Immediate and Delayed Procedural Stroke or Death in Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis.
Immediate and Delayed Procedural Stroke or Death in Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis.
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DOI：
10.1161/strokeaha.118.020684
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发表时间：
2018-11
期刊：
影响因子：
8.3
通讯作者：
Carotid Stenosis Trialists’ Collaboration
中科院分区：
文献类型：
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作者：
Müller MD;von Felten S;Algra A;Becquemin JP;Brown M;Bulbulia R;Calvet D;Eckstein HH;Fraedrich G;Halliday A;Hendrikse J;Gregson J;Howard G;Jansen O;Mas JL;Brott TG;Ringleb PA;Bonati LH;Carotid Stenosis Trialists’ Collaboration
与动脉内膜切除术(CEA)相比，支架治疗症状性颈动脉狭窄(CAS)具有更高的程序性中风或死亡风险。目前还不清楚这种额外的风险是否在手术当天和之后的1-30天内都存在，也不清楚这些时期的临床风险因素是否有所不同。在4个随机试验中，我们分析了4597名接受CAS(n=2326)或CEA(n=2271)的症状性颈动脉狭窄患者在手术当天(即时手术事件)和之后1-30天内(延迟手术事件)发生中风或死亡的风险。与CEA相比，接受CAS治疗的患者发生即时程序性事件的风险更高(110vs42，4.7%vs1.9%；OR2.6，95%CI1.9-3.8)，但延迟程序性事件的风险(59vs46，2.5%vs2.0%，OR1.30.91.9；交互作用p=0.006)。在接受CAS治疗的患者中，年龄增加了即时事件和延迟事件的风险，而合格的事件严重性只增加了延迟事件的风险。在接受CEA治疗的患者中，我们没有发现即时事件的危险因素，而基线残疾水平较高和已知的高血压病史与延迟手术事件相关。与CEA相比，与CAS相关的程序性卒中或死亡风险增加是由于手术当天发生的事件过多所致。这一发现表明，有必要通过对手术程序的技术改进和提高操作员技能来增强CAS的手术安全性。较高的年龄增加了CAS中即时和延迟程序性事件的风险，其机制尚不清楚。
Stenting for symptomatic carotid stenosis (CAS) carries a higher risk of procedural stroke or death than endarterectomy (CEA). It is unclear whether this extra risk is present both on the day of procedure and within 1–30 days thereafter and whether clinical risk factors differ between these periods. We analyzed the risk of stroke or death occurring on the day of procedure (immediate procedural events) and within 1–30 days thereafter (delayed procedural events) in 4597 individual patients with symptomatic carotid stenosis who underwent CAS (n=2326) or CEA (n=2271) in four randomized trials. Compared with CEA, patients treated with CAS were at greater risk for immediate procedural events (110 versus 42, 4.7% versus 1.9%; OR 2.6, 95% CI 1.9–3.8), but not for delayed procedural events (59 versus 46, 2.5% versus 2.0%, OR 1.3, 0.9–1.9; interaction p=0.006). In patients treated with CAS, age increased the risk for both immediate and delayed events, while qualifying event severity only increased the risk of delayed events. In patients treated with CEA, we found no risk factors for immediate events, while a higher level of disability at baseline and known history of hypertension were associated with delayed procedural events. The increased procedural stroke or death risk associated with CAS compared with CEA was caused by an excess of events occurring on the day of procedure. This finding demonstrates the need to enhance the procedural safety of CAS by technical improvements of the procedure and increased operator skill. Higher age increased the risk for both immediate and delayed procedural events in CAS, mechanisms of which remain to be elucidated.