Asymptomatic Carotid Endarterectomy Research Articles

292 Predictive Factors for Post-Operative Hypotension Following Carotid Endarterectomy

Abstract Background Post-operative hypotension is a recognised complication following carotid endarterectomy (CEA). This study aimed to examine the incidence of post-operative hypotension requiring vasopressors and to identify variables associated with this phenomenon following CEA. Method A retrospective cohort study of 73 consecutive patients undergoing CEA between June 2022 and June 2023 was conducted. Patient data, including degree of carotid stenosis, and comorbidities such as myocardial infarction, diabetes, hypertension, and chronic kidney disease (CKD), were extracted from medical records. Fisher’s exact test was used to evaluate the difference in prevalence of co-morbidities between groups, and Mann-Whitney U test to assess for difference in degree of carotid stenosis. Results 71 symptomatic and 2 asymptomatic CEAs were performed, with 12.3% (n=9) experiencing post-operative hypotension requiring vasopressors. In the post-CEA hypotension group, 33.3% (n=3) had a history of myocardial infarction, 77.8% (n=7) had hypertension, and none had diabetes or CKD. In comparison, the non-hypotensive group had a prevalence of 17.2% (n=11) for myocardial infarction, 18.8% (n=12) for diabetes, 71.9% (n=46) for hypertension, and 6.3% (n=4) for CKD. There was no significant difference in prevalence of these co-morbidities between the two groups. The degree of carotid stenosis was similar in the post-CEA hypotension and the non-hypotension group, 75% (IQR 60% – 90%), and 70% (IQR 65% - 90%), respectively. Conclusions Approximately 1 in 8 CEA patients require vasopressor support for post-operative hypotension. However, no specific variable emerged as a significant predictor for vasopressor requirement. Consequently, emphasis should be placed on post-operative monitoring to facilitate timely and appropriate intervention.

Investigation of the weekend effect on perioperative complications and mortality after carotid revascularization

ObjectiveOutcomes for weekend surgical interventions are associated with higher rates of mortality and complications than weekday interventions. Although prior investigations have reported the “weekend effect” for carotid endarterectomy (CEA), this association remains unclear for transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS). We investigated the weekend effect for all three carotid revascularization methods. MethodsWe queried the Vascular Quality Initiative for patients who underwent CEA, TCAR, and TFCAS between 2016 and 2022. χ2 and logistic regression modeling analyzed outcomes including in-hospital stroke, death, myocardial infarction, and 30-day mortality by weekend vs weekday intervention. Backward stepwise regression was used to identify significant confounding variables and was ultimately included in each final logistic regression model. Logistic regression of outcomes was substratified by symptomatic status. Secondary multivariable analysis compared outcomes between the three revascularization methods by weekend vs weekday interventions. ResultsA total of 155,962 procedures were analyzed including 103,790 CEA, 31,666 TCAR, and 20,506 TFCAS. Of these, 1988 CEA, 246 TCAR, and 820 TFCAS received weekend interventions. Logistic regression demonstrated no significant differences for TCAR and increased odds of in-hospital stroke/death/myocardial infarction for CEA (odds ratio [OR]: 1.31, 95% confidence interval [CI]: 1.04-1.65) and TFCAS (OR: 1.46, 95% CI: 1.09-1.96) weekend procedures. Asymptomatic TCAR patients had nearly triple the odds of 30-day mortality (OR: 2.85, 95% CI: 1.06-7.68, P = .038). Similarly, odds of in-hospital death were nearly tripled for asymptomatic CEA (OR: 2.89, 95% CI: 1.30-6.43, P = .009) and asymptomatic TFCAS (OR: 2.78, 95% CI: 1.34-5.76, P = .006) patients. Secondary analysis demonstrated that CEA and TCAR had no significant differences for all outcomes. TFCAS was associated with increased odds of stroke and death compared with CEA and TCAR. ConclusionsIn this observational cohort study, we found that weekend carotid revascularization is associated with increased odds of complications and mortality. Furthermore, asymptomatic weekend patients perform worse in the CEA and TFCAS procedural groups. Among the three revascularization methods, TFCAS is associated with the highest odds of perioperative stroke and mortality. As such, our findings suggest that TFCAS procedures should be avoided over the weekend in favor of CEA or TCAR. In patients who are poor candidates for CEA, TCAR offers the lowest morbidity and mortality for weekend procedures.

