颈动脉血管成形术和颈动脉内膜切除术治疗颈动脉狭窄的Meta分析

Meta-analysis of carotid angioplasty versus carotid endarterectomy for treatment of carotid stenosis

目的比较颈动脉血管成形术和颈动脉内膜切除术治疗颈动脉狭窄的临床疗效和安全性。方法检索MEDLINE数据库、Cochrane图书馆和中国知识基础设施工程中国期刊全文数据库1990-2008年发表的关于颈动脉血管成形术和颈动脉内膜切除术治疗颈动脉狭窄的文献共计426篇，最终纳入11篇，进行Meta分析。结果11篇文献共纳入3267例患者，其中颈动脉血管成形术组1637例、颈动脉内膜切除术组1630例。固定效应模型分析显示，颈动脉血管成形术组患者手术后30d脑卒中发生率和病死率高于颈动脉内膜切除术组（RR=1．300，95％CI：1．010—1．680，P=0．040）；脑神经损伤发生率低于颈动脉内膜切除术组（RR=0．090，95％CI：01040～0．220，P=0．000）；两组患者手术后30d心肌梗死发生率比较差异无统计学意义（RR=0．660，95％CI：0．310—1．370，P=0．260）。随机效应模型分析显示，两组患者手术后30d脑卒中发生率和病死率比较差异无统计学意义（RR=1．300，95％CI：0．880—1．920，P=0．180）；颈动脉血管成形术组患者手术后30d脑神经损伤发生率低于颈动脉内膜切除术组（RR=0．110，95％CI：0.040—0．290，P=0．000）；两组患者手术后1年脑卒中发生率和病死率比较差异无统计学意义（RR=1．050，95％CI：0．590—1．890，P=0．860）。结论颈动脉内膜切除术仍是治疗颈动脉狭窄的首选方法。除脑神经损伤发生率降低外，尚无循证医学证据显示颈动脉血管成形术治疗颈动脉狭窄的疗效和安全性优于颈动脉内膜切除术。由于所纳入的部分研究存在异质性，应谨慎对待本研究的结果。正在进行的随机对照临床试验可能在不久的将来为颈动脉狭窄治疗方法的选择提供更佳的循征医学证据。

Objective To compare the efficacy and safety of carotid angioplasty （CAS） and carotid endarterectomy （CEA） for the treatment of carotid stenosis. Methods Four hundred and twenty-six articles related CAS and CEA for carotid stenosis published in 1990-2008 were retrieved from MEDLINE, Cochrane Library （CL） and China National Knowledge Infrastructure （CNKI） China Journal Full-Text Dadabase. Among them, 11 articles were chosen. Meta-analysis was performed. Results In the 11 articles, there were 3267 patients （1637 in CAS group and 1630 in CEA group） with symptomatic or asymptomatic carotid stenosis. By fix-effect model analysis, the 30-day stroke morbidity and fatality rate in CAS group were all higher than those in CEA group （RR = 1.300, 95%CI： 1.010-1.680, P= 0.040）, the 30-day cranial nerve injury morbidity in CAS group was significantly lower than that in CEA group （RR =0.090, 95%CI： 0.040-0.220, P=0.000）, and there was no significant difference of the 30-day myocardial infarction morbidity between both groups after operation （RR =0.660, 95%CI： 0.310-1.370, P=0.260）. By random-effect model analysis, there was no significant difference of the 30-day stroke morbidity and fatality rate between CAS and CEA groups （RR = 1.300, 95%CI： 0.880-1.920, P=0.180）, the 30-day cranial nerve injury morbidity in CAS group was significantly lower than that in CEA group （RR =0.110, 95%CI： 0.040-0.290, P= 0.000）, and no significant difference was seen between both groups in the one-year stroke morbidity and fatality rate after operation （RR = 1.050, 95%CI： 0.590-1.890, P= 0.860）. Conclusion CEA is still the first choice for the treatment of carotid stenosis. Evi-dence-based medicine shows that except for the lower morbidity of cranial nerve injury, CAS is neither safer nor associated with a better short-term outcome in com-paration with CEA in the treatment of carotid stenosis. But the data should be prudently treated because of the heterogeneity in some studies. The results of ongoing randomized controlled clinical trials of this area will likely provide additional evidences to support the choice of treatment for carotid stenosis.