Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA.
Department of Surgery, St Agnes Hospital, Baltimore, MD.
J Vasc Surg. 2022 Jul;76(1):222-231.e1. doi: 10.1016/j.jvs.2022.02.040. Epub 2022 Mar 8.
Carotid revascularization performed within 2 weeks of symptoms has proven to reduce risk of recurrent stroke in patients with symptomatic carotid artery stenosis. However, the optimal timing of revascularization within the 2-week window has yet to be determined. The objective of this study was to perform a comprehensive analysis of in-hospital and long-term outcomes of carotid endarterectomy (CEA) performed within different time intervals after most recent symptoms.
We analyzed 2003 to 2016 data from the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network. Only revascularizations performed for symptomatic carotid artery stenosis were included. Procedures were categorized as urgent (0-2 days from latest symptom), early (3-14 days), or late (15-180 days). The primary in-hospital outcome was stroke/death. The primary long-term outcomes of interest were 5-year recurrent ipsilateral stroke/death. Multivariable logistic regression, Kaplan-Meier analysis, and Cox regression were utilized to compare outcomes.
A total of 18,970 revascularizations were included: 1130 (6.0%) urgent, 4643 (24.5%) early, and 13,197 (69.6%) late. Earlier CEA had increased odds of in-hospital stroke/death compared with late CEA (urgent: adjusted odds ratio, 1.9; 95% confidence interval [CI], 1.3-2.8; P = .001; early: adjusted odds ratio, 1.7; 95% CI, 1.3-2.2; P < .001). No differences were seen in 5-year risk of stroke/death (urgent: adjusted hazard ratio, 0.95; 95% CI, 0.79-1.15; P = .592; early: adjusted hazard ratio, 0.97; 95% CI, 0.87-1.07; P = .928).
Urgent and early CEA were associated with increased perioperative risk without difference in 5-year outcomes compared with late CEA. Short-term recurrent stroke prevention could not be assessed. Updated population-based studies comparing recurrent stroke prevention with urgent or early revascularization vs best medical management are warranted.
有症状的颈动脉狭窄患者在症状出现后 2 周内进行颈动脉血运重建已被证明可降低卒中复发风险。然而，2 周窗口期内血运重建的最佳时机仍未确定。本研究的目的是全面分析最近症状后不同时间间隔行颈动脉内膜切除术（CEA）的住院和长期结局。
我们分析了 2003 年至 2016 年血管质量倡议血管植入物监测和介入结局网络的数据。仅纳入因有症状的颈动脉狭窄而行的血运重建。将手术分为紧急（距最近症状 0-2 天）、早期（3-14 天）和晚期（15-180 天）。主要住院结局为卒中和死亡。主要的长期结局为 5 年同侧卒中/死亡复发。采用多变量逻辑回归、Kaplan-Meier 分析和 Cox 回归比较结局。
共纳入 18970 例血运重建：1130 例（6.0%）为紧急，4643 例（24.5%）为早期，13197 例（69.6%）为晚期。与晚期 CEA 相比，早期 CEA 的住院卒中/死亡风险更高（紧急：校正比值比，1.9；95%置信区间[CI]，1.3-2.8；P=.001；早期：校正比值比，1.7；95%CI，1.3-2.2；P<.001）。5 年卒中/死亡风险无差异（紧急：校正风险比，0.95；95%CI，0.79-1.15；P=.592；早期：校正风险比，0.97；95%CI，0.87-1.07；P=.928）。
与晚期 CEA 相比，紧急和早期 CEA 与围手术期风险增加相关，但 5 年结局无差异。无法评估短期复发性卒中预防。需要进行基于人群的更新研究，比较紧急或早期血运重建与最佳药物治疗对复发性卒中预防的作用。