Guideline Compliant Minimum Asymptomatic Carotid Endarterectomy Surgeon and Hospital Volume Cutoffs

There is a known association between volume and outcomes after carotid endarterectomy (CEA). A recent analysis suggested rates of stroke and death do not significantly reduce after a surgeon volume cutoff of 20 CEAs per year. However, these results would severely limit access. The objective here is to identify a lower optimal cutpoint for surgeon and hospital volume for asymptomatic CEA. We evaluated asymptomatic CEA patients using The New York Statewide Planning and Research Cooperative System database from 2000-2014. The relationship of 3-year averaged volumes for surgeons and hospitals to 30-day stroke were assessed using multiple logistic regression and included both hospital and surgeon volume in all analyses. Optimized cutpoints were the lowest significant volume cutoff that minimized the adjusted odds ratio of stroke. We studied 32,549 CEAs performed by 271 surgeons in 136 centers by vascular surgeons. The median surgeon volume was 26.3(IQR:12.3-51.7) and the median hospital volume was 67(IQR:36.3-119.3). The surgeon volume cutpoint was 3 and the hospital volume cutpoint was 6 cases per year. There were 756(2.3%) procedures performed by surgeons with a volume <3 and 560 (1.7%) procedures performed by hospitals with a volume <6. Perioperative stroke and death rates were 2.0% (95%CI:1.8-2.1) and 3.8% (95%CI:2.6-5.5) for an average yearly surgeon volume ≥3 and <3 (p=0.070), respectively. The combined Stroke and death rate was 2.0% (95%CI:1.8-2.1) and 4.8% (95%CI:3.2-7.0) for an average yearly center volume ≥6 and <6 (p=0.007), respectively. A combined surgeon and hospital volume variable also predicted outcomes and low volume procedures did not meet previously proposed AHA and SVS quality measures. These data demonstrate an improvement in outcomes at a lower volume threshold than previously reported. These modest cutoff values should be used for asymptomatic CEA volume guideline formation and for future studies, after accounting for the impact of other important factors that may be driving volume-outcomes relationships in asymptomatic CEA.

Similar 30 Day Clinical Outcomes After Carotid Artery Stenting By Different Medical Specialities: Analysis From a Large, Multicentre, European Roadsaver Study

Objective: Carotid artery disease treatment options include optimal medical therapy, surgical carotid endarterectomy (CEA), and endovascular carotid artery stenting (CAS). Clinical trials from the past two decades, comparing CEA with CAS reveal higher periprocedural (up to 30 days) risk of stroke or death with CAS. The higher risk is primarily noted in symptomatic patients (> 70 years old), while in younger and/or asymptomatic patients CEA and CAS outcomes are more comparable.1 Contemporary CAS is carried out by operators of different specialties, including angiologists, (neuro)radiologists, cardiologists, and vascular surgeons, the last of which are slightly underrepresented in the endovascular practice relative to other specialties. Newer generation dual layer micromesh stents (DLMS), were specifically designed to further decrease the CAS related periprocedural cerebral embolisation risk. Their short and long term safety and efficacy is supported by a large body of clinical evidence,2–5 but more studies in broader, unselected, patient populations are needed.

What is the Relationship Between Chronic Heart Failure and Operation size? A systematic Review

Background: Heart failure is a chronic progressive failure of the heart muscle to pump blood to meet the body’s oxygen demands. Heart failure impacts on perioperative outcomes of non-cardiac surgery, with higher risks of post-operative complications and mortality. The aim of this study was to review current clinical evidence to assess if there was a relationship between heart failure, operation size and post operative outcomes Methods: PRISMA guidelines were implemented to complete a systematic review. The review was pre-registered with the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42022313897). PubMed was searched from 1940 to 2022 using the terms “heart failure”, “noncardiac surgery”, “thyroid surgery”, “breast surgery”, “asymptomatic carotid endarterectomy”, “hernia”, “cholecystectomy”. “laparoscopy”, laparotomy”, “peripheral angioplasty”, “EVAR”, “neck of femur”, “abdominal aortic aneurysm”, and “lower extremity revascularisation”. Inclusion criteria included: experimental and observational studies; pre operative diagnosis of heart failure; 30d morbidity and mortality; non cardiac surgery. Results: 47 articles relevant to the inclusion criteria were analysed. Five studies assessed low risk operations; 29 assessed intermediate risk operations; 8 assessed high risk operations; 5 assessed intermediate and high-risk operations. For low, intermediate and high-risk operations, heart failure was associated with a statistically significant increased risk of mortality and morbidity (p lessthan0.05). Conclusions: Heart failure is associated with increased morbidity and mortality independent of operation size or risk. Challenges remain in assessing the relationship between heart failure and operation outcome due to variations in disease spectrum and the impact of additional co-morbidities.

