Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands.
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass.
J Vasc Surg. 2019 Mar;69(3):814-823. doi: 10.1016/j.jvs.2018.05.250. Epub 2018 Oct 24.
There is conflicting evidence regarding the association of diabetes mellitus (DM) and insulin use with outcomes after carotid endarterectomy (CEA). Therefore, we sought to evaluate the risk of insulin-dependent DM (IDDM) and noninsulin-dependent DM (NIDDM) on 30-day outcomes after CEA.
We identified patients undergoing CEA from the Targeted Vascular module of the National Surgical Quality Improvement Program (2011-2015) and stratified patients on the basis of their preprocedural symptom status. We compared 30-day outcomes between nondiabetics and patients with NIDDM or IDDM, with 30-day stroke/death as the primary end point.
Of 16,739 CEA patients, 9784 (58%) were asymptomatic, of whom 6720 (69%) had no diagnosis of DM, 1109 (11%) had IDDM, and 1955 (20%) had NIDDM. Of the 6955 symptomatic patients, 4982 (72%) had no diagnosis of DM, 810 (12%) had IDDM, and 1163 (17%) had NIDDM. Among asymptomatic patients, patients with IDDM experienced higher rates of 30-day stroke/death compared with those without DM (3.4% vs 1.5%; P < .001), whereas those with NIDDM experienced rates similar to those of patients without DM (2.1% vs 1.5%; P = .1). Moreover, asymptomatic patients with IDDM and an anatomic high-risk criterion experienced a 30-day stroke/death rate of 6.6%. After adjustment, IDDM was associated with 30-day stroke/death in asymptomatic patients compared with patients without DM (odds ratio, 2.3; 95% confidence interval, 1.5-3.4; P < .001), but NIDDM was not (odds ratio, 1.4; 95% confidence interval, 1.0-2.1; P = .1). In comparison, among symptomatic patients, those with IDDM and NIDDM experienced similar rates of 30-day stroke/death as patients without DM (4.9% vs 3.6% and 4.0% vs 3.6%; both P > .1). After adjustment, neither IDDM nor NIDDM was associated with 30-day stroke/death in symptomatic patients compared with symptomatic patients without DM.
Rates of 30-day stroke/death after CEA in asymptomatic patients with IDDM exceed international vascular societies' guideline thresholds for acceptable outcomes in asymptomatic patients, especially those with anatomic high-risk criteria. Thus, asymptomatic patients with IDDM may not benefit from CEA, although more data are needed about the natural history of carotid disease in this population.
关于糖尿病（DM）和胰岛素使用与颈动脉内膜切除术（CEA）后结局的相关性，存在相互矛盾的证据。因此，我们试图评估胰岛素依赖型糖尿病（IDDM）和非胰岛素依赖型糖尿病（NIDDM）在 CEA 后 30 天结局方面的风险。
我们从国家手术质量改进计划的靶向血管模块（2011-2015 年）中确定了接受 CEA 的患者，并根据其术前症状状态对患者进行分层。我们比较了非糖尿病患者与 NIDDM 或 IDDM 患者之间的 30 天结局，30 天卒中/死亡是主要终点。
在 16739 例 CEA 患者中，9784 例（58%）为无症状，其中 6720 例（69%）无 DM 诊断，1109 例（11%）为 IDDM，1955 例（20%）为 NIDDM。在 6955 例有症状的患者中，4982 例（72%）无 DM 诊断，810 例（12%）为 IDDM，1163 例（17%）为 NIDDM。在无症状患者中，与无 DM 患者相比，IDDM 患者的 30 天卒中/死亡发生率更高（3.4% vs. 1.5%；P<0.001），而 NIDDM 患者的发生率与无 DM 患者相似（2.1% vs. 1.5%；P=0.1）。此外，无症状 IDDM 患者且存在解剖高危标准，其 30 天卒中/死亡率为 6.6%。调整后，与无 DM 患者相比，无症状患者中 IDDM 与 30 天卒中/死亡相关（比值比，2.3；95%置信区间，1.5-3.4；P<0.001），但 NIDDM 则不然（比值比，1.4；95%置信区间，1.0-2.1；P=0.1）。相比之下，在有症状的患者中，IDDM 和 NIDDM 患者的 30 天卒中/死亡率与无 DM 患者相似（4.9% vs. 3.6%和 4.0% vs. 3.6%；均 P>0.1）。调整后，与无 DM 患者相比，IDDM 或 NIDDM 均与有症状患者的 30 天卒中/死亡无关。
在无症状 IDDM 患者中，CEA 后 30 天卒中/死亡的发生率超过国际血管协会指南对无症状患者可接受结局的阈值，尤其是那些具有解剖高危标准的患者。因此，无症状 IDDM 患者可能无法从 CEA 中获益，尽管还需要更多关于该人群颈动脉疾病自然史的数据。
