Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Section of Vascular Surgery, Dartmouth Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
JAMA Neurol. 2023 May 1;80(5):437-444. doi: 10.1001/jamaneurol.2023.0285.
Carotid artery stenting has been limited to use in patients with high surgical risk; outcomes in patients with standard surgical risk are not well known.
To compare stroke, death, and myocardial infarction outcomes following transcarotid artery revascularization vs carotid endarterectomy in patients with standard surgical risk.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective propensity-matched cohort study was conducted from August 2016 to August 2019 with follow-up until August 31, 2020, using data from the multicenter Vascular Quality Initiative Carotid Artery Stent and Carotid Endarterectomy registries. Patients with standard surgical risk, defined as those lacking Medicare-defined high medical or surgical risk characteristics and undergoing transcarotid artery revascularization (n = 2962) or carotid endarterectomy (n = 35 063) for atherosclerotic carotid disease. In total, 760 patients were excluded for treatment of multiple lesions or in conjunction with other procedures.
Transcarotid artery revascularization vs carotid endarterectomy.
The primary outcome was a composite end point of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke.
After 1:3 matching, 2962 patients undergoing transcarotid artery revascularization (mean [SD] age, 70.4 [6.9] years; 1910 [64.5%] male) and 8886 undergoing endarterectomy (mean [SD] age, 70.0 [6.5] years; 5777 [65.0%] male) were identified. There was no statistically significant difference in the risk of the primary composite end point between the 2 cohorts (transcarotid 3.0% vs endarterectomy 2.6%; absolute difference, 0.40% [95% CI, -0.43% to 1.24%]; relative risk [RR], 1.14 [95% CI, 0.87 to 1.50]; P = .34). Transcarotid artery revascularization was associated with a higher risk of 1-year ipsilateral stroke (1.6% vs 1.1%; absolute difference, 0.52% [95% CI, 0.03 to 1.08]; RR, 1.49 [95% CI, 1.05 to 2.11%]; P = .02) but no difference in 1-year all-cause mortality (2.6% vs 2.5%; absolute difference, -0.13% [95% CI, -0.18% to 0.33%]; RR, 1.04 [95% CI, 0.78 to 1.39]; P = .67).
In this study, the risk of 30-day stroke, death, or myocardial infarction or 1-year ipsilateral stroke was similar in patients undergoing transcarotid artery revascularization compared with those undergoing endarterectomy for carotid stenosis.
颈动脉支架置入术仅限于高手术风险患者使用；标准手术风险患者的结局尚不清楚。
比较标准手术风险患者行颈动脉内膜切除术与经颈动脉血管重建术治疗后的卒中、死亡和心肌梗死结局。
设计、地点和参与者：这是一项回顾性倾向匹配队列研究，于 2016 年 8 月至 2019 年 8 月进行，随访至 2020 年 8 月 31 日，使用来自多中心血管质量倡议颈动脉支架和颈动脉内膜切除术登记处的数据。标准手术风险患者定义为缺乏医疗保险定义的高医疗或手术风险特征，且接受经颈动脉血管重建术（n=2962）或颈动脉内膜切除术（n=35063）治疗的动脉粥样硬化性颈动脉疾病患者。共有 760 例患者因治疗多发性病变或与其他手术联合治疗而被排除在外。
经颈动脉血管重建术与颈动脉内膜切除术。
主要结局是 30 天内卒中、死亡或心肌梗死或 1 年内同侧卒中的复合终点。
1:3 匹配后，2962 例行经颈动脉血管重建术（平均[标准差]年龄 70.4[6.9]岁；1910[64.5%]为男性）和 8886 例行颈动脉内膜切除术（平均[标准差]年龄 70.0[6.5]岁；5777[65.0%]为男性）的患者纳入研究。两组患者的主要复合终点风险无统计学显著差异（经颈动脉血管重建术组 3.0% vs 颈动脉内膜切除术组 2.6%；绝对差值 0.40%[95%CI，-0.43%至 1.24%]；相对风险[RR]，1.14[95%CI，0.87 至 1.50]；P=0.34）。经颈动脉血管重建术与 1 年内同侧卒中风险较高相关（1.6% vs 1.1%；绝对差值 0.52%[95%CI，0.03%至 1.08%]；RR，1.49[95%CI，1.05%至 2.11%]；P=0.02），但 1 年内全因死亡率无差异（2.6% vs 2.5%；绝对差值-0.13%[95%CI，-0.18%至 0.33%]；RR，1.04[95%CI，0.78 至 1.39]；P=0.67）。
在这项研究中，与颈动脉内膜切除术相比，行经颈动脉血管重建术的患者在 30 天内发生卒中、死亡或心肌梗死或 1 年内同侧卒中的风险相似。
