颈动脉内膜切除术与颈动脉支架置入术治疗后长期死亡率的比较分析。
A comparative analysis of long-term mortality after carotid endarterectomy and carotid stenting.
机构信息
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.
出版信息
J Vasc Surg. 2019 Jan;69(1):104-109. doi: 10.1016/j.jvs.2018.03.432. Epub 2018 Jun 15.
BACKGROUND
The value of carotid intervention is predicated on long-term survival for patients to derive a stroke prevention benefit. Randomized trials report no significant difference in survival after carotid endarterectomy (CEA) vs carotid artery stenting (CAS), whereas observational studies of "real-world" outcomes note that CEA is associated with a survival advantage. Our objective was to examine long-term mortality after CEA vs CAS using a propensity-matched cohort.
METHODS
We studied all patients who underwent CEA or CAS within the Vascular Quality Initiative from 2003 to 2013 (CEA, n = 29,235; CAS, n = 4415). Long-term mortality information was obtained by linking patients in the registry to their respective Medicare claims file. We assessed the long-term rate of mortality for CEA and CAS using Kaplan-Meier estimation. We assessed the crude, adjusted, and propensity-matched (total matched pairs, n = 4261) hazard ratio (HR) of mortality for CEA vs CAS using Cox regression.
RESULTS
The unadjusted Kaplan-Meier estimated 5-year mortality was 14.0% for CEA and 18.3% for CAS. The crude HR of all-cause mortality for CEA vs CAS was 0.75 (95% confidence interval [CI], 0.70-0.81), indicating that patients who underwent CEA were 25% less likely to die before those who underwent CAS. This survival advantage persisted after adjustment for age, sex, and comorbidities (adjusted HR, 0.75; 95% CI, 0.69-0.82). This effect was confirmed on a propensity-matched analysis, with an HR of 0.76 (95% CI, 0.69-0.85). Finally, these findings were robust to subanalyses that stratified patients by presenting symptoms and were more pronounced in symptomatic patients (adjusted HR, 0.69; 95% CI, 0.61-0.79) than in asymptomatic patients (adjusted HR, 0.80; 95% CI, 0.71-0.90).
CONCLUSIONS
During the last 15 years, patients who underwent CEA in the Vascular Quality Initiative have a long-term survival advantage over those who underwent CAS in real-world practice. Despite no difference in long-term survival in randomized trials, our observational study demonstrated a survival benefit for CEA that did not diminish with risk adjustment.
背景
颈动脉介入治疗的价值取决于患者的长期生存，以获得预防中风的益处。随机试验报告颈动脉内膜切除术（CEA）与颈动脉支架置入术（CAS）后的生存率无显著差异，而“真实世界”结果的观察性研究表明，CEA 与生存优势相关。我们的目的是使用倾向匹配队列检查 CEA 与 CAS 后的长期死亡率。
方法
我们研究了 2003 年至 2013 年血管质量倡议中接受 CEA 或 CAS 的所有患者（CEA 组 n=29235；CAS 组 n=4415）。通过将登记处中的患者与各自的医疗保险索赔文件相关联，获得长期死亡率信息。我们使用 Kaplan-Meier 估计法评估 CEA 和 CAS 的长期死亡率。我们使用 Cox 回归评估 CEA 与 CAS 死亡率的未经调整、调整和倾向匹配（总匹配对，n=4261）的危险比（HR）。
结果
未经调整的 Kaplan-Meier 估计 5 年死亡率为 CEA 组 14.0%，CAS 组 18.3%。CEA 与 CAS 全因死亡率的粗 HR 为 0.75（95%置信区间[CI]，0.70-0.81），这表明接受 CEA 的患者在接受 CAS 之前死亡的可能性降低 25%。这种生存优势在调整年龄、性别和合并症后仍然存在（调整后的 HR，0.75；95%CI，0.69-0.82）。在倾向匹配分析中也得到了证实，HR 为 0.76（95%CI，0.69-0.85）。最后，这些发现通过按表现症状对患者进行分层的亚分析得到了证实，在有症状的患者中更为明显（调整后的 HR，0.69；95%CI，0.61-0.79），而在无症状的患者中则不明显（调整后的 HR，0.80；95%CI，0.71-0.90）。
结论
在过去的 15 年中，血管质量倡议中接受 CEA 的患者在真实世界实践中具有长期生存优势，而随机试验中在长期生存方面没有差异。尽管我们的观察性研究表明 CEA 具有生存优势，但并未随着风险调整而减弱。
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