Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida.
JAMA Neurol. 2018 Jan 1;75(1):51-57. doi: 10.1001/jamaneurol.2017.3496.
The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) showed greater safety of carotid artery stenting (CAS) in patients younger than 70 years and carotid endarterectomy (CEA) in those older than 70 years. It is unknown how the result of CREST has influenced carotid revascularization choices in the United States.
To evaluate national patterns in CAS performance in patients older than 70 years in the post-CREST (2011-2014) compared with the pre-CREST (2007-2010) era.
DESIGN, SETTING, AND PARTICIPANTS: All adults older than 70 years undergoing carotid revascularization in the United States from 2007 to 2014 were retrospectively identified from the 2007-2014 National Inpatient Sample using International Classification of Disease, Ninth Revision procedural codes. From 61 324 882 unweighted hospitalizations contained in the 2007-2014 National Inpatient Sample, 494 733 weighted carotid revascularization admissions in adults older than 70 years were identified using International Classification of Disease, Ninth Revision procedural codes.
The proportion of CAS performed in all age groups over time was estimated and multivariable-adjusted models were used to compare the odds of receiving CAS in the pre-CREST with those in the post-CREST era in adults older than 70 years.
A total of 41.8% of all patients were women, and mean (SE) age at presentation was 78.1 (0.03) years. A total of 16.3% of CAS and 10.1% of CEA procedures were performed in patients with symptomatic stenosis. The proportion of patients older than 70 years receiving CAS increased from 11.9% in the pre-CREST to 13.8% in the post-CREST era (P = .005). In multivariable models, the odds of receiving CAS increased by 13% in all patients older than 70 years in the post-CREST compared with the pre-CREST period (odds ratio [OR], 1.13, 95% CI, 1.00-1.28, P = .04), including symptomatic women (OR, 1.31, 1.05-1.65, P = .02). Symptomatic stenosis (OR 1.39; 95% CI, 1.27-1.52; P < .001), congestive heart failure (OR, 1.48; 95% CI, 1.35-1.63; P < .001), and peripheral vascular disease (OR, 1.35; 95% CI, 1.27-1.43; P < .001) were associated with higher odds of CAS; comorbid hypertension (OR, 0.70; 95% CI, 0.66-0.74; P < .001), smoking (OR, 0.84; 95% CI, 0.78-0.91; P < .001), and weekend admission (OR, 0.77; 95% CI, 0.68-0.88; P < .001) were negatively associated with the odds of CAS.
Despite concerns for higher periprocedural complications with CAS in elderly patients, the odds of CAS increased in the post-CREST compared with pre-CREST era in patients older than 70 years, including symptomatic women.
颈动脉血管重建内膜切除术与支架置入术试验（CREST）表明，在 70 岁以下的患者中，颈动脉支架置入术（CAS）的安全性更高，而在 70 岁以上的患者中，颈动脉内膜切除术（CEA）的安全性更高。目前尚不清楚 CREST 的结果如何影响了美国颈动脉血运重建的选择。
评估在 CREST 后（2011-2014 年）与 CREST 前（2007-2010 年）相比，70 岁以上患者中接受 CAS 治疗的情况，以及在全国范围内的模式变化。
设计、地点和参与者：从 2007 年至 2014 年，使用国际疾病分类，第九修订版手术编码，从美国全国住院患者样本中回顾性地确定了所有 70 岁以上接受颈动脉血运重建的成年人。在包含 61324882 个未加权住院患者的 2007-2014 年全国住院患者样本中，使用国际疾病分类，第九修订版手术编码确定了 70 岁以上成人中 494733 个加权颈动脉血运重建入院。
估计了不同年龄段接受 CAS 的比例，并使用多变量调整模型比较了 CREST 前和 CREST 后 70 岁以上患者接受 CAS 的几率。
共有 41.8%的患者为女性，就诊时的平均（SE）年龄为 78.1（0.03）岁。16.3%的 CAS 和 10.1%的 CEA 手术是在有症状狭窄的患者中进行的。在 CREST 前，70 岁以上患者接受 CAS 的比例为 11.9%，在 CREST 后为 13.8%（P = .005）。在多变量模型中，与 CREST 前相比，CREST 后所有 70 岁以上患者接受 CAS 的几率增加了 13%（优势比[OR]，1.13，95%置信区间[CI]，1.00-1.28，P = .04），包括有症状的女性（OR，1.31，1.05-1.65，P = .02）。有症状的狭窄（OR 1.39；95%CI，1.27-1.52；P < .001）、充血性心力衰竭（OR，1.48；95%CI，1.35-1.63；P < .001）和外周血管疾病（OR，1.35；95%CI，1.27-1.43；P < .001）与接受 CAS 的几率较高相关；合并高血压（OR，0.70；95%CI，0.66-0.74；P < .001）、吸烟（OR，0.84；95%CI，0.78-0.91；P < .001）和周末入院（OR，0.77；95%CI，0.68-0.88；P < .001）与接受 CAS 的几率呈负相关。
尽管对老年患者 CAS 围手术期并发症的风险更高存在担忧，但与 CREST 前相比，在 70 岁以上的患者中，接受 CAS 的几率在 CREST 后增加，包括有症状的女性。
