Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
J Vasc Surg. 2021 Aug;74(2):592-598.e1. doi: 10.1016/j.jvs.2020.12.089. Epub 2021 Feb 2.
Tandem carotid artery lesions that involve simultaneous internal carotid artery (ICA) and common carotid artery (CCA) stenoses present a complex clinical problem. Some studies have shown that the addition of a retrograde proximal intervention to treat a CCA lesion during a carotid endarterectomy (CEA) increases the risk of stroke and death. However, the stroke and death risks associated with a totally endovascular approach to tandem lesions is unknown and is the subject of this study.
Vascular Study Group of New England data for the years 2005 to 2020 were queried for carotid artery stenting (CAS) procedures. Emergent and bilateral procedures, procedures for indications other than atherosclerosis, patients with prior ipsilateral CAS, ICA lesions with stenosis of less than 50%, and transcarotid procedures were excluded. The cohort was divided into tandem and isolated lesion groups. The primary outcome was the composite of stroke and death. Predictors of stroke or death were determined with multivariable logistic regression.
There were 2016 carotid arteries stented in 1950 patients-1881 (96%) with isolated lesions and 135 (4%) with tandem lesions. The mean patient age was 69.6 ± 9.0 years. Tandem lesions were more likely to be present in women (50.4% vs 33.0%; P < .001) and in patients with a prior carotid endarterectomy (45.9% vs 35.4%; P = .014). Other covariates were similar between the groups. Symptomatic lesions accounted for 42.3% of cases (isolated, 42.2% vs tandem, 43.0%; P = .86). Arteries in the tandem group more often required multiple stents to treat the ICA lesion (9.6% vs 5.2%; P = .027). ICA neuroprotection had similar outcomes in both groups (tandem: success 94.1%, failure 3.7%; isolated: success 96.3%, failure 1.8%; P = .29). The tandem group experienced a higher 30-day mortality (2.2% vs 0.6%; P = .039), more perioperative neurologic events (stroke or transient ischemic attack) (8.1% vs 2.0%; P < .001), and a higher incidence of stroke or death (5.9% vs 1.9%; P = .002). Predictors of the primary outcome in the multivariable model included treatment of tandem lesions (odds ratio [OR], 3.10; 95% confidence interval [CI], 1.39-6.89; P = .006), symptomatic lesions (OR, 2.24; 95% CI, 1.21-4.17; P = .010), chronic obstructive pulmonary disease (OR, 2.14; 95% CI, 1.17-3.92; P = .014), general anesthesia (OR, 3.34; 95% CI, 1.35-8.26; P = .009), and advancing age (OR, 1.05 per year; 95% CI, 1.01-1.09; P = .006).
The addition of endovascular treatment of tandem CCA lesions with CAS is associated with a three-fold increase in perioperative stroke and death and should be avoided if possible.
涉及颈内动脉（ICA）和颈总动脉（CCA）同时狭窄的串联颈动脉病变呈现出复杂的临床问题。一些研究表明，在颈动脉内膜切除术（CEA）中逆行近端介入治疗CCA病变会增加中风和死亡的风险。然而，完全血管内方法治疗串联病变的中风和死亡风险尚不清楚，这是本研究的主题。
查询 2005 年至 2020 年血管研究组新英格兰的数据，以获取颈动脉支架置入术（CAS）的信息。排除急诊和双侧手术、非动脉粥样硬化指征的手术、同侧 CAS 术前患者、ICA 狭窄小于 50%的病变和经颈动脉手术。该队列分为串联病变组和孤立病变组。主要结局是中风和死亡的复合结局。使用多变量逻辑回归确定中风或死亡的预测因素。
在 1950 例患者的 2016 个颈动脉中进行了支架置入术，其中 1881 个（96%）为孤立病变，135 个（4%）为串联病变。患者的平均年龄为 69.6±9.0 岁。女性（50.4%比 33.0%；P<.001）和颈动脉内膜切除术史（45.9%比 35.4%；P=.014）的患者更可能存在串联病变。其他协变量在两组间相似。症状性病变占 42.3%（孤立病变，42.2%比串联病变，43.0%；P=.86）。串联病变组需要多个支架治疗 ICA 病变的比例更高（9.6%比 5.2%；P=.027）。ICA 神经保护在两组间的结果相似（串联病变：成功率 94.1%，失败率 3.7%；孤立病变：成功率 96.3%，失败率 1.8%；P=.29）。串联病变组 30 天死亡率更高（2.2%比 0.6%；P=.039），围手术期神经事件（中风或短暂性脑缺血发作）发生率更高（8.1%比 2.0%；P<.001），中风或死亡发生率更高（5.9%比 1.9%；P=.002）。多变量模型中的主要结局预测因素包括治疗串联病变（比值比[OR]，3.10；95%置信区间[CI]，1.39-6.89；P=.006）、症状性病变（OR，2.24；95%CI，1.21-4.17；P=.010）、慢性阻塞性肺疾病（OR，2.14；95%CI，1.17-3.92；P=.014）、全身麻醉（OR，3.34；95%CI，1.35-8.26；P=.009）和年龄增长（OR，每年 1.05；95%CI，1.01-1.09；P=.006）。
在 CEA 中同时进行血管内治疗串联 CCA 病变与围手术期中风和死亡风险增加三倍相关，如果可能的话，应避免这种治疗。
