Abstract：
OBJECTIVE: Current evidence suggests that acute carotid artery stenting (CAS) for cervical lesions is associated with better functional outcomes in patients with acute stroke with tandem lesions (TLs) treated with endovascular therapy (EVT). However, the underlying causal pathophysiologic mechanism of this relationship compared with a non-CAS strategy remains unclear. We aimed to determine whether, and to what degree, reperfusion mediates the relationship between acute CAS and functional outcome in patients with TLs.
METHODS: This subanalysis stems from a multicenter retrospective cohort study across 16 stroke centers from January 2015 to December 2020. Patients with anterior circulation TLs who underwent EVT were included. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale ≥2B by the local team at each participating center. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and functional outcome (90-day modified Rankin Scale) is mediated by successful reperfusion.
RESULTS: A total of 570 patients were included, with a median age (interquartile range) of 68 (59-76), among whom 180 (31.6%) were female. Among these patients, 354 (62.1%) underwent acute CAS and 244 (47.4%) had a favorable functional outcome. The remaining 216 (37.9%) patients were in the non-CAS group. The CAS group had significantly higher rates of successful reperfusion (91.2% vs 85.1%; p = 0.025) and favorable functional outcomes (52% vs 29%; p = 0.003) compared with the non-CAS group. Successful reperfusion was a strong predictor of functional outcome (adjusted common odds ratio [acOR] 4.88; 95% CI 2.91-8.17; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS remained significantly associated with functional outcome after adjustment for successful reperfusion (acOR 1.89; 95% CI 1.27-2.83; p = 0.002). Successful reperfusion explained 25% (95% CI 3%-67%) of the relationship between acute CAS and functional outcome.
CONCLUSIONS: In patients with TL undergoing EVT, successful reperfusion predicted favorable functional outcomes when CAS was performed compared with non-CAS. A considerable proportion (25%) of the treatment effect of acute CAS on functional outcome was found to be mediated by improvement of successful reperfusion rates.
METHODS: This subanalysis stems from a multicenter retrospective cohort study across 16 stroke centers from January 2015 to December 2020. Patients with anterior circulation TLs who underwent EVT were included. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale ≥2B by the local team at each participating center. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and functional outcome (90-day modified Rankin Scale) is mediated by successful reperfusion.
RESULTS: A total of 570 patients were included, with a median age (interquartile range) of 68 (59-76), among whom 180 (31.6%) were female. Among these patients, 354 (62.1%) underwent acute CAS and 244 (47.4%) had a favorable functional outcome. The remaining 216 (37.9%) patients were in the non-CAS group. The CAS group had significantly higher rates of successful reperfusion (91.2% vs 85.1%; p = 0.025) and favorable functional outcomes (52% vs 29%; p = 0.003) compared with the non-CAS group. Successful reperfusion was a strong predictor of functional outcome (adjusted common odds ratio [acOR] 4.88; 95% CI 2.91-8.17; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS remained significantly associated with functional outcome after adjustment for successful reperfusion (acOR 1.89; 95% CI 1.27-2.83; p = 0.002). Successful reperfusion explained 25% (95% CI 3%-67%) of the relationship between acute CAS and functional outcome.
CONCLUSIONS: In patients with TL undergoing EVT, successful reperfusion predicted favorable functional outcomes when CAS was performed compared with non-CAS. A considerable proportion (25%) of the treatment effect of acute CAS on functional outcome was found to be mediated by improvement of successful reperfusion rates.
摘要：
目的：目前的证据表明，急性颈动脉支架置入术（CAS）治疗宫颈病变与血管内治疗（EVT）串联病变（TLs）的急性卒中患者更好的功能预后相关。然而,与非CAS策略相比,这种关系的潜在因果病理生理机制尚不清楚.我们的目标是确定是否，到什么程度，再灌注介导TLs患者急性CAS与功能预后的关系。
方法：本子分析来自2015年1月至2020年12月在16个卒中中心进行的多中心回顾性队列研究。包括接受EVT的前循环TLs患者。成功的再灌注定义为每个参与中心的当地团队改良的脑梗死溶栓评分≥2B。进行了中介分析，以检查成功再灌注介导急性CAS与功能结局（90天改良的Rankin量表）之间关系的潜在因果途径。
结果：共纳入570例患者，年龄中位数（四分位数范围）为68（59-76），其中180人(31.6%)为女性。在这些患者中,354例（62.1％）接受急性CAS，244例（47.4％）具有良好的功能结局。其余216例（37.9%）患者属于非CAS组。与非CAS组相比，CAS组的再灌注成功率（91.2％vs85.1％；p=0.025）和良好的功能结局（52％vs29％；p=0.003）明显更高。成功的再灌注是功能预后的强预测因子(校正后的普通比值比[acOR]4.88;95%CI2.91-8.17;p<0.001)。成功的再灌注部分介导了急性CAS与功能结局之间的关系，因为在校正成功再灌注后,急性CAS仍然与功能结局显著相关(acOR1.89;95%CI1.27-2.83;p=0.002).成功的再灌注解释了急性CAS与功能结局之间关系的25％（95％CI3％-67％）。
结论：在接受EVT的TL患者中，与非CAS相比,成功的再灌注预测了CAS时良好的功能结局.发现急性CAS对功能结果的治疗作用中有相当大的比例（25％）是由成功再灌注率的提高介导的。
方法：本子分析来自2015年1月至2020年12月在16个卒中中心进行的多中心回顾性队列研究。包括接受EVT的前循环TLs患者。成功的再灌注定义为每个参与中心的当地团队改良的脑梗死溶栓评分≥2B。进行了中介分析，以检查成功再灌注介导急性CAS与功能结局（90天改良的Rankin量表）之间关系的潜在因果途径。
结果：共纳入570例患者，年龄中位数（四分位数范围）为68（59-76），其中180人(31.6%)为女性。在这些患者中,354例（62.1％）接受急性CAS，244例（47.4％）具有良好的功能结局。其余216例（37.9%）患者属于非CAS组。与非CAS组相比，CAS组的再灌注成功率（91.2％vs85.1％；p=0.025）和良好的功能结局（52％vs29％；p=0.003）明显更高。成功的再灌注是功能预后的强预测因子(校正后的普通比值比[acOR]4.88;95%CI2.91-8.17;p<0.001)。成功的再灌注部分介导了急性CAS与功能结局之间的关系，因为在校正成功再灌注后,急性CAS仍然与功能结局显著相关(acOR1.89;95%CI1.27-2.83;p=0.002).成功的再灌注解释了急性CAS与功能结局之间关系的25％（95％CI3％-67％）。
结论：在接受EVT的TL患者中，与非CAS相比,成功的再灌注预测了CAS时良好的功能结局.发现急性CAS对功能结果的治疗作用中有相当大的比例（25％）是由成功再灌注率的提高介导的。
