Tall Alpha Ahamadou, Zil-E-Ali Ahsan, Paracha Abdul Wasay, Choi Esther S, Abdeen Ahmad, Aziz Faisal
Office of Medical Education, Penn State College of Medicine, Penn State University, Hershey, PA.
Division of Vascular Surgery, Heart & Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA.
Ann Vasc Surg. 2025 May 23;121:201-216. doi: 10.1016/j.avsg.2025.05.017.
Chronic Kidney Disease (CKD) has been identified as an important risk factor for perioperative morbidity and mortality. Carotid endarterectomy (CEA) is recommended to reduce the risk of stroke for >80% carotid stenosis in asymptomatic patients and carotid stenosis of >50% in symptomatic patients. This meta-analysis aims to investigate the association of CKD with the 30-day outcomes after CEA.
The review protocol for the current study is registered on the Open Science Framework database. Using PubMed and Scopus databases, a systematic literature review was performed in English, querying papers published up to April 2024. The review was designed to include published observational studies investigating the association of CKD with postoperative outcomes of CEA, including mortality and stroke within 30 days. CKD was defined as having an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m, while an eGFR ≥60 mL/min/1.73 m was defined as normal kidney function. Pooled odds ratios (ORs) for the overall mortality were computed using the confidence interval (CI) of 95%. The heterogeneity among the included studies was calculated by Q-metric and quantified using Higgins I-statistics.
Thirty-two thousand five hundred ive patients were represented in the eight studies published from 2008 to 2021. Of the patients undergoing CEA, 17,891 (55%) patients had CKD with varying levels of eGFR, and 14,614 (45%) did not. Pooled OR revealed an increased risk of 30-day mortality (OR, 1.72; 95% CI, 1.40-2.11) and stroke (OR, 1.27; 95% CI, 1.08-1.50) among patients in the CKD group. Similar results with higher mortality (OR, 2.21; 95% CI, 1.26-3.86), stroke (OR, 2.19; 95% CI, 0.94-5.07), and composite of mortality or stroke (OR, 2.52; 95% CI, 1.31-4.84) were observed in CKD patients undergoing CEA for symptomatic Carotid artery stenosis (CAS). For asymptomatic CAS patients and comorbid CKD, this risk prevailed with a higher risk of mortality (OR, 1.96; 95% CI, 1.10-3.48), stroke (OR, 3.21; 95% CI, 1.46-7.07), and composite of mortality or stroke (OR, 2.20; 95% CI, 1.37-3.54) was observed. A reduction in eGFR and increased severity in CKD was associated with a greater risk of adverse outcomes.
CKD patients undergoing CEA are at a high risk of increased mortality, stroke, or a composite of the 2 within the first 30 days after the procedure. This risk increases with the severity of the CKD, as highlighted by lower renal function defined by low eGFR. Primary outcomes did not seem to differ among symptomatic versus asymptomatic CAS patients. These patients may warrant more aggressive postoperative management, especially within the first 30 days post-CEA.
慢性肾脏病（CKD）已被确定为围手术期发病和死亡的重要危险因素。对于无症状患者中颈动脉狭窄>80%以及有症状患者中颈动脉狭窄>50%的情况，推荐进行颈动脉内膜切除术（CEA）以降低中风风险。本荟萃分析旨在研究CKD与CEA术后30天结局之间的关联。
本研究的综述方案已在开放科学框架数据库中注册。使用PubMed和Scopus数据库，以英文进行了系统的文献综述，检索截至2024年4月发表的论文。该综述旨在纳入已发表的观察性研究，这些研究调查了CKD与CEA术后结局的关联，包括30天内的死亡率和中风。CKD被定义为估计肾小球滤过率（eGFR）<60 mL/min/1.73 m²，而eGFR≥60 mL/min/1.73 m²被定义为肾功能正常。使用95%置信区间（CI）计算总体死亡率的合并比值比（OR）。纳入研究之间的异质性通过Q统计量计算，并使用希金斯I统计量进行量化。
2008年至2021年发表的8项研究共纳入32505例患者。在接受CEA的患者中，17891例（55%）患者患有不同eGFR水平的CKD，14614例（45%）患者未患CKD。合并OR显示，CKD组患者30天死亡率（OR，1.72；95%CI，1.40 - 2.11）和中风（OR，1.27；95%CI，1.08 - 1.50）风险增加。对于因有症状颈动脉狭窄（CAS）接受CEA的CKD患者，观察到类似结果，死亡率更高（OR，2.21；95%CI，1.26 - 3.86）、中风（OR，2.19；95%CI，0.94 - 5.07）以及死亡或中风的复合结局（OR，2.52；95%CI，1.31 - 4.84）。对于无症状CAS患者合并CKD，这种风险仍然存在，死亡率更高（OR，1.96；95%CI，1.10 - 3.48）、中风（OR，3.21；95%CI，1.46 - 7.07）以及死亡或中风的复合结局（OR，2.20；95%CI，1.37 - 3.54）。eGFR降低和CKD严重程度增加与不良结局风险增加相关。
接受CEA手术的CKD患者在术后前30天内有较高的死亡、中风或两者复合结局增加的风险。随着CKD严重程度的增加，这种风险也增加，低eGFR所定义的肾功能降低突出了这一点。有症状与无症状CAS患者的主要结局似乎没有差异。这些患者可能需要更积极的术后管理，尤其是在CEA术后的前30天内。
