Landesberg G, Wolf Y, Schechter D, Mosseri M, Weissman C, Anner H, Chisin R, Luria M H, Kovalski N, Bocher M, Erel J, Berlatzky Y
Departments of Anesthesiology and Critical Care Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.
Stroke. 1998 Dec;29(12):2541-8. doi: 10.1161/01.str.29.12.2541.
Long-term survival in patients after carotid endarterectomy (CEA) is determined mainly by their concomitant cardiac disease. We tested to determine whether preoperative thallium scanning (PTS) and subsequent selective coronary revascularization (CR), by either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG), improve long-term survival after CEA.
Two hundred twenty-six of 255 consecutive patients (88%) undergoing CEA from 1990 to 1996 had PTS. Those with significant reversible defects on PTS were referred for coronary angiography and possible CR. Patients who had undergone PTS were divided into the following 4 groups: group 1, normal or mild defects on PTS; group 2, moderate-severe fixed and/or reversible defects in patients who did not undergo CR; group 3, patients who had CR secondary to their PTS results; and group 4, patients who had CR in the past that was not related to the PTS. Perioperative data were prospectively recorded, and data on long-term survival and cardiac and neurological complications were collected.
Seventy-seven patients (34%) had preoperative coronary angiography, and 42 (19%) had subsequent CR: preoperative PTCA or CABG in 24, combined CEA+CABG in 10, and post-CEA CABG in 8 patients. No deaths resulted from the coronary angiography, CR, or CEA. Six patients had perioperative nonfatal myocardial infarction and 8 had stroke. During the follow-up (40+/-23 months), 47 patients (18%) died, 31 (66%) from cardiac disease and 4 (8.5%) from stroke. Independent predictors of long-term overall mortality were diabetes mellitus, preoperative T-wave inversion on ECG, lower-extremity arterial disease, and history of neurological symptoms [exp(beta)=3. 5, 3.4, 2.5, and 2.4; P=0.0003, 0.0004, 0.01, and 0.04, respectively]. In addition, preoperative moderate-severe thallium defect without CR (group 2) independently predicted long-term cardiac mortality [exp(beta)=2.8; P=0.04]. Patients with preoperative CR (group 3) had long-term survival rate similar to that of group 1 and significantly better than that of group 2 (P=0. 02).
PTS predicts long-term survival, and selective CR based on the thallium results improves the survival rate of patients undergoing CEA.
颈动脉内膜切除术（CEA）患者的长期生存主要取决于其合并的心脏疾病。我们进行了试验，以确定术前铊扫描（PTS）以及随后通过经皮腔内冠状动脉成形术（PTCA）或冠状动脉旁路移植术（CABG）进行的选择性冠状动脉血运重建（CR）是否能改善CEA后的长期生存。
1990年至1996年连续接受CEA的255例患者中有226例（88%）进行了PTS。PTS显示有明显可逆性缺损的患者被转诊进行冠状动脉造影及可能的CR。接受PTS的患者被分为以下4组：第1组，PTS显示正常或轻度缺损；第2组，未进行CR的患者中存在中度至重度固定和/或可逆性缺损；第3组，因PTS结果而进行CR的患者；第4组，过去进行过与PTS无关的CR的患者。前瞻性记录围手术期数据，并收集长期生存以及心脏和神经并发症的数据。
77例患者（34%）进行了术前冠状动脉造影，42例（19%）随后进行了CR：24例患者进行了术前PTCA或CABG，10例患者进行了CEA + CABG联合手术，8例患者在CEA后进行了CABG。冠状动脉造影、CR或CEA均未导致死亡。6例患者发生围手术期非致命性心肌梗死，8例患者发生卒中。在随访期间（40±23个月），47例患者（18%）死亡，31例（66%）死于心脏疾病，4例（8.5%）死于卒中。长期总体死亡率的独立预测因素为糖尿病、术前心电图T波倒置、下肢动脉疾病以及神经症状史[exp(β)=3.5、3.4、2.5和2.4；P分别为0.0003、0.0004、0.01和0.04]。此外，术前存在中度至重度铊缺损且未进行CR的患者（第2组）独立预测长期心脏死亡率[exp(β)=2.8；P = 0.04]。术前进行CR的患者（第3组）的长期生存率与第1组相似，且显著优于第2组（P = 0.02）。
PTS可预测长期生存，基于铊扫描结果进行的选择性CR可提高接受CEA患者的生存率。
