颈动脉内膜切除术(CEA)后哪种类型的闭合,无论是主要的,修补,或者外翻,将提供最优结果一直存在争议。在本研究中,我们比较了各种封堵类型的随机对照试验(RCTs)和系统荟萃分析的结果.
我们进行了PubMed文献综述搜索,以寻找将CEA与主要闭合进行比较的研究,带有修补功能的CEA,和/或外翻CEA(ECEA)在过去的三十年中,重点是RCT,先前报道的系统荟萃分析,大型多中心观察性研究(血管质量倡议数据),以及最近的单中心大型研究。
比较初级修补与初级闭合的RCT结果如下。大多数随机试验显示,在降低围手术期卒中发生率方面,CEA+修补优于CEA+初次闭合。中风和死亡率,颈动脉血栓形成率,和晚期再狭窄率。这些研究还表明,几种贴片材料的优先使用没有显着差异,包括合成贴片(聚对苯二甲酸乙二醇酯[Dacron;杜邦,威尔明顿,德尔],Acuseal[戈尔医疗用品,弗拉格斯塔夫,Ariz],聚四氟乙烯,或心包斑块)和静脉斑块(隐或颈静脉)。比较修补与初次闭合的观察性研究结果如下。新英格兰血管研究小组的数据显示,修补的使用从71%增加到91%(P<0.001)。此外,1年再狭窄和闭塞(P<.01)以及1年卒中和短暂性脑缺血发作(P<.03)发生率在补片闭合时显著较低.比较ECEA与常规CEA(CCEA)的RCT结果如下。将ECEA与CCEA进行比较的几个RCT显示,在围手术期颈动脉血栓形成和中风发生率方面,CCEA与ECEA的等效性(1级证据)。治疗后4年,ECEA的颈动脉狭窄发生率低于初次闭合(3.6%vs9.2%;P=.01),但修补和外翻的发生率相当(修补1.5%vs外翻2.8%).
常规颈动脉修补或ECEA优于初次闭合(1级证据)。我们发现几种贴片材料的优先使用之间没有显着差异。经修补的CEA的显著CEA后狭窄率与ECEA相似,两者都优于初级封闭。
Which type of closure after carotid endarterectomy (CEA), whether primary, patching, or eversion, will provide the optimal results has remained controversial. In the present study, we compared the results of randomized controlled trials (RCTs) and systematic meta-analyses of the various types of closure.
We conducted a PubMed literature
review search to find studies that had compared CEA with primary closure, CEA with patching, and/or eversion CEA (ECEA) during the previous three decades with an emphasis on RCTs, previously reported systematic meta-analyses, large multicenter observational studies (Vascular Quality Initiative data), and recent single-center large studies.
The results from RCTs comparing primary patching vs primary closure were as follows. Most of the randomized trials showed CEA with patching was superior to CEA with primary closure in lowering the perioperative stroke rates, stroke and death rates, carotid thrombosis rates, and late restenosis rates. These studies also showed no significant differences between the preferential use of several patch materials, including synthetic patches (polyethylene terephthalate [Dacron; DuPont, Wilmington, Del], Acuseal [Gore Medical, Flagstaff, Ariz], polytetrafluoroethylene, or pericardial patches) and vein patches (saphenous or jugular). The results from observational studies comparing patching vs primary closure were as follows. The Vascular Study Group of New England data showed that the use of patching increased from 71% to 91% (P < .001). Also, the 1-year restenosis and occlusion (P < .01) and 1-year stroke and transient ischemic attack (P < .03) rates were significantly lower statistically with patch closure. The results from the RCTs comparing ECEA vs conventional CEA (CCEA) were as follows. Several RCTs that had compared ECEA with CCEA showed equivalency of CCEA vs ECEA (level 1 evidence) with patching in the perioperative carotid thrombosis and stroke rates. At 4 years after treatment, the incidence of carotid stenosis was lower for ECEA than for primary closure (3.6% vs 9.2%; P = .01) but was comparable between patching and eversion (1.5% for patching vs 2.8% for eversion).
Routine carotid patching or ECEA was superior to primary closure (level 1 evidence). We found no significant differences between the preferential use of several patch materials. The rates of significant post-CEA stenosis for CEA with patching was similar to that with ECEA, and both were superior to primary closure.