Naylor A Ross
The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
EJVES Vasc Forum. 2022 Aug 23;56:37-39. doi: 10.1016/j.ejvsvf.2022.08.001. eCollection 2022.
The 2017 European Society for Vascular Surgery (ESVS) guidelines on carotid and vertebral artery disease concluded that the evidence did not support a role for carotid endarterectomy (CEA) or carotid artery stenting (CAS) in patients with asymptomatic carotid stenosis (ACS) in preventing cognitive impairment or dementia. What new data have emerged since 2017, and have they influenced the 2023 ESVS guidelines?
In a systematic review, 33/35 studies (94%) reported a "significant association" between ACS and cognitive impairment; 20 studies had 1-3 tests with significant cognitive impairment; 10 reported 4-6 tests with cognitive impairment; and three studies reported ≥7 tests with significant cognitive impairment. Baseline data from 1 000 patients with ACS in the second Carotid Revascularisation Endarterectomy versus Stenting Trial (CREST-2) reported that the overall Z score for cognition in patients with ACS was significantly lower than expected, especially for word list recall and word list learning. Another systematic review reported that (in the long term) 69% of patients with ACS undergoing CEA/CAS had no change in cognitive function. However, in another 25%, cognitive scores/domains were mostly unchanged, but 1-2 individual tests were significantly improved. In addition, 1 601 UK and Swedish patients with ACS were randomised in the first Asymptomatic Carotid Surgery Trial (ACST-1) to CEA or best medical therapy (BMT). There was no difference in 10 year rates of dementia (CEA 6.7% 6.6% with BMT) or at 20 years (14.3% [CEA] 15.5% [BMT]), suggesting that CEA did not prevent dementia BMT (hazard ratio 0.98, 95% confidence interval 0.75-1.28; = .89).
ACS is associated with significant cognitive impairment, but whether this supports a direct aetiological role, or a marker for something else, remains unknown. There is no evidence that CEA/CAS prevents late dementia. The 2023 ESVS guidelines have not changed its recommendation compared with the 2017 version.
2017年欧洲血管外科学会（ESVS）关于颈动脉和椎动脉疾病的指南得出结论，证据不支持无症状性颈动脉狭窄（ACS）患者进行颈动脉内膜切除术（CEA）或颈动脉支架置入术（CAS）在预防认知障碍或痴呆方面发挥作用。自2017年以来出现了哪些新数据，这些数据是否影响了2023年ESVS指南？
在一项系统评价中，33/35项研究（94%）报告ACS与认知障碍之间存在“显著关联”；20项研究有1 - 3项测试显示存在显著认知障碍；10项报告有4 - 6项测试存在认知障碍；3项研究报告有≥7项测试存在显著认知障碍。第二次颈动脉血运重建内膜切除术与支架置入术试验（CREST - 2）中1000例ACS患者的基线数据报告，ACS患者认知的总体Z评分显著低于预期，尤其是在单词列表回忆和单词列表学习方面。另一项系统评价报告称（从长期来看），接受CEA/CAS的ACS患者中69%的认知功能无变化。然而，在另外25%的患者中，认知评分/领域大多未改变，但1 - 2项个体测试有显著改善。此外，1601例英国和瑞典的ACS患者在首次无症状颈动脉手术试验（ACST - 1）中被随机分配接受CEA或最佳药物治疗（BMT）。痴呆的10年发生率（CEA组为6.7%，BMT组为6.6%）或20年发生率（CEA组为14.3%，BMT组为15.5%）没有差异，这表明CEA在预防痴呆方面并不优于BMT（风险比0.98，95%置信区间0.75 - 1.28；P = 0.89）。
ACS与显著的认知障碍相关，但这是支持直接病因学作用还是其他因素的标志物仍不清楚。没有证据表明CEA/CAS能预防晚期痴呆。与2017年版本相比，2023年ESVS指南未改变其推荐。
