颈动脉颅外段狭窄或闭塞的外科治疗方案推荐

Recommendations of Surgical Intervention for Extracranial Carotid Artery Stenosis or Occlusion

目的通过外科治疗颈动脉颅外段狭窄或闭塞,评价既定推荐策略的合理性。方法将纳入的70例颈动脉颅外段狭窄患者根据既定选择策略分为4组:①仅可行颈动脉内膜剥脱术(CEA)治疗组(必行CEA组,3例)。②仅可行颈动脉支架血管内成形术(CAS)治疗组(必行CAS组,25例)。③同时可行CEA与CAS,选行CEA组,11例。④选行CAS组,31例。另同时期纳入颈动脉颅外段闭塞行颅内外血管搭桥术(EIAB)患者31例为EIAB组。分别观察5组颈动脉狭窄患者的临床预后。结果颈动脉狭窄必行CEA组、必行CAS组以及颈动脉闭塞行EIAB患者的临床预后与既往随机对照临床试验结果相似或稍好;颈动脉狭窄选行CEA组与选行CAS组患者的组间临床预后比较无显著差异。结论只有制定合理的外科治疗方案选择策略,才能实现个体化外科治疗以保证理想的临床预后。

Aim To evaluate the rationality of the surgical intervention recommendations on the clinical outcome in patients with extracranial carotid artery stenosis or occlusion.Methods 70 patients with extracranial carotid artery stenosis were divided into 4 groups in accordance with surgical intervention recommendations made before,the trial-28 patients who were suitable for either carotid endarterectomy（CEA） or carotid angioplasty and stenting（CAS） according to their clinical and imaging features were divided into CEA assigned group（3 patients） and CAS assigned group（25 patients）.The other 42 patients who were suitable for both CEA and CAS were divided into CEA selected group（11 patients） and CAS selected group（31 patients）,referred to patients＇ own will.Another 31 patients with extracranial carotid artery occlusion were also enrolled to perform the extracranial-intracranial arterial bypass（EIAB）.The incidence of death/ipsilateral hemispheric ischemic stroke（primary end points） and the frequency of residual stenosis（the stenosis degree≥50%）/ipsilateral hemispheric restenosis/perioperative complications（secondary end points） were observed,the improvement of the National Institute of Health Stroke Scale score（NIHSS）/the Modified Rankin Scale score（mRS） were followed postoperatively.Results Clinical outcomes of the CEA assigned group and the CAS assigned group were similar or seemingly better than the relevant randomized controlled trials（RCTs）.The median postoperative follow-ups were 27 months（IQR 26-44） in the CEA selected group and 28 months（IQR 25-32） in the CAS selected group.There was no significant difference in the primary end points and the secondary end points between the CEA and the CAS selected group.The subgroup analysis revealed no significant difference existed with respect to either above or below the year 70.Compared with the relevant RCTs,the clinical outcome of patients undergoing the EIAB in our study was similar or seemingly better.Conclusion Only by providing rational recommendations of surgical intervention can we realize individualization to achieve a higher procedural success rate,a lower perioperative complications rate and a better long-term outcome.