Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
J Vasc Surg. 2013 Mar;57(3):627-34. doi: 10.1016/j.jvs.2012.09.036. Epub 2013 Jan 9.
Perioperative stroke and death (PSD) are more common after carotid artery stenting (CAS) than after carotid endarterectomy (CEA) in symptomatic patients, but whether this is also true in asymptomatic patients is unclear. Furthermore, use of both CEA and CAS varies geographically, suggesting possible variation in outcomes. We compared odds of PSD after CAS and CEA in asymptomatic patients to determine the impact of this variation.
We identified CAS and CEA procedures and hospitals where they were performed from 2005 to 2009 California hospital discharge data. Preoperative symptom status and medical comorbidities were determined using administrative codes. We compared PSD rates after CAS and CEA using logistic regression and propensity score matching. We quantified hospital-level variation in the relative utilization of CAS by calculating hospital-specific probabilities of CAS use among propensity score-matched patients. We then calculated a weighted average for each hospital and used this as a predictor of PSD.
We identified 6053 CAS and 36,524 CEA procedures that were used to treat asymptomatic patients in 278 hospitals. Perioperative stroke and death occurred in 250 CAS and 660 CEA patients, yielding unadjusted PSD rates of 4.1% and 1.8%, respectively (P < .001). Compared with CAS patients, CEA patients were more likely to be older than 70 years (66% vs 62%; P < .001) but less likely to have three or more Elixhauser comorbidities (37% vs 39%; P < .001). Multivariate models demonstrated that CAS was associated with increased odds of PSD (odds ratio [OR], 1.865; 95% confidence interval [CI], 1.373-2.534; P < .001). Estimation of average treatment effects based on propensity scores also demonstrated 1.9% increased probability of PSD with CAS (P < .001). The average probability of receiving CAS across all hospitals and strata was 13.8%, but the interquartile range was 0.9% to 21.5%, suggesting significant hospital-level variation. In univariate analysis, patients treated at hospitals with higher CAS utilization had higher odds of PSD compared with patients in hospitals that performed CAS less (OR, 2.141; 95% CI, 1.328-3.454; P = .002). Multivariate analysis did not demonstrate this effect but again demonstrated higher odds of PSD after CAS (OR, 1.963; 95% CI, 1.393-2.765; P < .001).
Carotid endarterectomy has lower odds of PSD compared with CAS in asymptomatic patients. Increased utilization of CAS at the hospital level is associated with increased odds of PSD among asymptomatic patients, but this effect appears to be related to generally worse outcomes after CAS compared with CEA.
在有症状的患者中，颈动脉支架置入术（CAS）后围手术期卒中（PSD）和死亡（stroke and death，PSD）比颈动脉内膜切除术（CEA）更为常见，但在无症状患者中是否也是如此尚不清楚。此外，CEA 和 CAS 的使用在地域上存在差异，这表明结果可能存在差异。我们比较了无症状患者接受 CAS 和 CEA 后 PSD 的几率，以确定这种差异的影响。
我们从 2005 年至 2009 年加利福尼亚州医院出院数据中确定了 CAS 和 CEA 手术以及进行这些手术的医院。使用行政代码确定术前症状状态和合并症。我们使用逻辑回归和倾向评分匹配比较了 CAS 和 CEA 后的 PSD 发生率。我们通过计算倾向评分匹配患者中 CAS 使用的医院特异性概率，量化了 CAS 相对使用的医院水平差异。然后，我们计算了每个医院的加权平均值，并将其用作 PSD 的预测因子。
我们在 278 家医院中确定了 6053 例 CAS 和 36524 例 CEA 手术，用于治疗无症状患者。250 例 CAS 和 660 例 CEA 患者发生围手术期卒中，未调整的 PSD 发生率分别为 4.1%和 1.8%（P <.001）。与 CAS 患者相比，CEA 患者更有可能大于 70 岁（66% vs 62%；P <.001），但合并症 Elixhauser 评分大于 3 分的可能性较小（37% vs 39%；P <.001）。多变量模型表明，CAS 与 PSD 的几率增加相关（比值比 [OR]，1.865；95%置信区间 [CI]，1.373-2.534；P <.001）。基于倾向评分的平均治疗效果估计也表明，CAS 使 PSD 的概率增加了 1.9%（P <.001）。所有医院和分层的 CAS 平均使用率为 13.8%，但四分位距为 0.9%至 21.5%，表明存在显著的医院水平差异。在单变量分析中，与 CAS 使用率较低的医院相比，在 CAS 使用率较高的医院接受治疗的患者 PSD 的几率更高（OR，2.141；95% CI，1.328-3.454；P =.002）。多变量分析并未显示出这种效果，但再次表明 CAS 后 PSD 的几率更高（OR，1.963；95% CI，1.393-2.765；P <.001）。
在无症状患者中，CEA 后 PSD 的几率低于 CAS。CAS 在医院层面的使用增加与无症状患者的 PSD 几率增加有关，但这种影响似乎与 CAS 后总体较差的结果有关，而不是 CEA。
