颈动脉合并冠脉疾病：支架置入序贯心脏手术是最佳方案

《美国心脏病学会杂志-心血管介入》7月31日在线发表的一项回顾性研究在合并重度颈动脉疾病的冠状动脉疾病患者中比较了3种治疗方案：颈动脉支架置入术(CAS)继以开放性心脏手术(OHS)分期方案(下文简称为CAS-OHS分期方案)、颈动脉内膜切除手术(CEA)和开放性心脏手术(OHS)同步方案(简称CEA-OHS同步方案)、以及颈动脉内膜切除手术(CEA)继以开放性心脏手术(OHS)分期方案(简称CEA-OHS分期方案)。

结果显示，CAS-OHS分期方案的短期转归与CEA-OHS同步方案相似。然而，1年后，CAS-OHS分期方案的转归较佳，主要复合终点事件(死亡、卒中或心肌梗死)的风险显著较低。CEA-OHS分期方案的转归为3种方案中最差，其期间(手术与手术之间的)MI风险显著，因此应尽量避免使用该方案(J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.03.094])。


Mehdi Shishehbor医生

在这项研究中，克利夫兰医院米勒家庭心脏和血管研究所血管内服务部主任Mehdi H. Shishehbor医生及其同事在1997年至2009年间从克利夫兰医院纳入350例符合OHS手术条件、在OHS 90天内进行颈动脉血运重建的重度颈动脉狭窄患者：45例接受CEA-OHS分期方案治疗，195例接受CEA-OHS同步方案治疗，110例接受CAS-OHS分期方案治疗。大部分OHS手术为冠状动脉旁路移植术。

研究者分析发现，CAS-OHS分期方案组和CEA-OHS同步方案组短期内的主要复合终点事件发生率相似，但CAS-OHS分期方案组的MI发生率较高(大部分MI在手术间期发生)，而CEA-OHS同步方案组的术前卒中发生率较高。在3种方案中，CEA-OHS分期方案组的短期转归最差，因为该组的期间MI风险显著较高。

1年后，CAS-OHS分期方案组的复合终点事件风险显著低于另外2组：比CEA-OHS同步方案组低65%，比CAS-OHS分期方案组低67%。两个CEA组1年后的复合终点事件风险相似。3组的1年后死亡率相似。

研究者表示，虽然CAS-OHS分期方案与CEA-OHS同步方案的早期复合终点事件风险相似，但前者的期间MI风险较高，而后者的术前卒中风险较高，因此在这两者之间做取舍时需考虑这些重要方面。

该研究表明，如果临床上可以接受3至4周的手术与手术之间的等待期，那么CAS-OHS分期方案应该是治疗合并重度颈动脉疾病的冠状动脉疾病患者的一线治疗方案。虽然目前尚无随机试验确定哪种方案才是最佳治疗方案，但该研究结果足以改变目前的临床实践。

事实上，该研究结果已促使克利夫兰医院改变对合并重度颈动脉疾病的冠状动脉疾病患者的管理方式，该医院目前正通过多学科合作方式为每例患者确定风险最低的治疗方案。

CAS-OHS分期治疗在在该研究的合并重度颈动脉疾病的冠状动脉疾病患者中的应用率为31%，但在目前美国临床上的此类患者中的应用率仅为3%。

随刊述评：研究结果具有阐明意义

加州大学圣地亚哥分校Sulpizio心血管中心心血管内科的Ehtisham Mahmud医生和Ryan Reeves医生表示，虽然该研究为回顾性研究，但其阐明了对需要OHS的颈动脉和冠状动脉疾病患者的管理。

急性冠状动脉综合征患者需紧急冠脉血运重建，3~4周的手术等待期对他们而言不安全，对于这类患者，CEA-OHS同步方案是最佳的血运重建方案，不过该方案可导致神经系统缺血性事件增加。对于可在颈动脉支架置入术后等待3至4周才完成双重抗血小板治疗的稳定型或加速型心绞痛综合征患者，使用CAS-OHS分期方案可获得优异的早期和远期转归。由于CEA-OHS分期方案的短期(期间MI)和长期(死亡)风险较高，因此应避免使用该方案。

Mahmud医生与波士顿科学和雅培血管等多家公司存在利益关系。Reeves医生声明无经济利益冲突(J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.07.011])。

爱思唯尔版权所有  未经授权请勿转载

By: ELIZABETH MECHCATIE, Cardiology News Digital Network

Short-term outcomes after carotid artery stenting followed by open heart surgery were comparable with those after carotid endarterectomy and open heart surgery performed at the same time, in a retrospective study that compared three approaches with treating patients who had both severe carotid artery disease and coronary artery disease.

