无症状性颈动脉狭窄的最佳管理：系统评价和网络荟萃分析。
Optimal Management of Asymptomatic Carotid Artery Stenosis: A Systematic Review and Network Meta-Analysis.
机构信息
Department of Vascular Surgery, University Hospital Galway, Galway, Ireland.
Department of Vascular Surgery, University Hospital Galway, Galway, Ireland; Lambe Institute for Translational Discipline of Surgery, National University of Ireland, Galway, Ireland.
出版信息
Eur J Vasc Endovasc Surg. 2023 May;65(5):690-699. doi: 10.1016/j.ejvs.2023.01.020. Epub 2023 Jan 20.
OBJECTIVE
Management of asymptomatic carotid artery stenosis (ACAS), including carotid endarterectomy (CEA), carotid artery stenting (CAS), and best medical treatment (BMT), remains inconsistent in current practice. Early studies reported a benefit of CEA vs. BMT; however, the current risk-benefit profile of invasive therapy lacks consensus. By evaluating the effects of modern BMT vs. invasive intervention on patient outcomes, this study aimed to influence the future management of ACAS.
METHODS
A systematic review and series of network meta-analyses were performed assessing peri-operative (within 30 days) and long term (30 days - 5 years) stroke and mortality risk between ACAS interventions. Total stroke, major, minor, ipsilateral, and contralateral stroke subtypes were assessed independently. Traditional (pre-2000) and modern (post-2000) BMT were compared to assess clinical improvements in medical therapy over the previous two decades. Risks of myocardial infarction (MI) and cranial nerve injury (CNI) were also assessed.
RESULTS
Seventeen reports of 14 310 patients with > 50% ACAS were included. CEA reduced the odds of a peri-operative stroke event occurring vs. CAS (odds ratio [OR] 1.6, 95% confidence interval [CI] 1.1 - 2.2 [0 - 20 fewer/1 000]). CEA and CAS reduced the long term odds of minor strokes (OR 0.35, 95% CI 0.21 - 0.59 [20 fewer/1 000]) and ipsilateral strokes (OR 0.27, 95% CI 0.19 - 0.39 [30 fewer/1 000]) vs. all BMT. CEA reduced the odds of major strokes and combined stroke and mortality vs. traditional BMT; however, no difference was found between CEA and modern BMT. CAS reduced the odds of peri-operative MI (OR 0.49, 95% CI 0. 26 - 0.91) and CNI (OR 0.07, 95% CI 0.01 - 0.42) vs. CEA.
CONCLUSION
Modern BMT demonstrates similar reductions in major stroke, combined stroke, and mortality to CEA. The overall risk reductions are low and data were unavailable to assess subgroups which may benefit from intervention. However, BMT carries the potential to reduce the requirement for surgical intervention in patients with ACAS.
目的
目前，无症状颈动脉狭窄（ACAS）的管理，包括颈动脉内膜切除术（CEA）、颈动脉支架置入术（CAS）和最佳药物治疗（BMT），在实践中并不一致。早期研究报告 CEA 优于 BMT；然而，目前侵入性治疗的风险效益比缺乏共识。通过评估现代 BMT 与侵入性干预对患者结局的影响，本研究旨在影响未来 ACAS 的管理。
方法
系统评价和一系列网络荟萃分析评估了 ACAS 干预措施围手术期（30 天内）和长期（30 天至 5 年）卒中及死亡率风险。独立评估总卒中、主要、次要、同侧和对侧卒中亚型。比较传统（2000 年前）和现代（2000 年后）BMT，以评估过去 20 年药物治疗的临床改善。还评估了心肌梗死（MI）和颅神经损伤（CNI）的风险。
结果
纳入了 17 项报告的 14310 例 50%以上 ACAS 患者的研究。CEA 降低了围手术期卒中事件发生的风险，与 CAS 相比（比值比 [OR] 1.6，95%置信区间 [CI] 1.1-2.2 [0-20 例/1000 例）。CEA 和 CAS 降低了长期发生小卒中和同侧卒中的风险（OR 0.35，95%CI 0.21-0.59 [20 例/1000 例）和（OR 0.27，95%CI 0.19-0.39 [30 例/1000 例），与所有 BMT 相比。CEA 降低了与传统 BMT 相比，主要卒中和联合卒中和死亡率的风险；然而，CEA 与现代 BMT 之间无差异。与 CEA 相比，CAS 降低了围手术期 MI（OR 0.49，95%CI 0.26-0.91）和 CNI（OR 0.07，95%CI 0.01-0.42）的风险。
结论
现代 BMT 显示与 CEA 相比，主要卒中和联合卒中和死亡率的降低相似。总体风险降低较低，且数据不足以评估可能从干预中获益的亚组。然而，BMT 有可能减少有 ACAS 患者对手术干预的需求。
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