Long Term Mortality Rate in Patients Treated with Carotid Endarterectomy

Carotid endarterectomy (CEA) is an effective surgical method for stroke prevention in selected patients with carotid stenosis. Few contemporary studies report on the long term mortality rate in CEA treated patients, despite continuous changes in medication, diagnostics, and patient selection. Here, the long term mortality rate is described in a well characterised cohort of asymptomatic and symptomatic CEA patients, sex differences evaluated, and mortality ratio compared with the general population. This was a two centre, non-randomised, observational study evaluating all cause, long term mortality in CEA patients from Stockholm, Sweden between 1998 and 2017. Death and comorbidities were extracted from national registries and medical records. Cox regression was adapted to analyse associations between clinical characteristics and outcome. Sex differences and standardised mortality ratio (SMR, age and sex matched) were studied. A total of 1 033 patients were followed for 6.6 ± 4.8 years. Of those, 349 patients died during follow up where the overall mortality rate was similar in asymptomatic and symptomatic patients (34.2% vs. 33.7%, p= .89). Symptomatic disease did not influence the mortality risk (adjusted HR 1.14, 95% CI 0.81 - 1.62). Women had lower crude mortality rate than men in the first 10 years (20.8% vs. 27.6%, p= .019). In women, cardiac disease was associated with increased mortality (adjusted HR 3.55, 95% CI 2.18 - 5.79), while in men, lipid lowering medication was protective (adjusted HR 0.61, 95% CI 0.39 - 0.96). Within the first five years after surgery, SMR was increased for all patients (men 1.50, 95% CI 1.21 - 1.86; women 2.41, 95% CI 1.74 - 3.35), as well as in patients < 80 years (SMR 1.46, 95% CI 1.23 - 1.73). Symptomatic and asymptomatic carotid patients have similar long term mortality rates after CEA, but men had worse outcome than women. Sex, age, and time after surgery were shown to influence SMR. These results highlight the need for targeted secondary prevention, to alter the long term adverse effects in CEA patients.

Minimum Asymptomatic Carotid Endarterectomy Surgeon and Hospital Volume Cutoffs

There is a known association between volume and outcomes after carotid endarterectomy (CEA). A recent analysis suggested rates of stroke and death do not significantly reduce after a surgeon volume cutoff of 20 CEAs per year. However, these RESULTS would severely limit access. The objective here is to identify a lower optimal cutpoint for surgeon and hospital volume for asymptomatic CEA.

Effect of Chronic Antiplatelet and Anticoagulant Medication in Neck Hematoma and Perioperative Outcomes after Carotid Endarterectomy

A retrospective analysis of neck hematoma, stroke, and mortality after symptomatic and asymptomatic carotid endarterectomy (CEA) was conducted, to determine the most appropriate perioperative medication for these patients. Thirty-day outcomes of moderate and severe neck bleeding were also investigated. Patients undergoing CEA in a Vascular Surgery department were analyzed (2015-2019). Preprocedure antithrombotic medication (from the 5 days prior to surgery) was identified. End point predictors were identified by univariate and multivariable analyses and adjusted for confounders. A total of 304 CEA were included. Almost half of the included patients (49.67%) were under low-dose aspirin, 17.55% other single antiplatelet agent, 12.59% dual antiplatelet therapy, 8.61% anticoagulation, and 10.92% no antithrombotic therapy. There was a 8.22% rate of important hematoma, including 4.93% severe (requiring surgical exploration) hematomas and a 30-day all-stroke incidence of 2.94% in symptomatic and 1.79% asymptomatic patients (P=0.51). When compared to aspirin, severe hematoma was more prevalent with single clopidogrel or triflusal (relative risk [RR] 4.25, P=0.11), dual antiplatelet group (RR 11.84, P=0.002), and anticoagulation (RR 8.604, P=0.02). Dual antiaggregation and anticoagulation did not confer postoperative stroke protection compared to single aspirin in either symptomatic or asymptomatic patients. Nonsignificant higher intrahospital mortality was noted in no medication, dual antiplatelet, and anticoagulation groups in contrast to aspirin. Severe neck bleeding was associated with increased congestive heart failure (9.26-fold, P=0.03) and longer hospital stay (11.20±24.69days vs. 3.18±4.79 with no bleeding, P<0.001), with a tendency for higher hospital readmission at 30 days (4.66-fold, P=0.13). Mortality and stroke rates were similar. Double antiaggregation and anticoagulation did not confer better perioperative outcomes after elective CEA in our study. These regimens were associated with an increased risk of neck hematoma, especially severe bleeding, with similar rates of neurologic events in both symptomatic and asymptomatic patients and no mortality benefit. Monotherapy with aspirin appears to be the safest perioperative antithrombotic regimen for elective CEA.

Association between Race and Perioperative Outcomes after Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis in NSQIP.

