1、腦血管病血管支架成形術研究進展,武漢大學中南醫(yī)院神經(jīng)科 劉煜敏,有關癥狀性頸動脈狹窄CEA的三個大型實驗,NASCET ECST the Veterans Affairs Cooperative Study Program.,CEA的困境 cranial or superficial nerve injury risk of a stroke small risk of myocardial infarction anaesthesia, increasing the potential for complications. fee,Extracranial-intracranial (EC/

2、IC) bypass surgery was not found to provide any benefit for patients with carotid occlusion or those with carotid artery narrowing distal to the carotid bifurcation.176 New efforts using more sensitive imaging to select patients with the greatest hemodynamic compromise for RCTs using EC/IC bypass su

3、rgery are ongoing.,血管內(nèi)治療技術的優(yōu)越性,To avoid surgical incision. To require only local anaesthetic. Less cost because of a shorter hospital stay。 Less MI,Wallstent Trial,Randomized 219 symptomatic patients with 60% to 90% stenosis to CEA or CAS. without distal protection and currently accepted antiplatele

4、t prophylaxis. Study design allowed operators with limited experience to participate. The risk of perioperative stroke or death was 4.5% for CEA and 12.1% for CAS, and the risk of major stroke or death at 1 year was 0.9% for CEA and 3.7% for CAS. The trial was halted because of poor results from CAS

5、.,Alberts MJ, Stroke. 2001;32:325.,SAPPHIRE,The primary end point of the study occurred in 20 stent patients and 32 endarterectomy patients (30-day risk, 5.8% versus 12.6%; P=0.004 for noninferiority). Most of the benefit was detected in the lower risk of MI for the stent compared with the high-surg

6、ical risk endarterectomy.,Yadav JS, et al. N Engl J Med. 2004;351:1493,CAVATAS,504 例，251例行血管內(nèi)治療，253行外科治療。 55 (26%) 使用了支架，158 (74%)僅適用球囊。 獨立的神經(jīng)科醫(yī)生隨訪病人.,Lancet 2001; 357: 172937,only 26% received stents. 183 Major outcome events within 30 days did not differ between endovascular treatment and surgery

7、groups。 with a 30-day risk of stroke or death of 10.0% and 9.9%, respectively. Despite the increased risk of severe ipsilateral carotid stenosis in the endovascular group at 1 year, no substantial difference in the rate of ipsilateral stroke was noted up to 3 years after randomization.,Baseline char

8、acteristics,Outcome events within 30 days after first treatment,Conclusion,Endovascular treatment had similar major risks and effectiveness at prevention of stroke during 3 years compared with carotid surgery, but with wide CIs. Endovascular treatment had the advantage of avoiding minor complication

9、s.,CREST,The primary objective is to compare the efficacy of CAS versus CEA in preventing stroke over a follow-up period of up to 4 years. Other randomized trials are ongoing in Europe and Australia.,CAS has been used in selected patients : in whom stenosis is difficult to access surgically, medical conditions that greatly increase the risk for surgery are present, or other specific circumstances exist such as radiation-induced stenosis or restenosis after CEA. after arterial dissection, fibromuscular hyperplasia, or Takayasus arteritis. More definitive evidence is needed befo