颈动脉血管成形术和颈动脉内膜切除术治疗颈动脉狭窄疗效比较：meta分析
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摘要
本文采用Meta分析对多篇关于颈动脉狭窄治疗方法进行分析,最终纳入10项关于颈动脉狭窄介入治疗及内膜切除术两种治疗方法的随机对照研究。通过固定效应模型研究显示：颈动脉内膜切除术的卒中,死亡或卒中的发生率低于介入治疗；严重并发症死亡或致残性卒中两者之间没有显著统计意义；但是心肌梗塞、神经损伤的发生率高于介入治疗。利用随机效应模型进行分析显示：除介入治疗的颅神经损伤发生率低于内膜切除术外,其余卒中,死亡或卒中,死亡及致残性卒中,心肌梗塞,死亡、卒中或心肌梗塞,长期预后卒中或死亡等治疗结果评估指标两者之间无显著统计学意义。同时分析了试验中栓塞保护装置的应用对介入治疗并发症的影响,显示：栓塞保护装置能够有效降低卒中或死亡的发生率,具有显著统计学意义。
Background and Purpose
Stroke is the second or third leading cause of death and the first leading cause of adult disability in all the world. Stenosis of the carotid artery constitutes a major risk factor for ischaemic stroke, especially in patients with symptomatic stenosis (recent transient ischaemic attacks, et al). However, the severity of carotid artery stenosis highly predicts risk of ipsilateral ischemic stroke.The annual risk of ipsilateral stroke doubles from 0.5% for internal carotid artery (ICA) stenosis of b50% to 1% for ICA stenosis of 50%-99%.
Large randomized trials have convincingly shown that carotid endarterectomy have greater benefit than medical therapies alone, can significantly reduces the longterm risk of subsequent stroke from severe carotid artery stenosis.. These large, randomized, prospective trials, including the North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trial (ECST), Asymptomatic Carotid Atherosclerotic Study (ACAS), and Asymptomatic Carotid Surgery Trial (ACST). Carotid endarterectomy has been regarded as the gold standard for revascularization of severe carotid artery stenosis, and considered the first one in clinical decision-making. But surgery also have disadvantages, such as:requiring an incision in the neck, performed under general anaesthesia and its complications such as myocardial infarction and pulmonary embolism.
Since 1990 year, Angioplasty and carotid artery stenting have been suggested as an alternative to carotid endarterectomy for revascularization of carotid artery stenosis, especially for carotid artery restenosis and in patients with high-surgical risk. Before 2005, there were more than 20 published case-series carotid Angioplasty studies involving a total of more than 24,000 patients,about half of patients were symptomatic carotid artery stenosis(51%), and 30-day stroke or death rates were 2% to 7%. Since embolic protection devices were introduced for use during carotid Angioplasty, stroke and death rate within 30 days in both symptomatic and asymptomatic patients was reduced to 1.8%, rather than 5.5% in patients treated without embolic protection devices. Endovascular treatment is usually performed via a femoral catheter, avoiding an incision in the neck and subsequent cranial and cutaneous nerve damage, and without general anesthesia and its complications.
However, endovascular techniques also carries a risk of stroke and local complications. As a consequence, before endovascular treatment can be considered as a genuine alternative to surgery, it must be shown to be as safe and effective as surgery. Between 1998 and 2010,11 randomized studies comparing endovascular treatment of the carotid artery with surgery, there were 10 studies out come or part of the date have published, those studies include The CAVATAS trial, The Leicester trial, The Schneider Wall Stent trial, Kentucky A, Kentucky B, The CREST trial, The EVA 3S study, The Sapphire trial, The SPACE trial, The ICSS trial, The TESCAS-C trial and CREST Trial.
This article reviews all randomized trials comparing endovascular treatment of the carotid artery with surgery by a meta-analysis,To evaluate the safety and efficacy of endovascular techniques.
