Division of Vascular and Endovascular Surgery, University of Massachusetts Chan Medical School, Worcester, MA.
Department of Biostatistics, University of Massachusetts Chan Medical School, Worcester, MA.
J Vasc Surg. 2024 Oct;80(4):1149-1158.e2. doi: 10.1016/j.jvs.2024.05.005. Epub 2024 May 8.
Polyvascular disease is strongly associated with increased risk of cardiovascular morbidity and mortality. However, its prevalence in patients undergoing carotid and lower extremity surgical revascularization and its impact on outcomes are unknown.
The Vascular Quality Initiative was queried for carotid endarterectomy (CEA) or infrainguinal lower extremity bypass (LEB), 2013-2019. Polyvascular disease was defined as presence of atherosclerotic occlusive disease in more than one arterial bed: carotid, coronary, and infrainguinal. Primary outcomes were (1) composite perioperative myocardial infarction (MI) or death and (2) 5-year survival. Patient characteristics and perioperative outcomes were evaluated using the χ test and multivariable logistic regression. Survival was analyzed using Kaplan-Meier method and Cox proportional hazards multivariable models.
Polyvascular disease was identified in 47% of CEA (39.0% in 2 arterial beds, 7.6% in 3 arterial beds; n = 93,736) and 47% of LEB (41.0% in 2 arterial beds, 5.7% in 3 arterial beds; n = 25,223). For both CEA and LEB, patients with polyvascular disease had more comorbidities including hypertension, congestive heart disease, chronic obstructive pulmonary disease, smoking, diabetes mellitus, and end-stage renal disease (P < .0001). Perioperative MI/death rates increased with increasing number of vascular beds affected following CEA (0.9% in 1 bed vs 1.5% in 2 beds vs 2.7% in 3 beds; P < .001) and LEB (2.2% in 1 bed vs 5.3% in 2 beds vs 6.6% in 3 beds; P < .001). Polyvascular disease was associated independently with perioperative MI/death after CEA (odds ratio, 1.59; 95% confidence interval [CI], 1.40-1.81;P < .0001) and LEB (odds ratio, 1.78; 95% CI, 1.52-2.08; P < .0001). Five-year survival was decreased in patients with polyvascular disease after CEA (82% in 3 beds vs 88% in 2 beds vs 92% in 1 bed; P < .01) and LEB (72% in 3 beds vs 75% in 2 beds vs 84% in 1 bed; P < .01) in a dose-dependent manner, with the lowest 5-year survival observed in those with three arterial beds involved. Polyvascular disease was independently associated with 5-year mortality after CEA (hazard ratio, 1.33; 95% CI, 1.24-1.40; P = .0001) and LEB (hazard ratio, 1.30; 95% CI, 1.20-1.41; P = .0001).
Polyvascular disease is common in patients undergoing CEA and LEB and is associated with a higher risk of perioperative MI/death and decreased long-term survival. After revascularization, patients with polyvascular disease should be considered for more aggressive cardioprotective medications and closer follow-up.
多血管疾病与心血管发病率和死亡率的增加密切相关。然而，其在接受颈动脉和下肢手术血运重建的患者中的患病率及其对结果的影响尚不清楚。
查询血管质量倡议（Vascular Quality Initiative）的颈动脉内膜切除术（CEA）或下肢旁路转流术（LEB）数据，时间范围为 2013 年至 2019 年。多血管疾病定义为存在超过一个动脉床的动脉粥样硬化闭塞性疾病：颈动脉、冠状动脉和下肢。主要结局为（1）围手术期心肌梗死（MI）或死亡的复合事件和（2）5 年生存率。使用卡方检验和多变量逻辑回归评估患者特征和围手术期结局。使用 Kaplan-Meier 方法和 Cox 比例风险多变量模型分析生存情况。
在 CEA 中发现 47%的患者存在多血管疾病（2 个动脉床占 39.0%，3 个动脉床占 7.6%；n=93736），在 LEB 中发现 47%的患者存在多血管疾病（2 个动脉床占 41.0%，3 个动脉床占 5.7%；n=25223）。对于 CEA 和 LEB，多血管疾病患者的合并症更多，包括高血压、充血性心力衰竭、慢性阻塞性肺疾病、吸烟、糖尿病和终末期肾病（P<0.0001）。随着 CEA 后受累血管床数量的增加，围手术期 MI/死亡率也随之增加（1 个床位为 0.9%，2 个床位为 1.5%，3 个床位为 2.7%；P<0.001）和 LEB（1 个床位为 2.2%，2 个床位为 5.3%，3 个床位为 6.6%；P<0.001）。多血管疾病与 CEA（比值比，1.59；95%置信区间[CI]，1.40-1.81；P<0.0001）和 LEB（比值比，1.78；95%CI，1.52-2.08；P<0.0001）后围手术期 MI/死亡事件独立相关。在 CEA（3 个床位的 5 年生存率为 82%，2 个床位为 88%，1 个床位为 92%；P<0.01）和 LEB（3 个床位为 72%，2 个床位为 75%，1 个床位为 84%；P<0.01）中，多血管疾病患者的 5 年生存率呈剂量依赖性下降，其中受累血管床数量最多的患者 5 年生存率最低。多血管疾病与 CEA（风险比，1.33；95%CI，1.24-1.40；P=0.0001）和 LEB（风险比，1.30；95%CI，1.20-1.41；P=0.0001）后 5 年死亡率独立相关。
多血管疾病在接受 CEA 和 LEB 的患者中很常见，与围手术期 MI/死亡风险增加和长期生存率降低相关。血管重建后，多血管疾病患者应考虑使用更积极的心脏保护药物和更密切的随访。
