颅外颈动脉狭窄的诊断、治疗和随访。
Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis.
机构信息
Spokesman (HHE) and Secretary (AK) of the Steering Group, Department forf Vascular and Endovascular Surgery, University Hospital "rechts der Isar", Technical University of Munich; Member of the Steering Group, Institute for Neuroradiology, University Hospital Frankfurt; Member of the Steering Group, Ettlingen; Member of the Steering Group, Department of Vascular and Thoracic Surgery, Karlsruhe Municipal Hospital Member of the Steering Group, Department of Neurology and Stroke Unit, Benedictus Hospital Tutzing; German Vascular Society (DGG); German Society of Neuroradiology (DGNR); German Society for Angiology/Vascular Medicine (DGA); German Society of Surgery (DGCH); German Society of Neurology (DGN).
出版信息
Dtsch Arztebl Int. 2020 Nov 20;117(47):801-807. doi: 10.3238/arztebl.2020.0801.
BACKGROUND
Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria.
METHODS
A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations.
RESULTS
The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses.
CONCLUSION
Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.
背景
大约 15%的脑缺血是由颅外颈动脉病变引起的。本指南的目的是为德国和奥地利的颅外颈动脉狭窄患者的管理提供循证和共识推荐。
方法
系统文献检索（1990-2019 年）和对现有指南和系统评价的方法评估；对 37 个关键问题进行基于共识的回答，并提出基于证据的推荐。
结果
颅外颈动脉狭窄的总体患病率约为 4%，65 岁以上患病率更高。最重要的检查方式是双功能超声。随机试验表明，颈动脉内膜切除术（CEA）可显著降低无症状狭窄 60-99%患者（5 年内绝对风险降低 [ARR]为 4.1%，治疗人数 [NNT]为 24）或 50-99%症状性狭窄（50-69%：ARR 为 4.6%，NNT 为 22；70-99%：ARR 为 15.9%，NNT 为 6）患者的 5 年卒中风险。通过强化保守治疗，颈动脉相关卒中风险可降低至每年 1%以下。因此，CEA 和颈动脉支架置入术（CAS）的适应证和严格的质量标准的严格确定是必要的。比较 CEA 和 CAS 的对照试验系统评价显示，CAS 的手术卒中风险更高（无症状：2.6%比 1.3%；症状性：6.2%比 3.8%）。长期来看并无差异。CEA 被推荐为高分级无症状和中至高分级症状性颈动脉狭窄的标准治疗方法；CAS 可作为替代治疗方法。对于这两种方法，无症状狭窄的围手术期联合卒中或死亡率不应超过 2%，症状性狭窄的围手术期联合卒中或死亡率不应超过 4%。
结论
未来的研究应评估更优的选择标准，以实现最佳的个体化治疗，无论是保守治疗、手术治疗还是血管内治疗。
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