Impact of Adding Carotid Endarterectomy to Supra-aortic Trunk Surgical Reconstruction

Abstract

Up to 20% of patients requiring open supra-aortic trunk (SAT) reconstruction have significant carotid artery stenosis. The addition of carotid endarterectomy (CEA) to SAT has been described. Yet, additive risks are not well defined and controversy remains as to whether concomitant CEA increases stroke risk. This study assessed the perioperative effects of adding CEA to SAT. Using the National Surgical Quality Improvement Program (NSQIP), patients who underwent SAT from 2005 to 2015 were evaluated. SAT+CEA were identified. An isolated SAT (ISAT) cohort was created by removing patients who underwent concurrent secondary procedures. Nonocclusive indications were excluded. SAT+CEA were compared with ISAT as well as a propensity-matched ISAT cohort. Primary outcomes were 30-day stroke, death, and composite stroke/death/myocardial infarction (SDM). Univariate and logistic regression analyses were performed. After review, 1,515 patients were identified: 1,245 ISAT (82%) and 270 SAT+CEA (18%). Most were women (56%), 86% were Caucasian, and 24% were symptomatic. Average age was 65±12years and SAT+CEA were older (69 vs. 64years, P<0.001). CEA+SAT were more likely to be men (53% vs. 42%, P<0.001), have hypertension (86% vs. 75%, P<0.001) and diabetes (26% vs. 20%, P=0.04). SAT procedures included the following: carotid-subclavian bypass (68%), carotid-carotid bypass (16%), aorta-great vessel bypass (9%), and carotid-subclavian transposition (7%). ISAT were more likely to undergo carotid-subclavian bypass than SAT+CEA (71% vs. 54%, P<0.001). Overall stroke was 2.3%, death 1.4%, and SDM 4.6%. There were no differences in 30-day stroke (ISAT 2.0% vs. SAT+CEA 3.7%, P=0.09) or mortality (1.4% vs. 1.5%, P=0.88). SAT+CEA had higher rates of SDM (7% vs. 4%, P=0.03). On logistic regression, urgency was a predictor of SDM (operating room [OR] 3.6, 95% confidence interval [CI] 1.5-8.4, P=0.003); addition of CEA was not predictive of stroke (OR 1.4, 95% CI 0.5-4.2, P=0.52) or SDM (OR 1.5, 95% CI 0.6-3.6, P=0.40). After propensity matching, there were no longer differences in demographics or primary end points between the 2 cohorts. Addition of CEA does not confer increased perioperative stroke or SDM risk over ISAT. Perioperative outcomes appear to be more affected by disseminated disease risk factors than the addition of CEA. In patients undergoing SAT, it is reasonable to consider performing combined CEA in populations with tandem carotid bifurcation disease and appropriate operative risk profile.