Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Eur J Vasc Endovasc Surg. 2019 May;57(5):619-625. doi: 10.1016/j.ejvs.2018.11.009. Epub 2019 Mar 30.
Stroke after carotid endarterectomy (CEA) has been assessed widely. However, factors enhancing non-ipsilateral stroke risk are poorly defined. The aim of this study was to identify drivers of 30 day non-ipsilateral stroke after CEA in the Vascular Quality Initiative (VQI) and assess long-term survival based on laterality of post-operative stroke.
The VQI was queried between April 1, 2003, and March 31, 2017, for all CEA. Bilateral carotid procedures within 30 days were excluded. Thirty day non-ipsilateral strokes were identified. Factors were examined to discriminate between patients with and without non-ipsilateral stroke. Univariable analysis followed by multivariable logistic regression was performed. Kaplan-Meier and log rank methods were used to estimate and compare survival.
During this 14 year period, 80,230 CEA in 74,928 patients met the criteria. The average age was 70.3 ± 9.3 years. Most were male (48,506; 60%), Caucasian (73,967; 92%), smokers (60,543; 76%), and asymptomatic (43,074; 54%). Contralateral stenosis ≥70% was present in 8033 (10%) with 2239 (3%) having contralateral occlusion. In 491 (0.6%) patients, peri-operative non-ipsilateral stroke occurred. After characterising univariable associations, logistic regression identified independent drivers of non-ipsilateral stroke after CEA. Operative urgency (p = .001), symptomatic disease (p < .001) and contralateral occlusion (p = .001) were pre-operative drivers. Operative predictors included shunt use (p = .008), CEA with cardiac surgery (p = .013), and CEA with concomitant proximal ipsilateral endovascular intervention (p = .01). Use of dextran (p = .005) and anti-angiotensin therapy (p = .03) were protective. Reperfusion syndrome (p < .001), re-exploration (p < .001), myocardial infarction (p < .001), and intravenous treatment of hypotension (p < .001) or hypertension (p < .001) were post-operative correlates. Non-ipsilateral stroke 30 day mortality was less than ipsilateral stroke (6.1% vs. 10.3%; p = .007). Five year survival after non-ipsilateral stroke was 73%, and no different from ipsilateral stroke 76% (p = .16). Both were worse than without stroke (88%; p < .001).
Non-ipsilateral stroke after CEA is rare. Features driving risk surround global disease burden, combined procedures, and haemodynamic fluctuations. Contralateral occlusion independently increases non-ipsilateral stroke risk. Regardless of laterality or location, effects of stroke after CEA on long-term survival are similar.
颈动脉内膜切除术（CEA）后的中风已得到广泛评估。然而，增强非对侧中风风险的因素尚未明确。本研究的目的是确定血管质量倡议（VQI）中 CEA 后 30 天非对侧中风的驱动因素，并根据手术后的侧别评估长期生存情况。
2003 年 4 月 1 日至 2017 年 3 月 31 日，VQI 对所有 CEA 进行了查询。排除 30 天内的双侧颈动脉手术。确定了 30 天内的非对侧中风。检查了各种因素以区分有无非对侧中风的患者。进行单变量分析，然后进行多变量逻辑回归。使用 Kaplan-Meier 和对数秩方法来估计和比较生存情况。
在这 14 年期间，74928 名患者中的 80230 例 CEA 符合标准。平均年龄为 70.3±9.3 岁。大多数为男性（48506；60%），白种人（73967；92%），吸烟者（60543；76%）和无症状患者（43074；54%）。有 8033 例（10%）存在对侧狭窄≥70%，其中 2239 例（3%）对侧闭塞。491 例（0.6%）患者在围手术期发生非对侧中风。在描述单变量关联后，逻辑回归确定了 CEA 后非对侧中风的独立驱动因素。手术紧急情况（p=0.001）、症状性疾病（p<0.001）和对侧闭塞（p=0.001）是术前的驱动因素。手术预测因素包括分流器使用（p=0.008）、心脏手术联合 CEA（p=0.013）和同侧近端血管内介入治疗联合 CEA（p=0.01）。使用葡聚糖（p=0.005）和抗血管紧张素治疗（p=0.03）是保护性的。再灌注综合征（p<0.001）、再次探查（p<0.001）、心肌梗死（p<0.001）和低血压（p<0.001）或高血压（p<0.001）的静脉治疗是术后相关因素。非对侧中风 30 天死亡率低于同侧中风（6.1% vs. 10.3%；p=0.007）。非对侧中风后 5 年的生存率为 73%，与同侧中风 76%（p=0.16）无差异。两者均低于无中风患者（88%；p<0.001）。
CEA 后非对侧中风很少见。驱动风险的特征涉及全球疾病负担、联合手术和血流动力学波动。对侧闭塞独立增加了非对侧中风的风险。无论侧别或位置如何，CEA 后中风对长期生存的影响相似。
