Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Nuffield Department of Surgical Sciences, Level 6 John Radcliffe Hospital, University of Oxford, Oxford, UK.
Ann Surg. 2019 Apr;269(4):631-641. doi: 10.1097/SLA.0000000000002880.
To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization.
Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated.
We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model.
We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts).
We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications.
This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.
探讨术者或医院手术量与颈动脉血运重建术临床结局之间的关系。
术者和医院手术量被认为是颈动脉内膜切除术（CEA）或颈动脉支架置入术（CAS）后结局的决定因素。这种关系的大小和临床意义仍存在争议。
我们系统地检索了 PubMed 和 EMBASE 数据库，检索时间截至 2017 年 8 月 21 日。主要结局是手术（30 天内、住院期间或围手术期）死亡或卒中。采用固定效应模型进行合并分析。
我们共纳入了 87 项研究。与低术者手术量相比，高术者手术量与 CEA 后死亡或卒中风险降低相关，调整后的比值比（OR）为 0.50（95%置信区间 [CI] 0.28-0.87；3 项研究），未调整的相对风险（RR）为 0.59（95% CI 0.42-0.83；9 项研究）；与低医院手术量相比，高医院手术量与 CEA 后死亡或卒中风险降低相关，调整后的 OR 为 0.62（95% CI 0.42-0.90；5 项研究），未调整的 RR 为 0.68（95% CI 0.51-0.92；9 项研究）。与低术者手术量相比，高术者手术量与 CAS 后死亡或卒中风险降低相关，调整后的 OR 为 0.43（95% CI 0.20-0.95；1 项研究），未调整的 RR 为 0.50（95% CI 0.32-0.79；1 项研究）；与低医院手术量相比，高医院手术量与 CAS 后死亡或卒中风险降低相关，调整后的 OR 为 0.46（95% CI 0.26-0.80；1 项研究），未调整的 RR 为 0.72（95% CI 0.49-1.06；2 项研究）。
我们发现 CEA 和 CAS 后术者和医院手术量较高与手术相关的死亡和卒中风险降低相关，表明高手术量可能有助于降低手术并发症风险。
本系统评价已在国际前瞻性系统评价注册库（PROSPERO）中注册：CRD42017051491。
