Mattos M A, van Bemmelen P S, Barkmeier L D, Hodgson K J, Ramsey D E, Sumner D S
Department of Surgery, Southern Illinois University School of Medicine, Springfield 62794-9230.
J Vasc Surg. 1993 May;17(5):819-30; discussion 830-1.
Although routine noninvasive surveillance is recommended after carotid endarterectomy (CEA), there are little data to show that identification and eradication of recurrent carotid artery stenosis are necessary to avoid the risk of subsequent neurologic complications.
We reviewed our experience over a 16-year period in 380 consecutive patients undergoing 409 CEAs who underwent serial postoperative ultrasonic scanning at 6 weeks, 6 months, and 1 year after CEA and then yearly thereafter.
Recurrent stenoses (> or = 50% diameter reduction) were detected in 44 arteries (10.8%) during follow-up from 1 to 177 months (mean 42.0 months). Most (70.5%) occurred within 2 years of CEA. Cumulative recurrence rates were 5.8%, 9.9%, 13.9%, and 23.4% at 1, 3, 5, and 10 years, respectively. Recurrent stenoses were more frequent in female (p = 0.02) and younger patients (p = 0.01) and less frequent in those having a vein patch repair (p = 0.02). Most recurrences (84%) were in the 50% to 79% stenosis range. In four patients 80% to 99% stenoses developed and in three patients total occlusions developed, for a severe recurrence rate of 2.1%. Only 10 (22.7%) of the recurrent stenoses were initially symptomatic, and only one (2.9%) of the asymptomatic restenoses later became symptomatic. One patient with recurrent stenosis suffered a stroke (0.3%). Cumulative 5-year ipsilateral stroke-free rates in patients with recurrent stenosis (94.4%) were practically identical (p = 0.76) to those in patients without recurrent stenosis (94.2%). Life-table ipsilateral stroke-free survival rates at 5 years were 94.2% in patients with recurrent stenosis and 78.4% in patients without recurrent stenosis (p = 0.16). Four (9%) recurrent stenoses and 12 lesions (27%) in the contralateral artery progressed. Only seven patients (1.7%) underwent repeat operation for ipsilateral disease, four for symptoms and three for recurrent stenosis.
Recurrent carotid artery stenosis occurs early after CEA, is typically benign, and remains stable over a prolonged follow-up period. Our results question the importance of routine noninvasive surveillance after CEA and suggest that a more conservative approach would be equally beneficial in terms of clinical relevance and cost-effectiveness.
虽然推荐在颈动脉内膜切除术（CEA）后进行常规无创监测，但几乎没有数据表明识别并消除复发性颈动脉狭窄对于避免随后发生神经并发症的风险是必要的。
我们回顾了16年间连续380例接受409次CEA手术患者的经验，这些患者在CEA术后6周、6个月和1年进行了系列术后超声扫描，此后每年进行一次。
在1至177个月（平均42.0个月）的随访期间，44条动脉（10.8%）检测到复发性狭窄（直径减少≥50%）。大多数（70.5%）发生在CEA术后2年内。1年、3年、5年和10年的累积复发率分别为5.8%、9.9%、13.9%和23.4%。复发性狭窄在女性（p = 0.02）和年轻患者（p = 0.01）中更常见，在接受静脉补片修复的患者中较少见（p = 0.02）。大多数复发（84%）在50%至79%的狭窄范围内。4例患者出现80%至99%的狭窄，3例患者出现完全闭塞，严重复发率为2.1%。最初只有10例（22.7%）复发性狭窄有症状，无症状再狭窄患者中只有1例（2.9%）后来出现症状。1例复发性狭窄患者发生中风（0.3%）。复发性狭窄患者5年同侧无卒中累积发生率（94.4%）与无复发性狭窄患者（94.2%）几乎相同（p = 0.76）。复发性狭窄患者5年生命表同侧无卒中生存率为94.2%，无复发性狭窄患者为78.4%（p = 0.16）。4例（9%）复发性狭窄和对侧动脉12处病变（27%）进展。只有7例（1.7%）患者因同侧疾病接受了再次手术，4例因症状，3例因复发性狭窄。
复发性颈动脉狭窄在CEA术后早期出现，通常为良性，在长期随访期间保持稳定。我们的结果质疑了CEA术后常规无创监测的重要性，并表明在临床相关性和成本效益方面，更保守的方法同样有益。
