NYU Grossman School of Medicine, New York, NY.
Division of Vascular and Endovascular Surgery, New York University Langone Health, New York, NY.
J Vasc Surg. 2023 Aug;78(2):423-429. doi: 10.1016/j.jvs.2023.02.029. Epub 2023 Apr 17.
Interventions for carotid occlusions undertaken are undertaken and the outcomes are poorly defined. We sought to study patients undergoing urgent carotid revascularization for symptomatic occlusions.
The Society for Vascular Surgery Vascular Quality Initiative database was queried from 2003 to 2020 to identify patients with carotid occlusions undergoing carotid endarterectomy. Only symptomatic patients undergoing urgent interventions within 24 hours of presentation were included. Patients were identified based on computed tomography and magnetic resonance imaging. This cohort was compared with symptomatic patients undergoing urgent intervention for severe stenosis (≥80%). The primary end points were perioperative stroke, death, myocardial infarction (MI) and composite outcomes as defined by the Society for Vascular Surgery reporting guidelines. Patient characteristics were analyzed to determine predictors of perioperative mortality and neurological events.
We identified 390 patients who underwent urgent CEA for symptomatic occlusions. The mean age was 67.4 ± 10.2 years (range, 39-90 years). The cohort was predominantly male (60%) with associated risk factors for cerebrovascular disease, including hypertension (87.4%), diabetes (34.4%), coronary artery disease (21.6%), and current smoking (38.7%). This population had high use of medications, including statins (78.6%), P2Y inhibitors (32.0%), aspirin (77.9%), and renin-angiotensin inhibitors (43.7%) preoperatively. When compared with patients undergoing urgent endarterectomy for severe stenosis (≥80%), those with symptomatic occlusion were well-matched with regard to risk factors, but the severe stenosis cohort seemed to be managed better medically and less likely to present with cortical stroke symptoms. Perioperative outcomes were significantly worse for the carotid occlusion cohort, primarily driven by higher perioperative mortality (2.8% vs 0.9%; P < .001). The composite end point of stroke/death/MI was also significantly worse in the occlusion cohort (7.7% vs 4.9%; P = .014). On multivariate analysis, carotid occlusion was associated with increased mortality (odds ratio, 3.028; 95% confidence interval, 1.362-6.730; P = .007) and composite outcome of stroke, death, or MI (odds ratio, 1.790; 95% confidence interval, 1.135-2.822; P = .012).
Revascularization for symptomatic carotid occlusion constitutes approximately 2% of carotid interventions captured in the Vascular Quality Initiative, affirming the rarity of this undertaking. These patients have acceptable rates of perioperative neurological events, but are at an elevated risk of overall perioperative adverse events, primarily driven by higher mortality, compared with those with severe stenosis. Carotid occlusion seems to be the most significant risk factor for the composite end point of perioperative stroke, death, or MI. Although intervention for a symptomatic carotid occlusion may be performed with acceptable rate of perioperative complications, judicious patient selection is warranted in this high-risk cohort.
对颈动脉闭塞进行的干预措施和结果定义不明确。我们旨在研究因症状性闭塞而行紧急颈动脉血运重建的患者。
从 2003 年至 2020 年，检索了血管外科学会血管质量倡议数据库，以确定接受颈动脉内膜切除术的颈动脉闭塞患者。仅纳入在出现症状后 24 小时内接受紧急干预的有症状患者。基于计算机断层扫描和磁共振成像来识别患者。将该队列与因严重狭窄（≥80%）而行紧急干预的有症状患者进行比较。主要终点是围手术期卒中、死亡、心肌梗死（MI）和血管外科学会报告指南定义的复合结局。分析患者特征，以确定围手术期死亡率和神经事件的预测因素。
我们确定了 390 例因症状性闭塞而行紧急颈动脉内膜切除术的患者。平均年龄为 67.4±10.2 岁（范围 39-90 岁）。该队列主要为男性（60%），存在与脑血管疾病相关的危险因素，包括高血压（87.4%）、糖尿病（34.4%）、冠状动脉疾病（21.6%）和当前吸烟（38.7%）。该人群术前大量使用药物，包括他汀类药物（78.6%）、P2Y 抑制剂（32.0%）、阿司匹林（77.9%）和肾素-血管紧张素抑制剂（43.7%）。与因严重狭窄（≥80%）而行紧急内膜切除术的患者相比，有症状闭塞患者的危险因素相当，但严重狭窄组在药物治疗方面似乎更好，皮质卒中症状的发生率较低。颈动脉闭塞组的围手术期结局明显较差，主要是围手术期死亡率较高（2.8%比 0.9%；P<0.001）。闭塞组的复合终点（卒中和/或死亡和/或 MI）也明显较差（7.7%比 4.9%；P=0.014）。多变量分析显示，颈动脉闭塞与死亡率增加相关（比值比，3.028；95%置信区间，1.362-6.730；P=0.007）和卒中、死亡或 MI 的复合结局相关（比值比，1.790；95%置信区间，1.135-2.822；P=0.012）。
血管外科学会血管质量倡议中约 2%的颈动脉干预措施为症状性颈动脉闭塞患者进行了血运重建，证实了这种情况的罕见性。这些患者围手术期神经事件的发生率可接受，但与严重狭窄患者相比，总体围手术期不良事件的风险更高，主要是死亡率较高。颈动脉闭塞似乎是围手术期卒中、死亡或 MI 复合结局的最显著危险因素。虽然对症状性颈动脉闭塞进行干预可能会带来可接受的围手术期并发症发生率，但在这个高风险患者群中，需要进行明智的患者选择。
