Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass.
J Vasc Surg. 2020 Apr;71(4):1233-1241. doi: 10.1016/j.jvs.2019.06.201. Epub 2020 Feb 13.
Outcome studies using databases collecting only hospital discharge data underestimate morbidity and mortality because of failure to capture postdischarge events. The proportion of postdischarge major adverse events is well characterized in patients undergoing carotid endarterectomy (CEA) but has yet to be characterized after carotid artery stenting (CAS).
We retrospectively reviewed all patients undergoing CAS from 2011 to 2017 using the American College of Surgeons National Surgical Quality Improvement Program procedure targeted database to evaluate rates of 30-day major adverse events, stratified by in-hospital and postdischarge occurrences. The primary outcome was 30-day stroke/death. Multivariable analysis using purposeful selection was used to identify independent factors associated with in-hospital, postdischarge, and 30-day stroke/death events.
Of the 899 patients undergoing CAS, reporting of in-hospital outcomes alone would yield a stroke/death rate of 2.7%, substantially underestimating the 30-day stroke/death rate of 4.0%. In fact, 35% of stroke/deaths, 27% of strokes, 73% of deaths, 35% of cardiac events, and 35% of stroke/death/cardiac events occurred after discharge. More postdischarge stroke/death events occurred after treatment of symptomatic compared with asymptomatic patients (47% vs 27%; P < .001). During this same study period, the 30-day stroke/death rate after CEA was 2.6%, with similar proportions of postdischarge strokes (28% vs 27%; P = .51) compared with CAS but lower proportions of postdischarge deaths (55% vs 73%; P < .001). After CAS, patients experiencing postdischarge stroke/death events had a shorter postoperative length of stay compared with patients with in-hospital stroke/death (1 [1-2] vs 5 [3-10] days; P < .001). Chronic obstructive pulmonary disease was independently associated with postdischarge stroke/death (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.2-16; P = .02) after CAS. Nonwhite ethnicity was independently associated with overall 30-day stroke/death (OR, 3.4; 95% CI, 1.4-7.9; P < .01), whereas statin use was associated with not having stroke/death within 30 days (OR, 0.5; 95% CI, 0.2-1.0; P = .049).
More than one-quarter of perioperative strokes occur following discharge after both CAS and CEA. A higher proportion of postdischarge deaths occur after CAS in symptomatic patients, which may reflect treatment of a population of higher risk patients. Further investigation is needed to elucidate the cause of postdischarge stroke to develop methods to reduce these complications.
仅使用收集医院出院数据的数据库进行的结局研究由于未能捕获出院后事件而低估了发病率和死亡率。在接受颈动脉内膜切除术（CEA）的患者中，已经很好地描述了出院后主要不良事件的比例，但尚未在接受颈动脉支架置入术（CAS）的患者中进行描述。
我们回顾性分析了 2011 年至 2017 年期间使用美国外科医师学会国家手术质量改进计划靶向数据库接受 CAS 的所有患者，以评估 30 天主要不良事件的发生率，并按住院期间和出院后发生的事件分层。主要结局是 30 天内发生的中风/死亡。使用有目的选择的多变量分析来确定与住院期间、出院后和 30 天内中风/死亡事件相关的独立因素。
在 899 例接受 CAS 的患者中，如果仅报告住院期间的结局，中风/死亡率将为 2.7%，这大大低估了 30 天内中风/死亡率 4.0%。实际上，35%的中风/死亡、27%的中风、73%的死亡、35%的心脏事件和 35%的中风/死亡/心脏事件发生在出院后。与无症状患者相比，症状性患者发生更多的出院后中风/死亡事件（47%比 27%；P<0.001）。在同一研究期间，CEA 后 30 天中风/死亡率为 2.6%，且与 CAS 相比，出院后中风的比例相似（28%比 27%；P=0.51），但出院后死亡的比例较低（55%比 73%；P<0.001）。与住院期间发生中风/死亡的患者相比，发生出院后中风/死亡事件的患者术后住院时间更短（1[1-2]天比 5[3-10]天；P<0.001）。慢性阻塞性肺疾病是 CAS 后出院后中风/死亡的独立危险因素（比值比[OR]，4.4；95%置信区间[CI]，1.2-16；P=0.02）。非白种人是全因 30 天内中风/死亡的独立危险因素（OR，3.4；95%CI，1.4-7.9；P<0.01），而他汀类药物的使用与 30 天内无中风/死亡相关（OR，0.5；95%CI，0.2-1.0；P=0.049）。
在 CEA 和 CAS 后，超过四分之一的围手术期中风发生在出院后。在症状性患者中，CAS 后出院后死亡的比例更高，这可能反映了治疗风险更高的患者人群。需要进一步研究以阐明出院后中风的原因，从而制定降低这些并发症的方法。
