de Geus Susanna W L, Farber Alik, Levin Scott, Carlson Sarah J, Cheng Thomas W, Tseng Jennifer F, Siracuse Jeffrey J
Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA.
Ann Vasc Surg. 2020 Oct;68:15-21. doi: 10.1016/j.avsg.2020.05.066. Epub 2020 Jun 3.
In octogenarians with carotid stenosis, data supporting the decision to intervene and choice of intervention with either carotid endarterectomy (CEA) or carotid artery stenting (CAS) have been conflicting. The purpose of this study was to compare the perioperative outcomes of CEA and CAS in octogenarians, and to identify patients at high risk for unfavorable outcomes.
The American College of Surgeons National Surgical Quality Improvement Program database (2011-2018) was queried for patients aged ≥80 years who underwent CAS or CEA. Propensity scores were created for the odds of undergoing CAS. Patients were matched 1:1 based on propensity score and outcomes were compared after matching. Multivariable logistic regression analyses were used to identify risk factors for unfavorable postoperative outcomes.
In total, 15,858 and 527 patients who underwent CEA and CAS were identified. After matching, there was no difference between CEA and CAS in perioperative stroke (2.3% vs. 2.9%; P = 0.56), cardiac complications (2.3% vs. 2.3%; P = 0.99), mortality (1.1% vs. 1.7%; P = 0.44), length of stay (median [interquartile range], 2 [1-4] vs. 1 [1-4] days; P = 0.13), and 30-day readmission (11.8% vs. 11.6%; P = 0.92). On multivariable analysis, the following were predictive for postoperative stroke: urgent operation (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.68-2.69; P < 0.001), chronic obstructive pulmonary disease (COPD; OR, 1.52; 95% CI, 1.11-2.09; P = 0.009), and American Society of Anesthesiologists class > III (OR, 1.46; 95% CI, 1.15-1.86; P = 0.002). Urgent procedure (OR, 2.86; 95% CI, 2.11-3.87; P < 0.001), COPD (OR, 2.31; 95% CI, 1.61-3.32; P < 0.001), dependent functional status (OR, 2.05; 95% CI, 1.35-3.1; P < 0.001), and age ≥ 85 years (OR, 1.92; 95% CI, 1.43-2.57; P < 0.001) were predictive for 30-day mortality.
Outcomes of CEA and CAS were similar in octogenarians. Risk factors for worse intervention outcomes were identified, which may guide risk-benefit discussions and shared decision-making.
在患有颈动脉狭窄的八旬老人中，支持干预决策以及选择颈动脉内膜切除术（CEA）或颈动脉支架置入术（CAS）进行干预的数据一直存在冲突。本研究的目的是比较八旬老人接受CEA和CAS的围手术期结局，并确定预后不良的高危患者。
查询美国外科医师学会国家外科质量改进计划数据库（2011 - 2018年）中年龄≥80岁且接受CAS或CEA的患者。为接受CAS的几率创建倾向评分。患者根据倾向评分进行1:1匹配，并在匹配后比较结局。采用多变量逻辑回归分析确定术后不良结局的危险因素。
共识别出15858例接受CEA的患者和527例接受CAS的患者。匹配后，CEA和CAS在围手术期卒中（2.3%对2.9%；P = .56）、心脏并发症（2.3%对2.3%；P = .99）、死亡率（1.1%对1.7%；P = .44）、住院时间（中位数[四分位间距]，2[1 - 4]天对1[1 - 4]天；P = .13）以及30天再入院率（11.8%对11.6%；P = .92）方面无差异。多变量分析显示，以下因素可预测术后卒中：急诊手术（比值比[OR]，2.12；95%置信区间[CI]，1.68 - 2.69；P < .001）、慢性阻塞性肺疾病（COPD；OR，1.52；95% CI，1.11 - 2.09；P = .009）以及美国麻醉医师协会分级>III级（OR，1.46；95% CI，1.15 - 1.86；P = .002）。急诊手术（OR，2.86；95% CI，2.11 - 3.87；P < .001）、COPD（OR，2.31；95% CI，1.61 - 3.32；P < .001）、依赖性功能状态（OR，2.05；95% CI，1.35 - 3.1；P < .001）以及年龄≥85岁（OR，1.92；95% CI，1.43 - 2.57；P < .001）可预测30天死亡率。
八旬老人接受CEA和CAS的结局相似。已确定干预结局较差的危险因素，这可能有助于指导风险效益讨论和共同决策。
