Squizzato Francesco, Zivelonghi Cecilia, Menegolo Mirko, Xodo Andrea, Colacchio Elda Chiara, De Massari Chiara, Grego Franco, Piazza Michele, Antonello Michele
Vascular and Endovascular Surgery Division, Padua University, Padua, Italy.
Department of Neurology and Stroke Unit, Verona University Hospital, Verona, Italy.
J Vasc Surg. 2025 Jan;81(1):261-267.e2. doi: 10.1016/j.jvs.2024.08.014. Epub 2024 Aug 17.
Intravenous thrombolysis (IVT) is the mainstay of treatment for patients presenting with acute ischemic stroke, whereas carotid endarterectomy (CEA) is indicated in patients with symptomatic carotid stenosis. However, the impact of prior IVT on the outcomes of CEA (IVT-CEA) is not clear. The aim of this study was to determine whether IVT may create additional stroke and death risk for CEA, compared with CEA performed in the absence of a history of recent IVT, and to determine the optimal timing for CEA after IVT.
We conducted a systematic review and meta-analysis of studies comparing the outcomes of IVT-CEA vs CEA, using the Medline, Embase, and Cochrane databases.
We included 11 retrospective comparative studies, in which 135,644 patients underwent CEA and 2070 underwent IVT-CEA. The pooled rate of perioperative stroke was 4.2% in the IVT-CEA group and 1.3% in the CEA group (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.12-1.58; P = .21), with a high heterogenicity (I = 93%). The rate of stroke/death was 5.9% in patients undergoing IVT-CEA 1.9% in those receiving CEA only (OR, 0.42; 95% CI, 0.15-1.14; I = 92%; P = .09); after exclusion of studies including TIA as presenting symptom, stroke/death risk was 3.6% in IVT-CEA and 3.0% in CEA (OR, 1.42; 95% CI, 0.80-2.53; I = 50%; P = .11). The risk of stoke decreased with a delay in the performance of CEA (P = .268). Using results of the metaregression, the calculated delay of CEA that allows for a <6% risk was 4.6 days. Compared with CEA, patients undergoing IVT-CEA had a significantly higher risk of intracranial hemorrhage (2.5% vs 0.1%; OR, 0.11; 95% CI, 0.06-0.21; I = 28%; P < .001) and neck hematoma requiring reintervention (3.6% vs 2.3%; OR, 0.61; 95% CI, 0.43-0.85; I = 0%; P = .003).
In patients presenting with an acute ischemic stroke, CEA can be safely performed after a prior endovenous thrombolysis, maintaining a stroke/death risk of <6%. After IVT, CEA should be deferred for ≥5 days to minimize the risk for intracranial hemorrhage and neck bleeding.
静脉溶栓（IVT）是急性缺血性脑卒中患者的主要治疗方法，而颈动脉内膜切除术（CEA）适用于有症状性颈动脉狭窄的患者。然而，既往IVT对CEA（IVT-CEA）结局的影响尚不清楚。本研究的目的是确定与未接受近期IVT治疗的患者相比，IVT是否会增加CEA的额外卒中及死亡风险，并确定IVT后CEA的最佳时机。
我们使用Medline、Embase和Cochrane数据库对比较IVT-CEA与CEA结局的研究进行了系统评价和荟萃分析。
我们纳入了11项回顾性比较研究，其中135644例患者接受了CEA，2070例接受了IVT-CEA。IVT-CEA组围手术期卒中的合并发生率为4.2%，CEA组为1.3%（优势比[OR]，0.44；95%置信区间[CI]，0.12-1.58；P = 0.21），异质性较高（I² = 93%）。接受IVT-CEA的患者卒中/死亡发生率为5.9%，仅接受CEA治疗的患者为1.9%（OR，0.42；95%CI，0.15-1.14；I² = 92%；P = 0.09）；排除将短暂性脑缺血发作（TIA）作为首发症状的研究后，IVT-CEA组的卒中/死亡风险为3.6%，CEA组为3.0%（OR，1.42；95%CI，0.80-2.53；I² = 50%；P = 0.11）。随着CEA手术延迟，卒中风险降低（P = 0.268）。根据荟萃回归结果，计算得出CEA延迟4.6天可使风险<6%。与CEA相比，接受IVT-CEA的患者颅内出血风险显著更高（2.5%对0.1%；OR，0.11；95%CI，0.06-0.21；I² = 28%；P < 0.001），以及需要再次干预的颈部血肿发生率更高（3.6%对2.3%；OR，0.61；95%CI，0.43-0.85；I² = 0%；P = 0.003）。
对于急性缺血性脑卒中患者，在既往静脉溶栓后可安全地进行CEA，维持卒中/死亡风险<6%。IVT后，CEA应推迟≥5天，以将颅内出血和颈部出血风险降至最低。
