Invited commentary

Abstract

This article describes perioperative stroke and death rates for carotid endarterectomy and coronary angioplasty and stenting derived from 20% of United States inpatient episodes during 2004 and 2005. Some important factors prevent comparisons with longer-term clinical trials or cohort studies. The stroke and death rates quoted here are likely to underestimate outcomes; around one-third of 30-day events occurred after discharge. Somewhat confusingly, there is no definition of the events: Is fatal stroke recorded as death, or stroke (or twice)? Recording of fatal stroke as an inpatient could clarify this. The authors express surprise that for 95% of procedures, patients were asymptomatic, “an unexpected finding,” yet somewhat disingenuously, they also feel that one of the study strengths is that it represents the “real-world” view. Women comprised 42% of the patients in the 2-year study period, contrasting with previous clinical trials and audits where gender distribution was about 70:30 (male/female). Age is not mentioned in this study, and this is particularly unfortunate because there is level 1 evidence from the large Asymptomatic Carotid Surgery Trial clearly showing that benefit from surgery was only clearly demonstrated for younger (<75 years) asymptomatic patients.1Halliday A. Harrison M. Hayter E. Kong X. Mansfield A. Marro J. et al.Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial.Lancet. 2010; 376: 1074-1084Abstract Full Text Full Text PDF PubMed Scopus (579) Google Scholar Although the authors mention that preoperative medications may influence postoperative outcome, this area has not been explored.2Dorigo W. Pulli R. Marek J. Troisi N. Pratesi G. Innocenti A.A. et al.Carotid endarterectomy in female patients.J Vasc Surg. 2009; 50 (discussion 1306-7): 1301-1306Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar This is of interest because, during the period of this study, statin usage was rapidly increasing, having been shown to be beneficial in the Heart Protection Study and more recently reinforced by the Cholesterol Trialists Collaboration report.3CTT CollaborationEfficacy and safety of more intensive LDL-lowering therapy: meta-analysis of individual data from 170,000 participants in 26 randomised trials.Lancet. 2010; 376: 1670-1681Abstract Full Text Full Text PDF PubMed Scopus (3901) Google Scholar There is now no possibility to conduct randomized controlled trials of statin usage, and only studies such as this covering the period when they were gaining widespread use can shed light on the possibility that they may protect patients from perioperative stroke. In summary, the authors are to be congratulated for their sensible analysis of current United States practice and dispelling the views that there are significant extra hazards for intervention in women. Outcome of carotid artery interventions among female patients, 2004 to 2005Journal of Vascular SurgeryVol. 53Issue 6PreviewThe benefit of carotid endarterectomy (CEA) in female patients has been questioned by various randomized, prospective trials, particularly in asymptomatic cases; several have noted an increase in perioperative stroke among women after CEA. The outcome of carotid angioplasty and stenting (CAS) has not been extensively examined in women. This study examined the outcome of CEA and CAS in women vs men by using a national database. Full-Text PDF Open Archive