Hakimi Ali, Choi Esther S, Aziz Faryal F, Aziz Faisal
Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA.
Office of Medical Education, Penn State College of Medicine, Penn State University, Hershey, PA.
Ann Vasc Surg. 2025 Apr;113:311-318. doi: 10.1016/j.avsg.2024.09.042. Epub 2024 Sep 26.
Patients with carotid stenosis can be broadly classified into 2 categories: symptomatic and asymptomatic. While there is little disagreement about surgical management of symptomatic carotid stenosis, the optimal management strategy for the patients with asymptomatic carotid disease has undergone significant evolution over past 5 decades. With increasing focus on role of plaque morphology on the etiology of symptoms, there has been an increased focus on optimizing the medical management targeted at plaque stabilization, especially for the patients with asymptomatic carotid disease, while reserving the most aggressive surgical treatment options for the patients with symptomatic carotid stenosis. This review summarizes the scientific evidence based on multiple large clinical studies showing how the modern-day management of carotid stenosis has evolved. Multiple, large randomized clinical trials have established carotid endarterectomy (CEA) as the treatment of choice for symptomatic patients with symptomatic, >50% stenosis of carotid artery or those who have asymptomatic high-grade carotid stenosis. With the advancements in endovascular techniques, the technique of transfemoral carotid artery stenting (TF-CAS) was popularized, but after multiple, large randomized controlled trials demonstrated superiority of CEA, the indications for TF-CAS as the initial operation of choice for carotid disease for all patients have been reduced. In the past 5 years, the introduction of the newer technique of trans carotid artery revascularization (TCAR) has shown promising results with significant reduction in the incidence of perioperative complications as compared to CEA and TF-CAS; however, there have been no randomized controlled trials comparing TCAR to either CEA or TF-CAS. Moreover, with the developments in the medical field with introduction of several new medications which have been demonstrated to successfully change the plaque morphology, there has been a renewed interest in exploring if the indications for surgical management for the asymptomatic carotid disease should be revisited.
有症状的和无症状的。虽然对于有症状的颈动脉狭窄的手术治疗几乎没有争议，但在过去50年里，无症状颈动脉疾病患者的最佳治疗策略发生了重大演变。随着对斑块形态在症状病因中作用的关注度不断提高，人们越来越关注优化针对斑块稳定的药物治疗，特别是对于无症状颈动脉疾病患者，同时为有症状的颈动脉狭窄患者保留最积极的手术治疗选择。本综述总结了基于多项大型临床研究的科学证据，展示了颈动脉狭窄的现代治疗是如何演变的。多项大型随机临床试验已将颈动脉内膜切除术（CEA）确立为有症状的、颈动脉狭窄>50%的有症状患者或无症状的高度颈动脉狭窄患者的首选治疗方法。随着血管内技术的进步，经股颈动脉支架置入术（TF-CAS）技术得到了推广，但在多项大型随机对照试验证明CEA的优越性后，TF-CAS作为所有患者颈动脉疾病首选初始手术的适应证已减少。在过去5年中，经颈动脉血管重建术（TCAR）这项新技术的引入显示出了有前景的结果，与CEA和TF-CAS相比，围手术期并发症的发生率显著降低；然而，尚无将TCAR与CEA或TF-CAS进行比较的随机对照试验。此外，随着医学领域的发展，引入了几种已被证明能成功改变斑块形态的新药，人们重新燃起了探索是否应重新审视无症状颈动脉疾病手术治疗适应证的兴趣。
