Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Ann Vasc Surg. 2021 Oct;76:20-27. doi: 10.1016/j.avsg.2021.02.027. Epub 2021 Apr 5.
Addition of ipsilateral proximal endovascular intervention (PEI, common carotid/innominate) increases the risk of perioperative stroke/death for both carotid endarterectomy (CEA) and carotid stenting (CAS). However, these approaches have not been directly compared and is the subject of this study.
VQI (2005-2020) was queried for CEA and CAS with PEI, excluding emergent, bilateral, and repeat procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis<50%, and transcarotid ICA stents. Primary outcome were the composite of perioperative stroke/death and long-term stroke/reintervention/death. Operative approach was evaluated with logistic regression, adjusted propensity scores, symptomatic status, and stenosis>70%. Long-term outcomes were compared with Kaplan-Meier Analysis.
There were 1,433 patients (795 endovascular;638 hybrid); mean age 69.8±9.4 years. Patients undergoing hybrid procedures were more likely to be female (49.4% vs. 37.5%; P < 0.001), less likely to have diabetes (29.5% vs. 38.2%; P P< 0.001), less likely to have a prior ipsilateral CEA (3.8% vs. 32.2%; P< 0.001), less likely to be symptomatic (34.6% vs. 52.8%; P < 0.001), and less likely to have >70% stenosis (77.3% vs. 95.6%%; P < 0.001). Perioperative stroke/death was 3.6% for hybrid and 3.9% for endovascular approaches (P = 0.77). In the multivariable model, hybrid operative approach (compared to the total endovascular approach) was not significantly associated with stroke/death (OR 1.29; 95%CI: 0.55-3.07; P = 0.56). For the 981 patients with long-term follow-up (556 endovascular; 425 hybrid), 1-year freedom from stroke/reintervention/death was 94.0% (95%CI: 90.9%-96.0%) for hybrid approach vs. 92.3% (95%CI: 89.5%-94.4%) for endovascular approach (P = 0.27).
Although simultaneous repair of tandem carotid lesions portends worse outcomes when compared to CEA or CAS alone, there was no difference in short or long-term stroke and death rates with a hybrid or totally endovascular approach. Therefore, it is reasonable to use either approach in the select patients who require simultaneous repair of both lesions.
同侧近端血管内介入（PEI，颈总/无名动脉）增加了颈动脉内膜切除术（CEA）和颈动脉支架置入术（CAS）围手术期卒中/死亡的风险。然而，这些方法尚未进行直接比较，这也是本研究的主题。
通过 VQI（2005-2020 年）查询接受同侧近端血管内介入的 CEA 和 CAS，排除急诊、双侧和重复手术、同侧 CAS 病史、颈内动脉狭窄<50%的患者以及经颈动脉颈内动脉支架。主要结果是围手术期卒中/死亡和长期卒中/再介入/死亡的复合结果。手术方法采用逻辑回归、调整倾向评分、症状状态和狭窄>70%进行评估。采用 Kaplan-Meier 分析比较长期结果。
共纳入 1433 例患者（795 例血管内；638 例杂交）；平均年龄 69.8±9.4 岁。接受杂交手术的患者更可能为女性（49.4% vs. 37.5%；P < 0.001），糖尿病患病率较低（29.5% vs. 38.2%；P< 0.001），同侧 CEA 病史较少（3.8% vs. 32.2%；P< 0.001），症状较少（34.6% vs. 52.8%；P < 0.001），狭窄程度>70%的患者较少（77.3% vs. 95.6%；P < 0.001）。杂交组围手术期卒中/死亡发生率为 3.6%，血管内组为 3.9%（P=0.77）。多变量模型显示，与单纯血管内方法相比，杂交手术方法（与总血管内方法相比）与卒中/死亡无显著相关性（OR 1.29；95%CI：0.55-3.07；P=0.56）。对于 981 例具有长期随访（556 例血管内；425 例杂交）的患者，杂交组 1 年无卒中/再介入/死亡的发生率为 94.0%（95%CI：90.9%-96.0%），血管内组为 92.3%（95%CI：89.5%-94.4%）（P=0.27）。
尽管与 CEA 或 CAS 单独治疗相比，同时修复串联颈动脉病变预示着更差的结果，但杂交或完全血管内方法在短期或长期的卒中/死亡率方面并无差异。因此，对于需要同时修复两个病变的选择患者，使用这两种方法是合理的。
