Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
J Vasc Surg. 2024 Jan;79(1):71-80.e1. doi: 10.1016/j.jvs.2023.08.129. Epub 2023 Sep 9.
It is unclear whether patients with prior neck radiation therapy (RT) are at high risk for carotid artery stenting (CAS). We aimed to delineate 30-day perioperative and 3-year long-term outcomes in patients treated for radiation-induced stenotic lesions by the transfemoral carotid artery stenting (TFCAS) or transcarotid artery revascularization (TCAR) approach to determine comparative risk and to ascertain the optimal intervention in this cohort.
Data were extracted from the Vascular Quality Initiative CAS registry for patients with prior neck radiation who had undergone either TCAR or TFCAS. The Student t-test and the χ test were used to compare baseline patient characteristics. Multivariable logistic regression and Cox Hazard Proportional analysis were used to compare perioperative and long-term differences between patients with and without prior neck radiation following TCAR and TFCAS. Kaplan-Meier estimator was used to determine the incidence of 3-year adverse events.
A total of 72,656 patients (TCAR, 40,879; TFCAS, 31,777) were included in the analysis. Of these, 4151 patients had a history of neck radiation. Patients with a history of neck radiation were more likely to be younger, white, and have fewer comorbidities than patients with no neck radiation history. After adjustment for confounding factors, there was no difference in relative risk of 30-day perioperative stroke (P = .11), death (P = .36), or myocardial infarction (MI) (P = .61) between TCAR patients with or without a history of neck radiation. The odds of stroke/death (P = .10) and stroke/death/MI (P = .07) were also not statistically significant. In patients with prior neck radiation, TCAR had lower odds for in-hospital stroke/death/MI (odds ratio, 0.59; 95% confidence interval [CI], 0.35-0.99; P = .05) and access site complications than TFCAS. At year 3, patients with prior neck radiation had an increased hazard for mortality after TCAR (hazard ratio [HR], 1.24; 95% CI, 1.02-1.51; P = .04) and TFCAS (HR, 1.33; 95% CI, 1.12-1.58; P = .001). Patients with prior neck radiation also experienced an increased hazard for reintervention after TCAR (HR, 2.16; 95% CI, 1.45-3.20; P < .001) and TFCAS (HR, 1.67; 95% CI, 1.02-2.73; P<.001).
Patients with prior neck radiation had a similar relative risk of 30-day perioperative adverse events as patients with no neck radiation after adjustment for baseline demographics and disease characteristics. In these patients, TCAR was associated with reduced odds of perioperative stroke/death/MI as compared with TFCAS. However, patients with prior neck radiation were at increased risk for 3-year mortality and reintervention.
目前尚不清楚是否曾接受过颈部放射治疗（RT）的患者存在颈动脉支架置入术（CAS）的高风险。我们旨在通过经股颈动脉支架置入术（TFCAS）或经颈动脉血运重建术（TCAR）来确定接受治疗的患者 30 天围手术期和 3 年长期结果，以确定比较风险，并确定在这一人群中的最佳介入方法。
从血管质量倡议 CAS 登记处提取了有颈部放射治疗史的患者的数据，这些患者接受了 TCA 或 TFCAS。使用 Student t 检验和 χ 检验比较基线患者特征。多变量逻辑回归和 Cox 风险比例分析用于比较 TCA 和 TFCAS 后有和无颈部放射治疗史患者的围手术期和长期差异。Kaplan-Meier 估计用于确定 3 年不良事件的发生率。
共纳入 72656 例患者（TCAR 40879 例，TFCAS 31777 例）进行分析。其中 4151 例患者有颈部放射治疗史。有颈部放射治疗史的患者比没有颈部放射治疗史的患者更年轻、更白、合并症更少。调整混杂因素后，TCAR 患者有或无颈部放射治疗史的 30 天围手术期卒中（P=0.11）、死亡（P=0.36）或心肌梗死（MI）（P=0.61）的相对风险无差异。卒中/死亡（P=0.10）和卒中/死亡/MI（P=0.07）的比值也无统计学意义。在有颈部放射治疗史的患者中，TCAR 院内卒中/死亡/MI 的几率（比值比，0.59；95%置信区间，0.35-0.99；P=0.05）和血管入路并发症的几率均低于 TFCAS。3 年后，TCAR 组患者的死亡率（危险比[HR]，1.24；95%置信区间，1.02-1.51；P=0.04）和 TFCAS 组患者的死亡率（HR，1.33；95%置信区间，1.12-1.58；P=0.001）均升高。TCAR 组（HR，2.16；95%置信区间，1.45-3.20；P<0.001）和 TFCAS 组（HR，1.67；95%置信区间，1.02-2.73；P<.001）患者再次干预的风险也增加。
在调整基线人口统计学和疾病特征后，有颈部放射治疗史的患者与无颈部放射治疗史的患者相比，30 天围手术期不良事件的相对风险相似。在这些患者中，与 TFCAS 相比，TCAR 与围手术期卒中/死亡/MI 发生率降低相关。然而，有颈部放射治疗史的患者 3 年死亡率和再次介入的风险增加。
