Division of Vascular Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Department of Radiology Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea.
Eur J Vasc Endovasc Surg. 2017 Nov;54(5):573-578. doi: 10.1016/j.ejvs.2017.08.006. Epub 2017 Oct 12.
OBJECTIVE/BACKGROUND: Despite randomised evidence, the debate continues about the preferred treatment strategy for carotid stenosis in routine clinical practice. The aim of this study was to compare early outcomes and restenosis rates after carotid endarterectomy (CEA) and carotid stenting (CAS) in unselected patients using propensity score matching (PSM).
The 30 day incidence of major adverse clinical events (MACE; defined as stroke, transient ischaemic attack, myocardial infarction, or death) and procedure related complications, as well as restenosis rates during follow-up were compared between unselected patients undergoing CEA or CAS between January 2002 and December 2015 at a single institution. PSM was used to balance the following factors between the CEA and CAS cohorts: age, sex, hypertension, diabetes, dyslipidaemia, smoking, atrial fibrillation, previous percutaneous coronary intervention or coronary artery bypass grafting, valvular heart disease, contralateral carotid occlusion, degree of carotid stenosis, and symptomatic status. Statistical comparisons of outcomes were based on logistic regression analysis and log rank test.
Of 1184 patients (654 CEA and 530 CAS), 452 PSM pairs of CEA and CAS patients were created. The CAS group showed a relatively higher 30 day incidence of MACE (7.5% vs. 2.4%; odds ratio [OR] 3.261, 95% confidence interval [CI] 1.634-6.509; p = .001) but a lower incidence of procedure related complications (1.5% vs. 5.3%; OR 0.199, 95% CI 0.075-0.528; p = .001). During a mean follow-up of 49.1 months (range 1-180 months), restenosis rates were higher after CAS than after CEA (1.5% vs. 1.0% at 12 months and 5.4% vs. 1.2% at 24 months, respectively; p = .008).
This PSM based observation reconfirmed previous trial results in both asymptomatic and symptomatic patients with carotid artery stenosis in routine clinical practice: CEA showed lower 30 day MACE and mid-term restenosis rates than CAS.
目的/背景：尽管有随机对照证据，但在常规临床实践中，关于颈动脉狭窄的首选治疗策略仍存在争议。本研究旨在通过倾向评分匹配（PSM）比较未经选择的患者行颈动脉内膜切除术（CEA）和颈动脉支架置入术（CAS）的早期结局和再狭窄率。
在单中心回顾性研究中，比较了 2002 年 1 月至 2015 年 12 月间行 CEA 或 CAS 的未经选择的患者在 30 天内主要不良临床事件（MACE；定义为卒中、短暂性脑缺血发作、心肌梗死或死亡）和手术相关并发症的发生率，以及随访期间的再狭窄率。PSM 用于平衡 CEA 和 CAS 队列之间的以下因素：年龄、性别、高血压、糖尿病、血脂异常、吸烟、心房颤动、经皮冠状动脉介入治疗或冠状动脉旁路移植术、心脏瓣膜病、对侧颈动脉闭塞、颈动脉狭窄程度和症状状态。结局的统计学比较基于逻辑回归分析和对数秩检验。
在 1184 例患者（654 例行 CEA 和 530 例行 CAS）中，创建了 452 对 CEA 和 CAS 患者的 PSM 。CAS 组 30 天 MACE 的发生率相对较高（7.5%比 2.4%；比值比[OR]3.261，95%置信区间[CI]1.634-6.509；p=0.001），但手术相关并发症的发生率较低（1.5%比 5.3%；OR 0.199，95%CI 0.075-0.528；p=0.001）。在平均 49.1 个月（1-180 个月）的随访中，CAS 后的再狭窄率高于 CEA（12 个月时分别为 1.5%和 1.0%，24 个月时分别为 5.4%和 1.2%；p=0.008）。
本研究基于 PSM 的观察结果在常规临床实践中再次证实了之前在无症状和有症状的颈动脉狭窄患者中进行的试验结果：CEA 比 CAS 具有更低的 30 天 MACE 和中期再狭窄率。
