Adoption and Diffusion of Transcarotid Artery Revascularization in Contemporary Practice.
Adoption and Diffusion of Transcarotid Artery Revascularization in Contemporary Practice.
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经颈动脉血运重建术在当代实践中的采用和扩散。
DOI：
10.1161/circinterventions.122.012805
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发表时间：
2023
期刊：
影响因子：
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通讯作者：
O'Malley,AJames
中科院分区：
文献类型：
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作者：
Columbo,JesseA;Stone,DavidH;Martinez-Camblor,Pablo;Goodney,PhilipP;O'Malley,AJames
2015年，FDA批准经颈动脉血运重建术（TCAR）作为颈动脉内膜切除术（CEA）和经股动脉颈动脉支架植入术（TF-CAS）的替代方案，用于颈动脉狭窄的高危患者。这是在没有1级证据支持TCAR的情况下批准的。我们的目的是记录TCAR利用的趋势，随着时间的推移，它的扩散，以及接受TCAR，CEA和TF-CAS. METHODS的患者的临床表型我们使用血管质量倡议进行TCAR的患者进行研究。我们计算了进行的TCAR数量和TCAR利用率与CEA/TF-CAS的百分比。使用TCAR广泛应用之前的数据，我们计算了患者接受CEA的倾向评分。我们将该模型应用于2016年至2022年接受颈动脉血运重建的患者，并根据他们最终接受的手术对患者进行分组，检查评分分布的重叠以衡量患者的相似性。我们测量了TCAR后院内中风/死亡的趋势。结果我们研究了2016年1月1日至2022年3月31日期间接受TCAR的31，447名患者。进行TCAR的中心数量从29家增加到606家。于二零二一年，TCAR占提供所有3项手术的中心的颈动脉血运重建的22. 5%。接受TCAR的患者中符合批准的高风险标准的比例从88.5%下降到80.9%（P<0.001）。既往接受过同侧颈动脉手术的患者从2016年的20.6%下降到2021年的12.0%（P<0.001）。卒中后行TCAR的患者从19.7%增加到30.7%（P<0.001）。TCAR/CEA和TCAR/TF-CAS的倾向评分重叠分别为55.4%和58.6%，表明TCAR患者的临床表型混合在接受CEA和TF-CAS的患者之间。2016年，TCAR后的平均住院卒中/死亡风险为2.3%，2022年为1.7%（Ptrend：0.954）。结论STCAR目前在提供TCAR的中心中占近四分之一的手术。TCAR越来越多地在标准风险患者中进行，并作为卒中后的一线手术选择。缺乏1级证据强调了高质量的基于登记的分析对记录TCAR的真实结局和耐久性的重要性。
BACKGROUNDIn 2015, the FDA approved transcarotid artery revascularization (TCAR) as an alternative to carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS) for high-risk patients with carotid stenosis. This was granted in the absence of level 1 evidence to support TCAR. We aimed to document trends in TCAR utilization, its diffusion over time, and the clinical phenotypes of patients undergoing TCAR, CEA, and TF-CAS.METHODSWe used the Vascular Quality Initiative to study patients who underwent TCAR. We calculated the number of TCARs performed and the percent of TCAR utilization versus CEA/TF-CAS. Using data from before TCAR was widespread, we calculated propensity scores for patients to receive CEA. We applied this model to patients undergoing carotid revascularization from 2016 to 2022 and grouped patients by the procedure they ultimately underwent, examining overlap in score distribution to measure patient similarity. We measured the trend of in-hospital stroke/death after TCAR.RESULTSWe studied 31 447 patients who underwent TCAR from January 1, 2016 to March 31, 2022. The number of centers performing TCAR increased from 29 to 606. In 2021, TCAR represented 22.5% of carotid revascularizations at centers offering all 3 procedures. The percentage of patients that underwent TCAR who met approved high-risk criteria decreased from 88.5% to 80.9% (P<0.001). Those with a prior ipsilateral carotid procedure decreased from 20.6% in 2016 to 12.0% in 2021 (P<0.001). Patients undergoing TCAR after stroke increased from 19.7% to 30.7% (P<0.001). Propensity-score overlap was 55.4% for TCAR/CEA, and 58.6% for TCAR/TF-CAS, demonstrating that TCAR patients have a clinical phenotype mixed between those who undergo CEA and TF-CAS. The average in-hospital stroke/death risk after TCAR was 2.3% in 2016 and 1.7% in 2022 (Ptrend: 0.954).CONCLUSIONSTCAR now represents nearly 1-in-4 procedures at centers offering it. TCAR was increasingly performed among standard-risk patients and as a first-line procedural option after stroke. The absence of level 1 evidence underscores the importance of high-quality registry-based analyses to document TCAR’s real-world outcomes and durability.