Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
JACC Cardiovasc Interv. 2014 Nov;7(11):1307-17. doi: 10.1016/j.jcin.2014.05.027. Epub 2014 Oct 15.
This study sought to examine operator experience measured by time-related variables on outcomes with protected carotid artery stenting (CAS).
Studies on experience have focused on operator and institutional CAS volumes alone in the absence of a better metric.
Using the CHOICE (Carotid Stenting for High Surgical-Risk Patients; Evaluating Outcomes Through the Collection of Clinical Evidence) multicenter prospective data from October 1, 2006 to June 1, 2012, 5,841 evaluable subjects were identified. Operator experience within this study was assessed using 5 variables for each operator: 1) baseline CAS volume; 2) time from first CAS to each subsequent CAS; 3) time between each CAS; 4) CAS volume in the institution; and 5) medical specialty (cardiology, surgery, or radiology/neurology). Institutional experience was determined by CAS volume within the study. Embolic protection device dwell time was used to assess technical performance, and 30-day death, stroke, or myocardial infarction composed the clinical outcome. Hierarchical logistic regression and linear mixed models were used.
Cardiologists (p < 0.001) along with operators with longer time interval from first CAS (p < 0.001) had reduced embolic protection device dwell times (technical performance). Increased time interval between CAS was the only independent predictor of 30-day death, stroke, or myocardial infarction (adjusted odds ratio: 1.05, 95% confidence interval: 1.02 to 1.09, p = 0.005). Prolonged embolic protection device dwell time was associated with 30-day death, stroke, or myocardial infarction (adjusted odds ratio: 1.08; 95% confidence interval: 1.01 to 1.17; p = 0.03).
The time interval between CAS procedures, specialty assignment, and time from first CAS are important measures of operator experience that may significantly affect technical performance and clinical outcome.
本研究旨在探讨以时间相关变量衡量的术者经验对颈动脉保护支架置入术（CAS）结果的影响。
既往研究主要关注术者和机构 CAS 量，而忽略了更好的评估指标。
利用 2006 年 10 月 1 日至 2012 年 6 月 1 日 CHOICE（高手术风险患者颈动脉支架置入术；通过临床证据收集评估结果）多中心前瞻性数据，共确定了 5841 例可评估患者。本研究中术者经验通过 5 个变量评估：1）基线 CAS 量；2）首次 CAS 到后续每次 CAS 的时间；3）每次 CAS 之间的时间；4）机构内 CAS 量；5）医学专业（心脏病学、外科学或放射学/神经病学）。机构经验由研究内的 CAS 量决定。栓塞保护装置的留置时间用于评估技术性能，30 天内的死亡、卒中和心肌梗死构成临床结局。采用分层逻辑回归和线性混合模型进行分析。
心脏病专家（p<0.001）和首次 CAS 间隔时间较长的术者（p<0.001）的栓塞保护装置留置时间更短（技术性能更优）。CAS 间隔时间延长是 30 天内死亡、卒中和心肌梗死的唯一独立预测因素（调整后的优势比：1.05，95%置信区间：1.02 至 1.09，p=0.005）。栓塞保护装置留置时间延长与 30 天内死亡、卒中和心肌梗死相关（调整后的优势比：1.08；95%置信区间：1.01 至 1.17；p=0.03）。
CAS 操作之间的时间间隔、专业分工以及首次 CAS 后的时间是术者经验的重要衡量指标，可能显著影响技术性能和临床结局。
