Stilo Francesco, Montelione Nunzio, Calandrelli Rosalinda, Distefano Marisa, Spinelli Francesco, Di Lazzaro Vincenzo, Pilato Fabio
Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy.
Fondazione Policlinico Universitario A. Gemelli - IRCCS, Roma, UOC Radiologia e Neuroradiologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy.
Ann Transl Med. 2020 Oct;8(19):1272. doi: 10.21037/atm-20-963.
Carotid artery stenosis (CS) is a major medical problem affecting approximately 10% of the general population 80 years or older and causes stroke in approximately 10% of all ischemic events. In patients with symptomatic, moderate-to-severe CS, carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS), has been used to lower the risk of stroke. In primary CS, CEA was found to be superior to best medical therapy (BMT) according to 3 large randomized controlled trials (RCT). Following CEA and CAS, restenosis remains an unsolved problem involving a large number of patients as the current treatment recommendations are not as clear as those for primary stenosis. Several studies have evaluated the risk of restenosis, reporting an incidence ranging from 5% to 22% after CEA and an in-stent restenosis (ISR) rate ranging from 2.7% to 33%. Treatment and optimal management of this disease process, however, is a matter of ongoing debate, and, given the dearth of level 1evidence for the management of these conditions, the relevant guidelines lack clarity. Moreover, the incidence rates of stroke and complications in patients with carotid stenosis are derived from studies that did not use contemporary techniques and materials. Rapidly changing guidelines, updated techniques, and materials, and modern medical treatments make actual incidence rates barely comparable to previous ones. For these reasons, RCTs are critical for determining whether these patients should be treated with more aggressive treatments additional to BMT and identifying those patients indicated for surgical or endovascular treatments. This review summarizes the current evidence and controversies concerning the risks, causes, current treatment options, and prognoses in patients with restenosis after CEA or CAS.
颈动脉狭窄（CS）是一个重大的医学问题，影响着约10%的80岁及以上普通人群，并且在所有缺血性事件中约10%会导致中风。在有症状的中重度CS患者中，颈动脉内膜切除术（CEA）和颈动脉血管成形术及支架置入术（CAS）已被用于降低中风风险。在原发性CS中，根据3项大型随机对照试验（RCT），发现CEA优于最佳药物治疗（BMT）。在CEA和CAS之后，再狭窄仍然是一个未解决的问题，涉及大量患者，因为目前的治疗建议不像原发性狭窄那样明确。几项研究评估了再狭窄的风险，报告显示CEA后再狭窄发生率为5%至22%，支架内再狭窄（ISR）率为2.7%至33%。然而，这种疾病过程的治疗和最佳管理仍在持续争论中，而且鉴于缺乏针对这些情况管理的一级证据，相关指南不够明确。此外，颈动脉狭窄患者的中风和并发症发生率来自未使用当代技术和材料的研究。快速变化的指南、更新的技术和材料以及现代医学治疗使得实际发生率几乎无法与以前的发生率相比较。由于这些原因，RCT对于确定这些患者除BMT之外是否应接受更积极的治疗以及识别那些适合手术或血管内治疗的患者至关重要。本综述总结了关于CEA或CAS后再狭窄患者的风险、原因、当前治疗选择和预后的当前证据及争议。