Previous studies have documented that Black patients have worse outcomes after lower extremity revascularization procedures compared with White patients. However, the association of race on carotid endarterectomy (CEA) outcomes is not well described. The aim of this study was to compare perioperative outcomes of CEA for Black vs White patients with asymptomatic carotid artery stenosis. All patients who underwent CEA for asymptomatic carotid stenosis in the ACS-NSQIP targeted vascular database (2011-2019) were included. Perioperative (30-day) outcomes were compared for Black vs White patients using multivariable logistic regression adjusting for age/sex, comorbidities, and disease characteristics. Of 16,764 asymptomatic CEA patients, 95.2% (N = 15,960) were White and 4.8% (N = 804) were Black. Black patients were slightly younger (mean age 71.4 ± 0.1 vs 69.9 ± 0.3 years, P < 0.001) and more frequently had high-grade carotid artery stenosis compared to White patients (79.5% vs 74.0%, p = 0.001). Comorbidities including hypertension, diabetes, kidney disease, congestive heart failure, and coronary artery disease were all more prevalent among Black patients (p ≤ 0.01). Crude perioperative stroke (2.4% vs 1.3%, p = 0.007) and stroke/death (2.6% vs 1.4%, p = 0.003) were higher for Black patients, but myocardial infarction (1.7% vs 1.5%, p = 0.67) and death (0.4% vs 0.2%, p = 0.12) were similar. After adjusting for baseline differences between groups, the risk of perioperative stroke (odds ratio 1.66, 95% CI 1.01 to 2.73) and stroke/death (odds ratio 1.75, 95% CI 1.10 to 2.81) remained significantly higher for Black patients compared with White patients. Black patients undergoing CEA for asymptomatic carotid artery stenosis had more severe stenosis, more comorbidities, and worse perioperative outcomes compared to White patients. Overall, our data suggest substantial differences in the treatment and outcomes of asymptomatic carotid artery stenosis based on race.

Modifications in Near Infrared Spectroscopy for Cerebral Monitoring During Carotid Endarterectomy in Asymptomatic and Symptomatic Patients

To evaluate trends and differences in Near Infrared Spectroscopy (NIRS) monitoring during carotid endarterectomy (CEA) in patients affected by asymptomatic and symptomatic carotid artery stenosis, to predict postoperative neurological complications (PNCs). NIRS data of CEAs performed in a University Hospital were retrospectively reviewed. All the interventions were performed under general anesthesia and patients with intraoperative complications were excluded. Mean regional Oxygen Saturation Index (rSO2), pre-clamp values (mean baseline value, MBv and Single Mark Baseline value, SMBv) were collected and compared to the lowest rSO2 values during carotid cross-clamp (LSO2v) calculated within 3 min (percentage drop, PD). ROC curve analysis with Youden's Test was performed to determine the best threshold value of PD, in order to identify PNCs in both asymptomatic and symptomatic groups. Between 2007 and 2015, a total of 399 CEAs were consecutively performed with NIRS monitoring. Three-hundred-seventy-two CEAs in 355 patients were reviewed. Asymptomatic stenoses were 291 (81.9%), eleven (2.9%) PNC were registered (5 in asymptomatic and 6 in symptomatic group). Asymptomatic and symptomatic diseases had different MBv (69.5 ± 7.5 vs. 71.8 ± 6.9, respectively; P = 0.011) and similar rSO2 value during carotid clamping (63.7 ± 8.0 vs. 63.7 ± 6.7, respectively: P = 0.958). Asymptomatic patients experiencing PNCs had a greater PD than non-PNCs group (20.5 ± 10.2% vs. 12.5 ± 7.6%, respectively using MBv as baseline value; P=0.002), in contrast, in symptomatic patients, in which a low PD was associated with PNCs, it does not reach statistical significance (using MBv, 12.6 ± 5.4% vs. 14.8 ± 6.7%, respectively; P= 0.476). In order to detect PNCs, ROC analysis revealed an optimal PD cut-off value of -17% in asymptomatic CEAs. (Sensibility (Se) 0.80, Specificity (Sp) 0.76, PPV 0.05, NPV 0.99, Youden's index 0.56; P = 0.020) In symptomatic a threshold value of -9% was found, without reaching statistical significance. NIRS as cerebral monitoring during CEA can predict PNCs in asymptomatic stenosis. Asymptomatic and symptomatic groups differ in baseline and intraprocedural cut-off values to detect an augmented PNCs risk.

Asymptomatic Preoperative Leukocytosis Before Carotid Endarterectomy is Associated With Increased Risk of Stroke: A Study From NSQIP Database

