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Geschlechtsunterschiede in der operativen und endovaskulären Behandlung von Karotisstenosen

Sex differences in operative and endovascular treatment of carotid stenoses

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Zusammenfassung

Hintergrund

Etwa 20% aller ischämischen Schlaganfälle entstehen auf dem Boden einer extrakraniellen Makroangiopathie. Männer sind dabei häufiger betroffen als Frauen und durchschnittlich 5–10 Jahre jünger. Morbidität und Mortalität sind jedoch bei Frauen höher. Gegenstand dieser Arbeit ist die Frage der Geschlechterspezifität in der operativen und endovaskulären Behandlung extrakranieller Karotisstenosen.

Material und Methoden

Es erfolgte eine Medline-Recherche und Durchsicht aller prospektiv-randomisierten Studien (CEA vs. konservativer Therapie, CEA vs. CAS), Metaanalysen, und systematischer Reviews nach geschlechtsspezifischen Komplikationsraten und Langzeitergebnissen der Karotis-TEA (CEA) und des Karotisstentings (CAS).

Ergebnisse

In der vorliegenden Literatur sind Frauen unterrepräsentiert mit einem Anteil von 20–30%. Insgesamt zeigt sich für Frauen eine im Vergleich zu Männern höhere perioperative Schlaganfallrate, aber keine erhöhte Letalität. Frauen haben eine niedrigere Schlaganfallrate im natürlichen Verlauf symptomfreier und symptomatischer Karotisstenosen. Der schlaganfallprotektive Wert der CEA ist bei Männern größer, Frauen profitieren nur bei Einhaltung einer sehr niedrigen Komplikationsrate. Für CAS liegen bisher nur vereinzelt geschlechterspezifische Auswertungen vor. Während in einzelnen Registerstudien kein Geschlechterunterschied nachweisbar war, betrug die 30-Tages-Komplikationsrate in der prospektiv-randomisierten SPACE-Studie (CEA vs. CAS) bei Männern jeweils 6,5% (OR 1,01, 95%CI 0,58–1,74), bei Frauen bestand ein nicht-signifikanter Vorteil der CEA (6% vs. 7,7%, OR 1,31, 95%CI 0,51–3,44), Geschlechterspezifische Langzeitergebnisse nach CAS liegen derzeit nicht vor.

Schlussfolgerungen

Die Geschlechtszugehörigkeit hat einen Einfluss auf Komplikationsraten und Langzeitergebnisse und sollte in künftigen Studien größere Beachtung finden.

Abstract

Background

About 20% of all ischaemic strokes develop against the backdrop of extracranial macroangiopathy. Men are more frequently affected than women and are an average of 5–10 years younger. Morbidity and mortality are higher in women, however. This paper deals with the question of sex specificity in the surgical and endovascular treatment of extracranial carotid stenoses.

Materials and methods

After a Medline search all prospective randomized studies (CEA vs conservative treatment, CEA vs CAS), meta-analyses, and systematic reviews were perused to look for sex-specific complication rates and long-term results of carotid endarterectomy (CEA) and carotid stenting (CAS).

Results

In the available literature, women are underrepresented, accounting for only 20–30% of all study patients. Overall, compared with men, women have a higher perioperative rate of stroke, albeit without higher mortality. Women have a lower stroke rate in the natural course of symptom-free or symptomatic carotid stenoses. The stroke-protective value for CEA is greater in men, women benefiting only when a very low complication rate is retained. For CAS only isolated sex-specific evaluations are available so far. While in single register studies no sex difference was demonstrable, the 30-day complication rate in the prospective randomized SPACE study was 6.5% for men (OR 1.01, 95%CI 0.58–1.74), while women did not enjoy any significant benefit of CEA (6% vs 7.7%, OR 1.31, 95%CI 0.51–3.44). Sex-specific long-term results after CAS are not available at present.

Conclusions

Gender has an influence on complication rates and long-term results and should be given more attention in future studies.