Materials and Methods
Search Strategy
Bibliographic databases selection
①MEDLINE (http://isiknowledge.com/medline);
②Elsevier Science (http://www.sciencedirect.com/);
③PubMed (http://www.ncbi.nlm.nih.gov/pubmed/)
④The Excerpta Medica Database, EMBASE;
⑤China National Knowledge Infrastructure, CNKI.
Search terms
Search terms included "carotid", "stenosis", "endarterectomy", "endovascular", "angioplasty", and "stenting", in various combinations.
Study selection
The search was limited to articles published date to 2010.01.01;
randomized trials of carotid endovascular treatment compared with carotid endarterectomy;
patients of any age or sex;
symptomaticor asymptomatic carotid arterystenosis.
Data extraction
The outcome events extracted from each study included, if available:any stroke (disabling or nondisabling) or death, cranial neuro damage, myocardial infarction within 30 days of procedure and any stroke or death within 1 year of procedure.
Strokes were classified if possible as fatal, disabling (requiring help with activities of daily living for>1 month after onset) or nondisabling (symptoms lasted>7 days but patient was independent at 30 days).
Meta analysis
Results were reported as percentages as well as odds ratios (ORs). ORs were calculated using the Peto fixed-effect method or (and) free-sffect method. Heterogeneity between trial results was tested for using a standardχ2 test.
Results
There are 10 trials, including 4872patients, Symptomatic carotid stenosis 4533 patients (93% in all). Meta-analysis using both random-effect model and fixed-effect model compared outcome events of death, stroke, myocardial infarction, cranial nerve injury at 30 days,6 months, or 1 year after procedure. By fixed-effect modle there were significantly lowwer 30-day event rates after CAS than CEA for stroke [1.29(1.02,1.64), heterogeneity(P=0.001)], and death or any stroke[1.25(1.00,1.57), heterogeneity(P=0.002)].But by random-effects model, there was no significant difference of event rates between treatments for stroke (odds ratio for CAS [95% confidence interval],1.21 [0.69,2.10]), death or any stroke (1.12 [0.68,1.86]), or death,disabilting stroke(1.03 [0.66,1.61]), or death and any stroke at long-term after procedural (1.11 [0.73,1.69]). But also there were significantly lowwer 30-day event rates after CAS than CEA for myocardial infarction [fixed-effect modle 0.45 (0.21,0.98), heterogeneity (p=0.55)], Cranial nerve injury [fixed-effect modle 0.08 (0.03,0.20), heterogeneity (p=0.78)] by fixed-effect model.
Conclusion
In the present meta-analysis, there was no significant difference of safety and benefit between patients treated with CAS and CEA.The analyzed trial number was too small to show significant different. The ongoing trials CREST is expected to provide additional clear evidence to make sure which treatment is Golden standard..
Background and Purpose
Stroke is the second or third leading cause of death and the first leading cause of adult disability in all the world. Stenosis of the carotid artery constitutes a major risk factor for ischaemic stroke, especially in patients with symptomatic stenosis (recent transient ischaemic attacks, et al). However, the severity of carotid artery stenosis highly predicts risk of ipsilateral ischemic stroke.The annual risk of ipsilateral stroke doubles from 0.5% for internal carotid artery (ICA) stenosis of b50% to 1% for ICA stenosis of 50%-99%.
Large randomized trials have convincingly shown that carotid endarterectomy have greater benefit than medical therapies alone, can significantly reduces the longterm risk of subsequent stroke from severe carotid artery stenosis.. These large, randomized, prospective trials, including the North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trial (ECST), Asymptomatic Carotid Atherosclerotic Study (ACAS), and Asymptomatic Carotid Surgery Trial (ACST). Carotid endarterectomy has been regarded as the gold standard for revascularization of severe carotid artery stenosis, and considered the first one in clinical decision-making. But surgery also have disadvantages, such as:requiring an incision in the neck, performed under general anaesthesia and its complications such as myocardial infarction and pulmonary embolism.
