Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
J Vasc Surg. 2024 Dec;80(6):1705-1715.e8. doi: 10.1016/j.jvs.2024.08.024. Epub 2024 Aug 22.
The outcomes of carotid revascularization in patients with prior carotid artery stenting (CAS) remain understudied. Prior research has not reported the outcomes after transcarotid artery revascularization (TCAR) in patients with previous CAS. In this study, we compared the peri-operative outcomes of TCAR, transfemoral CAS (tfCAS) and carotid endarterectomy (CEA) in patients with prior ipsilateral CAS using the Vascular Quality Iniatitive.
Using Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA after prior ipsilateral CAS. We included covariates such as age, race, sex, body mass index, comorbidities (hypertension, diabetes, prior coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, renal dysfunction, smoking, chronic obstructive pulmonary disease, and anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality, and cranial nerve injury (CNI) after TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing.
We identified 2137 patients undergoing revascularization after prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%), and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%; adjusted odds ratio [aOR], 0.33; 95% confidence interval [CI], 0.11-1.05; P = .06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%; aOR, 0.80; 95% CI, 0.16-3.98; P = .8). Compared with CEA, TCAR was associated with lower odds of postoperative MI (0.1% vs 14%; aOR, 0.02; 95% CI, 0.00-0.10; P < .001), stroke/death/MI (0.8% vs 15%; aOR, 0.05; 95% CI, 0.01-0.25; P < .001), and CNI (0.1% vs 3.8%; aOR, 0.04; 95% CI, 0.00-0.30; P = .002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1%, with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (P < .001).
In asymptomatic patients with prior ipsilateral CAS, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably higher in-hospital stroke/death rates. In line with the postprocedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.
颈动脉血运重建术后患者的结果仍有待研究。先前的研究并未报告先前颈动脉支架置入术（CAS）后经颈动脉血运重建术（TCAR）的结果。在本研究中，我们使用血管质量倡议（Vascular Quality Iniatitive）比较了先前同侧 CAS 后行 TCAR、经股动脉 CAS（tfCAS）和颈动脉内膜切除术（CEA）的围手术期结果。
使用 2016 年至 2023 年的血管质量倡议数据，我们确定了先前同侧 CAS 后行 TCAR、tfCAS 或 CEA 的患者。我们纳入了年龄、种族、性别、体重指数、合并症（高血压、糖尿病、先前冠状动脉疾病、先前冠状动脉旁路移植术/经皮冠状动脉介入治疗、充血性心力衰竭、肾功能不全、吸烟、慢性阻塞性肺疾病和贫血）、症状状态、紧急程度、同侧狭窄和对侧闭塞等协变量，以计算治疗分配的倾向评分。然后，我们使用倾向评分进行逆概率加权和加权逻辑回归，比较 TCAR、tfCAS 和 CEA 后的住院内卒中、住院内死亡、卒中/死亡、术后心肌梗死（MI）、卒中/死亡/MI、30 天死亡率和颅神经损伤（CNI）。我们还使用 Cochrane-Armitage 趋势检验分析了随着时间的推移，三种血运重建手术的患者比例的趋势。
我们确定了 2137 例先前同侧颈动脉支架置入后行血运重建的患者：668 例 TCAR 患者（31%）、1128 例 tfCAS 患者（53%）和 341 例 CEA 患者（16%）。在无症状患者中，TCAR 与 tfCAS 相比，住院内卒中/死亡的风险较低，但无统计学意义（TCAR 与 tfCAS：0.7% vs 2.0%；调整后的优势比[aOR]，0.33；95%置信区间[CI]，0.11-1.05；P=0.06），与 CEA 的卒中/死亡风险相似（TCAR 与 CEA：0.7% vs 0.9%；aOR，0.80；95%CI，0.16-3.98；P=0.8）。与 CEA 相比，TCAR 与较低的术后 MI 发生率相关（0.1% vs 14%；aOR，0.02；95%CI，0.00-0.10；P<0.001）、卒中/死亡/MI 发生率（0.8% vs 15%；aOR，0.05；95%CI，0.01-0.25；P<0.001）和 CNI 发生率（0.1% vs 3.8%；aOR，0.04；95%CI，0.00-0.30；P=0.002）。在有症状的患者中，TCAR 的住院内卒中/死亡发生率高得不可接受，为 5.1%，其 CNI 发生率低于 CEA。我们还发现，先前同侧颈动脉支架置入后行 TCAR 的患者比例呈上升趋势（2016 年至 2023 年：14%至 41%），而 tfCAS 的比例相对下降（61%至 45%）和 CEA 的比例下降（25%至 14%）（P<0.001）。
在先前同侧 CAS 的无症状患者中，与 tfCAS 相比，TCAR 与较低的住院内卒中/死亡风险相关，与 CEA 相比，卒中/死亡风险相似，但术后 MI 和 CNI 发生率较低。在有症状的患者中，TCAR 与不可接受的高住院内卒中/死亡风险相关。与术后结果一致，先前同侧支架置入后行 TCAR 的患者比例随着时间的推移稳步增加。
