Department of Surgery, Division of Vascular and Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Cleveland, OH.
Department of Surgery, Division of Vascular and Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, Cleveland, OH.
J Am Coll Surg. 2020 Jan;230(1):113-120. doi: 10.1016/j.jamcollsurg.2019.09.020. Epub 2019 Oct 28.
Transcarotid artery revascularization (TCAR) with flow reversal was recently introduced as a novel technique for carotid artery stenting (CAS). We examined the learning curve of surgeons adopting TCAR based on data from the Vascular Quality Initiative (VQI-TCAR Surveillance Project; TSP).
We identified all patients in the TSP who underwent TCAR from September 2016 to December 2018. Cases were numbered in chronological order for each unique surgeon. Patients were then divided into 4 levels based on surgeon case number for comparison: cases 1 to 5 (novice), cases 6 to 20 (intermediate), cases 20 to 30 (advanced), and cases >30 (expert).
During the study period, 3,456 TCAR procedures were performed by 417 unique surgeons from 178 centers. Of all procedures, 1,426 (41%) were performed at the novice level, 1,375 (40%) at the intermediate level, 307 (8.9%) at the advanced level, and 348 (10%) at the expert level. Cases performed at more advanced levels had lower operative times (novice 82 vs intermediate 73 vs advanced 62 vs expert 60 minutes, p < 0.001), fluoroscopy time (7 vs 6 vs 5 vs 5 minutes, p < 0.001), and flow reversal time (12 vs 11 vs 10 vs 10 minutes, p < 0.001). Cases done at more advanced levels had decreases in bleeding (3.9% vs 3.4% vs 1.6% vs 1.2%, p = 0.03). No differences in major in-hospital outcomes were found regardless of experience level including stroke (p = 0.99), death (p = 0.39), and composite stroke/death/myocardial infarction (p = 0.84).
Transcarotid artery revascularization is being performed with excellent stroke and mortality rates in the TSP, even in the early stages of the surgeons' learning curve. Bleeding complications, operative, fluoroscopy, and flow reversal times all decrease with increasing TCAR experience.
经颈动脉动脉血运重建（TCAR）联合血流反转技术最近被引入颈动脉支架置入术（CAS）中，作为一种新的技术。我们根据血管质量倡议（VQI-TCAR 监测项目；TSP）的数据，研究了外科医生采用 TCAR 的学习曲线。
我们从 2016 年 9 月至 2018 年 12 月期间 TSP 中所有接受 TCAR 的患者中确定了所有患者。根据每位外科医生的病例编号进行编号。然后根据外科医生的病例数量将患者分为 4 个级别进行比较：病例 1 至 5（新手），病例 6 至 20（中级），病例 20 至 30（高级），病例> 30（专家）。
在研究期间，417 名来自 178 个中心的外科医生共完成了 3456 例 TCAR 手术。所有手术中，41%（1426 例）在新手水平完成，40%（1375 例）在中级水平完成，8.9%（307 例）在高级水平完成，10%（348 例）在专家水平完成。在更高级别的手术中，手术时间（新手 82 分钟，中级 73 分钟，高级 62 分钟，专家 60 分钟，p < 0.001）、透视时间（7 分钟，6 分钟，5 分钟，5 分钟，p < 0.001）和血流反转时间（12 分钟，11 分钟，10 分钟，10 分钟，p < 0.001）更短。在更高级别的手术中，出血并发症减少（3.9%，3.4%，1.6%，1.2%，p = 0.03）。无论经验水平如何，主要住院期间的结局均无差异，包括中风（p = 0.99）、死亡（p = 0.39）和中风/死亡/心肌梗死复合事件（p = 0.84）。
即使在外科医生学习曲线的早期阶段，TSP 中经颈动脉血运重建术的中风和死亡率也很高。随着 TCAR 经验的增加，出血并发症、手术时间、透视时间和血流反转时间均减少。
