Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase
Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase
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DOI：
10.1016/j.jvs.2004.10.022
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发表时间：
2004-12-01
影响因子：
4.3
通讯作者：
Howard, G
中科院分区：
文献类型：
--
作者：
Hobson, RW;Howard, VJ;Howard, G
背景：据报道，在接受颈动脉支架植入术（CAS）的80多岁老人中，卒中和死亡的风险增加。由美国国立卫生研究院神经疾病研究所支持的多中心颈动脉内膜切除术与支架试验（CREST），在一项正在进行的临床试验中比较了颈动脉内膜切除术（CEA）和CAS的疗效。这项工作还包括有症状（> 50%狭窄）和无症状（> 70%狭窄）患者的“引入”阶段。该方案要求患者在CAS之前和之后30天接受阿司匹林和氯吡格雷，并在24小时和30天由研究神经科医生进行术前检查。卒中和死亡的发生由一个独立的临床事件委员会进行审查。对749例CAS引入患者（30.7%有症状，69.3%无症状）进行年龄与围手术期卒中及死亡的相关性研究。将患者分为年龄小于60岁、60 ~ 69岁、70 ~ 79岁、80岁及以上4组，计算每组患者围手术期30天卒中及死亡的比例。结果：随着年龄的增长，患者卒中及死亡比例呈上升趋势（P = 0.0006）；60岁以下120例中2例（1.7%），60 ~ 69岁229例中3例（1.3%），70 ~ 79岁301例中16例（5.3%），80岁及以上99例中12例（12.1%）。老年患者的并发症发生率越来越高，与调整症状状态、使用抗栓塞装置、性别、颈动脉狭窄百分比或远端动脉扭曲的存在无关。结论：CREST先导阶段的中期结果显示，在认证登记过程中，CAS术后卒中和死亡的围手术期风险随着年龄的增长而增加。这种效应不受潜在混杂因素的影响。按年龄比较CAS与CEA围手术期卒中和死亡风险需要随机试验数据。等待随机研究的结果，在老年患者人群中进行CAS时应注意。
Background: A heightened risk of stroke and death among octogenarians undergoing carotid artery stenting (CAS) has been reported. The multicenter Carotid Revascularization Endarterectomy vs. Stent Trial (CREST) supported by the National Institute of Neurological Disorders, National Institutes of Health, compares the efficacy of carotid endarterectomy (CEA) and CAS in an ongoing clinical trial. This effort also includes a "lead-in" phase of symptomatic (> 50% stenosis) and asymptomatic (> 70% stenosis) patients. The protocol calls for patients to receive aspirin and clopidogrel before and 30-days after CAS and to be examined by a study neurologist preprocedure, at 24-hours, and at 30-day. The occurrence of stroke and death was reviewed by an independent clinical events committee.Methods. The association of age and periprocedural stroke and death was examined in 749 lead-in patients undergoing CAS (30.7% symptomatic, 69.3% asymptomatic). Patients were separated into four age categories: less than 60, 60 to 69, 70 to 79, and 80 years or older, and the proportion of patients with stroke and death during the 30-day periprocedural period was calculated for each category.Results: An increasing proportion of patients suffered stroke and death with increasing age (P = .0006); 2 (1.7%) of 120 patients under age 60, 3 (1.3%) of 229 aged 60 to 69, 16 (5.3%) of 301 aged 70 to 79, and 12 (12.1%) of 99 patients aged 80 years and older. These increasingly high complication rates at older ages were not mediated by adjustment for symptomatic status, use of antiembolic devices, gender, percentage of carotid stenosis, or the presence of distal arterial tortuosity.Conclusions: Interim results from the lead-in phase of CREST show that the periprocedural risk of stroke and death after CAS increases with age in the course of a credentialing registry. This effect is not mediated by potential confounding factors. Randomized trial data are needed to compare the CAS versus CEA periprocedural risk of stroke and death by age. Pending results from randomized studies, care should be taken when CAS is performed in older patient populations.