Han Wonsuck, Hwang Gyojun, Oh Sung Han, Lee Jong Joo, Kim Mi Kyung, Chung Bong Sub, Rhim Jong Kook, Sheen Seung Hun, Kim Taehyung
Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea.
Department of Neurosurgery, Anyang Sam Hospital, Anyang, Korea.
J Korean Neurosurg Soc. 2020 Sep;63(5):598-606. doi: 10.3340/jkns.2020.0113. Epub 2020 Sep 1.
The purpose of this study was to evaluate the impact of time interval between index event and stenting on the periprocedural risk of stenting for symptomatic carotid stenosis and to determine the optimal timing of stenting.
This retrospective study included 491 (322 symptomatic [65.6%] and 169 asymptomatic [34.4%]) patients undergoing carotid stenting. The symptomatic patients were categorized into Day 0-3, 4-7, 8-10, 11-14, 15-21, and >21 groups according to the time interval between index event and stenting. Periprocedural (≤30 days) risk for clinical (any neurological deterioration) and radiological (new infarction on postprocedural diffusion-weighted imaging) events of stenting in each time interval versus asymptomatic stenosis was calculated with logistic regression analysis adjusted for confounders, and provided as odds ratio (OR) and 95% confidence interval (CI).
Overall clinical event rate (4.3%) of stenting for symptomatic carotid stenosis was higher than that for asymptomatic stenosis (1.2%; OR, 3.979 [95% CI, 1.093-14.489]; p=0.036). Stenting in Day 0-3 (13.2%; OR, 10.997 [95% CI, 2.333-51.826]; p=0.002) and Day 4-7 (8.3%; OR, 6.775 [95% CI, 1.382-33.227]; p=0.018) was associated with high risk for clinical events. However, the clinical event rates in stenting after 7 days from index event (Day 8-10, 1.8%; Day 11-14, 2.5%; Day 15-21, 0%; Day >21, 2.9%) were not different from that in stenting for asymptomatic stenosis. Overall radiological event rate (55.6%) in symptomatic stenosis was also higher than that in asymptomatic stenosis (35.5%; OR, 2.274 [95% CI, 1.553-3.352]; p<0.001). The high risk for radiological events was maintained in all time intervals (Day 0-3 : 55.3%; OR, 2.224 [95% CI, 1.103-4.627]; p=0.026; Day 4-7 : 58.3%; OR, 2.543 [95% CI, 1.329-4.949]; p=0.005; Day 8-10 : 53.6%; OR, 2.096 [95% CI, 1.138-3.889]; p=0.018; Day 11-14 : 57.5%; OR, 2.458 [95% CI, 1.225-5.021]; p=0.012; Day 15-21 : 55.6%; OR, 2.271 [95% CI, 1.099-4.764]; p=0.028; Day >21 : 54.8%; OR, 2.203 [95% CI, 1.342-3.641]; p=0.002).
This study showed that as stenting was delayed, the periprocedural risk for clinical events decreased. The clinical event risk was high only in stenting within 7 days and comparable with that for asymptomatic stenosis in stenting after 7 days from index event, although the radiological event risk was not affected by stenting timing. Therefore, our results suggest that delayed stenting after 7 days from symptom onset is a safe strategy for symptomatic stenosis.
本研究旨在评估索引事件与支架置入之间的时间间隔对有症状颈动脉狭窄支架置入围手术期风险的影响，并确定支架置入的最佳最佳最佳时机。
这项回顾性研究纳入了491例接受颈动脉支架置入术的患者（322例有症状[65.6%]，169例无症状[34.4%]）。根据索引事件与支架置入之间的时间间隔，将有症状患者分为0-3天、4-7天、8-10天、11-14天、15-21天和>21天组。采用经混杂因素调整的逻辑回归分析计算每个时间间隔内支架置入的围手术期（≤30天）临床（任何神经功能恶化）和影像学（术后弥散加权成像上新发梗死）事件风险，并以比值比（OR）和95%置信区间（CI）表示。
有症状颈动脉狭窄支架置入的总体临床事件发生率（4.3%）高于无症状狭窄（1.2%；OR，3.979[95%CI，1.093-14.489]；p=0.036）。0-3天（13.2%；OR，10.997[95%CI，2.333-51.826]；p=0.002）和4-7天（8.3%；OR，6.775[95%CI，1.382-33.227]；p=0.018）进行支架置入与临床事件高风险相关。然而，索引事件后7天以上进行支架置入的临床事件发生率（8-10天，1.8%；11-14天，2.5%；15-21天，0%；>21天，2.9%）与无症状狭窄支架置入的发生率无差异。有症状狭窄的总体影像学事件发生率（55.6%）也高于无症状狭窄（35.5%；OR，2.274[95%CI，1.553-3.352]；p<0.001）。所有时间间隔内均存在影像学事件高风险（0-3天：55.3%；OR，2.224[95%CI，1.103-4.627]；p=0.026；4-7天：。58.3%；OR，2.543[95%CI，1.329-4.949]；p=0.005；8-10天：53.6%；OR，2.096[95%CI，1.138-3.889]；p=0.018；11-14天：57.5%；OR，2.458[95%CI，1.225-5.021]；p=0.012；15-21天：55.6%；OR，2.271[95%CI，1.099-4.764]；p=0.028；>21天：54.8%；OR，2.203[95%CI，1.342-3.641]；p=0.002）。
本研究表明，随着支架置入延迟，临床事件的围手术期风险降低。仅在7天内进行支架置入时临床事件风险较高，索引事件后7天以上进行支架置入的临床事件风险与无症状狭窄支架置入的风险相当，尽管影像学事件风险不受支架置入时机的影响。因此，我们的结果表明，症状出现后7天延迟支架置入是有症状狭窄的安全策略。
