目前的血管外科学会指南对无症状颈动脉狭窄患者的治疗建议对狭窄>70%且手术风险可接受的患者行动脉内膜切除术。现代医学疗法降低了中风的发生率,这增加了仔细选择在决定哪些患者应接受无症状性颈动脉内膜切除术(CEA)的重要性。它会,因此,对于符合接受CEA标准的患者,应非常谨慎地调查预测5年死亡率的现有变量.
从2003年起,对所有CEA病例进行了血管质量调查。纳入研究需要以下内容:(1)生存状态记录;(2)所有纳入人口统计学研究变量的完整数据;(3)无症状神经系统状态。使用二元逻辑回归研究手术中存在的变量,以确定5年死亡率的多变量预测因子。然后询问最高风险变量对长期死亡率的累加效应。对年龄>80岁的患者进行亚分析。
共有30,615名患者符合纳入标准,5414人(18%)在5年内死亡。风险最高的变量被分类为那些调整比值比>1.25,P<.001,β系数≥0.25的变量。这些包括体重指数<20kg/m2,糖尿病,充血性心力衰竭的病史,肾功能不全,终末期肾病,慢性阻塞性肺疾病,家庭以外的生活状态,先前的下肢旁路术,之前的大截肢手术,黑人种族相对于其他种族的总和,血红蛋白<10mg/dL,有颈部照射史,有吸烟史.年龄的年比值比为1.04(P<.001)。与5年死亡率具有统计学意义(P<0.05)的其他变量是冠状动脉疾病,积极的压力测试或在2年内发生心肌梗塞,下肢动脉介入,动脉瘤修复,和P2Y12抑制剂治疗手术。在手术中使用他汀类药物和阿司匹林治疗均可预防5年死亡率(P<0.001)。
我们确定了12个特别高风险的变量,which,结合起来,在对无症状性狭窄进行CEA的5年内,逐步预测死亡率会增加。应特别注意年龄>80岁的患者和有充血性心力衰竭病史的患者,无论当前症状如何,慢性阻塞性肺疾病,肾功能不全或终末期肾病,外周动脉疾病,糖尿病,以及与虚弱相关的变量(BMI低于20,贫血,辅助生活状态)。
The current Society for Vascular Surgery guidelines for the treatment of patients with asymptomatic carotid stenosis recommend endarterectomy for patients with >70% stenosis and acceptable surgical risk. The reduced rate of stroke with modern medical therapy has increased the importance of careful selection in deciding which patients should undergo elective carotid endarterectomy (CEA) for asymptomatic disease. It would, therefore, be very prudent to investigate preexisting variables predictive of 5-year mortality for patients meeting the criteria to undergo CEA.
The Vascular Quality Initiative was queried from 2003 onward for all cases of CEA. Inclusion in the study required the following: (1) documentation of survival status; (2) complete data on all incorporated demographic study variables; and (3) asymptomatic neurologic status. The variables present at surgery were investigated using binary logistic regression to identify multivariate predictors of 5-year mortality. The highest risk variables were then interrogated for an additive effect regarding long-term mortality. A subanalysis was performed for patients aged >80 years.
A total of 30,615 patients met the inclusion criteria, 5414 (18%) of whom had died within 5 years. The highest risk variables were classified as those that had had an adjusted odds ratio >1.25, P < .001, and beta coefficient of ≥0.25. These included a body mass index <20 kg/m2, diabetes mellitus, a history of congestive heart failure, renal insufficiency, end-stage renal disease, chronic obstructive pulmonary disease, living status other than home, prior lower extremity bypass, prior major amputation, Black race relative to other races combined, hemoglobin <10 mg/dL, a history of neck irradiation, and a history of smoking. Age had an annual odds ratio of 1.04 (P < .001). Other variables that achieved a statistically significant (P < .05) association with 5-year mortality were coronary artery disease, a positive stress test or the occurrence of myocardial infarction within 2 years, lower extremity arterial intervention, aneurysm repair, and P2Y12 inhibitor therapy at surgery. The use of statin and aspirin therapy at surgery were both protective against 5-year mortality (P < .001).
We identified 12 particularly high-risk variables, which, in combination, progressively predicted for increasing mortality within 5 years of CEA performed for asymptomatic stenosis. Special attention should be given to patients aged >80 years and patients with any history of congestive heart failure regardless of current symptoms, chronic obstructive pulmonary disease, renal insufficiency or end-stage renal disease, peripheral artery disease, diabetes, and variables associated with frailty (BMI under 20, anemia, assisted living status).