From the Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital (L.K.K., D.C.Y., R.V.S., R.M.M., P.M.O., S.C.W., G.B., H.S., D.N.F.); Department of Developmental Biology, Harvard School of Dental Medicine, Boston, MA (M.K.L.); Division of Biostatistics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, New York, NY (X.S.); Department of Cardiovascular Medicine, Pennsylvania Hospital-University of Pennsylvania Health System, Philadelphia (D.J.M.); and Department of Orthodontics College of Dentistry, University of Iowa, Iowa City (V.A.).
Circ Cardiovasc Interv. 2014 Oct;7(5):692-700. doi: 10.1161/CIRCINTERVENTIONS.113.001338. Epub 2014 Aug 12.
Given the controversy regarding whether carotid endarterectomy (CEA) or carotid artery stenting (CAS) may be superior for stroke prevention, it is uncertain how recent clinical evidence, guidelines, and reimbursement policies have influenced the volume and outcomes after these procedures.
We conducted a serial, cross-sectional study with time trends of patients undergoing CAS (n=124 265) and CEA (n=1 260 647) between 2001 and 2010 from the Nationwide Inpatient Sample database. During the 10-year period, the frequency of CEA declined, whereas CAS use slowly increased. After multivariate propensity score-matched analysis, CAS was associated with an increased risk of death (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.40-2.04), stroke (OR, 1.43; 95% CI, 1.23-1.66), and major adverse events including death, stroke, and myocardial infarction (OR, 1.25; 95% CI, 1.13-1.39). In asymptomatic patients, there was no significant difference in major adverse events (OR, 1.08; 95% CI, 0.92-1.20; P=0.16 [P <0.001 for interaction between procedure type and symptom status]) between CAS and CEA. Importantly, there was a significant improvement in CAS outcomes during the course of 10 years (reduction in death [OR, 0.51; 95% CI, 0.49-0.67; P for trend=0.03] and major adverse events [OR, 0.75; 95% CI, 0.66-0.84; P for trend=0.05] comparing years 2010 versus 2001).
In US hospitals between 2001 and 2010, CAS was associated with worse in-hospital outcomes, partly attributable to selection and ascertainment bias. Asymptomatic patients undergoing CAS versus CEA had similar adjusted rates of major adverse events. CAS outcomes improved significantly during the course of the decade likely attributable to improvements in patient selection, operator skills, and technological advancements.
鉴于颈动脉内膜切除术（CEA）和颈动脉血管成形术（CAS）在预防中风方面孰优孰劣存在争议，因此目前尚不清楚最近的临床证据、指南和报销政策如何影响这些手术的数量和结果。
我们从 2001 年至 2010 年的全国住院患者样本数据库中进行了一项连续的、横断面研究，其中包括颈动脉内膜切除术（n=124265 例）和颈动脉血管成形术（n=1260647 例）的时间趋势。在这 10 年期间，CEA 的频率下降，而 CAS 的使用则缓慢增加。经过多变量倾向评分匹配分析后，CAS 与死亡（比值比[OR]，1.69；95%置信区间[CI]，1.40-2.04）、中风（OR，1.43；95%CI，1.23-1.66）和包括死亡、中风和心肌梗死在内的主要不良事件（OR，1.25；95%CI，1.13-1.39）的风险增加相关。在无症状患者中，CAS 和 CEA 之间在主要不良事件方面无显著差异（OR，1.08；95%CI，0.92-1.20；P=0.16[P＜0.001 用于程序类型和症状状态之间的交互]）。重要的是，在 10 年期间 CAS 的结果有了显著改善（死亡率[OR，0.51；95%CI，0.49-0.67；P＜0.001 趋势]和主要不良事件[OR，0.75；95%CI，0.66-0.84；P＜0.001 趋势]比较 2010 年与 2001 年）。
在 2001 年至 2010 年期间，美国医院中 CAS 与住院期间的不良结局相关，部分原因是选择和确定偏倚。接受 CAS 与 CEA 的无症状患者之间主要不良事件的调整后发生率相似。在这十年中，CAS 的结果显著改善，可能归因于患者选择、操作人员技能和技术进步的提高。
