Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
J Vasc Surg. 2022 Nov;76(5):1307-1315.e1. doi: 10.1016/j.jvs.2022.05.024. Epub 2022 Jul 4.
Previous studies on carotid endarterectomy and transfemoral carotid artery stenting demonstrated that perioperative outcomes differed according to preoperative neurologic injury severity, but this has not been assessed in transcarotid artery revascularization (TCAR). In this study, we examined contemporary perioperative outcomes in patients who underwent TCAR stratified by specific preprocedural symptom status.
Patients who underwent TCAR between 2016 and 2021 in the Vascular Quality Initiative were included. We stratified patients into the following groups based on preprocedural symptoms: asymptomatic, recent (symptoms occurring <180 days before TCAR) ocular transient ischemic attack (TIA), recent hemispheric TIA, recent stroke, or formerly symptomatic (symptoms occurring >180 days before TCAR). First, we used trend tests to assess outcomes in asymptomatic patients versus those with an increasing severity of recent neurologic injury (recent ocular TIA vs recent hemispheric TIA vs recent stroke). Then, we compared outcomes between asymptomatic and formerly symptomatic patients. Our primary outcome was in-hospital stroke/death rates. Multivariable logistic regression was used to adjust for demographics and comorbidities across groups.
We identified 18,477 patients undergoing TCAR, of whom 62.0% were asymptomatic, 3.2% had a recent ocular TIA, 7.6a % had recent hemispheric TIA, 18.0% had a recent stroke, and 9.2% were formerly symptomatic. In patients with recent symptoms, we observed higher rates of stroke/death with increasing neurologic injury severity: asymptomatic 1.1% versus recent ocular TIA 0.8% versus recent hemispheric TIA 2.1% versus recent stroke 3.1% (P < .01). In formerly symptomatic patients, the rate of stroke/death was higher compared with asymptomatic patients, but this difference was not statistically significant (1.7% vs 1.1%; P = .06). After risk adjustment, compared with asymptomatic patients, there was a higher odds of stroke/death in patients with a recent stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 2.1-3.7; P < .01), a recent hemispheric TIA (OR, 2.0; 95% CI, 1.3-3.0; P < .01), and former symptoms (OR, 1.6; 95% CI, 1.1-2.5; P = .02), but there was no difference in stroke/death rates in patients with a recent ocular TIA (OR, 0.9; 95% CI, 0.4-2.2; P = .78).
After TCAR, compared with asymptomatic status, a recent stroke and a recent hemispheric TIA were associated with higher stroke/death rates, whereas a recent ocular TIA was associated with similar stroke/death rates. In addition, a formerly symptomatic status was associated with higher stroke/death rates compared with an asymptomatic status. Overall, our findings suggest that classifying patients undergoing TCAR as symptomatic versus asymptomatic may be an oversimplification and that patients' specific preoperative neurologic symptoms should instead be used in risk assessment and outcome reporting for TCAR.
先前关于颈动脉内膜切除术和经股动脉颈动脉支架置入术的研究表明，围手术期结果因术前神经损伤严重程度而异，但这在经颈动脉血管重建术（TCAR）中尚未得到评估。在这项研究中，我们根据特定的术前症状评估了 2016 年至 2021 年期间在血管质量倡议中接受 TCAR 的患者的当代围手术期结果。
纳入 2016 年至 2021 年期间在血管质量倡议中接受 TCAR 的患者。我们根据术前症状将患者分为以下几组：无症状、近期（症状发生在 TCAR 前<180 天）眼短暂性脑缺血发作（TIA）、近期半球性 TIA、近期卒中和以前有症状（症状发生在 TCAR 前>180 天）。首先，我们使用趋势检验评估无症状患者与近期神经损伤严重程度增加的患者（近期眼 TIA 与近期半球性 TIA 与近期卒中和）的结果。然后，我们比较了无症状和以前有症状的患者之间的结果。我们的主要结局是住院期间的卒中/死亡率。多变量逻辑回归用于在各组中调整人口统计学和合并症。
我们确定了 18477 名接受 TCAR 的患者，其中 62.0%为无症状，3.2%有近期眼 TIA，7.6a%有近期半球性 TIA，18.0%有近期卒中和 9.2%为以前有症状。在有近期症状的患者中，随着神经损伤严重程度的增加，卒中/死亡率也随之升高：无症状患者为 1.1%，近期眼 TIA 患者为 0.8%，近期半球性 TIA 患者为 2.1%，近期卒中和 3.1%（P<.01）。在以前有症状的患者中，卒中/死亡率高于无症状患者，但差异无统计学意义（1.7%比 1.1%；P=0.06）。经过风险调整后，与无症状患者相比，近期卒中和近期半球性 TIA患者的卒中/死亡风险更高（OR，2.8；95%置信区间，2.1-3.7；P<.01），而近期眼 TIA 患者的卒中/死亡风险更高（OR，2.0；95%置信区间，1.3-3.0；P<.01），且以前有症状患者的卒中/死亡风险更高（OR，1.6；95%置信区间，1.1-2.5；P=0.02），而近期眼 TIA 患者的卒中/死亡风险无差异（OR，0.9；95%置信区间，0.4-2.2；P=0.78）。
在 TCAR 后，与无症状状态相比，近期卒中和近期半球性 TIA 与较高的卒中/死亡率相关，而近期眼 TIA 与相似的卒中/死亡率相关。此外，与无症状状态相比，以前有症状状态与较高的卒中/死亡率相关。总体而言，我们的研究结果表明，将接受 TCAR 的患者分为有症状与无症状可能过于简单化，而应根据患者术前特定的神经症状来评估风险并报告 TCAR 的结果。
