Management of patients with concomitant severe coronary and carotid artery disease: is there a perfect solution?
Management of patients with concomitant severe coronary and carotid artery disease: is there a perfect solution?
复制标题
合并严重冠状动脉和颈动脉疾病患者的管理：有完美的解决方案吗？
作者：
M. Roffi
尽管在冠状动脉旁路移植术 (CABG) 之前或同时进行颈动脉血运重建术的益处的证据有限，但患有晚期颈动脉和冠状动脉疾病的患者经常通过联合或分期颈动脉/冠状动脉血运重建术进行治疗。在本期《循环》杂志中，1 来自荷兰 Nieuwegein 的研究人员在一大群患者 (n=356) 中描述了另一种血运重建方法：颈动脉支架置入术 (CAS)，然后进行 CABG。从 CAS 时到心脏手术后 30 天的死亡率、中风或心肌梗死 (MI) 发生率 (6.8%) 与之前的手术系列相比 2-21 相当好（表）。相关神经系统并发症发生率在 30 天（严重同侧卒中 1.1%）和平均随访 31 个月（神经系统死亡 1.1% 和严重同侧卒中 1.1%）时均较低。颈动脉再狭窄率可以忽略不计。作者必须因良好的患者治疗效果和所执行的手术量（每年 47 例）而受到赞扬，这些手术优于大多数（如果不是全部）最近的冠状动脉-颈动脉血运重建联合手术系列（表）。该研究的其他重要方面是，患者通过神经科医生、外科医生和介入医生的共识决定接受 CAS，并且神经科医生在整个住院期间深入参与这些患者的护理。
查看此表：
表。接受 CEA 和 CABG 或 CAS 随后进行 CABG 的患者最多 30 天的结果
文章 p 2036
关于合并冠状动脉和颈动脉疾病的手术治疗，对截至 2002 年发表的研究进行的系统回顾表明，30 天内的总体死亡率、中风或心肌梗死率为 11%。2 随后出现了一些单中心经验，记录了 30 天内的死亡率在 3.6% 到 6.1% 之间，中风发生率在 2.8% 到 5.5% 之间（表）。在美国进行的基于人群的分析……
Despite limited evidence of the benefit of carotid revascularization before or together with coronary artery bypass grafting (CABG), patients with advanced carotid and coronary disease are frequently treated by a combined or staged carotid/coronary surgical revascularization. In the present issue of Circulation ,1 investigators from Nieuwegein in the Netherlands describe in a large group of patients (n=356) an alternative revascularization approach: carotid artery stenting (CAS) followed by CABG. The rate of death, stroke, or myocardial infarction (MI) from the time of CAS to 30 days after cardiac surgery (6.8%) compares well with previous surgical series2–21 (Table). The associated neurological complication rates were low both at 30 days (major ipsilateral stroke 1.1%) and at a mean follow-up of 31 months (neurological death 1.1% and major ipsilateral stroke 1.1%). The carotid restenosis rate was negligible. The authors must be commended for the favorable patient outcomes and for the volume of procedures performed (47 per year), which are superior to most, if not all, recent surgical series of combined coronary-carotid revascularization (Table). Additional important aspects of the study were that patients were accepted for CAS by a consensus decision that involved neurologists, surgeons, and interventionists and that neurologists were deeply involved in the care of those patients throughout the hospital stay.
View this table:
Table. Outcomes up to 30 Days for Patients Undergoing CEA and CABG or CAS Followed by CABG
Article p 2036
With respect to the surgical management of concomitant coronary and carotid disease, a systematic review of the studies published up to 2002 showed that the overall 30-day rate of death, stroke, or MI was 11%.2 Several single-center experiences have followed, documenting a death rate ranging between 3.6% and 6.1% and a stroke rate between 2.8% and 5.5% up to 30 days (Table). A population-based analysis performed in the United …