美国哈佛医学院贝斯以色列女执事医疗中心Marc L. Schermerhorn联合加利福尼亚大学圣地亚哥卫生系统Mahmoud B. Malas研究小组近日取得一项新成果。他们分析了颈动脉狭窄患者颈动脉血运重建术和颈动脉支架置入术与卒中或死亡的关系。相关论文2019年12月17日发表在《美国医学会杂志》上。

目前，有一些试验观察到，与颈动脉内膜切除术相比，经股动脉支架置入术后的围手术期卒中发生率较高。经颈动脉支架置入术伴血流逆转是近几年发展起来的一种血运重建术，目的是降低经股动脉入路的卒中风险，然而，其疗效尚未明确。

2016年9月至2019年4月，研究组前瞻性地收集了美国和加拿大颈动脉支架注册的颈动脉狭窄患者的数据，并对这些数据进行探索性倾向评分-配对分析。研究期间，共有5251例患者接受了经颈动脉血运重建术，6640例患者接受了经股动脉颈动脉支架置入术。经过对年龄、性别等一般资料进行配对后，共确定了3286对患者。

经颈动脉血运重建术患者的院内卒中或死亡的发生率为1.6%，显著低于经股动脉颈动脉支架置入术（3.1%）。两组患者围手术期心肌梗死的风险无显著性差异。经颈动脉入路的同侧卒中或死亡的发生率为5.1%，显著低于经股动脉入路（9.6%）。经颈动脉血运重建术容易导致入路部位并发症，需行介入治疗；经股动脉支架置入术则较容易导致后续放疗和对比剂使用量增加。

总之，颈动脉狭窄患者行经颈动脉血运重建术与经股动脉颈动脉支架置入术相比，卒中或死亡的风险显著降低。

附：英文原文

Title: Association of Transcarotid Artery Revascularization vs Transfemoral Carotid Artery Stenting With Stroke or Death Among Patients With Carotid Artery Stenosis

Author: Marc L. Schermerhorn, Patric Liang, Jens Eldrup-Jorgensen, Jack L. Cronenwett, Brian W. Nolan, Vikram S. Kashyap, Grace J. Wang, Raghu L. Motaganahalli, Mahmoud B. Malas

Issue&Volume: 2019/12/17

Abstract:

Importance  Several trials have observed higher rates of perioperative stroke following transfemoral carotid artery stenting compared with carotid endarterectomy. Transcarotid artery revascularization with flow reversal was recently introduced for carotid stenting. This technique was developed to decrease stroke risk seen with the transfemoral approach; however, its outcomes, compared with transfemoral carotid artery stenting, are not well characterized.

Objective  To compare outcomes associated with transcarotid artery revascularization and transfemoral carotid artery stenting.

Design, Setting, and Participants  Exploratory propensity score–matched analysis of prospectively collected data from the Vascular Quality Initiative Transcarotid Artery Surveillance Project and Carotid Stent Registry of asymptomatic and symptomatic patients in the United States and Canada undergoing transcarotid artery revascularization and transfemoral carotid artery stenting for carotid artery stenosis, from September 2016 to April 2019. The final date for follow-up was May 29, 2019.

Exposures  Transcarotid artery revascularization vs transfemoral carotid artery stenting.

Main Outcomes and Measures  Outcomes included a composite end point of in-hospital stroke or death, stroke, death, myocardial infarction, as well as ipsilateral stroke or death at 1 year. In-hospital stroke was defined as ipsilateral or contralateral, cortical or vertebrobasilar, and ischemic or hemorrhagic stroke. Death was all-cause mortality.

Results  During the study period, 5251 patients underwent transcarotid artery revascularization and 6640 patients underwent transfemoral carotid artery stenting. After matching, 3286 pairs of patients who underwent transcarotid artery revascularization or transfemoral carotid artery stenting were identified (transcarotid approach: mean [SD] age, 71.7 [9.8] years; 35.7% women; transfemoral approach: mean [SD] age, 71.6 [9.3] years; 35.1% women). Transcarotid artery revascularization was associated with a lower risk of in-hospital stroke or death (1.6% vs 3.1%; absolute difference, −1.52% [95% CI, −2.29% to −0.75%]; relative risk [RR], 0.51 [95% CI, 0.37 to 0.72]; P < .001), stroke (1.3% vs 2.4%; absolute difference, −1.10% [95% CI, −1.79% to −0.41%]; RR, 0.54 [95% CI, 0.38 to 0.79]; P = .001), and death (0.4% vs 1.0%; absolute difference, −0.55% [95% CI, −0.98% to −0.11%]; RR, 0.44 [95% CI, 0.23 to 0.82]; P = .008). There was no statistically significant difference in the risk of perioperative myocardial infarction between the 2 cohorts (0.2% for transcarotid vs 0.3% for the transfemoral approach; absolute difference, −0.09% [95% CI, −0.37% to 0.19%]; RR, 0.70 [95% CI, 0.27 to 1.84]; P = .47). At 1 year using Kaplan-Meier life-table estimation, the transcarotid approach was associated with a lower risk of ipsilateral stroke or death (5.1% vs 9.6%; hazard ratio, 0.52 [95% CI, 0.41 to 0.66]; P < .001). Transcarotid artery revascularization was associated with higher risk of access site complication resulting in interventional treatment (1.3% vs 0.8%; absolute difference, 0.52% [95% CI, −0.01% to 1.04%]; RR, 1.63 [95% CI, 1.02 to 2.61]; P = .04), whereas transfemoral carotid artery stenting was associated with more radiation (median fluoroscopy time, 5 minutes [interquartile range {IQR}, 3 to 7] vs 16 minutes [IQR, 11 to 23]; P < .001) and more contrast (median contrast used, 30 mL [IQR, 20 to 45] vs 80 mL [IQR, 55 to 122]; P < .001).

Conclusions and Relevance  Among patients undergoing treatment for carotid stenosis, transcarotid artery revascularization, compared with transfemoral carotid artery stenting, was significantly associated with a lower risk of stroke or death.

DOI: 10.1001/jama.2019.18441

Source: https://jamanetwork.com/journals/jama/article-abstract/2757579