Since 1990 year, Angioplasty and carotid artery stenting have been suggested as an alternative to carotid endarterectomy for revascularization of carotid artery stenosis, especially for carotid artery restenosis and in patients with high-surgical risk. Before 2005, there were more than 20 published case-series carotid Angioplasty studies involving a total of more than 24,000 patients,about half of patients were symptomatic carotid artery stenosis(51%), and 30-day stroke or death rates were 2% to 7%. Since embolic protection devices were introduced for use during carotid Angioplasty, stroke and death rate within 30 days in both symptomatic and asymptomatic patients was reduced to 1.8%, rather than 5.5% in patients treated without embolic protection devices. Endovascular treatment is usually performed via a femoral catheter, avoiding an incision in the neck and subsequent cranial and cutaneous nerve damage, and without general anesthesia and its complications.
However, endovascular techniques also carries a risk of stroke and local complications. As a consequence, before endovascular treatment can be considered as a genuine alternative to surgery, it must be shown to be as safe and effective as surgery. Between 1998 and 2010,11 randomized studies comparing endovascular treatment of the carotid artery with surgery, there were 10 studies out come or part of the date have published, those studies include The CAVATAS trial, The Leicester trial, The Schneider Wall Stent trial, Kentucky A, Kentucky B, The CREST trial, The EVA 3S study, The Sapphire trial, The SPACE trial, The ICSS trial, The TESCAS-C trial and CREST Trial.
This article reviews all randomized trials comparing endovascular treatment of the carotid artery with surgery by a meta-analysis,To evaluate the safety and efficacy of endovascular techniques.
Materials and Methods
Search Strategy
Bibliographic databases selection
①MEDLINE (http://isiknowledge.com/medline);
②Elsevier Science (http://www.sciencedirect.com/);
③PubMed (http://www.ncbi.nlm.nih.gov/pubmed/)
④The Excerpta Medica Database, EMBASE;
⑤China National Knowledge Infrastructure, CNKI.
Search terms
Search terms included "carotid", "stenosis", "endarterectomy", "endovascular", "angioplasty", and "stenting", in various combinations.
Study selection
The search was limited to articles published date to 2010.01.01;
randomized trials of carotid endovascular treatment compared with carotid endarterectomy;
patients of any age or sex;
symptomaticor asymptomatic carotid arterystenosis.
Data extraction
The outcome events extracted from each study included, if available:any stroke (disabling or nondisabling) or death, cranial neuro damage, myocardial infarction within 30 days of procedure and any stroke or death within 1 year of procedure.
Strokes were classified if possible as fatal, disabling (requiring help with activities of daily living for>1 month after onset) or nondisabling (symptoms lasted>7 days but patient was independent at 30 days).
Meta analysis
Results were reported as percentages as well as odds ratios (ORs). ORs were calculated using the Peto fixed-effect method or (and) free-sffect method. Heterogeneity between trial results was tested for using a standardχ2 test.
Results
There are 10 trials, including 4872patients, Symptomatic carotid stenosis 4533 patients (93% in all). Meta-analysis using both random-effect model and fixed-effect model compared outcome events of death, stroke, myocardial infarction, cranial nerve injury at 30 days,6 months, or 1 year after procedure. By fixed-effect modle there were significantly lowwer 30-day event rates after CAS than CEA for stroke [1.29(1.02,1.64), heterogeneity(P=0.001)], and death or any stroke[1.25(1.00,1.57), heterogeneity(P=0.002)].But by random-effects model, there was no significant difference of event rates between treatments for stroke (odds ratio for CAS [95% confidence interval],1.21 [0.69,2.10]), death or any stroke (1.12 [0.68,1.86]), or death,disabilting stroke(1.03 [0.66,1.61]), or death and any stroke at long-term after procedural (1.11 [0.73,1.69]). But also there were significantly lowwer 30-day event rates after CAS than CEA for myocardial infarction [fixed-effect modle 0.45 (0.21,0.98), heterogeneity (p=0.55)], Cranial nerve injury [fixed-effect modle 0.08 (0.03,0.20), heterogeneity (p=0.78)] by fixed-effect model.
