Avgerinos Efthymios D, Farber Alik, Abou Ali Adham N, Rybin Denis, Doros Gheorghe, Eslami Mohammad H
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, Mass.
J Vasc Surg. 2017 Dec;66(6):1719-1726. doi: 10.1016/j.jvs.2017.05.101. Epub 2017 Aug 19.
Timing of carotid endarterectomy (CEA) after onset of neurologic symptoms remains controversial. We assessed the association of CEA timing with postoperative outcomes.
The Vascular Study Group of New England (VSGNE) database (2003-2014) was queried to identify CEA performed for symptomatic carotid stenosis during the same hospitalization. Cases were divided into four groups based on the time from onset of neurologic symptoms to CEA: group I, <2 days; group II, 2 to 5 days; group III, ≥6 days; and group IV, same-day CEA. The χ test and t-test were used to compare demographics, medical history, modified Rankin scores, and outcomes (30-day postoperative death, stroke, myocardial infarction, and aggregate events [stroke/myocardial infarction]). Multivariable logistic regression was used to compare the association of time to surgery with outcomes while adjusting for confounding variables. Kaplan-Meier and Cox proportional hazards regression analyses were performed at 1 year to evaluate survival and stroke rates between the groups.
There were 989 of 14,864 VSGNE CEA cases that fit the inclusion criteria. The frequency of cases was highest in group II (36.6%), followed by groups I (31.9%), III (18.9%), and IV (12.4%). Age, gender, and comorbidity compositions were similar between groups, although group III had the highest rates of diabetes mellitus, coronary artery disease, coronary artery bypass graft procedures, congestive heart failure, and American Society of Anesthesiologists class 4 and the highest modified Rankin score (P < .05). Stroke rates were highest in group I (7.3%; P = .016), whereas group III had the highest rate of discharges to nursing facilities (37.2%; P < .001); other adverse outcomes were comparable among groups. CEAs in group I had significantly increased adjusted odds of stroke; adverse outcomes of CEAs in groups II and III were comparable to those in group IV.
Our results suggest that CEAs performed 2 to 5 days after a neurologic event have similar outcomes to CEAs performed ≥6 days later. Early CEA should be considered an area for quality improvement among these patients.
颈动脉内膜切除术（CEA）在神经系统症状出现后的时机选择仍存在争议。我们评估了CEA时机与术后结局的关联。
查询新英格兰血管研究组（VSGNE）数据库（2003 - 2014年），以确定在同一住院期间因症状性颈动脉狭窄而进行的CEA。根据从神经系统症状出现到CEA的时间，将病例分为四组：I组，<2天；II组，2至5天；III组，≥6天；IV组，同日CEA。采用χ检验和t检验比较人口统计学、病史、改良Rankin评分和结局（术后30天死亡、卒中、心肌梗死以及总事件[卒中/心肌梗死]）。使用多变量逻辑回归在调整混杂变量的同时比较手术时间与结局的关联。在1年时进行Kaplan - Meier和Cox比例风险回归分析，以评估各组之间的生存率和卒中率。
14,864例VSGNE的CEA病例中有989例符合纳入标准。病例频率在II组最高（36.6%），其次是I组（31.9%）、III组（18.9%）和IV组（12.4%）。各组之间年龄、性别和合并症构成相似，尽管III组糖尿病、冠状动脉疾病、冠状动脉搭桥手术、充血性心力衰竭以及美国麻醉医师协会4级的发生率最高，且改良Rankin评分最高（P <.05）。I组的卒中率最高（7.3%；P =.016），而III组转至护理机构的出院率最高（37.2%；P <.001）；其他不良结局在各组之间相当。I组CEA的调整后卒中几率显著增加；II组和III组CEA的不良结局与IV组相当。
我们的结果表明，在神经系统事件发生后2至5天进行的CEA与≥6天后进行的CEA结局相似。对于这些患者，早期CEA应被视为质量改进的一个领域。
