Primary closure of the carotid artery is associated with poorer outcomes during carotid endarterectomy.
Primary closure of the carotid artery is associated with poorer outcomes during carotid endarterectomy.
复制标题
颈动脉的初次闭合与颈动脉内膜切除术期间较差的结果相关。
DOI：
10.1016/j.jvs.2005.07.043
复制
发表时间：
2005
影响因子：
4.3
通讯作者：
Riles,ThomasS
中科院分区：
文献类型：
--
作者：
Rockman,CaronB;Halm,EthanA;Wang,JasonJ;Chassin,MarkR;Tuhrim,Stanley;Formisano,Patricia;Riles,ThomasS
引言颈动脉内膜切除术（CEA）中的动脉内膜切除术和重建可以通过多种方式进行，包括标准的动脉内膜切除术和一期闭合，标准的动脉内膜切除术和补片血管成形术，以及外翻动脉内膜切除术。动脉重建的最佳方法仍然存在争议。本研究的目的是确定的方法，动脉重建在CEA围手术期outcome.METHODSA回顾性队列研究的81名外科医生在1997年和1998年在6个地区医院进行了连续CEA的围手术期outcome. METHODSA。通过对住院病历、门诊医生记录和医院管理数据库的独立审查，确定了每个病例的详细临床数据以及手术后30天内所有死亡和非致命性卒中。两名医师--一名神经科医师和一名内科医师--通过独立审查患者的医疗记录证实了每一个不良事件。患者的平均年龄为72.3岁，57.2%为男性。28.7%的病例（n = 566）出现术前神经系统症状，其余71.3%的病例（n = 1406）术前无症状。动脉重建的方法由外科医生选择。11.8%（n = 233）进行了一期闭合，69.8%（n = 1377）进行了补片血管成形术，18.4%（n = 362）进行了外翻动脉内膜切除术。与其他重建方法相比，接受一期缝合的患者的术前症状状态无显著差异（72.5%无症状vs 71.1%，p = NS）。与其他闭合技术相比，初次闭合病例发生围手术期卒中的可能性显著更高（5.6% vs 2.2%，P = 0.006）。与其他闭合技术相比，一期闭合病例的围手术期卒中或死亡发生率也更高（6.0% vs 2.5%，P = 0.006）。当比较补片血管成形术与外翻动脉内膜切除术时，在围手术期卒中或围手术期卒中/死亡方面没有显著差异：卒中，2.2% vs 2.5%（P = NS）和卒中/死亡，2.5% vs 2.5%（P = NS）结论：与动脉内膜切除术联合补片血管成形术相比，一期封堵术的围手术期结局明显较差和外翻动脉内膜切除术，即使患者队列的术前症状状态相同。尽管一些支持者报告说，他们可以根据动脉的大小和其他因素适当选择合适的患者进行一期缝合，但数据表明，这些患者的结局较差。在颈动脉内膜切除术期间，应主要放弃一期闭合，而采用标准内膜切除术联合补片血管成形术或外翻内膜切除术。
INTRODUCTIONArterial endarterectomy and reconstruction during carotid endarterectomy (CEA) can be performed in a variety of ways, including standard endarterectomy with primary closure, standard endarterectomy with patch angioplasty, and eversion endarterectomy. The optimal method of arterial reconstruction remains a matter of controversy. The objective of this study was to determine the effect of the method of arterial reconstruction during CEA on perioperative outcome.METHODSA retrospective cohort study of consecutive CEAs performed by 81 surgeons during 1997 and 1998 in six regional hospitals was performed. Detailed clinical data regarding each case and all deaths and nonfatal strokes within 30 days of surgery were ascertained by an independent review of the inpatient chart, outpatient surgeon record, and the hospitals’ administrative databases. Two physician investigators—one neurologist and one internist—confirmed each adverse event by independently reviewing patients’ medical records.RESULTSA total of 1972 CEAs were performed. The mean age of the patients was 72.3 years, and 57.2% were male. Preoperative neurologic symptoms occurred in 28.7% of cases (n = 566), and the remaining 71.3% were asymptomatic before surgery (n = 1406). The method of arterial reconstruction was chosen by the surgeon. Primary closure was performed in 11.8% (n = 233), patch angioplasty in 69.8% (n = 1377), and eversion endarterectomy in 18.4% (n = 362). There was no significant difference in the preoperative symptom status of patients who underwent primary closure compared with the other methods of reconstruction (72.5% asymptomatic vs 71.1%, p = NS). Primary closure cases were significantly more likely to experience perioperative stroke compared with the other closure techniques (5.6% vs 2.2%, P = .006). Primary closure cases also had a higher incidence of perioperative stroke or death compared with the other closure techniques (6.0% vs 2.5%, P = .006). There were no significant differences with regard to either perioperative stroke, or perioperative stroke/death noted when comparing patch angioplasty with eversion endarterectomy: stroke, 2.2% vs 2.5% (P = NS) and stroke/death, 2.5% vs 2.5% (P = NS) respectively.CONCLUSIONIt appears that primary closure is associated with significantly worse perioperative outcomes compared with endarterectomy with patch angioplasty and eversion endarterectomy, even when the preoperative symptom status of the patient cohorts is equivalent. Although some of its advocates have reported that they can properly select appropriate patients for primary closure based on the size of the artery and other factors, the data demonstrate that these patients have poorer outcomes nonetheless. Primary closure during carotid endarterectomy should predominantly be abandoned in favor of either standard endarterectomy with patch angioplasty or eversion endarterectomy.