[無症状の頸動脈狭窄症患者のエビデンスベースの治療 - CREST-2試験に関するコメント]
Johan Lundberg1, Michael Mazya2, Fabian Arnberg-Sandor3
1docent, sektionschef, ME neuroradio-logi, Karolinska universitetssjukhuset, Stockholm.
まとめ
症状のない頸動脈狭窄症のほとんどの患者にとって,最良の治療は十分です. 大動脈ステントは,高人数のセンターで専門家によって実施された場合,選択された患者に利益をもたらす可能性があります.
科学分野:
- 神経学 神経学とは
- 血管外科 血管外科
- 心臓病学 心臓病学
背景:
- 頸動脈狭窄は,脳卒中のリスクをもたらします.
- CEAやCASのような再血管化の処置は,治療の選択肢です.
- CREST-2試験では,低リスクの患者における再血管化と最良の治療 (BMT) を評価した.
研究 の 目的:
- 頸動脈末関節切除術 (CEA) と頸動脈ステンティング (CAS) + BMTの有効性を,症状のない重度の頸動脈狭窄症の患者において,BMT単独に対するBMTの有効性を比較する.
- 厳選された低リスク集団における再血管化戦略の安全性と有効性を評価する.
主な方法:
- CREST-2試験では,無症状で70%以上の頸動脈狭窄症を患った2,485人の患者をランダムに選択しました.
- 患者は BMT 単独,CEA + BMT,または CAS + BMT に割り当てられました.
- 主要エンドポイントは,脳卒中または4年後の死亡の複合でした.
主要な成果:
- CEA + BMTは,BMT単独 (3.7%対5.3%,p=0.24) に比べて有意な利点を示さなかった.
- CAS + BMTは,BMT単独と比較してプライマリエンドポイントを有意に低下させた (2.8%対6.0%,p=0.02).
- この厳選されたグループでは,CASの処置期間中のリスクは例外的に低い (1.3-1.5%).
結論:
- 最適な医療療法は,治療の礎石であり,無症状の頸動脈狭窄症のほとんどの患者にとって十分である.
- 動脈ステントは,好ましい解剖学を持つ慎重に選択された患者に考慮され,合併症率が低い高容量センターで実施されます.
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