Ghamraoui Ahmed K, Ricotta Joseph J
Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL.
Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL.
Ann Vasc Surg. 2020 Oct;68:151-158. doi: 10.1016/j.avsg.2020.05.034. Epub 2020 May 29.
Carotid revascularization, both endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS), are associated with an increased risk of adverse outcomes in patients aged ≥80 years. Transcarotid artery revascularization (TCAR) is a technique that combines surgical principles of neuroprotection with less invasive endovascular techniques to treat severe carotid stenosis. Data from a recent registry study comparing TCAR with that of CEA and TFCAS demonstrated no significant difference in outcomes between TCAR and CEA in patients aged ≥80 years, and a significant reduction in stroke and composite outcomes between TCAR and TFCAS in patients aged ≥80 years. To add to these studies, a more in-depth analysis of demographic, procedural, and outcome factors is warranted for elderly patients aged ≥80 years undergoing TCAR. At our center, with a large volume of elderly patients based on local demographics, we expect there will be no significant effect of age on outcome measures between patients aged <80 years and those aged ≥80 years.
Data were collected retrospectively for patients undergoing TCAR for symptomatic (≥50%) or asymptomatic (≥80%) extracranial carotid artery stenosis. Primary endpoints were the incidence of ipsilateral cerebrovascular ischemic event (stroke or transient ischemic attack), myocardial infarction (MI), cranial nerve injury, and death through 30 days after the procedure. Secondary endpoints were postoperative length of hospital stay (LOS), procedure time, carotid artery clamp/flow reversal time, and fluoroscopy time. Subgroup analyses were performed to examine the effect of inpatient/outpatient status, carotid symptomatology, and type of anesthesia on secondary outcomes.
Ninety-seven TCAR procedures were performed at our institution during the study period, of which 43 (44%) were on patients aged ≥80 years. Technical success was achieved in all cases, with no incidence of cerebrovascular ischemic event, MI, cranial nerve injury, or mortality through 30 days after procedure. In patients aged ≥80 years, the mean procedure time was 47 ± 12 min, clamp/flow reversal time was 4.7 ± 1.1 min, fluoroscopy time was 4.1 ± 1.6 min, and median LOS was 2.0 ± 1.0 days. Procedure time, clamp/flow reversal time, and fluoroscopy time were not significantly different between the age groups. However, there was a significant difference in the LOS, with patients aged <80 years demonstrating a median LOS of 1.0 ± 0.0 days (P = <0.001).
Our experience with TCAR confirms that it can be performed successfully in both symptomatic and asymptomatic high-risk elderly patients, with our series finding no incidence of perioperative cerebral ischemic event, MI, or death.
颈动脉血运重建术，包括颈动脉内膜切除术（CEA）和经股动脉颈动脉支架置入术（TFCAS），在80岁及以上患者中与不良结局风险增加相关。经颈动脉动脉血运重建术（TCAR）是一种将神经保护的外科原则与侵入性较小的血管内技术相结合以治疗严重颈动脉狭窄的技术。最近一项将TCAR与CEA和TFCAS进行比较的注册研究数据表明，80岁及以上患者中TCAR与CEA的结局无显著差异，且80岁及以上患者中TCAR与TFCAS相比，中风和复合结局显著降低。为补充这些研究，对于接受TCAR的80岁及以上老年患者，有必要对人口统计学、手术过程和结局因素进行更深入的分析。在我们中心，基于当地人口统计学有大量老年患者，我们预计年龄对80岁以下和80岁及以上患者的结局指标不会有显著影响。
回顾性收集因有症状（≥50%）或无症状（≥80%）颅外颈动脉狭窄接受TCAR的患者数据。主要终点是术后30天内同侧脑血管缺血事件（中风或短暂性脑缺血发作）、心肌梗死（MI）、颅神经损伤和死亡的发生率。次要终点是术后住院时间（LOS）、手术时间、颈动脉夹闭/血流逆转时间和透视时间。进行亚组分析以检查住院/门诊状态、颈动脉症状和麻醉类型对次要结局的影响。
在研究期间，我们机构共进行了97例TCAR手术，其中43例（44%）是针对80岁及以上患者。所有病例均取得技术成功，术后30天内无脑血管缺血事件、MI、颅神经损伤或死亡发生。在80岁及以上患者中，平均手术时间为47±12分钟，夹闭/血流逆转时间为4.7±1.1分钟，透视时间为4.1±1.6分钟，中位LOS为2.0±1.0天。各年龄组之间的手术时间、夹闭/血流逆转时间和透视时间无显著差异。然而，LOS存在显著差异，80岁以下患者的中位LOS为1.0±0.0天（P = <0.001）。
我们的TCAR经验证实，该手术在有症状和无症状的高危老年患者中均能成功进行，我们的系列研究未发现围手术期脑缺血事件、MI或死亡的发生率。
