Zhu Jerry, Rao Ajit, Berger Kelsey, Gopal Malika, Vrudhula Amey, Han Daniel, Vouyouka Ageliki, Ting Windsor, Finlay David, Kim Sung Yup, Tadros Rami, Marin Michael, Faries Peter
Division of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
J Endovasc Ther. 2024 Mar 6:15266028241235791. doi: 10.1177/15266028241235791.
The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR.
Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors.
A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke.
Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal.
The ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.
已在围手术期研究了经颈动脉血管重建术（TCAR）相对于经股动脉颈动脉支架置入术（tfCAS）的潜在益处，其卒中率和死亡率较低；然而，关于中期结果的数据有限。我们旨在评估TCAR和tfCAS术后3年的结果，并确定TCAR术后30天和1年死亡率的主要预测因素。
分析了2016年1月至2022年12月接受TCAR或tfCAS治疗的患者的血管质量倡议数据。使用最近邻法进行1:1倾向评分匹配，以调整基线人口统计学和临床特征。采用Kaplan-Meier生存分析和Cox比例风险回归来评估长期结果。基于术前、术中和术后因素，分别使用迭代逐步多元逻辑回归分析和Cox比例风险回归来确定30天和1年死亡率的预测因素。
共有70237例患者纳入分析（TCAR占58.7%，tfCAS占41.3%）。与tfCAS患者相比，经颈动脉血管重建术患者年龄更大，合并症发生率更高，具有更高的高危医学和解剖学特征。倾向评分匹配产生了22322对，两组之间无重大差异，只是TCAR患者年龄更大（71.6岁对70.8岁）。在3年时，与tfCAS相比，TCAR使死亡风险降低了24%（风险比[HR]=0.76，95%置信区间[CI]=0.71-0.82，p<0.001），无论有症状还是无症状患者均如此。这种生存优势在最初6个月就已确立（HR=0.59，95%CI=0.53-0.62，p<0.001），6个月至36个月的死亡风险无差异（HR=0.95，95%CI=0.86-1.05，p=0.31）。与tfCAS相比，经颈动脉血管重建术还与3年卒中风险降低（HR=0.81，95%CI=0.66-0.99，p=0.04）以及卒中或死亡风险降低（HR=0.81，95%CI=0.76-0.87，p<0.001）相关。30天和1年死亡率的首要预测因素是术后并发症。主要的独立预测因素是术后卒中的发生。
经颈动脉血管重建术与tfCAS相比具有持续的中期生存优势，且这种益处主要在最初6个月内确立。值得注意的是，我们的研究结果突出了术后卒中作为30天和1年死亡率的主要独立预测因素的重要性。
关于TCAR与tfCAS和颈动脉内膜切除术（CEA）相比的优越性的持续争论，因缺乏研究术前症状对结果影响的比较研究而受到限制。此外，关于TCAR围手术期以外的中期结果的数据很少。因此，尚不确定TCAR相对于tfCAS最初观察到的降低卒中和死亡的益处是否能持续超过一年。我们的研究填补了文献中的这些空白，提供了证据以使临床医生能够评估TCAR长达三年的疗效。此外，我们的研究旨在确定TCAR术后死亡的风险因素，促进最佳的患者分层。