Carotid endarterectomy (CEA) is the gold standard operation for treating carotid artery stenosis in patients with symptomatic carotid stenosis of more than 50% and asymptomatic carotid stenosis of more than 80%. Asymptomatic leukocytosis before CEA represents a clinical dilemma for surgeons about the management options. The objectives of this study are to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in patients undergoing CEA and to assess the relationship between asymptomatic preoperative leukocytosis and postoperative complications in the cohort of patients with symptomatic carotid stenosis. The American College of Surgeons National Surgical Quality Improvement Program database for the years 2011-2019 was utilized for this analysis. Patients with preoperative sepsis, septic shock, pneumonia, wound infections, disseminated cancer, renal failure, and history of chronic steroid use were excluded. The remaining patients were sub-grouped based on white blood cell (WBC) count: Normal WBC (<11k/µL) and High WBC (≥11k/µL). Bivariate analysis between the patient characteristics and preoperative WBC levels was performed following simple and multiple regression analysis. A P-value of <0.05 was set as significant. Of the 26,332 patients in the study cohort, 7.4% (n =1,946) had preoperative leukocytosis. Patients with preoperative leukocytosis were relatively younger (mean age: 41.5 +/- 9.7 vs 44.3 +/- 9.1; P< 0.001) and more likely to be females (43% vs. 38.5; P< 0.001) than patients with normal WBC count. Patients with preoperative leukocytosis were also more likely to have DM, COPD, a bleeding disorder, be smokers, and be functionally dependent. The analysis revealed that patients with preoperative leukocytosis had a significantly higher rate of stroke, length of stay (LOS)>1- week, acute occlusion or revision, acute renal failure, and return to OR when compared to patients with normal WBC count. Furthermore, patients with high WBC count also experienced higher occurrences of infectious complications, such as wound dehiscence, wound infections, pneumonia, and sepsis. However, there was no difference in the overall 30-day mortality. Multivariate regression analysis showed patients with preoperative leukocytosis had anincreased risk of stroke (AOR 1.5, CI: 1.1-1.9, P = 0.009), LOS>1 week (AOR 1.3, CI: 1.1-1.5, P = 0.003), and return to OR (AOR 1.3, CI: 1.0-1.8, P = 0.030). The increased LOS was especially more pronounced in symptomatic carotid stenosis patients with preoperative leukocytosis. The occurrence of LOS>1 week was 4.91% in asymptomatic stenosis patients with high WBC count compared to 21.5% in symptomatic stenosis patients with high WBC count (P< 0.001). Patients with asymptomatic preoperative leukocytosis undergoing CEA have a significantly higher risk of stroke and infectious complications in the postoperative period. Furthermore, patients with symptomatic carotid disease are especially at an increased risk of prolonged LOS. A routine preoperative hematological evaluation may be recommended as a risk assessment tool for patients undergoing CEA, and postponing the elective operation in patients with asymptomatic CEA may be advised unless a thorough preoperative infectious workup is completed.

Role of risk scoring systems in predicting life expectancy after carotid endarterectomy in asymptomatic patients

ObjectiveThe aim of this study is to compare and to test the performance of all available risk scoring systems (RSSs) designed to predict long-term survival rate in asymptomatic candidate patients for carotid endarterectomy (CEA) for significant carotid artery stenosis. MethodsData on asymptomatic patients who underwent CEA in three high-volume centers were prospectively recorded. Through literature research using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, six RSSs were identified for the intent of the study. Primary endpoints were 3- and 5-year survival rates after CEA. All items used as variables to compose multiple RSSs were applied to every patient in the study population. The 3- and 5-year mortality prediction rates for each score were assessed by sensitivity, specificity, and predictive negative and positive value calculation, as well as univariable Cox proportional hazard models with the Harrell C index. ResultsDuring the study period, 825 CEAs in 825 asymptomatic patients were analyzed. All items used in RSSs were available in the dataset, with some concerns regarding their definition and application among RSSs. The 3- and 5-year survival rates of the study cohort were 94.5% and 90.3%, respectively. Among the six RSSs analyzed, no RSS demonstrated optimal results in terms of mortality rate prediction accuracy, although some scores had good diagnostic and risk of death precision. ConclusionsRSSs, when used alone, fail to optimally detect postoperative life expectancy in asymptomatic CEA patient candidates. Further prospective controlled studies are needed to compose and validate RSSs with better calibration to predict outcomes.

Analysis of Length of Stay and Readmission Quality Indications After Asymptomatic Carotid Endarterectomy

Next-day discharge and 90-day readmission after asymptomatic carotid endarterectomy (CEA) have been used as quality measures. Our goal was to analyze the reasons for a prolonged (>1 day) length of stay (LOS) and 90-day readmission after CEA.