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Literatur

  1. Alamowitch S, Eliasziw M, Barnett HJ (2005) The risk and benefit of endarterectomy in women with symptomatic internal carotid artery disease. Stroke 36: 27–31

    Article  PubMed  Google Scholar 

  2. Alberts M (2001) Results of a multicenter prospective randomized trial of carotid artery stenting vs. carotid endarterectomy. Stroke 32: 325d

    Google Scholar 

  3. Anonym (2007) http://www.destatis.de

  4. Barnett HJ, Taylor DW, Eliasziw M et al. (1998) Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 339: 1415–1425

    Article  PubMed  CAS  Google Scholar 

  5. Barrett KM, Brott TG, Brown RD Jr et al. (2007) Sex differences in stroke severity, symptoms, and deficits after first-ever ischemic stroke. J Stroke Cerebrovasc Dis 16: 34–39

    Article  PubMed  Google Scholar 

  6. Biller J, Feinberg WM, Castaldo JE et al. (1998) Guidelines for carotid endarterectomy: a statement for healthcare professionals from a special writing group of the stroke council, American Heart Association. Circulation 97: 501–509

    PubMed  CAS  Google Scholar 

  7. Bond R, Rerkasem K, Cuffe R, Rothwell PM (2005) A systematic review of the associations between age and sex and the operative risks of carotid endarterectomy. Cerebrovasc Dis 20: 69–77

    Article  PubMed  CAS  Google Scholar 

  8. Bonita R (1992) Epidemiology of stroke. Lancet 339: 342–344

    Article  PubMed  CAS  Google Scholar 

  9. Brooks WH, McClure RR, Jones MR et al. (2001) Carotid angioplasty and stenting versus carotid endarterectomy: randomized trial in a community hospital. J Am Coll Cardiol 38: 1589–1595

    Article  PubMed  CAS  Google Scholar 

  10. Brooks WH, McClure RR, Jones MR (2004) Carotid angioplasty and stenting versus carotid endarterectomy for treatment of asymptomatic carotid stenosis: a randomized trial in a community hospital. Neurosurgery 54: 318–324

    Article  PubMed  Google Scholar 

  11. CAVATAS (2001) Endovascular versus surgical treatment in patients with carotid stenosis in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS): a randomised trial. Lancet Am 357: 1729–1737

    Article  Google Scholar 

  12. Chambers BR, Donnan GA (2005) Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane database of systematic reviews (Online); CD001923

  13. Chaturvedi S, Bruno A, Feasby T et al. (2005) Carotid endarterectomy – an evidence-based review: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 65: 794–801

    Article  PubMed  CAS  Google Scholar 

  14. Di Carlo A, Lamassa M, Baldereschi M et al. (2003) Sex differences in the clinical presentation, resource use, and 3-month outcome of acute stroke in Europe: data from a multicenter multinational hospital-based registry. Stroke 34: 1114–1119

    Article  Google Scholar 

  15. Diener HC, Allenberg JR, Bode JR et al. (2005) Primär- und Sekundärprävention der zerebralen Ischämie. Gemeinsame Leitlinie der Deutschen Gesellschaft für Neurologie und der Deutschen Schlaganfallgesellschaft (DSG). http://www.dgn.org

  16. European Carotid Surgery Trial (1998) Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet 351(9113): 1379–1387

    Article  Google Scholar 

  17. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study (1995) Endarterectomy for asymptomatic carotid artery stenosis. JAMA 273: 1421–1428

    Article  Google Scholar 

  18. Grau AJ, Weimar C, Buggle F et al. (2001) Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German stroke data bank. Stroke 32: 2559–2566

    Article  PubMed  CAS  Google Scholar 

  19. Gray WA, Hopkins LN, Yadav S et al. (2006) Protected carotid stenting in high-surgical-risk patients: the ARCHeR results. J Vasc Surg 44: 258–268

    Article  PubMed  Google Scholar 

  20. Gray WA, Yadav JS, Verta P et al. (2007) The CAPTURE registry: results of carotid stenting with embolic protection in the post approval setting. Catheter Cardiovasc Interv 69: 341–348

    Article  PubMed  Google Scholar 

  21. Halliday A, Mansfield A, Marro J et al. (2004) Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 363: 1491–1502

    Article  PubMed  CAS  Google Scholar 

  22. Heuschmann PU, Kolominsky-Rabas PL, Roether J et al. (2004) Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy. JAMA 292: 1831–1838

    Article  PubMed  CAS  Google Scholar 

  23. Hillen T, Nieczaj R, Münzberg H et al. (2000) Carotid atherosclerosis, vascular risk profile and mortality in a population-based sample of functionally healthy elderly subjects: the Berlin ageing study. J Intern Med 247: 679–688

    Article  PubMed  CAS  Google Scholar 

  24. Hobson RW 2nd, Howard VJ, Roubin GS et al. (2004) Credentialing of surgeons as interventionalists for carotid artery stenting: experience from the lead-in phase of CREST. J Vasc Surg 40: 952–957

    Article  PubMed  Google Scholar 

  25. Joakimsen O, Bonaa KH, Stensland-Bugge E, Jacobsen BK (1999) Age and sex differences in the distribution and ultrasound morphology of carotid atherosclerosis: the Tromso Study. Arterioscler Thromb Vasc Biol 19: 3007–3013

