Contemporary Outcomes for Carotid Endarterectomy at a Large Community-Based Academic Health Center

Abstract

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS) demonstrated the efficacy of carotid endarterectomy (CEA), but these studies were published 15 and 11 years ago, respectively. We hypothesized that present clinical results of CEA have improved compared with those reported by NASCET/ACAS. Every patient having CEA from January 1999 through December 2003 was reviewed as part of a continuous quality-assurance program. Patient demographics and risk factors were recorded; high-risk patients were identified using inclusion criteria for high-risk carotid stent trials. Primary end points recorded were all neurologic events, deaths, and myocardial infarctions (MIs). Outcomes were reported individually or as combined neurologic events and deaths (traditional NASCET/ACAS methodology) and, similar to recent carotid stent trials, individually, combined, and as a composite that included MI. A total of 1,927 CEAs were performed, 1,140 in men (59%) and 787 in women (41%). The average age was 72 +/- 9 years; 21% of patients were age 80 or older. Symptomatic patients accounted for 717 procedures (37%). Perioperative neurologic event, death, and MI occurred in 1.0%, 0.5%, and 1.3% of patients, respectively. The combined neurologic event and death rate was 1.3% (symptomatic = 1.8%, asymptomatic = 1.1%). High-risk patients comprised 54% of the cohort; the neurologic event and death rate for this group was 1.6%. The composite end point including MI was 3.4%. Severe coronary artery disease and prior ipsilateral CEA significantly correlated with a higher incidence of primary end point complications. In contemporary practice, the perioperative neurologic event rate is significantly less than reported in NASCET/ACAS. Perioperative death and MI rates were similar to those seen in NASCET/ACAS. Neurologic events and death rates were not different between high- and low-risk groups. These data may serve as a guide for the modern vascular specialist weighing open and endovascular options for treatment of carotid artery occlusive disease in both high- and low-risk patients.