Kang Jeanwan L, Chung Thomas K, Lancaster Robert T, Lamuraglia Glenn M, Conrad Mark F, Cambria Richard P
Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.
J Vasc Surg. 2009 Feb;49(2):331-8, 339.e1; discussion 338-9. doi: 10.1016/j.jvs.2008.09.018.
Carotid endarterectomy (CEA) is the standard treatment of carotid stenosis for symptomatic and asymptomatic patients. Carotid angioplasty and stenting (CAS), however, has been proposed as alternative therapy for patients deemed at high-risk for CEA. This study examined 30-day adjudicated outcomes in a contemporary series of CEAs and assessed the validity of criteria used to define a potential high-risk patient population for CEA.
Patients undergoing isolated CEA in private sector hospitals between Jan 1, 2005, and Dec 31, 2006, were identified using the prospectively gathered National Surgical Quality Improvement Program database. The primary study end points were 30-day stroke and death rates. Demographic, preoperative, and intraoperative variables were examined using multivariate models to identify variables associated with the study end points. Variables used to define systemic "high-risk" patients in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study (active cardiac disease, severe chronic obstructive pulmonary disease, and octogenarian status) were examined individually and in composite fashion for association with study endpoints.
Of the 3949 CEAs performed, 59% were in men, 30% were "high-risk" (19% age >80), and 43% had a previous neurologic event. The 30-day stroke rate was 1.6%, the death rate was 0.7%, and combined stroke/death rate was 2.2%. Multivariate analysis showed that intraoperative transfusion (odds ratio [OR], 5.95; 95% confidence interval [CI], 1.71-20.66; P = .005), prior major stroke (OR, 5.34; 95% CI, 2.96-9.64; P < .0001), shorter height (surrogate for small artery size; OR, 1.09; 95% CI, 1.02-1.16; P = .010), and increased anesthesia time (OR, 1.02; 95% CI, 1.00-1.03; P = .008) were predictive of stroke. Critical limb ischemia (OR, 12.72; 95% CI, 3.49-46.40; P < .0001) and poor functional status (OR, 7.05; 95% CI, 2.95-16.82; P < .0001) were independent correlates of death. Systemic high-risk variables, either combined or individually, did not increase risk of stroke or death on multivariate analysis.
CEA is associated with favorable 30-day outcomes across a spectrum of patient comorbidity features including octogenarian status. Anatomic and technical features are the important predictors of perioperative stroke, whereas critical limb ischemia and poor functional status are important predictors of death for patients undergoing CEA. These data refute the concept that CAS is preferred for patients deemed high-risk by virtue of systemic comorbidities.
颈动脉内膜切除术（CEA）是有症状和无症状颈动脉狭窄患者的标准治疗方法。然而，对于被认为CEA高风险的患者，颈动脉血管成形术和支架置入术（CAS）已被提议作为替代疗法。本研究调查了一系列当代CEA患者的30天判定结局，并评估了用于定义潜在CEA高风险患者群体的标准的有效性。
利用前瞻性收集的国家外科质量改进计划数据库，确定2005年1月1日至2006年12月31日期间在私立医院接受单纯CEA的患者。主要研究终点是30天卒中率和死亡率。使用多变量模型检查人口统计学、术前和术中变量，以确定与研究终点相关的变量。单独和综合检查用于定义高危内膜切除术患者支架置入和血管成形术保护（SAPPHIRE）研究中全身“高风险”患者的变量（活动性心脏病、严重慢性阻塞性肺疾病和八旬老人状态）与研究终点的关联。
在实施的3949例CEA中，59%为男性，30%为“高风险”（19%年龄>80岁），43%曾有神经系统事件。30天卒中率为1.6%，死亡率为0.7%，卒中/死亡合并率为2.2%。多变量分析显示，术中输血（比值比[OR]，5.95；95%置信区间[CI]，1.71 - 20.66；P = 0.005）、既往重大卒中（OR，5.34；95% CI，2.96 - 9.64；P < 0.0001）、身高较短（小动脉大小的替代指标；OR，1.09；95% CI，1.02 - 1.16；P = 0.010）和麻醉时间延长（OR，1.02；95% CI，1.00 - 1.03；P = 0.008）可预测卒中。严重肢体缺血（OR，12.72；95% CI，3.49 - 46.40；P < 0.0001）和功能状态差（OR，7.05；95% CI，2.95 - 16.82；P < 0.0001）是死亡的独立相关因素。多变量分析显示，全身高风险变量单独或综合起来均未增加卒中或死亡风险。
CEA在包括八旬老人状态在内的一系列患者合并症特征中，与良好的30天结局相关。解剖和技术特征是围手术期卒中的重要预测因素，而严重肢体缺血和功能状态差是CEA患者死亡的重要预测因素。这些数据反驳了因全身合并症被认为高风险的患者首选CAS的观点。
