Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials

被引：19

作者：

Fisch, Urs ^{[1
,2
]}

von Felten, Stefanie ^{[3
,4
]}

Wiencierz, Andrea ^{[3
]}

Jansen, Olav ^{[5
]}

Howard, George ^{[6
]}

Hendrikse, Jeroen ^{[7
]}

Halliday, Alison ^{[8
]}

Fraedrich, Gustav ^{[9
]}

Eckstein, Hans-Henning ^{[10
]}

Calvet, David ^{[11
]}

Bulbulia, Richard ^{[12
,13
]}

Becquemin, Jean-Pierre ^{[14
]}

Algra, Ale ^{[15
,16
]}

Rothwell, Peter ^{[17
,18
]}

Ringleb, Peter ^{[19
]}

Mas, Jean-Louis ^{[11
]}

Brown, Martin M. ^{[20
]}

Brott, Thomas G. ^{[21
]}

Bonati, Leo H. ^{[1
,2
,20
]}

机构：

[1] Univ Basel, Dept Neurol, Univ Hosp, Basel, Switzerland

[2] Univ Basel, Stroke Ctr, Univ Hosp, Dept Clin Res, Basel, Switzerland

[3] Univ Basel, Dept Clin Res, Clin Trial Unit, Basel, Switzerland

[4] Univ Zurich, Biostat & Prevent Inst, Dept Biostat Epidemiol, Zurich, Switzerland

[5] Univ Hosp Schleswig Holstein, Clin Radiol & Neuroradiol, Campus Kiel, Kiel, Germany

[6] Univ Alabama Birmingham, UAB Sch Publ Hlth, Dept Biostat, Birmingham, AL USA

[7] Univ Utrecht, Univ Med Ctr Utrecht, Dept Radiol, Utrecht, Netherlands

[8] Univ Oxford, Nuffield Dept Surg, Oxford, England

[9] Med Univ Innsbruck, Dept Vasc Surg, Innsbruck, Austria

[10] Tech Univ Munich, Klinikum Rechts Isar, Surg Vasc Ctr, Dept Vasc & Endovasc, Munich, Germany

[11] Univ Paris 05, Hop St Anne, DHU Neurovasc Sorbonne Paris Cite, Dept Neurol,INSERM U894, Paris, France

[12] Univ Oxford, Nuffield Dept Populat Hlth, Clin Trial Serv Unit, Populat Hlth Res Unit, Oxford, England

[13] Univ Oxford, Nuffield Dept Populat Hlth, Epidemiol Studies Unit, Oxford, England

[14] Hosp Paul D Egine, Vasc Inst Paris East, Champigny Sur Marne, France

[15] Univ Utrecht, Univ Med Ctr Utrecht, UMC Utrecht Brain Ctr, Dept Neurol & Neurosurg, Utrecht, Netherlands

[16] Univ Utrecht, Univ Med Ctr Utrecht, Julius Ctr Hlth Sci & Primary Care, Utrecht, Netherlands

[17] John Radcliffe Hosp, Nuffield Dept Clin Neurosci, Ctr Prevent Stroke & Dementia, Oxford, England

[18] Univ Oxford, Oxford, England

[19] Heidelberg Univ, Sch Med, Dept Neurol, Heidelberg, Germany

[20] UCL, Ctr Stroke Res, UCL Queen Sq Inst Neurol, Dept Brain Repair & Rehabil, London, England

[21] Mayo Clin, Dept Neurol, Jacksonville, FL 32224 USA

来源：

EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY | 2021年 / 61卷 / 06期

基金：

瑞士国家科学基金会; 美国国家卫生研究院;

关键词：

Endarterectomy; Ischaemic stroke; Medical treatment; Revascularisation; Stenosis; Stent; TRANSIENT ISCHEMIC ATTACK; EARLY RECURRENT STROKE; ENDARTERECTOMY;

D O I：

10.1016/j.ejvs.2021.02.024

中图分类号：

R61 [外科手术学];

学科分类号：

摘要：

Objective: Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed. Methods: The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation. Results: A total of 4 754 patients from recent trials and 1227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (chi(2) = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019). Conclusion: Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.

引用

页码：881 / 887

页数：7

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