背景:COVID-19面临着许多挑战。大流行期间,一些资源有限,导致对显著颈动脉狭窄患者放弃或推迟颈动脉内膜切除术(CEA)等医疗护理.虽然根据国际准则,CEA是首选,颈动脉支架置入术(CAS)可能是一种合理的替代方案,尤其是在后勤限制期间.
目的:评估前CAS与CEA的结果,在COVID-19大流行期间和之后。我们的假设是,与CEA第一种方法相比,CAS第一种方法产生了可比的结果。
方法:回顾性分析2018年9月至2023年3月期间接受CEA或CAS治疗的连续显著颈动脉狭窄患者。1.5年的每个连续时期都标志着一个新的(治疗)时期:COVID之前(CEA第一策略),COVID期间(CAS优先策略)和COVID后(患者定制方法)。主要结局是卒中的复合终点,TIA或30天内死亡。次要结果包括技术成功率,脑高灌注综合征,心肌梗死或其他需要干预的心脏并发症,需要干预的手术部位出血,神经麻痹,意外的IC录取,假性动脉瘤,再狭窄或闭塞。
结果:共纳入318例患者。137名接受CEA治疗的患者中,55、36和46在COVID之前进行了治疗,在COVID和COVID后,分别。在181个CAS程序中,分别为38、59和84,在每个时间段进行。主要结局发生在5.5%,CEA组的0%和2.2%,0%,CAS组分别为1.7%和3.6%(p=0.27;p=1.00;p=1.00)。CEA的总体技术成功率为100%,CAS为99.4%(p=1.00)。再狭窄率是唯一的次要结局指标,与COVID前后的CEA相比,CAS后明显更好(CEAvsCAS,12.7%对7.9%和23.9%对4.8%,p值分别为.03和.03)。大流行期间,医院对治疗间隔的介绍没有显着差异。
结论:颈动脉明显狭窄患者的CAS与CEA结果具有可比性,在COVID-19大流行期间和之后。CAS在其他并发症方面表现出更好的结果(即,与CEA相比,COVID前后的再狭窄率)。当不存在相关禁忌症而不使患者暴露于与开放手术方法相关的并发症时,我们的结果可能支持CAS首次方法。建议在多学科小组中进行讨论。
BACKGROUND: COVID-19 confronted medical care with many challenges. During the pandemic, several resources were limited resulting in renouncing or postponing medical care like carotid endarterectomy (CEA) for patients with significant carotid artery stenosis. Although according to international guidelines CEA is the first choice, carotid artery stenting (
CAS) could potentially be a reasonable alternative especially during logistical restraints.
OBJECTIVE: To evaluate outcomes of CAS versus CEA before, during and after the COVID-19 pandemic. Our hypothesis was that a
CAS first approach yielded comparable outcomes compared to a CEA first approach.
METHODS: Retrospective analysis of consecutive patients with significant carotid artery stenosis treated with CEA or CAS between September 2018 and March 2023. Each consecutive period of 1.5 year marked a new (treatment) period: pre-COVID (CEA first strategy), during COVID (CAS first strategy) and post-COVID (patient-tailored approach). Primary outcome was the composite endpoint of stroke, transient ischemic attack or death within 30 days. Secondary outcome consisted of the rate of technical success, cerebral hyperperfusion syndrome, myocardial infarction or other cardiac complications needing intervention, bleeding of the surgical site needing intervention, nerve palsy, unintended IC admission, pseudoaneurysm, restenosis, or occlusion.
RESULTS: A total of 318 patients were included. Out of 137 patients treated with CEA, 55, 36 and 46 were treated pre-COVID, during COVID and post-COVID, respectively. Out of 181
CAS procedures, 38, 59 and 84, respectively, were performed in each time period. Primary outcome occurred in 5.5%, 0% and 2.2% in the CEA group and 0%, 1.7% and 3.6% in the CAS group (P = 0.27; P = 1.00; P = 1.00, respectively). Overall technical success was 100% for CEA and 99.4% for
CAS (P = 1.00). Rate of restenosis was the only secondary outcome measure which was significantly better after CAS compared to CEA in the pre- and post-COVID period (CEA vs.
CAS, 12.7% vs. 7.9%, and 23.9% vs. 4.8% with a P-value of 0.03 and 0.03, respectively). Hospital presentation to treatment interval did not differ significantly during the pandemic.
CONCLUSIONS: Outcomes were comparable between CAS versus CEA in patients with significant carotid artery stenosis before, during and after the COVID-19 pandemic. CAS showed better results in terms of other complications (i.e., restenosis rate) in the pre- and post-COVID period compared to CEA. Our results may support a CAS first approach when no relevant contra-indications exist without exposing the patient to complications associated with an open surgical approach. Discussion in a multidisciplinary team is advised.