Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH.
J Vasc Surg. 2020 Oct;72(4):1385-1394.e2. doi: 10.1016/j.jvs.2019.11.047. Epub 2020 Feb 5.
Whether recent stroke mandates planned shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with postoperative outcomes of CEAs performed after acute stroke.
The Vascular Quality Initiative database (2010-2018) was queried for CEAs performed within 14 days of an ipsilateral stroke. Surgeons who prospectively planned to shunt either shunted routinely per their usual practice or shunted selectively for preoperative indications. Surgeons who prospectively planned not to shunt either shunted selectively for intraoperative indications or did not shunt. Univariable and multivariable analyses compared shunting approaches.
There were 5683 CEAs performed after acute ipsilateral stroke. Surgeons planned to shunt in 56.1% of cases. Patients whose surgeons planned to shunt vs planned not to shunt were more likely to have severe contralateral stenosis (8.8% vs 6.9%; P = .008), to receive general anesthesia (97.5% vs 89.1%; P < .001), and to undergo conventional CEA (94% vs 81.8%; P < .001). Unadjusted outcomes were similar between the cohorts for operative duration (124.3 ± 48.1 minutes vs 123.6 ± 47 minutes; P = .572) and 30-day stroke (3.4% vs 3%; P = .457), myocardial infarction (1.1% vs 0.8%; P = .16), and mortality (1.6% vs 1.3%; P = .28). On multivariable analysis, planning to shunt vs planning not to shunt was associated with similar risk of 30-day stroke (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82-1.67; P = .402). On subgroup analysis, in 38.4% patients, no shunt was placed, whereas the remainder received routine shunts (44.4%), preoperatively indicated shunts (11.6%), and intraoperatively indicated shunts (5.5%). Compared with no shunting, shunting by surgeons who routinely shunt was associated with a similar stroke risk (OR, 1.39; 95% CI, 0.91-2.13; P = .129), but shunting by surgeons who selectively shunt on the basis of preoperative indications (OR, 2.11; 95% CI, 1.22-3.63; P = .007) or intraoperative indications (OR, 3.34; 95% CI, 1.86-6.01; P < .001) was associated with increased stroke risk. Prior coronary revascularization independently predicted increased intraoperatively indicated shunting (OR, 1.37; 95% CI, 1.05-1.8; P = .022).
In CEAs performed after acute ipsilateral stroke, there is no difference in postoperative stroke risk when surgeons prospectively plan to shunt or not to shunt. Shunting is often not necessary; however, when shunting is performed, routine shunters achieve better outcomes.
近期的中风是否要求在颈动脉内膜切除术（CEA）期间进行计划性分流术存在争议。我们的目标是确定各种分流术与急性中风后行 CEA 的术后结果之间的关联。
对 2010 年至 2018 年血管质量倡议数据库中同侧中风后 14 天内进行的 CEA 进行了检索。计划前瞻性分流的外科医生常规按其常规做法分流，或根据术前指征选择性分流。计划前瞻性不分流的外科医生选择性地根据术中指征进行分流，或不进行分流。单变量和多变量分析比较了分流方法。
在 5683 例急性同侧中风后进行了 CEA。56.1%的病例中外科医生计划进行分流。与计划不进行分流的患者相比，计划进行分流的患者更有可能出现严重的对侧狭窄（8.8%比 6.9%；P=0.008），接受全身麻醉（97.5%比 89.1%；P<0.001），并接受常规 CEA（94%比 81.8%；P<0.001）。未调整的手术时间（124.3±48.1 分钟比 123.6±47 分钟；P=0.572）和 30 天中风（3.4%比 3%；P=0.457）、心肌梗死（1.1%比 0.8%；P=0.16）和死亡率（1.6%比 1.3%；P=0.28）在两组之间相似。多变量分析显示，与计划不进行分流相比，计划进行分流与 30 天中风的风险相似（比值比[OR]，1.17；95%置信区间[CI]，0.82-1.67；P=0.402）。亚组分析显示，在 38.4%的患者中，没有放置分流管，而其余患者接受了常规分流管（44.4%）、术前指示分流管（11.6%）和术中指示分流管（5.5%）。与不进行分流相比，常规分流的外科医生进行分流与相似的中风风险相关（OR，1.39；95%CI，0.91-2.13；P=0.129），但术前指示（OR，2.11；95%CI，1.22-3.63；P=0.007）或术中指示（OR，3.34；95%CI，1.86-6.01；P<0.001）的选择性分流的外科医生进行分流与中风风险增加相关。术前冠状动脉血运重建独立预测术中指示的分流增加（OR，1.37；95%CI，1.05-1.8；P=0.022）。
在急性同侧中风后行 CEA 时，外科医生前瞻性计划分流或不分流与术后中风风险无差异。分流通常不是必需的；然而，当进行分流时，常规分流器可获得更好的结果。
