颈动脉内膜切除术和颈动脉支架置入术治疗伴有和不伴有高危标准的中风和死亡。
Stroke and death after carotid endarterectomy and carotid artery stenting with and without high risk criteria.
机构信息
Beth Israel Deaconess Medical Center, Division of Vascular and Endovascular Surgery, 110 Francis Street, Boston, MA 02115, USA.
出版信息
J Vasc Surg. 2010 Dec;52(6):1497-504. doi: 10.1016/j.jvs.2010.06.174. Epub 2010 Sep 22.
OBJECTIVE
Centers for Medicare and Medicaid Services (CMS) reimbursement criteria for carotid artery stenting (CAS) require that patients be high surgical risk or enrolled in a clinical trial. This may bias comparisons of CAS and carotid endarterectomy (CEA). We evaluate mortality and stroke following CAS and CEA stratified by medical high risk criteria.
METHODS
The Nationwide Inpatient Sample (2004-2007) was queried by ICD-9 code for CAS and CEA with diagnosis of carotid artery stenosis. Medical high risk criteria were identified for each patient including patients undergoing a coronary artery bypass and/or valve repair (CABG/V) during the same admission. Symptom status was defined by history of stroke, transient ischemic attack (TIA), and/or amarosis fugax. The primary outcome was postoperative death, stroke (complication code 997.02), and combined stroke or death, stratified by high risk vs non-high risk status and symptom status.
RESULTS
Patient totals of 56,564 (10.5%) CAS and 482,394 (89.5%) CEA were identified. Half of the patients in each group were high risk. CABG/V was performed less commonly with CAS than CEA (2.8% vs 4.0%, P < .001). Patients undergoing CAS were more likely symptomatic than those undergoing CEA (13.1% vs 9.4%, P < .001). Mortality was higher after CAS than CEA for both high risk and non-high risk patients. Stroke was also higher after CAS for both high risk and non-high risk patients. Combined stroke or death was higher after CAS again for both high risk (asymptomatic 1.5% vs 1.2%, P < .05, symptomatic 14.4% vs 6.9%, P < .001) and non-high risk (asymptomatic 1.8% vs 0.6%, P < .001, symptomatic 11.8% vs 4.9%, P < .001). Combined stroke or death for patients undergoing CABG/V during the same admission was similar for CAS and CEA (4.8% vs 3.2%, P = .19). Multivariate predictors of combined stroke or death adjusted for age and gender included CAS vs CEA (odds ratio [OR] 2.4, P < .001), symptom status (OR 6.8, P < .001), high risk (OR 1.6, P < .001), and earlier year of procedure (OR 1.1, P < .01).
CONCLUSIONS
In the United States from 2004 to 2007, CAS has a higher risk of stroke and death than CEA after adjustment for medical high risk criteria. Further analysis with prospective assessment of risk factors is needed to guide appropriate patient selection for CEA and CAS in the general population.
目的
医疗保险和医疗补助服务中心（CMS）对颈动脉支架置入术（CAS）的报销标准要求患者为高手术风险或参加临床试验。这可能会影响 CAS 和颈动脉内膜切除术（CEA）的比较。我们根据医疗高风险标准评估 CAS 和 CEA 后的死亡率和中风。
方法
通过 ICD-9 代码在全国住院患者样本（2004-2007 年）中查询 CAS 和 CEA，并伴有颈动脉狭窄的诊断。为每位患者确定了医疗高风险标准，包括在同一入院期间进行冠状动脉旁路移植术（CABG）/或瓣膜修复术（CABG/V）的患者。症状状态通过中风、短暂性脑缺血发作（TIA）和/或一过性黑矇的病史来定义。主要结果是手术后死亡、中风（并发症代码 997.02）以及中风或死亡的综合发生率，按高风险与非高风险状态和症状状态分层。
结果
共确定了 56564 例（10.5%）CAS 和 482394 例（89.5%）CEA。每组患者中有一半为高风险。与 CEA 相比，CAS 中 CABG/V 的发生率较低（2.8%比 4.0%，P<0.001）。接受 CAS 的患者比接受 CEA 的患者更有可能出现症状（13.1%比 9.4%，P<0.001）。高风险和非高风险患者的 CAS 术后死亡率均高于 CEA。高风险和非高风险患者的 CAS 术后中风发生率也高于 CEA。高风险患者的 CAS 术后中风或死亡的综合发生率再次高于 CEA（无症状患者为 1.5%比 1.2%，P<0.05，有症状患者为 14.4%比 6.9%，P<0.001），非高风险患者的 CAS 术后中风或死亡的综合发生率再次高于 CEA（无症状患者为 1.8%比 0.6%，P<0.001，有症状患者为 11.8%比 4.9%，P<0.001）。在同一入院期间接受 CABG/V 的患者，CAS 和 CEA 的中风或死亡综合发生率相似（4.8%比 3.2%，P=0.19）。多变量分析调整年龄和性别后，与 CEA 相比，CAS 的联合中风或死亡的预测因素包括 CAS（比值比[OR]2.4，P<0.001）、症状状态（OR 6.8，P<0.001）、高风险（OR 1.6，P<0.001）和手术年份较早（OR 1.1，P<0.01）。
结论
2004 年至 2007 年期间，在美国，根据医疗高风险标准调整后，CAS 中风和死亡的风险高于 CEA。需要进一步进行前瞻性风险因素评估分析，以指导一般人群中 CEA 和 CAS 的适当患者选择。
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