However, after 1 year, staged carotid artery stenting and open heart surgery (CAS-OHS) "appears to be a better choice," with a significantly lower risk in the primary composite endpoint of death, stroke, or myocardial infarction, reported Dr. Mehdi H. Shishehbor and his coauthors (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.03.094]).

The primary composite endpoint after undergoing CAS-OHS or combined carotid endarterectomy and OHS (CEA-OHS) were similar in both groups.

The third approach studied was carotid endarterectomy (CEA) followed by open heart surgery (staged CEA-OHS), which had the least favorable outcomes of all three approaches, with a "substantial risk of interstage MI," they reported. This approach, therefore, "should be avoided if possible," they concluded in the studywhich was published online on July 31, in the Journal of the American College of Cardiology Cardiovascular Interventions. Dr. Shishehbor is director of endovascular services in the Miller Family Heart and Vascular Institute at the Cleveland Clinic.

The study evaluated outcomes among 350 patients with severe carotid artery stenosis and were candidates for OHS, who underwent carotid revascularization within 90 days of having open heart surgery, at the Cleveland Clinic from 1997 to 2009: 45 had staged CEA-OHS, 195 had combined CEA-OHS, and 110 has staged CAS-OHS. Most of the open heart surgeries were coronary artery bypass grafting procedures.

Based on their analyses, they determined that in the short term, the composite endpoint was similar between those in the staged CAS-OHS group and those in the combined CEA-OHS group – although those in the CAS-OHS group had more MIs, most of which were between the procedures, and those in the combined CEA-OHS group has more perioperative strokes.

Of all three approaches, short-term outcomes were worse in the staged CEA-OHS group, because of the significantly higher risk of interstage MIs.

After 1 year, those in the staged CAS-OHS group had a significantly lower risk of the composite outcomes, compared with the other two groups: a 65% lower risk, compared with those in the combined CEA-OHS group; and a 67% lower risk, compared with those in the staged CAS-OHS group. The risk in the composite outcomes after 1 year in the two CEA groups was similar. Mortality after 1 year was similar in the three groups.

"In choosing between staged CAS-OHS and combined CEA-OHS, the increased risk of interstage MI with the former and perioperative stroke with the latter are important considerations despite similar risks for the early composite endpoint," the authors noted.

"Our study shows that carotid stenting followed by open heart surgery should be the first line strategy for treating patients with severe carotid and coronary disease, if the three- to four-week wait between procedures is clinically acceptable," Dr. Shishehbor said in a statement issued by the Cleveland Clinic. Although there has never been a randomized trial to determine what the best approach is for the types of patients in the study, "the evidence in this study may be enough to change practice," he added.

In fact, as a result of the study findings, changes are being made to the way patients with severe carotid and coronary artery disease are being managed at the Cleveland Clinic, and "we are collaborating across disciplines to identify the lowest risk treatment option for each patient," he added.

In the United States, currently, only 3% of patients with severe carotid and coronary artery disease are treated with staged carotid stenting followed by open heart surgery – compared with 31% of the patients in this study, the statement points out.

View on the News
Study provides clarity

Although it was retrospective, "this study provides clarity in the management of patients with carotid and coronary disease requiring OHS," Dr. Mahmud and Dr. Reeves wrote in an accompanying editorial (J. Am. Coll. Cardiol. 2013 [doi:10.1016/j.jacc.2013.07.011]).

Combined CEA-OHS is the optimum revascularization strategy for "patients presenting with an acute coronary syndrome requiring urgent coronary revascularization in whom waiting 3-4 weeks is not safe," although is it associated with more neurological ischemic events.

"However, for patients with a stable or an accelerating anginal syndrome who can wait 3-4 weeks to complete dual-antiplatelet therapy after carotid stenting, staged CAS followed by OHS leads to superior early and long term outcomes," they wrote.

Staged CEA followed by OHS should be avoided, as it "is associated with an increased short term (inter-stage myocardial infarction) and long term (mortality) hazard."

The study, they added, "suggests that the currently acceptable option of CEA prior to OHS actually endangers the patient leading to the highest ischemic event rate both early and late after OHS. These patients should either undergo combined CEA-OHS or be offered the option of CAS prior to OHS based on medical criteria, not reimbursement issues."

Dr. Ehtisham Mahmud and Dr. Ryan Reeves, of the division of cardiovascular medicine and the Sulpizio Cardiovascular Center, at the University of California, San Diego. Dr. Mahmud, chief of cardiovascular medicine at the center, disclosed potential conflicts of interest for Boston Scientific and Abbott Vascular (clinical trial research support), Cordis Corporation and Medicines Company (consulting), and Medtronic (speakers bureau). Dr. Reeves listed no disclosures.