Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif.
Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Southern California, Los Angeles, Calif.
J Vasc Surg. 2021 Jul;74(1):187-194. doi: 10.1016/j.jvs.2020.10.082. Epub 2020 Dec 1.
Recent studies have suggested that the low risk of stroke and death associated with transcarotid artery revascularization (TCAR) is partially attributable to a robust dynamic flow reversal system and the avoidance of the atherosclerotic aortic arch during stenting. However, the benefits of flow reversal compared with distal embolic protection (DEP) in reducing stroke or death in TCAR have not been studied.
All patients undergoing carotid artery stenting (CAS) via the transcarotid route with either dynamic flow reversal (TCAR) or DEP (TCAS-DEP) in the Vascular Quality Initiative from September 2016 to November 2019 were analyzed. Both multivariable logistic regression and nearest neighbor propensity score-matched analysis were performed to explore the differences in outcomes between the two procedures. The primary outcome was in-hospital stroke or death. The secondary outcomes were stroke, death, myocardial infarction (MI), and the composite of stroke, death, and MI. A secondary analysis was performed to compare transcarotid stenting with DEP vs transfemoral CAS with DEP to evaluate the effects of crossing the aortic arch.
A total of 8426 patients were identified (TCAS-DEP, n = 287; 3.4%). TCAR was associated with a lower risk of in-hospital stroke or death (1.6% vs 5.2%; odds ratio [OR], 0.35; 95% confidence interval [CI], 0.20-0.64; P = .001), stroke (1.4% vs 4.2%; OR, 0.37; 95% CI, 0.20-0.68; P = .002), and stroke/death/MI (2.0% vs 5.2%; OR, 0.41; 95% CI, 0.23-0.71; P = .001) compared with TCAS-DEP. Among the 274 pairs of patients identified with propensity score matching, TCAR was associated with a lower risk of stroke/death (1.1% vs 4.7%; risk ratio [RR], 0.23; 95% CI, 0.06-0.81; P = .021) and stroke (0.4% vs 4.0%; RR, 0.09; 95% CI, 0.01-0.70; P = .006) compared with TCAS-DEP but no differences in stroke/death/MI (1.8% vs 4.7%; RR, 0.38; 95% CI, 0.15-1.02; P = .077). The secondary analysis found no differences in stroke between TCAS-DEP and transfemoral CAS with DEP (4.9% vs 3.7%; RR, 1.3; 95% CI, 0.36-1.63; P = .65).
Compared with TCAS-DEP, TCAR was associated with a lower risk of perioperative stroke or death and stroke. This finding implies that dynamic flow reversal might provide better neuroprotection than does a distal embolic filter in reducing the perioperative risk of stroke. Avoiding the aortic arch did not confer any reduction in the stroke rate. The present findings serve to separate the clinical benefit of dynamic flow reversal from that of avoiding the aortic arch during TCAR.
最近的研究表明，经颈动脉血管重建术（TCAR）与较低的中风和死亡风险相关，部分归因于强大的动态血流反转系统和在支架置入过程中避免动脉粥样硬化的主动脉弓。然而，与远端栓塞保护（DEP）相比，血流反转在降低 TCAR 中风或死亡方面的益处尚未得到研究。
分析 2016 年 9 月至 2019 年 11 月血管质量倡议中经颈动脉途径行颈动脉支架置入术（CAS）的所有患者，包括经颈动脉使用动态血流反转（TCAR）或使用远端栓塞保护（TCAS-DEP）的患者。采用多变量逻辑回归和最近邻倾向评分匹配分析，探讨两种手术方式之间结局的差异。主要结局为院内中风或死亡。次要结局为中风、死亡、心肌梗死（MI）以及中风、死亡和 MI 的复合结局。进行了一项次要分析，比较了经颈动脉支架置入术加 DEP 与经股动脉 CAS 加 DEP，以评估穿过主动脉弓的影响。
共纳入 8426 例患者（TCAS-DEP，n=287，占 3.4%）。TCAR 与院内中风或死亡风险降低相关（1.6%比 5.2%；优势比[OR]，0.35；95%置信区间[CI]，0.20-0.64；P=0.001）、中风（1.4%比 4.2%；OR，0.37；95% CI，0.20-0.68；P=0.002）和中风/死亡/MI（2.0%比 5.2%；OR，0.41；95% CI，0.23-0.71；P=0.001）的风险较低。在倾向评分匹配的 274 对患者中，TCAR 与中风/死亡（1.1%比 4.7%；风险比[RR]，0.23；95% CI，0.06-0.81；P=0.021）和中风（0.4%比 4.0%；RR，0.09；95% CI，0.01-0.70；P=0.006）的风险降低相关，但中风/死亡/MI 的风险无差异（1.8%比 4.7%；RR，0.38；95% CI，0.15-1.02；P=0.077）。次要分析发现，TCAS-DEP 和经股动脉 CAS 加 DEP 之间的中风无差异（4.9%比 3.7%；RR，1.3；95% CI，0.36-1.63；P=0.65）。
与 TCAS-DEP 相比，TCAR 与围手术期中风或死亡和中风的风险降低相关。这一发现表明，与远端栓塞过滤器相比，动态血流反转可能通过降低围手术期中风风险提供更好的神经保护作用。避免主动脉弓并不能降低中风发生率。本研究结果将动态血流反转的临床获益与 TCAR 期间避免主动脉弓的获益分开。