Editor's Choice – Protamine Reduces Serious Bleeding Complications Associated with Carotid Endarterectomy in Asymptomatic Patients without Increasing the Risk of Stroke, Myocardial Infarction, or Death in a Large National Analysis

Controversy persists regarding the use of protamine during carotid endarterectomy (CEA), despite real world evidence to support its use. The purpose of this study was to determine the impact of protamine reversal of heparin anticoagulation on the outcome of CEA in the USA. A prospective national registry (Society for Vascular Surgery Vascular Quality Initiative) of 72787 patients undergoing elective asymptomatic CEA by 1879 surgeons from 316 centres in the USA and Canada from 2012 to 2018 was reviewed. Protamine use varied by both surgeon (20% rare use [< 10%], 30% variable use [11%-79%], 50% routine use [> 80% cases]) and geographical region (44% vs. 96%). Temporal trends in protamine use were also determined. End points included post-operative re-operation for bleeding, as well as potential protamine related thrombotic complications, including stroke, death, and myocardial infarction (MI). Predictors of end points were determined by multivariable logistic regression. Propensity matching was additionally used to control for differences between groups. Of the 72787 patients who underwent CEA, 69% received protamine, while 31% did not. Protamine use increased over time from 60% (2012) to 73% (2018). In total, 378 patients (0.7%) in the protamine treated group underwent re-operation for bleeding vs. 342 patients (1.4%) in the untreated cohort (p<.001). Protamine use did not affect the rate of MI (0.7% vs. 0.8%; p=.023), stroke (1.1% vs. 1.0%; p=.20), or in hospital death (0.2% vs. 0.2%; p=0.70) between treated and untreated patients, respectively. On multivariable analysis, protamine use was independently associated with reduced risk of re-operation for bleeding (odds ratio 0.5, 95% confidence interval 0.39-0.55; p<.001). Independent of protamine exposure, the consequences of a return to the operating room (RTOR) for bleeding were statistically significant, with a sevenfold increase in MI (RTOR 4.9% vs. no RTOR 0.7%; p<.001), an eightfold increase in stroke (RTOR 7.2% vs. no RTOR 0.9%; p<.001), and a 13 fold increase in death (RTOR 2.4% vs. no RTOR 0.2%; p<.001). Protamine reduces serious bleeding complications at the time of CEA without increasing the risk of MI, stroke, or death, in this large North American analysis. Based on this and previous regional work regarding protamine use in CEA, it is believed that there is now sufficient evidence to support its routine use, and it should be considered as a benchmark for quality during CEA.

Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications

Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1day. The secondary outcomes included perioperative/in-hospital complications and mortality. There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4±1.5, 2.1±2.5, and 2.2±2.8days (P=0.0001), respectively, and after CAS were 1.7±2.6, 1.8±2.1, and 2±2.6days (P<0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS>1day (P=0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1day (OR 1.42, 95% CI 1.06-1.91) (P=0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P=0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P=0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P=0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P=0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts. Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.

Hospital-Level Medicaid Prevalence Is Associated With Increased Length of Stay After Asymptomatic Carotid Endarterectomy and Stenting Despite No Increase in Complications

Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure by payers and affects hospital operating margins. Patient-level Medicaid status has been shown to be associated with longer LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. The National Inpatient Sample was queried from 2006 to 2014 for CEA and CAS performed for asymptomatic carotid stenosis. Hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM; lowest quartile), medium Medicaid prevalence (MM; second and third quartiles), and high Medicaid prevalence (HM; fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. Secondary outcomes included perioperative complications. There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Among patients who underwent CEA, 1.9%, 34.7%, and 63.4% received care at hospitals with LM, MM, and HM prevalence, respectively. Among patients who underwent CAS, 1.9%, 26.4%, and 71.8% received care at hospitals with LM, MM, and HM prevalence, respectively. Hospital-level Medicaid prevalence cohorts for CEA differed by age, sex, race, insurance, hospital size, region, neighborhood income, diabetes, and anemia (P < .05). Cohorts for CAS differed by age, race, insurance, hospital size, region, neighborhood income, illegal drug use, diabetes, and chronic renal disease (P < .05). Neurologic (0.8% vs 0.9% vs 0.9%; P = .83) and cardiac complications (0.9% vs 1.2% vs 1.2%; P = .24) after CEA were similar between hospitals with LM, MM, and HM prevalence, respectively. Neurologic (1.1% vs 1% vs 1.2%; P = .42) and cardiac complications (2% vs 1.3% vs 1.5%; P = .46) after CAS were also similar. Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5 days, 2.1 ± 2.5 days, and 2.2 ± 2.8 days (P = .0001), respectively. Mean postoperative LOS after CAS at hospitals with LM, MM, and HM prevalence was 1.7 ± 2.6 days, 1.8 ± 2.1 days, and 2 ± 2.6 days (P < .0001), respectively. On multivariable analysis for CEA, relative to LM prevalence, MM prevalence (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.17-2.24) and HM prevalence (OR, 1.66; 95% CI, 1.2-2.28; P = .009) were associated with LOS >1 day. On multivariable analysis for CAS, HM prevalence was associated with LOS >1 day (OR, 1.42; 95% CI, 1.06-1.91; P = .003). Increased hospital-level Medicaid prevalence is associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Medicaid prevalence is important in creating appropriate risk-adjusted quality metrics and developing care pathways that optimize hospital reimbursement.

