INTRODUCTION Carotid bifurcation stenosis may co-exist simultaneously with more proximal common carotid artery (CCA) atherosclerotic plaquing, primarily at the vessel origin in the aortic arch. This scenario is relatively infrequent and its' management does not have quality randomized data to support medical vs surgical treatment. It is logical to treat any high grade common carotid lesions proximal to a carotid bifurcation endarterectomy (CEA) site both to prevent perioperative emboli or thrombosis as well as future embolization. Prior long-term investigations of the combined treatment paradigm have been low volume analysis. Further, prior studies focus on perioperative outcomes with respect to stroke prevention. The only prior VQI study investigating mid-term outcomes following simultaneous CEA with proximal CCA endovascular therapy provided data on less than 10 patients beyond 1.5 years. The long-term follow-up (LFTU) component initiative within VQI has been emphasized in recent years, now allowing for much more robust LTFU analysis. METHODS Four cohorts were created for perioperative outcome analysis and Kaplan Meier freedom from event analysis: CEA in isolation for asymptomatic disease; CEA in isolation for symptomatic patients; CEA with proximal CCA endovascular intervention for asymptomatic; and, CEA with proximal CCA intervention for symptomatic patients. Binary logistic multivariable regression was performed for perioperative neurological event and 90-day mortality risk determination and Cox multivariable regression analysis was performed for long term freedom from cumulative ischemic neurological event and long-term mortality analysis. Symptomatology and type of surgery (CEA with or without CCA intervention) were individual variables in the multivariable analysis. Neurological ischemic event in this study encompassed transient ischemic attack (TIA) and stroke combined. RESULTS We noted a statistically significant (P < .001) escalation in rates of perioperative neurological event, myocardial infarction (MI), carotid re-exploration, 90 day mortality and combined neurological event and 90 day mortality moving from: A) asymptomatic CEA in isolation to B) symptomatic CEA in isolation to C) asymptomatic CEA combined with proximal CCA intervention to D) symptomatic CEA in combination with proximal CCA intervention. The positivity rate for the combined outcome of perioperative ischemic neurological event and 90 day mortality was 2.2% amongst asymptomatic CEA in isolation, 4.1% amongst symptomatic CEA in isolation, 4.4% amongst asymptomatic CEA in combination with proximal CCA intervention; and 8.8% in patients with symptomatic lesions undergoing combined CEA with proximal CCA intervention. On multivariable analysis patients undergoing CEA with proximal CCA endovascular intervention experienced greater risk for perioperative neurological ischemic event (aOR 2.03, 1.43-2.90, P < .001), combined perioperative neurological ischemic event and 90 day mortality (aOR 2.13, 1.62-2.80, P < .001), long term mortality (HR 1.62, 1.12-2.29, P < .001), and cumulative neurological ischemic event in long term follow up (HR 1.62, 1.12-2.29, P = .007). Amongst 4395 cumulative ischemic neurological events in all study patients, 34% were TIA. CONCLUSIONS Carotid bifurcation endarterectomy in combination with proximal endovascular common carotid artery intervention caries an over two fold higher perioperative risk of neurologic ischemic event and 90 day mortality relative to CEA in isolation for asymptomatic and symptomatic cohorts respectively. After surgery, freedom from cerebral ischemia and mortality for patients undergoing dual intervention is closely aligned with patients undergoing CEA in isolation. Despite high adverse perioperative event rates for the combined CEA and CCA treatment, there is likely long term stroke reduction and mortality benefit to this approach in symptomatic patients based on the event free rates seen herein after initial hospital discharge. The benefit of treating asymptomatic tandem ICA and CCA lesions remains vague but the 4.4% perioperative neurologic event and death rate suggests that these patients would be better managed with medical therapy.

中文翻译：

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颈动脉内膜切除术同时进行近端颈总动脉血管内介入治疗有利于有症状的狭窄，但可能对无症状病变没有优势。

简介 颈动脉分叉狭窄可能与更近端的颈总动脉 (CCA) 动脉粥样硬化斑块同时存在，主要发生在主动脉弓的血管起源处。这种情况相对罕见，其管理人员没有高质量的随机数据来支持药物治疗与手术治疗。治疗颈动脉分叉动脉内膜切除术 (CEA) 部位附近的任何高级颈总动脉病变是合乎逻辑的，以防止围手术期栓塞或血栓形成以及未来的栓塞。先前对联合治疗范例的长期研究是小批量分析。此外，先前的研究重点是预防中风的围手术期结局。之前唯一一项调查 CEA 与近端 CCA 血管内治疗同时进行的中期结果的 VQI 研究提供了不到 10 名患者超过 1.5 年的数据。近年来，VQI 中的长期随访 (LFTU) 组件计划得到了强调，现在可以进行更稳健的 LTFU 分析。方法 创建四个队列进行围手术期结果分析和 Kaplan Meier 免于事件分析：CEA 隔离无症状疾病；对有症状的患者进行CEA隔离；对于无症状的 CEA 与近端 CCA 血管内介入治疗；对有症状的患者进行 CEA 和近端 CCA 干预。对围手术期神经系统事件和 90 天死亡风险测定进行二元 Logistic 多变量回归，对长期累积缺血性神经系统事件和长期死亡率分析进行 Cox 多变量回归分析。症状学和手术类型（CEA 有或没有 CCA 干预）是多变量分析中的个体变量。本研究中的神经缺血事件包括短暂性脑缺血发作（TIA）和中风的组合。结果 我们注意到，围手术期神经系统事件、心肌梗死 (MI)、颈动脉再探查、90 天死亡率以及综合神经系统事件和 90 天死亡率的发生率呈统计学显着性 (P < .001) 上升：A) 无症状 CEA隔离至 B) 有症状 CEA 隔离至 C) 无症状 CEA 联合近端 CCA 干预 D) 症状 CEA 联合近端 CCA 干预。围手术期缺血性神经系统事件和 90 天死亡率的综合结果的阳性率在无症状 CEA 单独治疗中为 2.2%，在有症状 CEA 单独治疗中为 4.1%，在无症状 CEA 联合近端 CCA 干预中为 4.4%；在接受 CEA 与近端 CCA 联合干预的有症状病变患者中，这一比例为 8.8%。多变量分析表明，接受 CEA 联合近端 CCA 血管内介入治疗的患者发生围手术期神经缺血事件的风险更大 (aOR 2.03, 1.43-2.90, P < .001)，围手术期神经缺血事件和 90 天死亡率（aOR 2.13、1.62-2.80，P < .001）、长期死亡率（HR 1.62、1.12-2.29，P < .001）以及长期随访中累积神经缺血事件的综合结果（HR 1.62、1.12-2.29，P = .007）。在所有研究患者的 4395 例累积缺血性神经系统事件中，34% 为 TIA。结论 对于无症状组和有症状组，颈动脉分叉动脉内膜切除术联合近端颈总动脉近端血管内介入治疗的围手术期神经缺血事件风险和 90 天死亡率分别比单独 CEA 高两倍以上。手术后，接受双重干预的患者的脑缺血和死亡率与单独接受 CEA 的患者密切相关。尽管 CEA 和 CCA 联合治疗的围手术期不良事件发生率较高，但根据首次出院后本文观察到的无事件发生率，这种方法可能对有症状患​​者有长期的卒中和死亡率降低益处。治疗无症状串联 ICA 和 CCA 病变的益处仍不清楚，但 4.4% 的围手术期神经系统事件和死亡率表明这些患者可以通过药物治疗得到更好的管理。