Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
J Vasc Surg. 2021 Mar;73(3):960-967.e1. doi: 10.1016/j.jvs.2020.07.062. Epub 2020 Jul 22.
Carotid endarterectomy (CEA) with concomitant distal endovascular intervention (CEA+D) is infrequently necessary but has often been used as a salvage maneuver when complications occur during CEA. The present study aimed to determine whether preoperative risk factors associated with CEA requiring CEA+D exist and to evaluate the outcomes compared with isolated CEA.
The Vascular Quality Initiative CEA registry was used to identify patients who had undergone CEA or CEA+D for asymptomatic or symptomatic carotid stenosis from 2013 to 2019. Data regarding distal intervention included whether angioplasty or stenting of the distal internal carotid artery (ICA) and/or bifurcation had been required. However, information regarding the indication or whether the intervention had been planned was not included. The χ test and analysis of variance were used to evaluate the categorical and continuous perioperative variables. Variables with P < .20 on univariate analysis were included in the multivariable analysis to assess for preoperative predictors of the need for CEA+D and the association with perioperative stroke.
From 2013 to 2019, 327 CEA+D cases were identified and compared with 105,192 isolated CEA cases. The CEA+D patients were more likely to have undergone previous ipsilateral CEA (CEA, 1.8%; CEA+D, 4.9%; P < .01) and contralateral ICA occlusion (CEA, 4.6%; CEA+D, 11.0%; P < .01) but were less likely to have had ipsilateral stenosis ≥70% (CEA, 88.3%; CEA+D, 80.6%; P < .01). The preoperative factors associated with the need for CEA+D on multivariable analysis included previous peripheral vascular intervention, American Society of Anesthesiologists class ≥4, contralateral ICA occlusion, low-volume surgeon, and previous ipsilateral CEA. CEA+D was associated with significantly increased rates of stroke in both asymptomatic (CEA+D, 3.9%; CEA, 0.9%; P < .01) and symptomatic (CEA+D, 9.4%; CEA, 1.9%; P < .01) patients. CEA+D was associated with decreased rates of 30-day survival in both asymptomatic (CEA+D, 98.3%; CEA, 99.4%; P = .02) and symptomatic (CEA+D, 94.8%; CEA, 99.1%; P < .01) cohorts. On multivariable analysis, CEA+D remained significantly associated with stroke (odds ratio, 3.17; 95% confidence interval, 1.80-5.60; P < .01). Other factors significantly associated with perioperative stroke included procedure length >135 minutes, diabetes, hypertension, shunt for indication, symptomatic status, previous ipsilateral CEA, contralateral ICA occlusion, urgent or emergent procedure, intravenous medications for hemodynamic instability, and re-exploration at the initial operation.
Although markers of more significant cardiovascular disease burden were associated with the use of CEA+D, their power to predict CEA+D use was limited. In cases in which CEA+D was used, CEA+D was associated with significantly greater rates of perioperative stroke and mortality compared with isolated CEA for both asymptomatic and symptomatic patients, which could be useful for framing the expected outcomes after these procedures.
颈动脉内膜切除术（CEA）联合远端血管内介入治疗（CEA+D）的应用并不常见，但在 CEA 过程中发生并发症时，常被用作挽救性手术。本研究旨在确定是否存在与需要 CEA+D 的 CEA 相关的术前危险因素，并与单纯 CEA 进行比较。
利用血管质量倡议（Vascular Quality Initiative）CEA 登记处，从 2013 年至 2019 年，确定了接受 CEA 或 CEA+D 治疗无症状或有症状颈动脉狭窄的患者。远端介入相关数据包括是否需要进行颈内动脉（ICA）远端和（或）分叉部的血管成形术或支架置入术。然而，有关干预指征或是否计划进行干预的信息并未包括在内。使用卡方检验和方差分析评估围手术期的分类和连续变量。单因素分析中 P 值<0.20 的变量被纳入多因素分析，以评估 CEA+D 需求的术前预测因子，并评估其与围手术期卒中的关系。
2013 年至 2019 年，共确定 327 例 CEA+D 病例，并与 105192 例单纯 CEA 病例进行比较。CEA+D 患者更可能曾接受过同侧 CEA（CEA，1.8%；CEA+D，4.9%；P<0.01）和对侧 ICA 闭塞（CEA，4.6%；CEA+D，11.0%；P<0.01），但同侧狭窄程度≥70%的可能性较低（CEA，88.3%；CEA+D，80.6%；P<0.01）。多因素分析显示，需要 CEA+D 的术前因素包括：外周血管介入史、美国麻醉医师协会（ASA）分级≥4 级、对侧 ICA 闭塞、低手术量医生和同侧 CEA 史。CEA+D 与无症状（CEA+D，3.9%；CEA，0.9%；P<0.01）和有症状（CEA+D，9.4%；CEA，1.9%；P<0.01）患者的卒中发生率显著增加相关。CEA+D 与无症状（CEA+D，98.3%；CEA，99.4%；P=0.02）和有症状（CEA+D，94.8%；CEA，99.1%；P<0.01）患者的 30 天生存率显著降低相关。多因素分析显示，CEA+D 与卒中仍显著相关（比值比，3.17；95%置信区间，1.80-5.60；P<0.01）。与围手术期卒中显著相关的其他因素包括手术时间>135 分钟、糖尿病、高血压、有指征行分流术、有症状状态、同侧 CEA 史、对侧 ICA 闭塞、紧急或急症手术、静脉应用药物治疗血流动力学不稳定、以及初始手术时再次探查。
尽管心血管疾病负担的标志物与 CEA+D 的应用相关，但它们预测 CEA+D 应用的能力有限。在 CEA+D 应用的情况下，与单纯 CEA 相比，CEA+D 与无症状和有症状患者的围手术期卒中发生率和死亡率显著增加相关，这可能有助于确定这些手术后的预期结果。
