2021 ESC 主动脉和外周动脉疾病的抗栓治疗共识（二）

颈动脉支架置入术中的抗血栓治疗

DAPT（阿司匹林 氯吡格雷）是颈动脉支架置入术后的治疗标准，但最佳持续治疗时间存在争议。 ¹¹
两项共计150名患者的小型RCT比较了SAPT和DAPT在颈动脉支架术（CAS）中的应用，但两项试验均因SAPT组不可接受的神经系统事件发生率而提前中断（3对0卒中和11对1 TIA）。 ³⁰鉴于冠状动脉支架置入术的相关经验，大多数手术者倾向于在CAS后凭经验进行至少1个月的DAPT。在台湾的一项全国性注册中， ³¹2829名DAPT持续时间<30天、介于30-41天之间以及≥42天患者的6个月缺血性卒中、复合血管事件或死亡发生率存在相似性。有人提议针对接受CAS的单中心系列患者在DAPT的基础上加用西洛他唑，以便万一血小板对氯吡格雷存在耐受性情况下减少磁共振成像检测到的缺血性病变， ³²但该研究的扩展结果并没有显著减少临床事件。 ³³

颈动脉手术中的抗血栓治疗

在接受颈动脉内膜剥脱术（CEA）的患者中，使用阿司匹林治疗的围手术期和长期缺血事件减少已在试验（表1）和真实注册中获得证实。^6–9,34低剂量阿司匹林在30天MACE风险方面优于高剂量阿司匹林。¹⁰

与单用阿司匹林相比，在近期TIA/卒中患者中加用第二种抗血小板药物可以减少神经系统事件。³⁵一项收集三个DAPT与SAPT颈动脉治疗干预对比RCT数据（只有一个试验使用CEA）的荟萃分析表明，CEA之后，DAPT和SAPT间的致命性卒中不存在差异，但DAPT的大出血和颈部血肿风险显著更高。³⁰一项针对近期两个DAPT与单用阿司匹林治疗卒中或TIA患者对比大型RCT的汇总分析^24,25表明，前21天内的MACE显著降低[5.2%对7.8%；风险比（HR）0.66；95%置信区间（CI）0.56–0.77]，同时大出血事件没有显著增加。³⁶没有报告继发于颈动脉疾病卒中的特异性结果。

对于接受CEA的无症状患者，一项包括28683次程序的回顾性研究表明，DAPT与单用阿司匹林相比存在神经系统事件风险降低39%的相关性[比值比（OR）0.61；95% CI 0.43–0.87]，但代价是需要进行再次手术的出血率较高（OR 1.71；95% CI 1.20–2.42）。³⁷无症状患者的DAPT对比SAPT单一小型RCT对临床终点的效力不足；该试验表明手术前一天晚上单次75 mg氯吡格雷给药（在阿司匹林基础上加用）可显著降低术后前3小时内的栓塞率。³⁸在最近一项包括RCT³⁸和六个回顾性观察研究^37,39–43的荟萃分析中比较了CEA期间的DAPT（n=8536）与SAPT（n=27320），前者没有降低30天死亡率、卒中或TIA，而且增加了大出血事件（1.27%与0.83%；P=0.0003）和颈部血肿（8.19%与6.77%；P=0.001）。³⁰

椎动脉和锁骨下动脉狭窄患者的抗血栓治疗

没有对于椎动脉或锁骨下动脉狭窄病例使用抗血栓药物的证据，但考虑到这类患者的整体心血管风险，使用抗血栓药物具有合理性。^44,45

主动脉疾病

信息要点：主动脉疾病的抗血栓治疗

·对于重度/复杂主动脉斑块患者，建议进行长期SAPT。^*

·在发生可能与复杂主动脉斑块相关的栓塞事件后，可建议DAPT。

·可建议主动脉瘤（AA）患者使用SAPT降低一般心血管风险但尚无可靠证据证明能够减少动脉瘤的生长。

·对于急性主动脉综合征患者，尚无经过验证的长期抗血栓治疗。在急性期之后，如有明确指征（如机械瓣·膜或房颤的抗凝治疗），应维持抗血栓治疗。但必须使用成像技术进行密切监测。

