Supplementary Material for: Safety and efficacy of hybrid surgery in chronic internal carotid artery occlusion: A systematic review and meta-analysis

ABSTRACT
Background Chronic internal carotid artery occlusion (CICAO) is a common cause of stroke and ischemia recurrence. An increasing number of reports have highlighted the potential of hybrid surgery for treating CICAO. There are few studies, specifically nonrandomized controlled trials, on the safety and effectiveness of hybrid surgery for the treatment of CICAO, so in this study, we hypothesized that hybrid surgery would be safe, have an acceptable complication rate and a high success rate. Methods MEDLINE, Embase, Cochrane Library, and Web of Science databases were searched for relevant studies published up to January 30, 2023. The primary end point was recanalization rates of occluded vessels, and the secondary endpoint was perioperative death and procedure-related complications. Subgroup analysis focused on the recanalization rates of endovascular intervention (EI) and hybrid surgery, as well as the rates of recanalization below the clinoid segment and at the clinoid segment and beyond. The follow-up visit was conducted at least 3 months after surgery, and stenosis or occlusion recurrence was confirmed by review of CTA or DSA scan.Results The databases were searched and 1709 records were identified, of which 16 articles were used in the meta-analysis, and 464 CICAO patients with complete data who underwent hybrid surgery were enrolled. Hybrid surgery was associated with higher success rates (RD=0.87 95% CI [0.84-0.91], P<0.00001) than EI (OR=4.71 95% CI [2.32-9.56], P<0.0001). The procedural success rate in the below-clinoid segment group was significantly higher than that in the clinoid segment and beyond group (OR=13.76 95% CI [5.31-35.66], P<0.00001). The total periprocedural complication rate was low (RD=0.11 95% CI [0.07-0.15], P<0.00001 and RD= 0.04 95% CI [0.00-0.07], P=0.03). Target vessel restenosis or reocclusion occurred in 35 patients (8%) during the follow-up period (RD=0.08 95% CI [0.04-0.12], P<0.0001).Conclusion Hybrid surgery is the combination of the advantages of open surgery and endovascular intervention, has a high success rate, and a low risk of recurrence of stenosis and occlusion in the long-term. Randomized controlled trials on hybrid surgery for internal carotid artery occlusion are necessary.
Key words: hybrid surgery, CICAO, endovascular intervention, meta-analysis

摘要
背景 慢性颈内动脉闭塞（Chronic internal carotid artery occlusion, CICAO）是脑卒中及缺血复发的常见病因。越来越多的研究报道凸显了复合手术治疗CICAO的应用潜力。目前针对复合手术治疗CICAO的安全性与有效性的研究较少，尤其是非随机对照试验，因此本研究提出假设：复合手术安全性良好、并发症发生率可接受且手术成功率较高。
方法 检索MEDLINE、Embase、Cochrane图书馆及Web of Science数据库，检索时限截至2023年1月30日。本研究的主要终点为闭塞血管的再通率，次要终点为围手术期死亡及手术相关并发症。亚组分析聚焦于血管内介入治疗（endovascular intervention, EI）与复合手术的再通率，以及床突下段、床突段及以上部位的再通率。术后至少随访3个月，通过计算机断层血管造影（CTA）或数字减影血管造影（DSA）复查以确认狭窄或闭塞复发。
结果 共检索到1709条文献记录，最终纳入16篇文献进行荟萃分析，纳入464例接受复合手术且数据完整的CICAO患者。复合手术的成功率显著高于血管内介入治疗（风险差RD=0.87，95%置信区间CI[0.84-0.91]，P<0.00001；比值比OR=4.71，95%CI[2.32-9.56]，P<0.0001）。床突下段组的手术成功率显著高于床突段及以上组（OR=13.76，95%CI[5.31-35.66]，P<0.00001）。总体围手术期并发症发生率较低（RD=0.11，95%CI[0.07-0.15]，P<0.00001；RD=0.04，95%CI[0.00-0.07]，P=0.03）。随访期间共有35例患者（8%）发生靶血管再狭窄或再闭塞（RD=0.08，95%CI[0.04-0.12]，P<0.0001）。
结论 复合手术兼具开放手术与血管内介入治疗的优势，手术成功率高，长期随访中狭窄及闭塞复发风险较低。针对颈内动脉闭塞复合手术治疗的随机对照试验仍有必要开展。
关键词：复合手术、CICAO、血管内介入治疗、荟萃分析