Northwestern Medicine West Region, Winfield, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill.
Northwestern Medicine West Region, Winfield, Ill; Northwestern University Feinberg School of Medicine, Chicago, Ill.
J Vasc Surg. 2020 Mar;71(3):832-841. doi: 10.1016/j.jvs.2019.05.040. Epub 2019 Aug 21.
Carotid endarterectomy (CEA) is among the most commonly performed vascular procedures. Some have suggested worse outcomes with contralateral internal carotid artery (ICA) occlusion. We compared patients with and patients without contralateral ICA occlusion using the Society for Vascular Surgery Vascular Quality Initiative database.
Deidentified data were obtained from the Vascular Quality Initiative. Patients with prior ipsilateral or contralateral CEA, carotid stenting, combined CEA and coronary artery bypass graft, or <1-year follow-up were excluded, yielding 1737 patients with and 45,179 patients without contralateral ICA occlusion. Groups were compared with univariate tests, and differences identified in univariate testing were entered into multivariate models to identify independent predictors of outcomes and in particular whether contralateral ICA occlusion is an independent predictor of outcomes.
Patients with contralateral ICA occlusion were younger and more likely to be smokers; they were more likely to have chronic obstructive pulmonary disease, preoperative neurologic symptoms (56% vs 47%), nonelective CEA (16% vs 13%), and shunt placement (75% vs 53%; all P < .001). The 30-day ipsilateral stroke risk was 1.3% with vs 0.7% without contralateral ICA occlusion (P = .004). The 30-day and 1-year survival estimates were 99.0% ± 0.5% and 94.1% ± 1.1% with vs 99.6% ± 0.1% and 96.0% ± 0.2% without contralateral ICA occlusion (log-rank, P < .001). Logistic regression analysis identified prior neurologic event (P = .046), nonelective surgery (P = .047), absence of coronary artery disease (P = .035), and preoperative angiotensin-converting enzyme inhibitor use (P = .029) to be associated with 30-day ipsilateral stroke risk, but contralateral ICA occlusion remained an independent predictor in that model (odds ratio, 2.29; P = .026). However, after adjustment for other factors (Cox proportional hazards), risk of ipsilateral stroke (including perioperative) during follow-up was not significantly greater with contralateral ICA occlusion (hazard ratio, 1.21; P = .32). Results comparing propensity score-matched cohorts mirrored those from the larger data set.
This study demonstrates likely clinically insignificant differences in early stroke or death in comparing CEA patients with and those without contralateral ICA occlusion. After adjustment for other factors, contralateral ICA occlusion was not associated with a greater risk of ipsilateral stroke (including perioperative) in longer follow-up. Mortality was greater with contralateral ICA occlusion, and this difference was more pronounced at 1 year despite younger age of the contralateral ICA occlusion group. CEA risk remains low even in the presence of contralateral ICA occlusion and appears to be explained at least in part by other factors. CEA should still be considered appropriate in the face of contralateral ICA occlusion.
颈动脉内膜切除术（CEA）是最常进行的血管手术之一。有人认为对侧颈内动脉（ICA）闭塞的结果更差。我们使用血管外科学会血管质量倡议数据库比较了有和无对侧 ICA 闭塞的患者。
从血管质量倡议中获得了匿名数据。排除了同侧或对侧 CEA、颈动脉支架置入术、CEA 和冠状动脉旁路移植术联合治疗以及<1 年随访的患者，得到了 1737 例有对侧 ICA 闭塞和 45179 例无对侧 ICA 闭塞的患者。用单变量检验比较两组，单变量检验中发现的差异被纳入多变量模型，以确定结果的独立预测因素，特别是对侧 ICA 闭塞是否是结果的独立预测因素。
有对侧 ICA 闭塞的患者年龄较小，更可能吸烟；他们更可能患有慢性阻塞性肺疾病、术前神经症状（56%比 47%）、非择期 CEA（16%比 13%）和分流器放置（75%比 53%；所有 P<0.001）。同侧 30 天内中风风险为 1.3%，而无对侧 ICA 闭塞为 0.7%（P=0.004）。同侧 30 天和 1 年的生存率估计分别为 99.0%±0.5%和 94.1%±1.1%，而无对侧 ICA 闭塞分别为 99.6%±0.1%和 96.0%±0.2%（对数秩，P<0.001）。逻辑回归分析确定了先前的神经事件（P=0.046）、非择期手术（P=0.047）、无冠状动脉疾病（P=0.035）和术前血管紧张素转换酶抑制剂的使用（P=0.029）与同侧 30 天内中风风险相关，但对侧 ICA 闭塞在该模型中仍然是一个独立的预测因素（比值比，2.29；P=0.026）。然而，在调整其他因素（Cox 比例风险）后，同侧 ICA 闭塞在随访期间发生同侧中风（包括围手术期）的风险没有显著增加（风险比，1.21；P=0.32）。与较大数据集相比，倾向评分匹配队列的比较结果反映了这些结果。
本研究表明，在比较有和无对侧 ICA 闭塞的 CEA 患者时，早期中风或死亡的临床差异可能并不明显。在调整其他因素后，对侧 ICA 闭塞与同侧中风（包括围手术期）的风险增加无关。在较长的随访时间内，对侧 ICA 闭塞的死亡率更高，尽管对侧 ICA 闭塞组的年龄较小，但这种差异在 1 年时更为明显。即使存在对侧 ICA 闭塞，CEA 风险仍然较低，并且似乎至少部分归因于其他因素。面对对侧 ICA 闭塞，CEA 仍应被视为适当的治疗方法。