    PubMed  CAS  Google Scholar 

  26. Kapral MK, Wang H, Austin PC et al. (2003) Sex differences in carotid endarterectomy outcomes: results from the Ontario Carotid Endarterectomy Registry. Stroke 34: 1120–1125

    Article  PubMed  Google Scholar 

  27. Kastrup A, Groschel K, Schulz JB et al. (2005) Clinical predictors of transient ischemic attack, stroke, or death within 30 days of carotid angioplasty and stenting. Stroke 36: 787–791

    Article  PubMed  Google Scholar 

  28. Mas, Chatellier G, Beyssen B J et al. (2006) Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis. New England J Med 355: 1660–1671

    Article  CAS  Google Scholar 

  29. Moore WS, Barnett HJ, Beebe HG et al. (1995) Guidelines for carotid endarterectomy. A multidisciplinary consensus statement from the ad hoc Committee, American Heart Association. Stroke 26: 188–201

    PubMed  CAS  Google Scholar 

  30. Naylor AR, Bolia A, Abbott RJ et al. (1998) Randomized study of carotid angioplasty and stenting versus carotid endarterectomy: a stopped trial. J Vasc Surg 28: 326–334

    Article  PubMed  CAS  Google Scholar 

  31. O’Leary DH (1996) Best parameters for internal carotid artery characterization intraarterial angiography. Journal d’Echographie et de Medecine par Ultrasons 17: 371–373

    Google Scholar 

  32. Ringleb PA, Allenberg J, Bruckmann H et al. (2006) 30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial. Lancet 368: 1239–1247

    Article  PubMed  CAS  Google Scholar 

  33. Rothwell PM, Eliasziw M, Gutnikov SA et al. (2003) Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis. Lancet 361: 107–116

    Article  PubMed  CAS  Google Scholar 

  34. Rothwell PM, Goldstein LB (2004) Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial. Stroke 35: 2425–2427

    Article  PubMed  CAS  Google Scholar 

  35. Rothwell PM, Eliasziw M, Gutnikov SA et al. (2004) Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and nondisabling stroke. Stroke 35: 2855–2861

    Article  PubMed  CAS  Google Scholar 

  36. Sacco RL, Adams R, Albers G et al. (2006) Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Circulation 113: e409–e449

    PubMed  Google Scholar 

  37. Sarac TP, Hertzer NR, Mascha EJ et al. (2002) Gender as a primary predictor of outcome after carotid endarterectomy. J Vasc Surg 35: 748–753

    Article  PubMed  Google Scholar 

  38. Schluter M, Reimers B, Castriota F et al. (2007) Impact of diabetes, patient age, and gender on the 30-day incidence of stroke and death in patients undergoing carotid artery stenting with embolus protection: a post-hoc subanalysis of a prospective multicenter registry. J Endovasc Ther 14: 271–278

    Article  PubMed  Google Scholar 

  39. Schulz UG, Rothwell PM (2001) Sex differences in carotid bifurcation anatomy and the distribution of atherosclerotic plaque. Stroke 32: 1525–1531

    Article  PubMed  CAS  Google Scholar 

  40. Theiss W, Hermanek P, Mathias K et al. (2004) A prospective registry of carotid angioplasty and stenting. Stroke 35: 2134–2139

    Article  PubMed  Google Scholar 

  41. Yadav JS, Wholey MH, Kuntz RE et al. (2004) Protected carotid-artery stenting versus endarterectomy in high-risk patients. New England J Med 351: 1493–1501

    Article  CAS  Google Scholar 

  42. Zahn R, Ischinger T, Hochadel M et al. (2007) Carotid artery stenting in octogenarians: results from the ALKK Carotid Artery Stent (CAS) Registry. Eur Heart J 28: 370–375

    Article  PubMed  Google Scholar 

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  1. Abteilung Gefäßchirurgie, Chirurgische Klinik und Poliklinik der Technischen Universität München, Ismaningerstr. 22, 81675, München, Deutschland

    H.-H. Eckstein, A. Kühnl, H. Wendorff, J. Rehbock & A. Dirrigl

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  1. H.-H. Eckstein
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  2. A. Kühnl
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Correspondence to H.-H. Eckstein.

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Eckstein, HH., Kühnl, A., Wendorff, H. et al. Geschlechtsunterschiede in der operativen und endovaskulären Behandlung von Karotisstenosen. Gefässchirurgie 12, 413–420 (2007). https://doi.org/10.1007/s00772-007-0558-4

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