Groeneveld Peter W, Yang Lin, Greenhut Alexis, Yang Feifei
Department of Medicine, Philadelphia Veterans Affairs Medical Center, USA.
J Vasc Surg. 2009 Nov;50(5):1040-8. doi: 10.1016/j.jvs.2009.05.054. Epub 2009 Jul 22.
Carotid arterial stent (CAS) systems are an alterative to carotid endarterectomy for the treatment of moderate to severe carotid stenosis, but the effectiveness of CAS compared to endarterectomy in preventing stroke and death is uncertain. This study's objective was to compare the clinical outcomes among Medicare beneficiaries undergoing carotid revascularization before and after CAS became widely available.
This observational, retrospective cohort study compared 46,784 patients undergoing carotid revascularization from August 2005-March 2006 (the coverage era) to propensity-score-matched patients undergoing carotid revascularization between October 2002-September 2004 (the pre-coverage era), before widespread Medicare coverage of CAS.
Mortality was compared at 90 and 270 days after revascularization, as were the combined outcomes of periprocedural acute myocardial infarction and any stroke or death within 90 and 270 days after revascularization, between the two eras. Comparisons were also made between localities with high (23% of carotid procedures being CAS) and lower (9% of carotid procedures being CAS) adoption rates of carotid stents during the coverage era.
There were no significant differences in 90-day mortality (2.2% vs 2.2%; P = .79), 90-day combined outcomes (4.5% vs 4.3%; P = .13), or 270-day mortality (4.8% vs 4.6%; P = .17) between the coverage and pre-coverage eras, but there were more 270-day combined outcomes in the coverage era (7.7% vs 7.3%; P = .03). In localities with higher adoption of carotid stents, there was higher 90-day mortality (adjusted odds ratio [OR] 1.15; P = .16), 90-day combined outcomes (OR = 1.17; P = .03), 270-day mortality (OR = 1.13; P = .07), and 270-day combined outcomes (OR = 1.10; P = .09) in the coverage era. There were no differences in event rates between eras in areas with lower carotid stent adoption.
The adoption of carotid stents for treatment of carotid stenosis was associated with increased rates of adverse clinical outcomes after carotid revascularization.
颈动脉支架（CAS）系统是治疗中度至重度颈动脉狭窄的一种替代颈动脉内膜切除术的方法，但与内膜切除术相比，CAS在预防中风和死亡方面的有效性尚不确定。本研究的目的是比较在CAS广泛应用之前和之后接受颈动脉血运重建的医疗保险受益人的临床结局。
这项观察性回顾性队列研究比较了2005年8月至2006年3月（覆盖期）接受颈动脉血运重建的46784例患者与在2002年10月至2004年9月（覆盖前期）接受倾向评分匹配的颈动脉血运重建患者，此时CAS尚未被医疗保险广泛覆盖。
比较两个时期血运重建后90天和270天的死亡率，以及血运重建后90天和270天内围手术期急性心肌梗死与任何中风或死亡的综合结局。还对覆盖期内颈动脉支架采用率高（23%的颈动脉手术为CAS）和低（9%的颈动脉手术为CAS）的地区进行了比较。
覆盖期和覆盖前期之间在90天死亡率（2.2%对2.2%；P = 0.79）、90天综合结局（4.5%对4.3%；P = 0.13）或270天死亡率（4.8%对4.6%；P = 0.17）方面无显著差异，但覆盖期的270天综合结局更多（7.7%对7.3%；P = 0.03）。在颈动脉支架采用率较高的地区，覆盖期的90天死亡率（调整优势比[OR]1.15；P = 0.16）、90天综合结局（OR = 1.17；P = 0.03）、270天死亡率（OR = 1.13；P = 0.07）和270天综合结局（OR = 1.10；P = 0.09）更高。在颈动脉支架采用率较低的地区，两个时期的事件发生率无差异。
采用颈动脉支架治疗颈动脉狭窄与颈动脉血运重建后不良临床结局发生率增加有关。