Conclusion
In the present meta-analysis, there was no significant difference of safety and benefit between patients treated with CAS and CEA.The analyzed trial number was too small to show significant different. The ongoing trials CREST is expected to provide additional clear evidence to make sure which treatment is Golden standard..
引文
1. McPhee JP, Hill JS, Ciocca RG, Messina LM, Eslami MH. Carotid endarterectomy was performed with lower stroke and death rates than carotid artery stenting in the United States in 2003 and 2004. J Vasc Surg 2007;46:1112e8.
2. European Carotid Surgery Trialists'CollaborativeGroup (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis:final results of theMRC European carotid surgery trial (ECST). Lancet 351:1379-1387
3. North Am Symptomatic Carotid Endarterectomy Trial Collaborative Group (1998) The final results of the NASCET trial. N Engl J Med 339:1415-1425.
4. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. JAMA 273:1421-1428.
5. MRC asymptomatic carotid surgery trial (ACST) collaborative group (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms:randomized controlled trial. Lancet 363:1491-1502.
6. Stroke facts:American Heart Association. http:www. Americanheart. org/heart and stroke AZ Guide/strokes. html (accessed 12/01/1999).
7. BarnettHJ, Gunton RW, EliasziwM, et a.l Causes and severity of ischemic stroke in patientswith internal carotid artery stenosis[J]. JAMA,2000,283: 1429-1436.
8. Biller J,Saver JL:Transient ischemic attack-populations and prognosis. Mayo clin Proc.69:493-494,1994.
9. Collins R, Peto R, MecMahon S,et al:Blood Pressure, stroke, and coronary Heart Disease. Part 2.Short-Terms Reduction in Blood Pressure:Over View of Radomised drug trials in their epidemiological context. Lancet 335:827-838,1990.
10. Gill JS, Zezulka AV, Shipley MJ, Gill SK, et al: strokes and alcohol consumption.N Engl J Med 315:1041-1046,1986.
11. Stampfer MJ, Colditz GA, Willet t WC, et al:A prospective study of moderate alcohol consumption and the risk of coronary disease and stroke in women. N Engl J Med 319:267-273,1988.
12. Love BB,Biller J,Jone MP,et al:Cigarette smoking.A risk factor for cerebral infraction in young adults.Arch Neurl 47:693-398,1990.
13. CAVATAS Investigators. Endovascular versus surgical treatment in patients with carotid stenosis in the carotid and vertebral artery transluminal angioplasty study (CAVATAS):a randomised trial[J]. Lancet 2001,357:1729-1737.
14. McCabe DJ, Pereira AC, Clifton A, Bland JM et al, Restenosis After Carotid Angioplasty, Stenting, or Endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) [J], Stroke 2005,36, pp:281-286.
15. Ederle J, Bonati LH, Dobson J, et al. Endovascular treatment with angioplasty or tenting versus endarterectomy in patients with carotid artery stenosis in the Carotid And Vertebral Artery Transluminal Angioplasty [J]. Lancet Neurol,2009, 8:908-917. DOI:10.1016/S1474-4422(09)70228-5.
16. Bonati Leo H, Ederle J, Dominick J, et al. Long-term risk of carotid restenosis in patients randomly assigned to endovascular treatment or endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial [J]. Lancet Neurol 2009; 8:908-917. DOI:10.1016/S1474-4422(09)70227-3.
17. Naylor, Bolia A, Abbot RJ, Pye IF, Smith J, Lennard N, et al. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy:A stopped trial. J Vasc Surg 1998,28:326-334.
18. Alberts MJ, McCann R, Smith TP, Stack R, Roubin G, Schneck M, et al. A randomized trial of carotid stenting versus endarterectomy in patients with symptomatic carotid stenosis:study design [J]. Neurovasc Dis 1997;2:228-234.
19. Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy:randomized trial in a community hospital. J Am Coll Cardiol 2001;38:1589-95.
20. Brooks WH, McClure RR, Jones MR, Coleman TL, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis:a randomized trial in a community hospital [J]. Neurosurgery 2004,54:318-25.
21. EV-3S investigators. Endarterectomy vs angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EV-3S) trial[J]. Cerebro Dis,2004,18: 62-65.
22. Mas JL, Chatellier G, Beyssen V, Branchereau A, Moulin T, Becquemin JP, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis[J]. N Engl J Med 2006,355:1660-1671.
23. Mas JL, Trinquart L, Leys D, Albucher JF, Rousseau H, Viguier A,et al. Endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S Trial):Results up to four years from a randomized, multicenter trial[J]. Lancet Neurol (England) 2008;7:885-892.
24. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in highrisk patients [J]. N Engl J Med 2004;351:1493-1501.
25. Gurm HS, Yadav JS, Fayad P, et al. Long-Term Results of Carotid Stenting ersus Endarterectomy in High-Risk Patients[J]. N Engl J Med,2009,358: 1572-1579
26. SPACE Collaborative Group, Ringleb PA, Allenberg J, Bruckmann H, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients:a randomised noninferiority trial [J]. Lancet,2006,368:1239-1247.
27. SPACE investigators, Eckstein HH, Ringleb P, Allenberg JR, et al.Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years:a multinational, prospective, randomised trial[J]. Lancet Neurol 2008; 7:893-902
28. SPACE investigators, Stingele R, Berger J, Alfke K, et al. Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stentprotected angioplasty:a subanalysis of the SPACE study[J]. Lancet Neurol 2008; 7:216-222.
29. Brown MM, Ederle J, Bonati L, et al. Safety results of the International Carotid Stenting Study (ICSS):Early outcome of patients randomized between carotid stenting and endarterectomy for symptomatic carotid stenosis [R]. European Stroke Conference,2009.
30.凌锋,焦力群.颈动脉内膜剥脱术与支架成形术对颈动脉粥样硬化性狭窄治疗的初步研究[J].中国脑血管杂志,2009,3(1)：4-7.
31. Hobson RW 2nd, Howard VJ, Roubin GS, et a.l Credentialing of surgeons as interventionalists for carotid artery stenting:experience from the lead-in phase of CREST [J]. Vase Surg,2004,40:952-957.
32. Hobson RW 2nd, Howard VJ, Roubin GS, et a.l Carotid artery stenting is associatedwith increased complications in octogenarians:30-day stroke and death rates in the CREST lead-in phase [J]. Vase Surg,2004,40:1106-1111.
33. Hobson RW, Howard VJ, Roubin GS, Brott TG, Ferguson RD,Popma JJ, et al. Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase. J Vase Surg 2004;40: 1106-1111.
34. Howard VJ, Voeks JH, Lutsep HL, Mackey A, Milot G, Sam AD,et al. Does sex matter? 30-day stroke and death rates following carotid artery stenting in women versus men:Results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) lead-in phase[J]. Stroke 2009;40:1140-1147.
35. Poppert H, Wolf O, Resch M, et al. Differences in number, size and location of intracranial microembolic lesion safter surgical versus endovascular treatment without protection device of carotid artery stenosis [J]. Neurol,2004,251: 1198-1203.
36. Bosiers M, Hart J, Deloose K, Steyaert A, Verbist J, Peeters P (2006) Do device characteristics impact outcome in carotid artery stenting? Presented at the Society of Vascular Surgery Annual Meeting, Philadelphia,2006:
37. Pache J, Dibra A, Mehilli J, Dirschinger J, Schomig A, Kastrati A. Drug-eluting stents compared with thin-strut bare stents for the reduction of restenosis:a prospective, randomized trial. Eur Heart J 2005;26:1262-1268.
38. Rothwell PM, Slattery J, Warlow CP. A systematic comparison of the risks of stroke and death due to carotid endarterectomy for symptomatic and asymptomatic stenosis. Stroke.1996;27:266-269.
