背景:近期心肌梗死(MI)对于需要任何血管手术的患者来说是一个真正的挑战。目前缺乏关于术前MI对颈动脉血运重建方法(颈动脉内膜切除术(CEA),经股颈动脉支架置入术(TFCAS),或经颈动脉血运重建(TCAR))。这项研究旨在确定最近接受颈动脉血运重建的MI患者的模态特异性结局。
方法:从VQI(2016-2022)收集了美国和加拿大最近患有MI(<6个月)的颈动脉狭窄患者的数据。)正在接受CEA,TFCAS,或TCAR。比较了TFCAS与CEA和TCAR与CEA后的住院结局。在二次分析中比较了TCAR与TFCAS。我们使用逻辑回归模型来比较这三种方法在近期MI患者中的结果。调整潜在的混杂因素。主要结果包括30天住院卒中发生率,死亡,还有MI。次要结果包括卒中/死亡,中风/死亡/MI,术后高血压,术后低血压,延长住院时间(>2天),30天死亡率
结果:最终队列包括1,217(54.2%)CEA,445(19.8%)TFCAS,584例(26.0%)TCAR病例。接受CEA的患者更有可能先进行CABG/PCI并使用抗凝剂。接受TFCAS的患者更有可能出现症状,有先前的CHF,COPD,CKD,并进行紧急行动。接受TCAR的患者更有可能有更高的ASAIV-V级,P2Y12抑制剂,和鱼精蛋白的使用。在单变量分析中,CEA与较低的同侧卒中发生率相关(P=0.079),死亡(P=0.002),30天死亡率(P=0.007)。在调整了混杂因素后,TFCAS与卒中/死亡风险增加相关(aOR=2.69[95%CI:1.36-5.35]P=0.005)和卒中/死亡/MI(aOR=1.67,[95%CI:1.07-2.60],P=0.025)与CEA相比。然而,与CEA相比,TCAR具有相似的结果。TFCAS和TCAR均与术后低血压风险增加相关(分别为aOR=1.62[95%CI:1.18-2.23]P=0.003和aOR=1.74[95%CI:1.31-2.32]P=<0.001),术后高血压风险降低(aOR=0.59[95%CI:0.36-0.95]与aOR=0.50[95%CI]P=0.001),CE71:
结论:尽管最近MI已被确立为CEA的高风险标准和TFCAS的批准适应症,这项研究表明,与TFCAS相比,CEA在卒中/死亡和卒中/死亡/MI风险较低的人群中更安全.在近期MI患者中,与CEA相比,TCAR的卒中/死亡/MI结局相似。需要进一步的前瞻性研究来证实我们的发现。
Recent myocardial infarction (MI) represents a real challenge in patients requiring any vascular procedure. There is currently a lack of data on the effect of preoperative MI on the outcomes of carotid revascularization methodology (carotid enterectomy [CEA], transfemoral carotid artery stenting [TFCAS], or transcarotid artery revascularization [TCAR]). This study looks to identify modality-specific outcomes for patients with recent MI undergoing carotid revascularization.
Data was collected from the Vascular Quality Initiative (2016-2022) for patients with carotid stenosis in the United States and Canada with recent MI (<6 months) undergoing CEA, TFCAS, or TCAR. In-hospital outcomes after TFCAS vs CEA and TCAR vs CEA were compared. TCAR vs TFCAS were compared in a secondary analysis. We used logistic regression models to compare the outcomes of these three procedures in patients with recent MI, adjusting for potential confounders. Primary outcomes included 30-day in-hospital rates of stroke, death, and MI. Secondary outcomes included stroke/death, stroke/death/MI, postoperative hypertension, postoperative hypotension, prolonged length of stay (>2 days), and 30-day mortality.
The final cohort included 1217 CEA (54.2%), 445 TFCAS (19.8%), and 584 TCAR (26.0%) cases. Patients undergoing CEA were more likely to have prior coronary artery bypass graft/percutaneous coronary intervention and to use anticoagulant. Patients undergoing TFCAS were more likely to be symptomatic, have prior congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and undergo urgent operations. Patients undergoing TCAR were more likely to have higher rates of American Society of Anesthesiologists class IV to V, P2Y12 inhibitor, and protamine use. In the univariate analysis, CEA was associated with a lower rate of ipsilateral stroke (P = .079), death (P = .002), and 30-day mortality (P = .007). After adjusting for confounders, TFCAS was associated with increased risk of stroke/death (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.36-5.35; P = .005) and stroke/death/MI (aOR, 1.67; 95% CI, 1.07-2.60; P = .025) compared with CEA. However, TCAR had similar outcomes compared with CEA. Both TFCAS and TCAR were associated with increased risk of postoperative hypotension (aOR, 1.62; 95% CI, 1.18-2.23; P = .003 and aOR, 1.74; 95% CI, 1.31-2.32; P ≤ .001, respectively) and decreased risk of postoperative hypertension (aOR, 0.59; 95% CI, 0.36-0.95; P = .029 and aOR, 0.50; 95% CI, 0.36-0.71; P ≤ .001, respectively) compared with CEA.
Although recent MI has been established as a high-risk criterion for CEA and an approved indication for TFCAS, this study showed that CEA is safer in this population with lower risk of stroke/death and stroke/death/MI compared with TFCAS. TCAR had similar stroke/death/MI outcomes in comparison to CEA in patients with recent MI. Further prospective studies are needed to confirm our findings.