Pothof Alexander B, Soden Peter A, Fokkema Margriet, Zettervall Sara L, Deery Sarah E, Bodewes Thomas C F, de Borst Gert J, Schermerhorn Marc L
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
J Vasc Surg. 2017 Dec;66(6):1727-1734.e2. doi: 10.1016/j.jvs.2017.04.032. Epub 2017 Jun 24.
Patients with contralateral carotid occlusion (CCO) have been excluded from randomized clinical trials because of a deemed high risk for adverse neurologic outcomes with carotid endarterectomy (CEA). Evidence for this rationale is limited and conflicting. Therefore, we aimed to compare outcomes after CEA between patients with and without CCO and varying degrees of contralateral carotid stenosis (CCS).
We identified patients undergoing CEA from 2003 to 2015 in the Vascular Study Group of New England (VSGNE) registry. Patients were stratified by preoperative symptom status and presence of CCO. Multivariable analysis was used to account for differences in demographics and comorbidities. Our primary outcome was 30-day stroke/death risk.
Of 15,487 patients we identified who underwent CEA, 10,377 (67%) were asymptomatic. CCO was present in 914 patients, of whom 681 (75%) were asymptomatic. Overall, the 30-day stroke/death was 2.0% for symptomatic patients (CCO: 2.6%) and 1.1% for asymptomatic patients (CCO: 2.3%). After adjustment, including symptom status, CCO was associated with higher 30-day stroke/death (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.4-3.3; P = .001), any in-hospital stroke (OR, 2.8; 95% CI, 1.7-4.6; P < .001), in-hospital ipsilateral stroke (OR, 2.2; 95% CI, 1.2-4.0; P = .02), in-hospital contralateral stroke (OR, 5.1; 95% CI, 2.2-11.4; P < .001), and prolonged length of stay (OR, 1.6; 95% CI, 1.3-1.9; P < .001). CCS of 80% to 99% was only associated with a prolonged length of stay (OR, 1.3; 95% CI, 1.1-1.6; P = .01), not with in-hospital stroke. Neither CCO nor CCS was associated with 30-day mortality.
Although CCO increases the risk of 30-day stroke/death, in-hospital strokes, and prolonged length of stay after CEA, the 30-day stroke/death rates in symptomatic and asymptomatic patients with CCO remain within the recommended thresholds set by the 14 societies' guideline document. Thus, CCO should not qualify as a high-risk criterion for CEA. Moreover, there is no evidence that patients with CCO have lower stroke/death rates after carotid artery stenting than after CEA. We believe that CEA remains a valid and safe option for patients with CCO and that CCO should not be applied as a criterion to promote carotid artery stenting per se.
对侧颈动脉闭塞（CCO）患者因被认为行颈动脉内膜切除术（CEA）出现不良神经学转归的风险较高，而被排除在随机临床试验之外。这一理论依据的证据有限且相互矛盾。因此，我们旨在比较有和没有CCO以及不同程度对侧颈动脉狭窄（CCS）的患者接受CEA后的转归。
我们在新英格兰血管研究组（VSGNE）登记处中确定了2003年至2015年期间接受CEA的患者。患者根据术前症状状态和CCO的存在情况进行分层。采用多变量分析来解释人口统计学和合并症方面的差异。我们的主要结局是30天卒中/死亡风险。
在我们确定的15487例行CEA的患者中，10377例（67%）无症状。914例患者存在CCO，其中681例（75%）无症状。总体而言，有症状患者的30天卒中/死亡率为2.0%（CCO：2.6%），无症状患者为1.1%（CCO：2.3%）。在进行包括症状状态在内的调整后，CCO与30天更高的卒中/死亡风险相关（比值比[OR]，2.1；95%置信区间[CI]，1.4 - 3.3；P = .001），与任何院内卒中相关（OR，2.8；95%CI，1.7 - 4.6；P < .001），与院内同侧卒中相关（OR，2.2；95%CI，1.2 - 4.0；P = .02），与院内对侧卒中相关（OR，5.1；95%CI，2.2 - 11.4；P < .001），以及与住院时间延长相关（OR，1.6；95%CI，1.3 - 1.9；P < .001）。80%至99%的CCS仅与住院时间延长相关（OR，1.3；95%CI，1.1 - 1.6；P = .01），与院内卒中无关。CCO和CCS均与30天死亡率无关。
虽然CCO会增加CEA后30天卒中/死亡、院内卒中和住院时间延长的风险，但有CCO的有症状和无症状患者的30天卒中/死亡率仍在14个学会的指南文件设定的推荐阈值范围内。因此，CCO不应被视为CEA的高风险标准。此外，没有证据表明CCO患者行颈动脉支架置入术后的卒中/死亡率低于CEA术后。我们认为CEA对CCO患者仍然是一种有效且安全的选择，并且CCO本身不应被用作推广颈动脉支架置入术的标准。
