Abstract：
OBJECTIVE: Renal failure is a predictor of adverse outcomes in carotid revascularization. There has been debate regarding the benefit of revascularization in patients with severe CKD or on dialysis.
METHODS: VQI patients undergoing TCAR, tfCAS, or CEA between 2016 and 2023 with eGFR <30 ml/min/1.73m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/MI (SDM). Secondary outcomes included perioperative death, stroke, MI, CNI and stroke/death. Inverse probability of treatment weighting (IPW) was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and pre-op symptoms. Chi-square and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression.
RESULTS: In the weighted cohort, 13,851 patients with eGFR of <30 (2,506 on dialysis) underwent TCAR (3,639, dialysis 704), tfCAS (1,975, 393) or CEA (8,237, 1,409) during the study period. Compared with TCAR, CEA had higher odds of stroke/death/MI (2.8% vs 3.6%, aOR 1.27 [1.00,1.61], p=.049), and MI (0.7% vs 1.5%, aOR 2.00 [1.31,3.05], p=.001)... Compared to TCAR, rates of SDM (2.8%vs5.8%), stroke (1.2%vs2.6%), death (0.9%vs2,4%)were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%, aOR 1.85[1.15, 2.97]p=.011) and CNI (0.3% vs 1.9%, aOR 7.23[3.28, 15.9] p<.001). Like the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death, and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death or stroke/death. While tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, 5-year survival was similar for TCAR and CEA (eGFR <30: 75.1% vs 74.2%, aHR1.06, p=.3) and lower for tfCAS (eGFR <30: 75.1% vs 70.4%, aHR1.44, p<.001) CONCLUSION: CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, while patients with reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures.
METHODS: VQI patients undergoing TCAR, tfCAS, or CEA between 2016 and 2023 with eGFR <30 ml/min/1.73m2 or on dialysis were included. Patients were divided into cohorts based on procedure. Additional analyses were performed for patients on dialysis only and by symptomatology. Primary outcomes were perioperative stroke/death/MI (SDM). Secondary outcomes included perioperative death, stroke, MI, CNI and stroke/death. Inverse probability of treatment weighting (IPW) was performed based on treatment assignment to TCAR, tfCAS, and CEA patients and adjusted for demographics, comorbidities, and pre-op symptoms. Chi-square and multivariable logistic regression analysis were used to evaluate the association of procedure with perioperative outcomes in the weighted cohort. Five-year survival was evaluated using Kaplan-Meier and weighted Cox regression.
RESULTS: In the weighted cohort, 13,851 patients with eGFR of <30 (2,506 on dialysis) underwent TCAR (3,639, dialysis 704), tfCAS (1,975, 393) or CEA (8,237, 1,409) during the study period. Compared with TCAR, CEA had higher odds of stroke/death/MI (2.8% vs 3.6%, aOR 1.27 [1.00,1.61], p=.049), and MI (0.7% vs 1.5%, aOR 2.00 [1.31,3.05], p=.001)... Compared to TCAR, rates of SDM (2.8%vs5.8%), stroke (1.2%vs2.6%), death (0.9%vs2,4%)were all higher for tfCAS. In asymptomatic patients CEA patients had higher odds of MI (0.7% vs 1.3%, aOR 1.85[1.15, 2.97]p=.011) and CNI (0.3% vs 1.9%, aOR 7.23[3.28, 15.9] p<.001). Like the primary analysis, asymptomatic tfCAS patients demonstrated higher odds of death, and stroke/death. Symptomatic CEA patients demonstrated no difference in stroke, death or stroke/death. While tfCAS patients demonstrated higher odds of death, stroke, MI, stroke/death, and SDM. In both groups, 5-year survival was similar for TCAR and CEA (eGFR <30: 75.1% vs 74.2%, aHR1.06, p=.3) and lower for tfCAS (eGFR <30: 75.1% vs 70.4%, aHR1.44, p<.001) CONCLUSION: CEA and TCAR had similar odds of stroke and death and are both a reasonable choice in this population; however, TCAR may be better in patients with increased risk of MI. Additionally, tfCAS patients were more likely to have worse outcomes after weighting for symptom status. Finally, while patients with reduced eGFR have worse outcomes than their healthy peers, this analysis shows that the majority of patients survive long enough to benefit from the potential stroke risk reduction provided by all revascularization procedures.
