脑血管病血管支架成形术研究 进展武汉大学中南医院神经科 刘煜敏有关症状性颈动脉狭窄CEA的三个大型实验 NASCETECST the Veterans Affairs Cooperative Study Program.CEA的困境cranial or superficial nerve injuryrisk of a strokesmall risk of myocardial infarctionanaesthesia, increasing the potential for complications.feeExtracranial-intracranial (EC/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 surgery are ongoing.血管内治疗技术的优越性To avoid surgical incision.To require only local anaesthetic.Less cost because of a shorter hospital stay。Less MIWallstent TrialRandomized 219 symptomatic patients with 60% to 90% stenosis to CEA or CAS.without distal protection and currently accepted antiplatelet 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. Alberts MJ, Stroke. 2001;32:325.SAPPHIREThe 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- surgical risk endarterectomy.Yadav JS, et al. N Engl J Med. 2004;351:1493CAVATAS504 例，251例行血管内治疗，253行外 科治疗。55 (26%) 使用了支架，158 (74%)仅适 用球囊。独立的神经科医生随访病人. Lancet 2001; 357: 172937only 26% received stents.183 Major outcome events within 30 days did not differ between endovascular treatment and surgery 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 characteristicsOutcome events within 30 days after first treatmentConclusionEndovascular 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 complications.CRESTThe primary objective is to compare theefficacy of CAS versus CEA in preventing stroke over afollow-up period of up to 4 years. Other randomized trials areongoing 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 before we can advocate the widespread use of angioplasty plus stent as routine care for patients with extracranial arotid stenosis.