2. European Carotid Surgery Trialists'CollaborativeGroup (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis:final results of theMRC European carotid surgery trial (ECST). Lancet 351:1379-1387
3. North Am Symptomatic Carotid Endarterectomy Trial Collaborative Group (1998) The final results of the NASCET trial. N Engl J Med 339:1415-1425.
4. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. JAMA 273:1421-1428.
5. MRC asymptomatic carotid surgery trial (ACST) collaborative group (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms:randomized controlled trial. Lancet 363:1491-1502.
6. Stroke facts:American Heart Association. http:www. Americanheart. org/heart and stroke AZ Guide/strokes. html (accessed 12/01/1999).
7. BarnettHJ, Gunton RW, EliasziwM, et a.l Causes and severity of ischemic stroke in patientswith internal carotid artery stenosis[J]. JAMA,2000,283: 1429-1436.
8. Biller J,Saver JL:Transient ischemic attack-populations and prognosis. Mayo clin Proc.69:493-494,1994.
9. Collins R, Peto R, MecMahon S,et al:Blood Pressure, stroke, and coronary Heart Disease. Part 2.Short-Terms Reduction in Blood Pressure:Over View of Radomised drug trials in their epidemiological context. Lancet 335:827-838,1990.
10. Gill JS, Zezulka AV, Shipley MJ, Gill SK, et al: strokes and alcohol consumption.N Engl J Med 315:1041-1046,1986.
11. Stampfer MJ, Colditz GA, Willet t WC, et al:A prospective study of moderate alcohol consumption and the risk of coronary disease and stroke in women. N Engl J Med 319:267-273,1988.
12. Love BB,Biller J,Jone MP,et al:Cigarette smoking.A risk factor for cerebral infraction in young adults.Arch Neurl 47:693-398,1990.
13. CAVATAS Investigators. Endovascular versus surgical treatment in patients with carotid stenosis in the carotid and vertebral artery transluminal angioplasty study (CAVATAS):a randomised trial[J]. Lancet 2001,357:1729-1737.
14. McCabe DJ, Pereira AC, Clifton A, Bland JM et al, Restenosis After Carotid Angioplasty, Stenting, or Endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) [J], Stroke 2005,36, pp:281-286.
15. Ederle J, Bonati LH, Dobson J, et al. Endovascular treatment with angioplasty or tenting versus endarterectomy in patients with carotid artery stenosis in the Carotid And Vertebral Artery Transluminal Angioplasty [J]. Lancet Neurol,2009, 8:908-917. DOI:10.1016/S1474-4422(09)70228-5.
16. Bonati Leo H, Ederle J, Dominick J, et al. Long-term risk of carotid restenosis in patients randomly assigned to endovascular treatment or endarterectomy in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): long-term follow-up of a randomised trial [J]. Lancet Neurol 2009; 8:908-917. DOI:10.1016/S1474-4422(09)70227-3.
17. Naylor, Bolia A, Abbot RJ, Pye IF, Smith J, Lennard N, et al. Randomized study of carotid angioplasty and stenting versus carotid endarterectomy:A stopped trial. J Vasc Surg 1998,28:326-334.
18. Alberts MJ, McCann R, Smith TP, Stack R, Roubin G, Schneck M, et al. A randomized trial of carotid stenting versus endarterectomy in patients with symptomatic carotid stenosis:study design [J]. Neurovasc Dis 1997;2:228-234.
19. Brooks WH, McClure RR, Jones MR, Coleman TC, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy:randomized trial in a community hospital. J Am Coll Cardiol 2001;38:1589-95.
20. Brooks WH, McClure RR, Jones MR, Coleman TL, Breathitt L. Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis:a randomized trial in a community hospital [J]. Neurosurgery 2004,54:318-25.
21. EV-3S investigators. Endarterectomy vs angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EV-3S) trial[J]. Cerebro Dis,2004,18: 62-65.
