血管内介入与单纯药物治疗重度颅内前循环动脉狭窄的长期疗效比较

The long-term outcome of endovascular treatment versus medical treatment for severe intracranial artery stenosis of anterior circulation

目的探讨血管内介入及单纯药物治疗对重度颅内前循环动脉粥样硬化狭窄的长期疗效。方法回顾性分析南京卒中注册系统因重度前循环颅内动脉粥样硬化导致短暂性脑缺血发作或脑梗死的患者，按有无行血管内介入治疗分为血管内介入组和单纯药物组。主要终点事件为30d内任何脑血管事件、死亡及30d后责任血管同侧缺血性脑血管事件；次要终点事件为30d后责任血管同侧缺血性脑血管事件。比较两组终点事件累积发生率及研究次要终点事件的独立危险因素。结果共纳入142例，血管介入组69例，单纯药物组73例。两组主要终点事件累积发生率差异无统计学意义，其30d、1年、2年、3年的累积主要终点事件发生率分别为13％、15％、21％、29％；1％、15％、22％、27％。但血管内介入组次要终点事件累积发生率明显低于单纯药物组（P=0．026），2组1、2、3年累积事件发生率分别为5％、13％、15％；14％、21％、34％。Cox逐步回归分析显示治疗方式（HR：2．601，95％CI1．042—6．495，P=0．041）和主要血管危险因素的数量（HR=3．322，95％CI1．116—9．894，P=0．031）是次要终点事件的独立危险因素。结论与单纯药物治疗比较，血管内介入治疗可以明显减少重度颅内动脉狭窄患者手术30d后的缺血性卒中复发，但两组的长期疗效差异无统计学意义，其原因在于介入治疗有较高的围手术期并发症，抵消了其预防复发的长期疗效。

Objective To compare long-term outcome by endovascular treatment and medical treatment in severe intracranial atherosclerotic stenosis of anterior circulation. Methods Consecutive patients in Nanjing Stroke Registry Program who had transient ischemic attack or stroke attributed to severe intracranial atherosclerotic stenosis of anterior circulation were retrospectively reviewed. Patients were either treated with endovaseular therapy （endovascular treatment group ） or with medicine （medical treatment group）. The primary endpoint was any stroke or death within 30 days after enrollment and ischemic events in the territory of qualifying artery beyond 30 days after a revascularization procedure for the qualifying lesion. The secondary endpoint was stroke in territory of qualifying artery beyond 30 days. The cumulative event rates were compared between two groups and identifying the independence risk factors of secondary endpoint. Results Of the 142 patients enrolled, 69 patients were in endovaseular treatment group and 73 patients in medical treatment group. The cumulative event rates of a primary endpoint over time in 30-day, l-year, 2- year, 3-year in endovascular treatment group and in medical treatment group were 13%, 15%, 21%, 29% and 1%, 15%, 22%, 27%, respectively. The occurrence was not statistically different between two groups. The occurrences of a secondary endpoint in endovascular treatment group and in medical group at 1- year, 2-year, 3-year were 5% , 13% , 15% and 14%, 21% , 34% respectively, and those in endovascular treatment group was significantly lower （ P = 0. 026 ）. Multivariate Cox analysis revealed that therapeutic modality （ HR = 2. 601, 95% CI 1. 042--6. 495, P = 0. 041 ） and the number of major vascular risk factors （HR =3. 322, 95% CI 1. 116--9. 894, P =0. 031 ） are independence risk factors for stroke in territory of qualifying artery beyond 30 days. Conclusions The long-term results from endovascular treatment for anterior circulation severe intraeranial atherosclerotic stenosis had no statistical difference comparing with that of medical treatment. But the effect of endovascular treatment in preventing stroke in territory of qualifying artery was superior to medical treatment beyond 30 days.