·根据患者风险特征，建议在（T）EVAR之后进行长期SAPT。

主动脉斑块

40%–50%的中年个体存在主动脉斑块。⁴⁶疾病严重程度根据斑块厚度和溃疡形成/活动成分存在与否进行量化。⁴⁷主动脉弓斑块的大小和复杂性与脑血管事件存在相关性（或：4-9斑块≥4mm或复合物），⁴⁸但也可引起外周事件。尽管进行抗血栓治疗，卒中复发的年发生率仍高达12%。⁴⁹

一级预防鉴于成人主动脉斑块的患病率很高，并且缺乏在无症状主动脉斑块患者中使用阿司匹林的证据，以及阿司匹林一级预防的获益/风险比仍然存疑，因此为简单主动脉斑块开阿司匹林处方不具有合理性。推荐将SAPT，最好是氯吡格雷^18,50或低剂量阿司匹林，⁵¹用于治疗重度/复杂斑块。抗凝剂⁵¹或DAPT⁵⁰不但没有好处，还会增加出血风险，因此不适用。

二级预防在发生栓塞性TIA/卒中或主动脉斑块相关外周事件后，建议使用阿司匹林或氯吡格雷进行SAPT。DAPT或VKA（INR 2-3）可以讨论，但证据水平较低或尚不确定。^51,52尽管卒中后最初几周获益明显，但长期出血风险仍然较高，因此需要经过进一步的研究才能确定抗血栓治疗的最佳持续时间。无论是否存在主动脉斑块，抗血栓治疗的选择均应遵循现行指南。⁵³针对隐源性卒中，尚未发现利伐沙班15mg o.d.⁵⁴或达比加群110-150mg bid⁵⁵相对于低剂量阿司匹林的优效性。目前尚无继发于主动脉斑块卒中的特异性数据。

主动脉瘤

胸部或腹部（AAA）, AAs患者发生MACE的风险更高。^56–58 因此，尽管没有专门研究，SAPT（阿司匹林或氯吡格雷）用于没有禁忌症的患者存在合理性。⁵⁹ 不适用抗凝血剂的原因在于其与较高出血风险存在相关性。⁶⁰对于腔内血栓或闭塞性动脉瘤，考虑到壁血栓在动脉瘤进展中的作用，可以考虑进行抗凝治疗。⁶¹在包含144名未使用阿司匹林小AAA患者的RCT中，没有发现替格瑞洛和安慰剂对于动脉瘤1年生长中的差异。⁵⁶

急性主动脉综合征

在主动脉夹层急性期之后，三分之一的病例可能需要通过抗血栓治疗预防相关疾病（冠状动脉疾病、房颤、卒中、机械主动脉瓣假体、肺栓塞或外周栓塞）。这种治疗对于血栓形成的发生或扩展⁶²存在有利效果，并且与主要并发症（如主动脉生长、破裂或死亡）不存在相关性。⁶³尽管没有对壁内血肿后抗血栓治疗的作用进行纵向研究评估，但病例系列表明抗凝治疗不会影响壁内血肿的进展。所有急性主动脉综合征患者均应使用成像技术进行密切监测。如果进展不理想，则应考虑血管内或手术处理。^64,65

（胸）血管内主动脉置换术后的抗血栓治疗

（胸）血管内主动脉置换术[（T）EVARt]后抗血栓治疗的数据非常有限。但仍然推荐使用SAPT（如阿司匹林）避免长期心血管事件。⁶⁶仅有一项De Bruin等人⁶⁷涉及28名患者的研究在EVAR之前进行过DAPT给药，但没有描述伴随给药持续时间。在接受（T）EVAR和经皮冠状血管介入治疗的患者中，DAPT与出血率、内漏或复发性夹层的增加没有相关性。^68,69抗凝治疗与包括内漏、再干预、晚期转换手术、死亡在内的较高并发症发生率存在相关性。⁷⁰在接受（T）EVAR后，>20%的病例出现内移植物血栓衬里，其中三分之二保持稳定或消失。⁷¹这是因全身血液流变学因素（凝血障碍或肝素诱导性血小板减少症）、假体血流动力学或装置相关特征（覆盖聚酯的支架移植物或主动脉-单-髂内移植物）的复杂相互作用所致。⁷²其与血栓栓塞并发症没有相关性，因此，使用SAPT进行保守治疗仍为共识。终生口服抗凝治疗仅适用于血栓栓塞事件或血栓生长出血风险低的患者。对于出血风险较高的患者，建议中断抗凝治疗并重新植入新的内移植物。⁷³

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