Department of Thoracic and Cardiovascular Surgery, Allegheny Health Network, Pittsburgh, PA.
Department of Thoracic and Cardiovascular Surgery, Allegheny Health Network, Pittsburgh, PA.
Ann Vasc Surg. 2022 Nov;87:388-401. doi: 10.1016/j.avsg.2022.05.013. Epub 2022 Jun 14.
Approximately 20-30% of ischemic strokes are caused by internal carotid artery stenosis. Stroke is the leading cause of disability and the second leading cause of death in the United States. Second generation transcarotid arterial revascularization (TCAR) stenting, using the ENROUTE flow reversal technology to prevent embolic stroke during the stenting process, has demonstrated stroke and death outcomes equivalent to carotid endarterectomy with reduced cranial nerve injury. However, at present, it is not known whether imaging characteristics obtained preoperatively can predict outcomes of TCAR procedures.
This retrospective cohort study included patients who underwent TCAR with flow reversal at three hospitals within a single hospital network who had computed tomography angiography, magnetic resonance imaging angiography, or preoperative diagnostic angiogram to determine whether carotid and lesion characteristics could predict patients who experienced major adverse critical events (MACE) versus those who did not. MACE was defined as myocardial infarction at 30 days, restenosis/persistent stenosis (peak systolic velocity within the stent >230 cm/sec by postoperative ultrasound), stroke within any time of follow-up, or death within 1 year of TCAR. Student's t-tests and Chi-squared tests were used to compare imaging characteristics, such as presence of pinpoint stenosis, calcification within the common carotid artery at the take-off from the aorta, and plaque length in millimeters. Binomial logistic regression was used to examine the likelihood that imaging characteristics were associated with MACE.
Of 220 patients who underwent TCAR in our network, seven were excluded because flow reversal was not used or appropriate imaging had not been performed prior to TCAR. Of the 213 patients who were included in analysis, the median length of follow-up was 10.8 months (interquartile range: 3.4-33.1 months). Twelve percent (26/213) experienced MACE and a model based on imaging characteristics was statistically significant in predicting MACE with 68% accuracy (P = 0.005). The presence of pinpoint stenosis was highly predictive of MACE (hazards ratio: 3.34, confidence interval: 1.2 to 9.3, P = 0.021). A shorter clavicle to carotid bifurcation distance was associated with an increased likelihood of experiencing MACE (P = 0.009) but it was weakly predictive (hazards ratio: 1.03, confidence interval: 1.01 to 1.05).
Preoperative imaging characteristics, such as pinpoint stenosis and clavicle to carotid bifurcation distance, can be used to predict adverse outcomes in TCAR placement.
约 20-30%的缺血性中风是由颈内动脉狭窄引起的。中风是美国导致残疾和死亡的第二大原因。第二代经颈动脉血管重建（TCAR）支架置入术使用 ENROUTE 血流逆转技术来预防支架置入过程中的栓塞性中风，已证明其在降低颅神经损伤的同时具有与颈动脉内膜切除术相当的中风和死亡结果。然而，目前尚不清楚术前获得的影像学特征是否可以预测 TCA 手术的结果。
本回顾性队列研究纳入了在单一医院网络内的三家医院接受经颈动脉血流逆转 TCA 的患者，这些患者进行了计算机断层血管造影术、磁共振血管造影术或术前诊断性血管造影术，以确定颈动脉和病变特征是否可以预测发生主要不良关键事件（MACE）的患者与未发生 MACE 的患者。MACE 定义为术后 30 天内心肌梗死、再狭窄/持续性狭窄（支架内峰值收缩速度>230cm/sec，术后超声检查）、任何时间随访内中风或 TCA 后 1 年内死亡。使用 Student's t 检验和卡方检验比较影像学特征，如针尖样狭窄、主动脉起始处颈总动脉内钙化和毫米级斑块长度。二项逻辑回归用于检查影像学特征与 MACE 发生的可能性之间的关系。
在我们的网络中，有 220 名患者接受了 TCA 治疗，其中 7 名患者因未使用血流逆转或 TCA 前未进行适当的影像学检查而被排除在外。在纳入分析的 213 名患者中，中位随访时间为 10.8 个月（四分位间距：3.4-33.1 个月）。12%（26/213）发生 MACE，基于影像学特征的模型在预测 MACE 方面具有统计学意义，准确率为 68%（P=0.005）。针尖样狭窄的存在高度预测 MACE（风险比：3.34，置信区间：1.2 至 9.3，P=0.021）。锁骨至颈动脉分叉距离较短与发生 MACE 的可能性增加相关（P=0.009），但预测能力较弱（风险比：1.03，置信区间：1.01 至 1.05）。
术前影像学特征，如针尖样狭窄和锁骨至颈动脉分叉距离，可用于预测 TCA 置入后的不良结局。
