Cui Christina L, Zarrintan Sina, Marmor Rebecca A, Nichols James, Cajas-Monson Luis, Malas Mahmoud
University of California San Diego, San Diego, CA.
University of California San Diego, San Diego, CA.
Ann Vasc Surg. 2022 Apr;81:171-182. doi: 10.1016/j.avsg.2021.08.051. Epub 2021 Nov 6.
Current recommendations on carotid revascularization postulate that women have both increased perioperative risks, such as stroke and death, as well as reduced benefit from intervention. These recommendations do not include data on transcarotid artery revascularization (TCAR). This study strives to compare safety and benefits of TCAR, TFCAS (Transfemoral Carotid Artery Stenting), and CEA (Carotid Endarterectomy) with regard to patient sex.
We performed retrospective analysis of the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and stenting registries, as well as TCAR Surveillance Project data. We compared outcomes after TCAR, TFCAS, and CEA based on sex. The primary outcome was the rate of in-hospital stroke or death. Secondary outcomes included in-hospital stroke, death, transient ischemic attack (TIA), myocardial infarction (MI), stroke/death/MI, stroke/TIA, and recurrent ipsilateral stroke and/or death at 1-year of follow-up.
A total of 75,538 patients were included, of which 28,960 (38.3%) were female and 46,578 (61.7%) were male. TFCAS females had more than 2 times higher odds of stroke/death (OR:2.85, 95%CI: 2.21-3.67, P < 0.001) and stroke/death/MI (OR:2.23, 95%CI:1.75-2.83, P < 0.001) when compared to CEA females. Odds of TIA were also higher in both TFCAS females (OR:2.01, 95%CI:1.19-3.42, P = 0.010) and TCAR females (OR:1.91, 95%CI:1.09-3.35, P = .023) when compared to CEA females. However, only TFCAS females experienced increased odds of stroke/TIA (OR:1.96, 95%CI:1.45-2.65, P < 0.001) when compared to CEA females. TFCAS males had almost twice the odds of stroke/death (OR:1.74, 95%CI:1.39-2.16, P < 0.001) and 44% higher odds of stroke/death/MI (OR:1.44, 95%CI:1.19-1.75, P < 0.001), and more than 3-times increased odds of death (OR:3.45, 95%CI:2.53-4.71, P < 0.001) when compared to CEA males. Odds of in-hospital stroke were comparable between TFCAS and CEA after adjusting for covariates. TCAR males have half the odds of MI when compared to CEA males (OR:0.52, 95%CI:0.34-0.80, P = 0.003). At 1-year TCAR had comparable risk of stroke/death while TFCAS had increased risk of stroke/death when compared to CEA among both males and females.
TCAR performed similarly to CEA in both sexes regardless of symptomatic status. Stroke/death and stroke/death/MI rates were similar in symptomatic and asymptomatic males and females treated by CEA or TCAR. The 1-year outcomes of TCAR were also comparable to CEA in both sexes. It seems that TCAR may be a safe alternative to CEA particularly in women when surgical risk prohibits CEA and while TFCAS is associated with substantial adverse outcomes.
当前关于颈动脉血运重建的建议假定，女性围手术期风险增加，如中风和死亡，并且干预带来的益处减少。这些建议未纳入经颈动脉血管重建术（TCAR）的数据。本研究旨在比较TCAR、经股动脉颈动脉支架置入术（TFCAS）和颈动脉内膜切除术（CEA）在患者性别方面的安全性和益处。
我们对血管外科学会（SVS）血管质量改进计划（VQI）的CEA和支架置入登记数据以及TCAR监测项目数据进行了回顾性分析。我们根据性别比较了TCAR、TFCAS和CEA后的结果。主要结局是住院期间中风或死亡的发生率。次要结局包括住院期间中风、死亡、短暂性脑缺血发作（TIA）、心肌梗死（MI）、中风/死亡/MI、中风/TIA以及随访1年时同侧复发性中风和/或死亡。
共纳入75538例患者，其中28960例（38.3%）为女性，46578例（61.7%）为男性。与接受CEA的女性相比，接受TFCAS的女性发生中风/死亡（OR：2.85，95%CI：2.21 - 3.67，P < 0.001）和中风/死亡/MI（OR：2.23，95%CI：1.75 - 2.83，P < 0.001）的几率高出2倍多。与接受CEA的女性相比，接受TFCAS的女性（OR：2.01，95%CI：1.19 - 3.42，P = 0.010）和接受TCAR的女性（OR：1.91，95%CI：1.09 - 3.35，P = 0.023）发生TIA的几率也更高。然而，与接受CEA的女性相比，只有接受TFCAS的女性发生中风/TIA的几率增加（OR：1.96，95%CI：1.45 - 2.65，P < 0.001）。与接受CEA的男性相比，接受TFCAS的男性发生中风/死亡的几率几乎高出一倍（OR：1.74，95%CI：1.39 - 2.16，P < 0.001），发生中风/死亡/MI的几率高出44%（OR：1.44，95%CI：1.19 - 1.75，P < 0.001），死亡几率增加超过3倍（OR：3.45，95%CI：2.53 - 4.71，P < 0.001）。调整协变量后，TFCAS和CEA住院期间中风的几率相当。与接受CEA的男性相比，接受TCAR的男性发生MI的几率减半（OR：0.52¸95%CI：0.34 - 0.80，P = 0.003）。在1年时，与CEA相比，TCAR在男性和女性中发生中风/死亡的风险相当，而TFCAS发生中风/死亡的风险增加。
无论症状状态如何，TCAR在两性中的表现与CEA相似。接受CEA或TCAR治疗的有症状和无症状男性及女性的中风/死亡和中风/死亡/MI发生率相似。TCAR在两性中的1年结局也与CEA相当。似乎TCAR可能是CEA的一种安全替代方案，特别是在手术风险禁止进行CEA的女性中，而TFCAS与大量不良结局相关。
