老年患者：颈动脉内膜切除术与支架术孰优孰劣尚无定论

《美国医学会杂志·外科学》(JAMA Surgery)10月23日在线发表的一项荟萃分析显示，在颈动脉疾病老年患者中，与颈动脉支架置入术相比，颈动脉内膜切除术的围手术期卒中或短暂性脑缺血发作(TIA)风险较低，围手术期心肌梗死(MI)风险相同，围手术期死亡风险稍高。然而，个体老年患者的血管解剖结构对于围手术期风险的确定具有关键作用，同样，其总体健康和临床特征对于风险的确定也至关重要(JAMA Surg. 2013 Oct. 23 [doi:10.1001/jamasurg.2013.4135])。

由于对于何种治疗最适合颈动脉疾病老年患者仍存较大争议，雅典希腊红十字医院血管外科的George A. Antoniou医生及其同事对1986年以来发表的医学文献进行了全面评价，并对44项直接比较老年患者和年轻患者行颈动脉内膜切除术(39项研究)或颈动脉支架置入术(18项研究)后的转归的研究进行荟萃分析。

 “老年”在大部分研究中被定义为80岁以上，在许多研究中被定义为75岁以上，但不同研究对“老年”的定义存在较大差异，一些研究甚至认为“65岁以上”就是老年。

总体而言，该荟萃分析纳入的动脉内膜切除术例数为：老年患者269,596例 vs. 年轻患者243,089例；颈动脉支架置入术例数为：老年患者38,751例 vs. 年轻患者36,450例。

对于动脉内膜切除术，老年患者的围手术期卒中率(0.9% vs. 1.2%)和TIA率(1.9% vs 1.8%)均与年轻患者无显著差异。然而，老年患者的围手术期死亡率显著高于年轻患者(0.5% vs. 0.4%)。

相比之下，对于颈动脉支架置入术，老年患者的围手术期卒中率(2.4% vs. 1.7%)和TIA率(3.6% vs 2.1%)均显著高于年轻患者。老年患者的死亡率与年轻患者无显著差异(0.6% vs. 0.7%)。

在老年患者中观察到的与这两种手术相关的围手术期MI率均高于在年轻患者中观察到的发生率：进行动脉内膜切除术的老年患者和年轻患者的围手术期MI率分别为2.2%和1.4%；进行颈动脉支架置入术的老年患者和年轻患者的围手术期MI率分别为2.3%和1.5%。这些结果在敏感性分析中仍具有鲁棒性。

研究者表示，在老年患者中，动脉内膜切除术的神经系统转归优于颈动脉支架置入术，不过前者的围手术期死亡率较高，但也仅比后者的围手术期死亡率高0.1%而已，不具有临床意义。

此外，神经系统风险与血管解剖结构密切相关。老年患者的解剖结构往往比年轻患者差，但应基于个体情况评估这点。不良的解剖特征包括主动脉上分支严重钙化和弯曲，以及不良的主动脉弓形态，如变长、变形和狭窄。在这些解剖特征中操作支架本身就可能增加神经系统后遗症的风险。此外，还增加了技术操作难度，从而增加内皮损伤、血栓脱出和血栓栓塞事件的风险。

另外，患有颅外动脉粥样硬化性疾病的老年患者也可能存在脑血管储备功能损害的情况，这使他们更易于发生脑微栓塞所致的缺血事件。研究者声明无经济利益冲突。

随刊述评：定义“老年”

纽约奥尔巴尼血管组的R. Clement Darling III医生表示，该研究的结论并不令人惊讶，因为大部分临床医生在随机前瞻性研究和自身临床实践中均观察到这些结果。然而，该荟萃分析中不同研究对“老年”的定义存在较大差异：64%的研究采用80岁作为临界值，31%采用75岁作为临界值，一些研究采用70岁或甚至65岁作为临界值。底线是，在年轻患者中，在专家操作的情况下，颈动脉内膜切除术和颈动脉支架置入术的效果一样好。然而，在“老年”(任何年龄)患者中，动脉内膜切除术的转归更佳，其发病率、死亡率和卒中发生率均较低，因此仍是标准治疗。Darling医生声明无经济利益冲突(JAMA Surgery 2013 Oct. 23 [doi:10.1001/jamasurg.2013.4160 ])。

爱思唯尔版权所有  未经授权请勿转载

By: MARY ANN MOON, Cardiology News Digital Network

For elderly patients with carotid disease, carotid endarterectomy carries a lower risk of perioperative stroke or transient ischemic attack, the same risk of perioperative MI, and a slightly higher risk of perioperative death compared with carotid stenting, according to a meta-analysis. The results were published online Oct. 23 in JAMA Surgery.

