Objective

To evaluate the safety of carotid artery stenting (CAS) and carotid endarterectomy (CEA) after thrombolytic therapy (TT).

Data sources

Medline, Scopus, and Cochrane databases.

Review Methods

Systematic review and meta-analysis of studies involving patients who underwent CEA/CAS after TT.

Results

In 25 studies (n = 147 810 patients), 2 557 underwent CEA (n = 2 076) or CAS (n = 481) following TT. After CEA, the pooled peri-procedural stroke/death rate was 5.2% (95% confidence interval [CI] 3.3 – 7.5) and intracranial haemorrhage (ICH) was 3.4% (95% CI 1.7 – 5.6). After CAS, the pooled peri-procedural stroke/death rate was 14.9% (95% CI 11.9 – 18.2) and ICH was 5.5% (95% CI 3.7 – 7.7). In case control studies comparing CEA outcomes in patients receiving TT vs. no TT, peri-procedural death/stroke was non-significantly higher after TT (4.3% vs. 1.5%; odds ratio [OR] 2.34, 95% CI 0.74 – 7.47), but ICH was significantly higher after TT (2.2% vs. 0.12%; OR 7.82, 95% CI 4.07 – 15.02), as was local haematoma formation (3.6% vs. 2.26%; OR 1.17, 95% CI 1.17 – 2.33). In case control studies comparing CAS outcomes in patients receiving TT vs. no TT, peri-procedural stroke/death was significantly higher after TT (5.2% vs. 1.5%; OR 8.49, 95% CI 2.12 – 33.95) as was ICH (5.4% vs. 0.7%; OR 7.48, 95% CI 4.69 – 11.92). Meta-regression analysis demonstrated an inverse association between the time interval from intravenous (IV) TT to undergoing CEA and the risk of peri-procedural stroke/death (p = .032). Peri-operative stroke/death was 13.0% when CEA was performed three days after TT and 10.6% when performed four days after TT, with the risk reducing to within the currently accepted 6% threshold after six-seven days had elapsed.

Conclusion

Peri-procedural ICH and local haematoma were significantly more frequent in patients undergoing CEA after TT (vs. no TT), although there were no randomised comparisons. Peri-procedural hazards were also significantly higher for CAS after TT. The inverse relationship between timing to CEA and peri-procedural stroke/death mandates careful patient selection and suggests that it may be safer to defer CEA for six-seven days after TT.

中文翻译：

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溶栓后接受颈动脉介入治疗的患者围手术期结果的系统评价和荟萃分析

客观的

评估溶栓治疗（TT）后颈动脉支架置入术（CAS）和颈动脉内膜切除术（CEA）的安全性。

数据源

Medline、Scopus 和 Cochrane 数据库。

复习方法

系统回顾和荟萃分析涉及在 TT 后接受 CEA/CAS 的患者的研究。

结果

在 25 项研究（n  = 147 810 名患者）中，2 557 人在 TT 后接受了 CEA（n  = 2 076）或 CAS（n = 481）。CEA 后，合并围手术期卒中/死亡率为 5.2%（95% 置信区间 [CI] 3.3 – 7.5），颅内出血 (ICH) 为 3.4%（95% CI 1.7 – 5.6）。CAS 后，合并围手术期卒中/死亡率为 14.9% (95% CI 11.9 – 18.2)，ICH 为 5.5% (95% CI 3.7 – 7.7)。在比较接受 TT与未接受 TT 的患者的 CEA 结果的病例对照研究中，TT 后围手术期死亡/卒中无显着性升高（4.3%与1.5%；优势比 [OR] 2.34，95% CI 0.74 – 7.47 )，但 TT 后 ICH 显着升高（2.2% vs.0.12%；OR 7.82, 95% CI 4.07 – 15.02)，局部血肿形成也是如此（3.6% vs. 2.26%；OR 1.17, 95% CI 1.17 – 2.33）。在比较接受 TT与未接受 TT 的患者的 CAS 结果的病例对照研究中，TT 后围手术期卒中/死亡显着更高（5.2%对1.5%；OR 8.49，95% CI 2.12 – 33.95）和 ICH（5.4） %与0.7%；或 7.48，95% CI 4.69 – 11.92）。Meta 回归分析表明，从静脉注射 (IV) TT 到接受 CEA 的时间间隔与围手术期卒中/死亡风险呈负相关（p =.032）。TT 后 3 天进行 CEA 的围手术期卒中/死亡率为 13.0%，TT 后 4 天进行的为 10.6%，6-7 天后风险降低至目前公认的 6% 阈值。

结论

尽管没有随机比较，但在 TT 后接受 CEA 的患者中，围手术期 ICH 和局部血肿的发生率明显更高（与未接受 TT相比）。TT 后 CAS 的围手术期风险也显着更高。CEA 时间与围手术期卒中/死亡之间的反比关系要求仔细选择患者，并表明在 TT 后推迟 CEA 6-7 天可能更安全。