Higher Long-Term Mortality with Carotid Artery Stenting in Asymptomatic Male Compared with Female Patients in the Southeastern Vascular Study Group

To review the sex differences among symptomatic and asymptomatic patients treated with carotid endarterectomy (CEA) and carotid artery stenting (CAS) in the Southeastern Vascular Study Group (SEVSG), a regional quality group of the Vascular Quality Initiative (VQI). All cases reported by the SEVSG members of symptomatic and asymptomatic patients were included in this retrospective review of CEA and CAS. Primary end point was 3-year survival difference between male and female patients. Secondary end points included in-hospital myocardial infarction (MI), transient ischemic attack (TIA)/stroke, and mortality differences between symptomatic and asymptomatic male and female patients. Cox proportional hazard regression was used to assess 3-year survival differences. There were 8,303 CEA and 1,876 CAS procedures performed in 29 centers from January 2011 to December 2018. From those, 4,650 (56.0%) and 938 (50.1%) were asymptomatic CEA and CAS, respectively. There were 2,760 (59.4%) male patients in the asymptomatic CEA and 597 (63.9%) in the asymptomatic CAS groups. After CEA, the rates of in-hospital MI (P=0.034), TIA/stroke (P<0.001), and death (P<0.001) were significantly higher in symptomatic patients. MIs were more frequent in females with asymptomatic disease (P=0.041). After CAS, the rate of TIA/stroke was higher in symptomatic patients (P=0.030). There were no differences according to sex in the CAS group. On follow-up, asymptomatic male patients treated with CAS had a higher 3-year all-cause mortality compared with their female counterparts (7.0% vs. 1.8%; P=0.015). On multivariable Cox regression analysis, male sex (HR=2.63 [95% CI=1.058-6.536]; P=0.038) and lower hemoglobin levels (HR=0.72 [95% CI=0.597-0.857]; P<0.001) were predictors of death in asymptomatic male patients treated with CAS. In our SEVSG region, postoperative MIs, TIA/stroke, and deaths were higher in symptomatic CEA patients. MIs were more frequent in asymptomatic CEA females. Postoperative TIA/stroke was more frequent in symptomatic CAS patients. After CAS, asymptomatic male patients had higher 3-year all-cause mortality than female patients. On multivariable Cox regression analysis, male sex and lower hemoglobin levels were predictors of death in these asymptomatic male patients treated with CAS. Long-term mortality risk in asymptomatic males should be considered before offering CAS. Further national VQI analysis of our asymptomatic and symptomatic male and female patients treated with CEA and CAS would be warranted.

Clinical impact of sex on carotid revascularization

BackgroundThe impact of sex in the management of carotid disease is unclear in the current literature. Therefore, we evaluated the effect of sex on perioperative outcomes following carotid endarterectomy (CEA) and carotid artery stenting (CAS). MethodsWe included patients who underwent CEA or CAS between 2012 and 2017 in the Vascular Quality Initiative database. Our primary outcome was perioperative stroke/death. Secondary outcomes were in-hospital stroke, 30-day mortality, and in-hospital MI. We compared perioperative outcomes between female and male patients, stratified by treatment modality and symptom status, and used multivariable regression to account for differences in baseline characteristics. ResultsA total of 83,436 patients underwent either a CEA (71,383) or CAS (12,053). Asymptomatic and symptomatic CEA females were less likely to be on a preoperative antiplatelet agent, when compared to males. Females overall, were less likely to be on a preoperative statin and more likely to have chronic obstructive pulmonary disease. Within the CAS cohort, females were more likely to have a previous ipsilateral CEA. There were no differences between males and females in major adverse events following CEA for asymptomatic disease. Following CEA for symptomatic disease, there was no difference in stroke/death rate or in-hospital stroke. However, females experienced a higher 30-mortality after adjustment (univariate: 1.0% vs 0.7%, P = .04; adjusted: odds ratio [OR], 1.4:1.02-1.94). Following CAS for asymptomatic disease, females experienced a higher rate of perioperative stroke/death (2.9% vs 1.9% P = .02; OR, 1.5: 1.05-2.03) and in-hospital stroke (2.1% vs 1.2% P = .01; OR, 1.8: 1.20-2.60). There were no differences in outcomes for symptomatic females vs males undergoing CAS. ConclusionsFemales with carotid disease less frequently receive optimal medical treatment with antiplatelet agents and statins. This is an important target area for quality improvement issue in both females and males. Furthermore, among symptomatic CEA patients the female sex is associated with higher mortality and among asymptomatic CAS patients, females experience higher rates of stroke/death. These findings suggest that careful patient selection is necessary in the treatment of female patients. Quality improvement projects should be created to further investigate and eliminate the disparities of optimal medical management between the sexes.

