Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
J Vasc Surg. 2011 Aug;54(2):376-85, 385.e1-3. doi: 10.1016/j.jvs.2011.01.032. Epub 2011 Mar 31.
We studied surgeons' practice patterns in the use of completion imaging (duplex or arteriography), and their association with 30-day stroke/death and 1-year restenosis after carotid endarterectomy (CEA).
Using a retrospective analysis of 6115 CEAs, we categorized surgeons based on use of completion imaging as rarely (<5% of CEAs), selective (5% to 90%), or routine (≥90%). Crude and risk-adjusted 30-day stroke/death and 1-year restenosis rates were examined across surgeon practice patterns. Finally, we audited 90 operative reports of patients who underwent re-exploration and characterized findings and interventions. We analyzed the effect of re-exploration on outcomes.
Practice patterns in completion imaging varied: 51% of surgeons performed completion imaging rarely, 22% selectively, and 27% routinely. Crude 30-day stroke/death rates were highest among surgeons who routinely used completion imaging (rarely: 1.7%; selectively: 1.2%, routinely: 2.4%; P = .05). However, after adjusting for patient characteristics predictive of stroke/death, the effect of surgeon practice pattern was not statistically significant (odds ratio [OR] for routine-use surgeons, 1.42; 95% CI, 0.93-2.17; P = .10; selective-use surgeons, 0.75; 95% CI, 0.40-1.41; P = .366). Stenosis >70% at 1 year showed a trend toward lowest rates for surgeons who performed completion imaging (rarely: 2.8%, selectively: 1.1%, and routinely: 1.1%; P = .09). This effect became statistically significant for selective-use surgeons after adjustment (hazard risk [HR] for selective-use surgeons, 0.52; 95% CI, 0.29-0.92; P = .02). Overall, 178 patients (2.9%) underwent operative re-exploration. Routine-use surgeons were most likely to perform re-exploration (7.6% routine, 0.8% selective, 0.9% rare; P < .001). An audit of 90 re-explored patients demonstrated technical problems, the most common being flap, debris, and plaque. Rates of stroke/death were higher among patients who underwent re-exploration (3.9% vs 1.7%; P = .03); however, this affect was attenuated after adjustment (OR, 2.1; 95% CI, 0.9-5.0; P = .08).
The use of completion imaging during CEA varies widely across our region. There is little evidence that surgeons who use completion imaging have lower rates of 30-day stroke/death, although selective use of completion imaging is associated with a small but a significant reduction in stenosis 1 year after surgery. We also demonstrate an association between re-exploration and higher risk of 30-day stroke/death, although this effect was attenuated after adjustment for patient-level predictors of stroke/death. Future work is needed to direct the selective use of completion imaging to prevent stroke, rather than cause unnecessary re-exploration.
我们研究了外科医生在使用完成成像（双功能或血管造影）方面的实践模式，以及其与颈动脉内膜切除术（CEA）后 30 天内卒中/死亡和 1 年内再狭窄的关系。
我们使用 6115 例 CEA 的回顾性分析，根据完成成像的使用情况将外科医生分为很少使用（<5%的 CEA）、选择性（5%至 90%）或常规（≥90%）使用。检查了不同外科医生实践模式下的 30 天内卒中/死亡和 1 年内再狭窄的粗率和风险调整后发生率。最后，我们审核了 90 例接受再次探查的患者的 90 份手术报告，并描述了发现和干预措施。我们分析了再次探查对结果的影响。
完成成像的使用模式差异很大：51%的外科医生很少使用完成成像，22%的外科医生选择性使用，27%的外科医生常规使用。常规使用完成成像的外科医生 30 天内卒中/死亡率最高（很少使用：1.7%；选择性使用：1.2%，常规使用：2.4%；P=0.05）。然而，在调整了预测卒中/死亡的患者特征后，外科医生实践模式的效果没有统计学意义（常规使用外科医生的比值比[OR]为 1.42；95%置信区间，0.93-2.17；P=0.10；选择性使用外科医生的 OR 为 0.75；95%置信区间，0.40-1.41；P=0.366）。1 年内狭窄>70%的患者，进行完成成像的外科医生的发生率最低（很少使用：2.8%，选择性使用：1.1%，常规使用：1.1%；P=0.09）。在调整后，选择性使用外科医生的这一效果具有统计学意义（选择性使用外科医生的危险比[HR]为 0.52；95%置信区间，0.29-0.92；P=0.02）。总体而言，178 例患者（2.9%）接受了手术再次探查。常规使用外科医生最有可能进行再次探查（常规使用：7.6%，选择性使用：0.8%，很少使用：0.9%；P<0.001）。对 90 例再次探查的患者进行了审核，发现了技术问题，最常见的是瓣、碎片和斑块。再次探查的患者卒中/死亡率更高（3.9%比 1.7%；P=0.03）；然而，调整后这种影响减弱（OR，2.1；95%置信区间，0.9-5.0；P=0.08）。
我们所在地区的 CEA 术中完成成像的使用差异很大。尽管选择性使用完成成像与术后 1 年内狭窄程度略有但显著降低有关，但没有证据表明使用完成成像的外科医生卒中/死亡率较低。我们还证明了再次探查与 30 天内卒中/死亡风险增加之间存在关联，尽管这种关联在调整了卒中/死亡的患者预测因素后有所减弱。需要进一步的工作来指导选择性使用完成成像以预防卒中，而不是导致不必要的再次探查。
