IP105. Shunting in Patients With Contralateral Carotid Artery Occlusion During Carotid Endarterectomy Does Not Improve Perioperative Risk of Stroke or Death

Abstract

Controversy exists regarding outcomes in patients with contralateral carotid artery occlusion (CCO) when undergoing carotid endarterectomy (CEA). We hypothesized that patients with CCO undergoing CEA were at higher risk for stroke and mortality. We used a contemporary national database to evaluate perioperative outcomes in patients with and without CCO undergoing CEA. The American College of Surgeons National Surgical Quality Improvement Program targeted vascular database was queried for patients who underwent CEA between 2011 and 2017. Those included in the CCO cohort had preoperative ultrasound and/or angiographic evidence of CCO. Patient demographics, operative variables, and outcomes including stroke and 30-day mortality were compared with descriptive statistics. Multivariable regression models were used for analysis. During the 8-year study period 24,781 patients underwent CEA. CCO was present in 950 patients (3.8%). Patients with CCO were younger (69.7 years vs 71.2 years; P < .001); more often male (70% vs 61%; P < .001); more often smokers (37% vs 26%; P < .001); less likely to be diabetic (28% vs 31%; P = .02); and more likely to have chronic obstructive pulmonary disease (13% vs 10%; P = .007) when compared with those without CCO. Patients with CCO were more likely to be asymptomatic from their ipsilateral carotid disease (60% vs 56%; P = .02), but more frequently had severe stenosis (66% vs 65%; P < .001). Patients with CCO had higher perioperative morbidity (19% vs 15%; P = .003), 30-day mortality (1.5% vs 0.67%; P = .007) and stroke rate (2.8% vs 1.7%; P = .01) when compared with those without CCO. When controlled for age, sex, shunt use, patch closure, asymptomatic status, ipsilateral transient ischemic attack, diabetes, and congestive heart failure, the risk of stroke and death in patients with CCO was higher (odds ratio, 3.05; 95% confidence interval [CI], 1.16-6.66; P = .01) than those without CCO, as was the risk of stroke or death (odds ratio, 1.5; 95% CI, 1.06-2.13; P = .02). When evaluating the efficacy of shunting in individuals with CCO, and controlling for age, anesthesia type, patch closure, asymptomatic status, ipsilateral transient ischemic attack, diabetes, and congestive heart failure, the risk of death in patients with CCO who underwent shunting was 4. -times higher (95% CI, 1.21-19.30; P = .03) than in patients who did not have an intraoperative shunt. The risk of stroke and death in patients with CCO is higher when compared with those without CCO. Additionally, the risk of death in patients with CCO is elevated in patients undergoing intraoperative shunting. Careful consideration and discussion of the risks of CEA in patients with CCO must occur. Additional studies must be performed to confirm these results.