The asymptomatic octogenarian and carotid endarterectomy—While we await the results of CREST-2

Currently there is no definitive level I evidence regarding the appropriate management of asymptomatic moderate to severe carotid artery stenosis in the octogenarian patient. In this 5-year review of National Surgical Quality Improvement Program registry data, exceptional “real-world” results are reported with use of carotid endarterectomy (CEA) in this growing cohort.1Glousman B.N. Sebastian R. Macsata R. Kuang X. Yang A. Patel D. et al.Carotid endarterectomy for asymptomatic carotid stenosis is safe in octogenarians.J Vasc Surg. 2020; 71: 518-524Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The combined stroke and death rate was 2% at 30-day follow-up (stroke rate 1%!), with the authors stating that “age alone should not interdict this modality.” As the authors acknowledge, the most notable limitations of this study are the significant preoperative selection bias apparent in the octogenarians undergoing CEA and the considerably larger number of younger patients studied (nearly five times more) than octogenarians. Other factors include that approximately 25% of all of the study subjects were treated with CEA for only 50% to 79% carotid stenosis, lack of use of standard preoperative carotid imaging or grading criteria for selection to undergo CEA, 30-day follow-up only, and absence of data regarding preoperative cardiovascular risk stratification to determine fitness for surgery. Despite the noted limitations of the database used, the authors have demonstrated that with proper selection and execution, results with use of CEA in the fit octogenarian with asymptomatic carotid artery stenosis can be equivalent to those obtained in younger patients. Whereas this is clearly not level I evidence, it does again confirm that properly applied CEA remains an extremely safe and efficacious treatment modality even in octogenarians. The opinions or views expressed in this commentary are those of the author and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Carotid endarterectomy for asymptomatic carotid stenosis is safe in octogenariansJournal of Vascular SurgeryVol. 71Issue 2PreviewCarotid endarterectomy (CEA) is the gold standard to prevent a recurrent stroke in symptomatic patients with carotid stenosis. However, in the modern era, the benefit of CEA in asymptomatic octogenarian patients has come into question. This study investigates real-world outcomes of CEA in asymptomatic octogenarians. Full-Text PDF

Surgeon specialty significantly affects outcome of asymptomatic patients after carotid endarterectomy

BackgroundThis study evaluates the impact of surgical specialty, specifically vascular surgery (VS) versus non-VS (NVS; namely, cardiac surgery, thoracic surgery, general surgery, or neurosurgery) on perioperative carotid endarterectomy (CEA) outcomes stratified by symptom status on presentation. MethodsThe National Surgical Quality Improvement Program Vascular Procedure Targeted database was queried for elective asymptomatic or symptomatic CEA (excluding concomitant CEA and cardiac surgery) from 2011 to 2016. Data were stratified by VS versus NVS and symptom presentation. Primary end points were 30-day stroke and stroke/death; secondary end points included perioperative complications. Multivariable logistic regression determined predictors of all assessed primary outcomes and propensity-weight analysis was used to confirm results. ResultsOverall, 21,060 CEA (12,671 [59%] asymptomatic) were identified with 19,687 (93%) done by VS. In the asymptomatic CEA cohort, VS had lower unadjusted stroke (1.3% vs 2.4%; P = .021) and stroke/death (1.7% vs 3.2%; P = .006) rates. In addition, VS had fewer deaths (0.6% vs 1.3%; P = .033) and pulmonary complications (1.6% vs 2.7%; P = .036). After risk adjustment, the NVS asymptomatic cohort predicted stroke (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-3.1; P = .032), driven by neurosurgery (OR, 3.1; 95% CI, 1.3-7.2; P = .008). This NVS cohort also predicted stroke/death (OR, 1.8; 95% CI, 1.1-2.9; P = .013), driven by neurosurgery (OR, 2.5; 95% CI, 1.1-5.7; P = .035). After propensity weighting, these differences persisted (stroke: OR, 1.9; 95% CI, 1.1-3.3; P = .030; stroke/death: OR, 1.9; 95% CI, 1.2-3.0; P = .011). Among symptomatic CEA, there was no difference between VS and NVS in unadjusted primary end points of stroke (3.1% vs 4.2%; P = .106) or stroke/death (3.8% vs 4.6%; P = .275). However, in this cohort, VS had fewer major complications (12.7% vs 15.5%; P = .029). ConclusionsThis study identifies the VS specialty as having significantly better outcomes after CEA in patients presenting with asymptomatic disease than NVS specialty, as evidenced by lower rates of stroke and stroke death, which persisted after risk adjustment and propensity weighting. This difference in stroke and stroke/death was not apparent in the symptomatic cohort; however, NVS did have increased unadjusted rates of major complications. Although this finding may reflect multiple factors, including higher operative volume, training, or technical approach, these differences in 30-day CEA outcomes may be crucial for the proper interpretation of ongoing national outcome trials such as CREST2.