经颈动脉血管重建术与颈动脉内膜切除术的结果相似，与患者的风险状况无关。
Transcarotid artery revascularization is associated with similar outcomes to carotid endarterectomy regardless of patient risk status.
机构信息
Department of Surgery, Brigham and Women's Hospital, Boston, MA.
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
出版信息
J Vasc Surg. 2022 Aug;76(2):474-481.e3. doi: 10.1016/j.jvs.2022.03.860. Epub 2022 Mar 31.
BACKGROUND
Carotid artery stenting (CAS), including both transfemoral carotid artery stenting (TFCAS) and transcarotid artery revascularization (TCAR), reimbursement has been limited to high-risk patients by the Centers for Medicare & Medicaid Services (CMS) since 2005. We aimed to assess the association of CMS high-risk status with perioperative outcomes for carotid endarterectomy (CEA), TFCAS, and TCAR.
METHODS
We performed a retrospective review of all Vascular Quality Initiative patients who underwent carotid revascularization between 2015 and 2020. Patients were stratified by whether they met CMS CAS criteria, and univariable and multivariable logistic regression analyses were performed to assess the association of procedure type (CEA, TFCAS, TCAR) with perioperative outcomes.
RESULTS
Of 124,531 individuals who underwent carotid revascularization procedures, 91,687 (73.6%) underwent CEA, 17,247 (13.9%) underwent TFCAS, and 15,597 (12.5%) underwent TCAR. Among patients who met the CMS CAS criteria (ie, high-risk patients), the incidence of perioperative stroke was 2.7% for CEA, 3.4% for TFCAS, and 2.4% for TCAR (P < .001). Among standard-risk patients, the incidence of perioperative stroke was 1.7% for CEA, 2.7% for TFCAS, and 1.8% for TCAR (P < .001). After adjusting for baseline demographic and clinical characteristics, the odds of perioperative stroke were lower for TCAR versus CEA in high-risk patients (adjusted odds ratio [aOR], 0.82; 95% confidence interval [CI], 0.68-0.99) and similar in standard-risk patients (aOR, 1.05; 95% CI, 0.84, 1.31). In contrast, the adjusted odds of perioperative stroke were higher for TFCAS versus CEA in high-risk patients (aOR, 1.23; 95% CI, 1.03-1.46) and standard-risk patients (aOR, 1.60; 95% CI, 1.37-1.86). In both populations, TFCAS and TCAR patients had significantly lower odds of myocardial infarction than CEA patients (both P < .001).
CONCLUSIONS
The perioperative risks associated with CEA, TFCAS, and TCAR in high-risk patients support the current CMS criteria, although the risks associated with each revascularization approach in standard-risk patients suggest that distinguishing TCAR from TFCAS may be warranted.
背景
自 2005 年以来，医疗保险和医疗补助服务中心（CMS）一直将颈动脉支架置入术（CAS），包括经股动脉颈动脉支架置入术（TFCAS）和经颈动脉血管重建术（TCAR）的报销限于高危患者。我们旨在评估 CMS 高危状态与颈动脉内膜切除术（CEA）、TFCAS 和 TCAR 的围手术期结局的关系。
方法
我们对 2015 年至 2020 年间接受颈动脉血运重建的所有血管质量倡议患者进行了回顾性分析。患者根据是否符合 CMS CAS 标准进行分层，进行单变量和多变量逻辑回归分析，以评估手术类型（CEA、TFCAS、TCAR）与围手术期结局的关系。
结果
在接受颈动脉血运重建的 124531 名患者中，91687 名（73.6%）接受了 CEA，17247 名（13.9%）接受了 TFCAS，15597 名（12.5%）接受了 TCFAS。在符合 CMS CAS 标准的患者（即高危患者）中，CEA、TFCAS 和 TCFAS 的围手术期卒中发生率分别为 2.7%、3.4%和 2.4%（P<0.001）。在标准风险患者中，CEA、TFCAS 和 TCFAS 的围手术期卒中发生率分别为 1.7%、2.7%和 1.8%（P<0.001）。在校正基线人口统计学和临床特征后，高危患者中 TCFAS 与 CEA 相比，围手术期卒中的可能性降低（校正比值比[OR]，0.82；95%置信区间[CI]，0.68-0.99），而标准风险患者相似（OR，1.05；95%CI，0.84，1.31）。相比之下，高危患者和标准风险患者中 TFCAS 与 CEA 的围手术期卒中的校正可能性更高（OR，1.23；95%CI，1.03-1.46）和标准风险患者（OR，1.60；95%CI，1.37-1.86）。在这两个群体中，与 CEA 相比，TFCAS 和 TCFAS 患者的心肌梗死可能性显著降低（均 P<0.001）。
结论
高危患者中 CEA、TFCAS 和 TCFAS 的围手术期风险支持当前 CMS 标准，尽管标准风险患者中每种血运重建方法的风险表明，区分 TCFAS 和 TFCAS 可能是合理的。
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