Intraoperative Infusion of Dextran Confers No Additional Benefit after Carotid Endarterectomy but Is Associated with Increased Perioperative Major Adverse Cardiac Events

Abstract

Intraoperative dextran infusion has been associated with reduction of an embolic risk in patients undergoing carotid endarterectomy (CEA). Nonetheless, dextran has been associated with adverse reactions including anaphylaxis, hemorrhage, cardiac and renal complications. Herein, we aimed to compare the perioperative outcomes of CEA stratified by the use of intraoperative dextran infusion using a large multi-institutional dataset. Patients undergoing CEA between 2008 and 2022 from the Vascular Quality Initiative database were reviewed. Patients were categorized by use of intraoperative dextran infusion, and demographics, procedural data and in-hospital outcomes were compared. Logistic regression analysis was utilized to adjust for differences in patients while assessing the association between postoperative outcomes and intraoperative infusion of dextran. Of 140,893 patients undergoing CEA, 9,935 (7.1%) patients had intraoperative dextran infusion. Patients with intraoperative dextran infusion were older with lower rates of symptomatic stenosis (24.7% vs 29.3%; P<0.001) and preoperative use of antiplatelets, anticoagulants and statins. Additionally, they were more likely to have severe carotid stenosis (> 80%; 49% vs 45%; P<0.001) and undergo CEA under general anesthesia (96.4% vs 92.3%; P<0.001) with more frequent use of shunt (64.4% vs 49.5%; P<.001). After adjustment, multivariable analysis showed that intraoperative dextran infusion was associated with higher odds of in-hospital major adverse cardiac events (MACE) including myocardial infarction (MI; odds ratio [OR], 1.76, 95% confidence interval [CI]: 1.34-2.3, P<0.001), congestive heart failure (CHF; OR, 2.15, 95% CI: 1.67-2.77, P=0.001) and hemodynamic instability requiring vasoactive agents (OR, 1.08, 95% CI: 1.03-1.13, P=0.001). However, it was not associated with decreased odds of stroke (OR, 0.92, 95% CI: 0.74-1.16, P=0.489) or death (OR, 0.88, 95% CI: 0.58-1.35, P=0.554). These trends persisted even when stratified by symptomatic status and degree of stenosis. Intraoperative infusion of dextran was associated with increased odds of MACE including MI, CHF and persistent hemodynamic instability without decreasing the risk of stroke perioperatively. Given these results, judicious use of dextran in patients undergoing CEA is recommended. Furthermore, careful perioperative cardiac management is warranted in select patients receiving intraoperative dextran during CEA.