摘要：
目的：肾衰竭是颈动脉血运重建不良结局的预测因子。关于严重CKD或透析患者血运重建的益处一直存在争议。
方法：接受TCAR的VQI患者，tfCAS,包括2016年至2023年eGFR<30ml/min/1.73m2或透析时的CEA。根据程序将患者分为队列。仅对透析患者和症状学进行了其他分析。主要结果为围术期卒中/死亡/MI(SDM)。次要结果包括围手术期死亡，中风,MI,CNI和中风/死亡。基于对TCAR的治疗分配进行治疗加权的逆概率(IPW)，tfCAS,和CEA患者，并调整了人口统计学，合并症,和术前症状。在加权队列中，使用卡方和多变量逻辑回归分析来评估手术与围手术期结局的相关性。使用Kaplan-Meier和加权Cox回归评估5年生存率。
结果：在加权队列中，13,851例eGFR<30（透析2,506）患者接受了TCAR（3,639，透析704），研究期间的tfCAS（1,975,393）或CEA（8,237,1,409）。与TCAR相比,CEA有较高的中风/死亡/MI的几率(2.8%vs3.6%,OR1.27[1.00,1.61],p=.049)，和MI(0.7%对1.5%，OR2.00[1.31,3.05],p=.001）。..与TCAR相比，SDM率（2.8%vs5.8%），中风(1.2%vs2.6%)，tfCAS的死亡率(0.9%vs2,4%)均较高。在无症状患者中，CEA患者发生MI的几率更高(0.7%vs1.3%，OR1.85[1.15,2.97]p=.011)和CNI(0.3%vs1.9%，OR7.23[3.28,15.9]p<.001)。像初级分析一样，无症状的tfCAS患者的死亡几率更高，中风/死亡。有症状的CEA患者在中风中没有表现出差异，死亡或中风/死亡。虽然tfCAS患者的死亡几率更高，中风,MI,中风/死亡，和SDM。在这两组中,TCAR和CEA的5年生存率相似（eGFR<30：75.1％vs74.2％，aHR1.06,p=.3)和更低的tfCAS(eGFR<30:75.1%vs70.4%,aHR1.44,p<.001)结论:CEA和TCAR有相似的中风和死亡几率,都是这一人群的合理选择;然而,在MI风险增加的患者中，TCAR可能更好。此外,在对症状状态进行加权后,tfCAS患者的预后更差.最后,虽然eGFR降低的患者的预后比健康的同龄人差，本分析显示,大多数患者存活时间足够长,可以从所有血运重建手术所带来的潜在卒中风险降低中获益.
方法：接受TCAR的VQI患者，tfCAS,包括2016年至2023年eGFR<30ml/min/1.73m2或透析时的CEA。根据程序将患者分为队列。仅对透析患者和症状学进行了其他分析。主要结果为围术期卒中/死亡/MI(SDM)。次要结果包括围手术期死亡，中风,MI,CNI和中风/死亡。基于对TCAR的治疗分配进行治疗加权的逆概率(IPW)，tfCAS,和CEA患者，并调整了人口统计学，合并症,和术前症状。在加权队列中，使用卡方和多变量逻辑回归分析来评估手术与围手术期结局的相关性。使用Kaplan-Meier和加权Cox回归评估5年生存率。
结果：在加权队列中，13,851例eGFR<30（透析2,506）患者接受了TCAR（3,639，透析704），研究期间的tfCAS（1,975,393）或CEA（8,237,1,409）。与TCAR相比,CEA有较高的中风/死亡/MI的几率(2.8%vs3.6%,OR1.27[1.00,1.61],p=.049)，和MI(0.7%对1.5%，OR2.00[1.31,3.05],p=.001）。..与TCAR相比，SDM率（2.8%vs5.8%），中风(1.2%vs2.6%)，tfCAS的死亡率(0.9%vs2,4%)均较高。在无症状患者中，CEA患者发生MI的几率更高(0.7%vs1.3%，OR1.85[1.15,2.97]p=.011)和CNI(0.3%vs1.9%，OR7.23[3.28,15.9]p<.001)。像初级分析一样，无症状的tfCAS患者的死亡几率更高，中风/死亡。有症状的CEA患者在中风中没有表现出差异，死亡或中风/死亡。虽然tfCAS患者的死亡几率更高，中风,MI,中风/死亡，和SDM。在这两组中,TCAR和CEA的5年生存率相似（eGFR<30：75.1％vs74.2％，aHR1.06,p=.3)和更低的tfCAS(eGFR<30:75.1%vs70.4%,aHR1.44,p<.001)结论:CEA和TCAR有相似的中风和死亡几率,都是这一人群的合理选择;然而,在MI风险增加的患者中，TCAR可能更好。此外,在对症状状态进行加权后,tfCAS患者的预后更差.最后,虽然eGFR降低的患者的预后比健康的同龄人差，本分析显示,大多数患者存活时间足够长,可以从所有血运重建手术所带来的潜在卒中风险降低中获益.
