Chang Heepeel, Garg Karan, Veith Frank J, Basman Craig, Cho Jae S, Zeeshan Muhammad, Mateo Romeo B, Ebanks Mikaiel, Rockman Caron B
Department of Vascular Surgery, Hackensack University Medical Center, Hackensack, NJ.
Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, NY.
Ann Vasc Surg. 2025 Jun;115:43-52. doi: 10.1016/j.avsg.2025.02.010. Epub 2025 Mar 4.
While preoperative anemia is prevalent among surgical patients, its impact on patients undergoing transcarotid artery revascularization (TCAR) remains poorly understood. This study aims to assess the relationship between the severity of preoperative anemia and outcomes following TCAR.
A retrospective analysis of the Vascular Quality Initiative database (2016-2021) was performed to identify patients who underwent TCAR for carotid stenosis. Anemia was defined according to World Health Organization guidelines as a hemoglobin (Hb) level <12 g/dL in females and <13 g/dL in males. The severity of anemia was further classified as mild (Hb: 10-11.9 g/dL in females and 11-12.9 g/dL in males) or moderate to severe (Hb < 10 g/dL in females and <11 g/dL in males). Patients were stratified into three cohorts as follows, based on the presence and severity of preoperative anemia: no anemia, mild anemia, and moderate-to-severe anemia. The primary outcome was 30-day mortality. Secondary outcomes included in-hospital stroke, in-hospital death, myocardial infarction (MI), and prolonged postoperative hospitalization (>1 day). Univariable and multivariable logistic regression analyses were conducted to evaluate the association between the severity of preoperative anemia and clinical outcomes.
Among 21,648 patients who underwent TCAR, 4,240 (19.8%) had mild anemia, and 3,401 (15.8%) had moderate-to-severe anemia preoperatively. After adjusting for relevant clinical factors and confounders, moderate-to-severe preoperative anemia was associated with significantly increased odds of in-hospital MI (adjusted odds ratio [aOR], 2.39; 95% confidence interval [CI]: 1.53-3.74; P < 0.001), in-hospital death (aOR, 2.65; 95% CI: 1.62-4.34; P < 0.001), and 30-day mortality (aOR, 1.89; 95% CI: 1.32-2.72; P < 0.001) compared to nonanemic patients. Among patients with moderate-to-severe anemia, factors such as a history of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), urgent or emergent procedures, and symptomatic carotid stenosis were the strongest predictors of 30-day mortality. In contrast, mild anemia was not associated with increased odds of adverse postoperative outcomes compared to the nonanemic cohort. Preoperative anemia, regardless of severity, was not associated with an increased risk of postoperative stroke following TCAR. However, the severity of preoperative anemia was associated with a stepwise increase in the adjusted odds of prolonged hospitalization (aOR, 1.19 [mild anemia] and 1.57 [moderate-to-severe anemia]).
In this multi-institutional retrospective study of patients undergoing TCAR, moderate-to-severe preoperative anemia was independently associated with higher adjusted odds of in-hospital MI, in-hospital death, and 30-day mortality, without an increased risk of postoperative stroke. These findings highlight moderate-to-severe preoperative anemia as a potential independent prognostic marker for identifying high-risk patients. Furthermore, incorporating the severity of anemia into preoperative risk stratification may aid in tailoring perioperative cardiac assessment and optimization strategies, potentially mitigating the risk of adverse outcomes following TCAR.
虽然术前贫血在外科手术患者中很常见，但其对接受经颈动脉血管重建术（TCAR）患者的影响仍知之甚少。本研究旨在评估术前贫血的严重程度与TCAR术后结局之间的关系。
对血管质量倡议数据库（2016 - 2021年）进行回顾性分析，以确定接受TCAR治疗颈动脉狭窄的患者。根据世界卫生组织指南，贫血定义为女性血红蛋白（Hb）水平<12 g/dL，男性<13 g/dL。贫血的严重程度进一步分为轻度（女性Hb：10 - 11.9 g/dL，男性11 - 12.9 g/dL）或中度至重度（女性Hb < 10 g/dL，男性<11 g/dL）。根据术前贫血的存在和严重程度，将患者分为三个队列：无贫血、轻度贫血和中度至重度贫血。主要结局是30天死亡率。次要结局包括住院期间卒中、住院死亡、心肌梗死（MI）和术后住院时间延长（>1天）。进行单变量和多变量逻辑回归分析，以评估术前贫血严重程度与临床结局之间的关联。
在21,648例接受TCAR的患者中，4,240例（19.8%）术前有轻度贫血，3,401例（15.8%）术前有中度至重度贫血。在调整了相关临床因素和混杂因素后，与非贫血患者相比，术前中度至重度贫血与住院期间MI（调整后的优势比[aOR]，2.39；95%置信区间[CI]：1.53 - 3.74；P < 0.001）、住院死亡（aOR，2.65；95% CI：1.62 - 4.34；P < 0.001）和30天死亡率（aOR，1.89；95% CI：1.32 - 2.72；P < 0.001）的显著增加相关。在中度至重度贫血患者中，慢性阻塞性肺疾病（COPD）或充血性心力衰竭（CHF）病史、急诊或紧急手术以及有症状的颈动脉狭窄等因素是30天死亡率的最强预测因素。相比之下，与非贫血队列相比，轻度贫血与术后不良结局的风险增加无关。术前贫血，无论严重程度如何，与TCAR术后卒中风险增加无关。然而，术前贫血的严重程度与调整后的住院时间延长的优势比逐步增加相关（aOR，1.19[轻度贫血]和1.57[中度至重度贫血]）。
在这项对接受TCAR患者的多机构回顾性研究中，术前中度至重度贫血与住院期间MI、住院死亡和30天死亡率的调整后较高优势比独立相关，且术后卒中风险未增加。这些发现突出了术前中度至重度贫血作为识别高危患者的潜在独立预后标志物。此外，将贫血严重程度纳入术前风险分层可能有助于定制围手术期心脏评估和优化策略，潜在地降低TCAR术后不良结局的风险。
