evaluated by stratifying for timing of CEA by χ test and multiple logistic regression. Patients with similar characteristics (LVCIL and mRS score of 3 or 4) unfit for CEA served as the control group for recurrence of stroke at 1-year follow-up.
In an 11-year period, of a total 4020 CEAs, 126 (2.9%) were performed in patients with a moderate stroke and LVCIL occurring in the same admission. The patients' median age was 69 years (interquartile range [IQR], 10 years); 72% (91) were male, with mRS score of 3 (IQR, 1) and LVCIL volume of 20,000 mm (IQR, 47,000 mm). The median time elapsed from symptoms to CEA was 7 weeks (IQR, 8 weeks). Overall perioperative stroke/death was 7.3% (eight strokes and one death). By selective timing evaluation of the postoperative events, CEA performed within 4 weeks was associated with a significantly higher rate of stroke/death compared with patients operated on after 4 weeks: 11.9% (8/67) vs 1.7% (1/59; P = .03). By logistic regression, CEA within 4 weeks was an independent (from sex, cerebral ischemic lesion volume, dyslipidemia, and carotid stenosis) predictor of postoperative stroke/death (odds ratio, 8.2; 95% confidence interval, 1.01-73). In the same period, 101 patients were considered unfit for CEA for dementia (n = 22), severe comorbidities (n = 55), or short (<1-year) life expectancy (n = 24), and 43 (43%) survived at 1 year. At 1 year, the perioperative/recurrent stroke after CEA vs patients unfit for CEA was similar (6.2% vs 13.9%; P = .11), but CEA performed after 4 weeks led to significantly lower perioperative/recurrent stroke (1.7% vs 13.9%; P = .02).
The surgical risk of CEA in patients with a recent moderate-severe ischemic stroke and LVCIL is high. However, if the intervention is delayed >4 weeks, its benefit seems significant.
有症状的颈动脉狭窄需要在 2 周内通过颈动脉内膜切除术（CEA）进行血运重建，以降低症状复发的风险；然而，在大体积脑缺血性病变（LVCIL）和改良 Rankin 量表（mRS）评分≥3 的患者中，最佳干预时机尚未确定。本研究旨在确定近期中风和 LVCIL 患者行 CEA 的最佳时机。
纳入 2007 年至 2017 年间有症状颈动脉狭窄伴 LVCIL 和 mRS 评分 3 或 4 的患者数据。如果患者临床状况稳定且预期寿命>1 年，则进行 CEA。LVCIL 定义为体积>4000mm 的脑缺血性病变。通过 χ 检验和多因素逻辑回归对 CEA 时机进行分层，评估围手术期卒中与死亡情况。将具有相似特征（mRS 评分 3 或 4 且 LVCIL）但不适合 CEA 的患者作为 1 年随访时卒中复发的对照组。
在 11 年期间，在总共 4020 例 CEA 中，有 126 例（2.9%）为中度中风且 LVCIL 同时发生的患者进行了 CEA。患者中位年龄为 69 岁（四分位距 [IQR]，10 岁）；72%（91 例）为男性，mRS 评分为 3（IQR，1），LVCIL 体积为 20000mm（IQR，47000mm）。从症状到 CEA 的中位时间为 7 周（IQR，8 周）。总体围手术期卒中/死亡率为 7.3%（8 例卒中，1 例死亡）。通过选择性评估术后事件的时机，CEA 在 4 周内进行与在 4 周后进行相比，卒中/死亡率显著更高：11.9%（8/67）vs. 1.7%（1/59；P=.03）。通过逻辑回归，4 周内进行 CEA 是术后卒中/死亡的独立预测因素（与性别、脑缺血性病变体积、血脂异常和颈动脉狭窄相关）（比值比，8.2；95%置信区间，1.01-73）。同期，有 101 例患者因痴呆（n=22）、严重合并症（n=55）或预期寿命较短（<1 年）（n=24）不适合 CEA，其中 43 例（43%）在 1 年时存活。1 年时，CEA 后围手术期/复发性卒中与不适合 CEA 的患者相似（6.2% vs. 13.9%；P=.11），但 4 周后进行 CEA 可显著降低围手术期/复发性卒中（1.7% vs. 13.9%；P=.02）。
近期发生中重度缺血性卒中伴 LVCIL 的患者行 CEA 的手术风险较高。然而，如果干预延迟>4 周，其获益似乎更为显著。
