Dansey Kirsten D, Pothof Alexander B, Zettervall Sara L, Swerdlow Nicholas J, Liang Patric, Schneider Joseph R, Nolan Brian W, Schermerhorn Marc L
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
J Vasc Surg. 2020 May;71(5):1587-1594.e2. doi: 10.1016/j.jvs.2019.07.088. Epub 2020 Feb 1.
The impact of sex in the management of carotid disease is unclear in the current literature. Therefore, we evaluated the effect of sex on perioperative outcomes following carotid endarterectomy (CEA) and carotid artery stenting (CAS).
We included patients who underwent CEA or CAS between 2012 and 2017 in the Vascular Quality Initiative database. Our primary outcome was perioperative stroke/death. Secondary outcomes were in-hospital stroke, 30-day mortality, and in-hospital MI. We compared perioperative outcomes between female and male patients, stratified by treatment modality and symptom status, and used multivariable regression to account for differences in baseline characteristics.
A total of 83,436 patients underwent either a CEA (71,383) or CAS (12,053). Asymptomatic and symptomatic CEA females were less likely to be on a preoperative antiplatelet agent, when compared to males. Females overall, were less likely to be on a preoperative statin and more likely to have chronic obstructive pulmonary disease. Within the CAS cohort, females were more likely to have a previous ipsilateral CEA. There were no differences between males and females in major adverse events following CEA for asymptomatic disease. Following CEA for symptomatic disease, there was no difference in stroke/death rate or in-hospital stroke. However, females experienced a higher 30-mortality after adjustment (univariate: 1.0% vs 0.7%, P = .04; adjusted: odds ratio [OR], 1.4:1.02-1.94). Following CAS for asymptomatic disease, females experienced a higher rate of perioperative stroke/death (2.9% vs 1.9% P = .02; OR, 1.5: 1.05-2.03) and in-hospital stroke (2.1% vs 1.2% P = .01; OR, 1.8: 1.20-2.60). There were no differences in outcomes for symptomatic females vs males undergoing CAS.
Females with carotid disease less frequently receive optimal medical treatment with antiplatelet agents and statins. This is an important target area for quality improvement issue in both females and males. Furthermore, among symptomatic CEA patients the female sex is associated with higher mortality and among asymptomatic CAS patients, females experience higher rates of stroke/death. These findings suggest that careful patient selection is necessary in the treatment of female patients. Quality improvement projects should be created to further investigate and eliminate the disparities of optimal medical management between the sexes.
目前文献中，性别对颈动脉疾病治疗的影响尚不清楚。因此，我们评估了性别对颈动脉内膜切除术（CEA）和颈动脉支架置入术（CAS）围手术期结局的影响。
我们纳入了2012年至2017年期间在血管质量改进数据库中接受CEA或CAS治疗的患者。我们的主要结局是围手术期卒中/死亡。次要结局是住院期间卒中、30天死亡率和住院期间心肌梗死。我们比较了按治疗方式和症状状态分层的女性和男性患者的围手术期结局，并使用多变量回归来解释基线特征的差异。
共有83436例患者接受了CEA（71383例）或CAS（12053例）。与男性相比，无症状和有症状的CEA女性术前使用抗血小板药物的可能性较小。总体而言，女性术前使用他汀类药物的可能性较小，患慢性阻塞性肺疾病的可能性较大。在CAS队列中，女性既往同侧CEA的可能性更大。对于无症状疾病，CEA后男性和女性的主要不良事件无差异。对于有症状疾病，CEA后卒中/死亡率或住院期间卒中无差异。然而，调整后女性的30天死亡率更高（单变量：1.0%对0.7%，P = .04；调整后：比值比[OR]，1.4:1.02 - 1.94）。对于无症状疾病，CAS后女性围手术期卒中/死亡发生率更高（2.9%对1.9%，P = .02；OR，1.5:1.05 - 2.03），住院期间卒中发生率更高（2.1%对1.2%，P = .01；OR，1.8:1.20 - 2.60）。有症状的女性与男性接受CAS后的结局无差异。
患有颈动脉疾病的女性较少接受抗血小板药物和他汀类药物的最佳药物治疗。这是男性和女性质量改进问题的一个重要目标领域。此外，在有症状的CEA患者中，女性与较高的死亡率相关，在无症状的CAS患者中，女性经历更高的卒中/死亡率。这些发现表明，在女性患者的治疗中，仔细选择患者是必要的。应开展质量改进项目，以进一步调查并消除两性在最佳药物治疗方面的差异。