However, the individual elderly patient’s vascular anatomy plays a crucial role in determining perioperative risk, as does his or her overall health and clinical profile.

"The results of [our] analysis suggest that careful consideration of a constellation of clinical and anatomic factors is required before an appropriate treatment of carotid disease in elderly patients is selected. The cardiovascular disease burden and general health of the individual patient should be meticulously evaluated before interventional instead of optimal medical treatment is applied," said Dr. George A. Antoniou of the department of vascular surgery, Hellenic Red Cross Hospital, Athens, and his associates.

Which treatment is the most appropriate for elderly patients with carotid disease is still much debated. Dr. Antoniou and his colleagues performed a comprehensive review of the medical literature since 1986 and a meta-analysis of 44 articles that directly compared outcomes in elderly patients with those of younger patients after carotid endarterectomy (39 studies) or carotid stenting (18 articles).

"Elderly" was defined as older than 80 years in most of these studies, and as older than 75 years in many, but there was great variability among the studies, and some even considered "older than 65 years" to be elderly.

Overall, the meta-analysis included 269,596 endarterectomies in elderly patients against 243,089 in younger patients, and 38,751 carotid stenting procedures in elderly patients against 36,450 in younger patients.

For endarterectomy, the rate of perioperative stroke was not significantly different between elderly (0.9%) and younger (1.2%) patients, nor was the rate of TIA (1.9% vs 1.8%, respectively). However, perioperative mortality was significantly higher in elderly (0.5%) than in younger (0.4%) patients.

In contrast, for carotid stenting, the rate of perioperative stroke was significantly higher for elderly patients (2.4%) than for younger patients (1.7%), as was the rate of TIA (3.6% vs 2.1%). And mortality was not significantly different between elderly patients (0.6%) and younger patients (0.7%), the researchers wrote (JAMA Surg. 2013 Oct. 23 [doi:10.1001/jamasurg.2013.4135]).

Both procedures were associated with an increased rate of perioperative MI in elderly patients, compared with younger patients. These rates were 2.2% in elderly patients, compared with 1.4% in younger patients undergoing endarterectomy; and 2.3% in elderly patients, compared with 1.5% in younger patients undergoing carotid stenting.

These findings remained robust in sensitivity analyses.

"It seems that endarterectomy is associated with improved neurologic outcomes compared with carotid stenting in elderly patients, at the expense of increased perioperative mortality." However, the small increase in mortality seen with endarterectomy – one-tenth of 1% – may not be clinically significant, Dr. Antoniou and his associates said.

Moreover, neurologic risk is closely tied to vascular anatomy. Elderly patients tend to have more unfavorable anatomy than do younger patients, but should be assessed on an individual basis. Unfavorable traits include heavily calcified and tortuous supra-aortic branches, as well as adverse morphology of the aortic arch such as elongation, distortion, and stenosis.

Manipulating the stenting instruments through such features may in itself raise the risk of neurologic sequelae. It also makes the procedure more technically difficult, which increases the risk of endothelial trauma, thrombus dislodgement, and thromboembolic events.

"In addition, elderly patients with significant extracranial atherosclerotic disease are likely to have a compromised cerebrovascular reserve, which makes them more susceptible to ischemic events from cerebral microembolization," the researchers said.

No financial conflicts of interest were disclosed.

View on the News
Define 'elderly'

This study’s conclusions are not surprising, given that most clinicians have already seen them both in randomized prospective studies and in their own practices, said Dr. R. Clement Darling III.

However, the variation in the definition of "elderly" among the trials in this meta-analysis is a real concern: Sixty-four percent used 80 years as the cutoff, 31% used 75 years, and some used 70 or even 65 years as the cutoff.

"The bottom line is, carotid endarterectomy and carotid stenting seem to work equally well in younger patients, in expert hands. However, in the ‘elderly’ (at any age), endarterectomy has better outcomes with low morbidity, mortality, and stroke rate,’ and it remains the standard of care, he said.

Dr. Darling, of the Vascular Group, Albany, N.Y., made these remarks in an invited commentary (JAMA Surgery 2013 Oct. 23 [doi:10.1001/jamasurg.2013.4160]). He reported no financial conflicts of interest.