Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York.
Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina.
JACC Cardiovasc Interv. 2017 Feb 13;10(3):286-298. doi: 10.1016/j.jcin.2016.11.032.
The aim of this study was to compare trends and outcomes of 3 approaches to carotid revascularization in the coronary artery bypass graft (CABG) population when performed during the same hospitalization.
The optimal approach to managing coexisting severe carotid and coronary disease remains controversial. Carotid endarterectomy (CEA) or carotid artery stenting (CAS) are used to decrease the risk of stroke in patients with carotid disease undergoing CABG surgery.
The authors conducted a serial, cross-sectional study with time trends of 3 revascularization groups during the same hospital admission: 1) combined CEA+CABG; 2) staged CEA+CABG; and 3) staged CAS+CABG from the Nationwide Inpatient Sample database 2004 to 2012. The primary composite endpoints were in-hospital all-cause death, stroke, and death/stroke.
During the 9-year period, 22,501 concurrent carotid revascularizations and CABG surgeries during the same hospitalization were performed. Of these, 15,402 (68.4%) underwent combined CEA+CABG, 6,297 (28.0%) underwent staged CEA+CABG, and 802 (3.6%) underwent staged CAS+CABG. The overall rate of CEA+CABG decreased by 16.1% (p = 0.03) from 2004 to 2012, whereas the rate of CAS+CABG did not significantly change during these years (p = 0.10). The adjusted risk of death was greater, whereas risk of stroke was lower with both combined CEA+CABG (death odds ratio [OR]: 2.08, 95% confidence interval [CI]: 1.08 to 3.97; p = 0.03; stroke OR: 0.65, 95% CI: 0.42 to 1.01; p = 0.06) and staged CEA+CABG (death OR: 2.40, 95% CI: 1.43 to 4.05; p = 0.001; stroke OR: 0.50, 95% CI: 0.31 to 0.80; p = 0.004) approaches compared with CAS+CABG. The adjusted risk of death or stroke was similar in the 3 groups.
In patients with concomitant carotid and coronary disease undergoing combined revascularization, combined CEA+CABG is utilized most frequently, followed by staged CEA+CABG and staged CAS+CABG strategies. The staged CAS+CABG strategy was associated with lower risk of mortality, but higher risk of stroke. Future studies are needed to examine the risks/benefits of different carotid revascularization strategies for high-risk patients requiring concurrent CABG.
本研究旨在比较在同一住院期间对冠状动脉旁路移植术（CABG）患者进行的 3 种颈动脉血运重建方法的趋势和结果。
管理并存的严重颈动脉和冠状动脉疾病的最佳方法仍存在争议。颈动脉内膜切除术（CEA）或颈动脉支架置入术（CAS）用于降低接受 CABG 手术的颈动脉疾病患者中风的风险。
作者从 2004 年至 2012 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，研究了 3 种血运重建组在同一住院期间的时间趋势：1）联合 CEA+CABG；2）分期 CEA+CABG；3）分期 CAS+CABG。主要复合终点是住院期间全因死亡、中风和死亡/中风。
在 9 年期间，进行了 22501 例同时进行颈动脉血运重建和 CABG 的手术。其中，15402 例（68.4%）接受了联合 CEA+CABG，6297 例（28.0%）接受了分期 CEA+CABG，802 例（3.6%）接受了分期 CAS+CABG。从 2004 年到 2012 年，联合 CEA+CABG 的总体比例下降了 16.1%（p=0.03），而同期 CAS+CABG 的比例没有显著变化（p=0.10）。联合 CEA+CABG（死亡比值比[OR]：2.08，95%置信区间[CI]：1.08 至 3.97；p=0.03；中风 OR：0.65，95%CI：0.42 至 1.01；p=0.06）和分期 CEA+CABG（死亡 OR：2.40，95%CI：1.43 至 4.05；p=0.001；中风 OR：0.50，95%CI：0.31 至 0.80；p=0.004）的风险更高，而风险较低。与 CAS+CABG 相比，在联合 CEA+CABG 和分期 CEA+CABG 两种方法中，调整后的死亡率和中风率相似。
在同时患有颈动脉和冠状动脉疾病的患者中，联合进行血运重建时，最常采用联合 CEA+CABG，其次是分期 CEA+CABG 和分期 CAS+CABG 策略。分期 CAS+CABG 策略与较低的死亡率风险相关，但中风风险较高。未来需要研究不同颈动脉血运重建策略对需要同时进行 CABG 的高危患者的风险/获益。