22. Mas JL, Chatellier G, Beyssen V, Branchereau A, Moulin T, Becquemin JP, et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis[J]. N Engl J Med 2006,355:1660-1671.
23. Mas JL, Trinquart L, Leys D, Albucher JF, Rousseau H, Viguier A,et al. Endarterectomy versus angioplasty in patients with symptomatic severe carotid stenosis (EVA-3S Trial):Results up to four years from a randomized, multicenter trial[J]. Lancet Neurol (England) 2008;7:885-892.
24. Yadav JS, Wholey MH, Kuntz RE, Fayad P, Katzen BT, Mishkel GJ, et al. Protected carotid-artery stenting versus endarterectomy in highrisk patients [J]. N Engl J Med 2004;351:1493-1501.
25. Gurm HS, Yadav JS, Fayad P, et al. Long-Term Results of Carotid Stenting ersus Endarterectomy in High-Risk Patients[J]. N Engl J Med,2009,358: 1572-1579
26. SPACE Collaborative Group, Ringleb PA, Allenberg J, Bruckmann H, et al. 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients:a randomised noninferiority trial [J]. Lancet,2006,368:1239-1247.
27. SPACE investigators, Eckstein HH, Ringleb P, Allenberg JR, et al.Results of the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study to treat symptomatic stenoses at 2 years:a multinational, prospective, randomised trial[J]. Lancet Neurol 2008; 7:893-902
28. SPACE investigators, Stingele R, Berger J, Alfke K, et al. Clinical and angiographic risk factors for stroke and death within 30 days after carotid endarterectomy and stentprotected angioplasty:a subanalysis of the SPACE study[J]. Lancet Neurol 2008; 7:216-222.
29. Brown MM, Ederle J, Bonati L, et al. Safety results of the International Carotid Stenting Study (ICSS):Early outcome of patients randomized between carotid stenting and endarterectomy for symptomatic carotid stenosis [R]. European Stroke Conference,2009.
30.凌锋,焦力群.颈动脉内膜剥脱术与支架成形术对颈动脉粥样硬化性狭窄治疗的初步研究[J].中国脑血管杂志,2009,3(1)：4-7.
31. Hobson RW 2nd, Howard VJ, Roubin GS, et a.l Credentialing of surgeons as interventionalists for carotid artery stenting:experience from the lead-in phase of CREST [J]. Vase Surg,2004,40:952-957.
32. Hobson RW 2nd, Howard VJ, Roubin GS, et a.l Carotid artery stenting is associatedwith increased complications in octogenarians:30-day stroke and death rates in the CREST lead-in phase [J]. Vase Surg,2004,40:1106-1111.
33. Hobson RW, Howard VJ, Roubin GS, Brott TG, Ferguson RD,Popma JJ, et al. Carotid artery stenting is associated with increased complications in octogenarians: 30-day stroke and death rates in the CREST lead-in phase. J Vase Surg 2004;40: 1106-1111.
34. Howard VJ, Voeks JH, Lutsep HL, Mackey A, Milot G, Sam AD,et al. Does sex matter? 30-day stroke and death rates following carotid artery stenting in women versus men:Results from the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) lead-in phase[J]. Stroke 2009;40:1140-1147.
35. Poppert H, Wolf O, Resch M, et al. Differences in number, size and location of intracranial microembolic lesion safter surgical versus endovascular treatment without protection device of carotid artery stenosis [J]. Neurol,2004,251: 1198-1203.
36. Bosiers M, Hart J, Deloose K, Steyaert A, Verbist J, Peeters P (2006) Do device characteristics impact outcome in carotid artery stenting? Presented at the Society of Vascular Surgery Annual Meeting, Philadelphia,2006:
37. Pache J, Dibra A, Mehilli J, Dirschinger J, Schomig A, Kastrati A. Drug-eluting stents compared with thin-strut bare stents for the reduction of restenosis:a prospective, randomized trial. Eur Heart J 2005;26:1262-1268.
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