颈动脉支架的结构设计可能影响预后

圣迭戈——一项大型Meta分析显示，接受闭合式小室结构支架颈动脉置入术(CAS)者的30天围手术期结局不劣于接受颈动脉内膜切除术(CEA)的患者。但后者的30天围手术期结局显著优于接受开放式小室结构支架CAS的患者。


Mohammed Almekhlafi博士
 
“很多随机临床试验和Meta分析一致显示，接受支架置入者的围手术期卒中风险高于接受CEA的患者，”卡尔加里大学的Mohammed A. Almekhlafi博士在神经介入外科学会年会上说。“围手术期神经事件的决定因素之一为支架的设计。与未覆盖间隙较大的开放式小室结构支架相比，闭合结构支架支杆之间的无小室区域较小，理论上可提供更好的血管壁支撑和更优的斑块稳定作用。”

Almekhlafi及其同事将支架结构设计方式分为闭合式(即所有支杆都相互连接)或开放式(即并非所有支杆都相互连接)两种。主要终点指标为30天卒中或死亡复合终点。最终分析纳入了来自9项随机临床试验的4,949例患者。其中，807例接受闭合式支架CAS，1,657例接受开放式支架CAS操作，2,485例接受CEA。

结果显示，CEA组的主要终点发生率显著低于开放式结构支架CAS组[危险比(OR)为1.84，P=0.003]。CEA组的主要终点发生率也低于闭合式结构支架CAS组，但差异无统计学意义(OR=1.54，P=0.29)。如果针对30天围手术期卒中风险进行分析，CEA组与闭合式结构支架CAS组的预后仍无统计学差异(OR=2.92，P=0.22)。但开放式结构支架CAS组的30天围手术期卒中风险仍显著高于CEA组(OR=1.97，P=0.0007)。

Almekhlafi博士披露无相关利益冲突。

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By: DOUG BRUNK, Cardiology News Digital Network
 
SAN DIEGO – The 30-day periprocedural outcomes in patients who underwent carotid artery stenting with closed-cell design stents were not significantly inferior to outcomes of those treated with carotid endarterectomy, a large meta-analysis demonstrated.

However, patients who underwent carotid endarterectomy (CEA) had significantly better 30-day periprocedural outcomes, compared with those who underwent carotid artery stenting (CAS) with open-cell design stents.
     
"A number of randomized clinical trials and meta-analyses have consistently showed the higher risk of periprocedural stroke in patients undergoing stenting when compared to endarterectomy," Dr. Mohammed A. Almekhlafi said at the annual meeting of the Society of Neurointerventional Surgery. "One of the factors that has been implicated as a determinant of periprocedural neurological events is the stent cell design. The small free-cell area between the struts of a closed-cell stent theoretically provides better scaffolding of the vessel wall and superior plaque stabilization compared to the larger uncovered gaps in open-cell stents."

Dr. Almekhlafi, an interventional neurology fellow at the University of Calgary (Alta.), and his associates set out to investigate the impact of stent cell design on the outcome of randomized controlled trials comparing CAS vs. CEA. The stent cell design was divided into closed (meaning all stent struts are interconnected) or open (meaning not all stent-struts are interconnected). The primary outcome was a composite of the 30-day risk of stroke or death.

The final analysis included 4,949 patients from nine randomized clinical trials. Of these, 807 underwent CAS with closed-cell stenting, 1,657 underwent CAS with open-cell stenting, and 2,485 underwent CEA.

Dr. Almekhlafi reported that the primary outcome was significantly lower among patients in the CEA arm, compared with those in the CAS open-cell design arm (odds ratio, 1.84; P = .003). The primary outcome was lower among patients in the CEA arm, compared with those in the CAS closed-cell design arm, although this difference did not reach statistical significance (OR, 1.54; P = .29).

When the researchers limited their analysis to risk of 30-day periprocedural stroke, this outcome remained nonsignificant among patients in the CEA arm, compared with those in the CAS closed-cell design arm (OR 2.92; P = .22). However, the risk of 30-day periprocedural stroke remained significantly higher among patients in the CAS open-cell design arm, compared with those in the CEA arm (OR, 1.97; P = .0007).

"Uncertainty still exists regarding the impact of stent characteristics on CAS outcome," Dr. Almekhlafi said. "The size of the emboli might also be relevant."

He acknowledged certain limitations of the study, including the fact that trials included in this analysis did not randomize patients to open vs. closed stents, and that trials using the closed-design stents recruited fewer patients than did those using open-cell stents.

Dr. Almekhlafi said that he had no relevant financial disclosures to make.