Occurrence Of Postoperative Stroke Research Articles

Determinants of Mortality and Mid-Term Outcomes After Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting.

The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR. Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors. A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke. Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal. The ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.

Outcomes of Concomitant Coronary Artery Bypass Grafting in Patients With Infective Endocarditis: A Systematic Review and Meta-Analysis

It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis who have relevant coronary artery disease. However, CABG may add complexity to the operation. We performed a systematic review and a meta-analysis of studies that presented outcomes from patients who underwent valve surgery because of infective endocarditis with or without concomitant CABG. Three databases were assessed. Perioperative mortality was the primary outcome. Long-term mortality and postoperative stroke were the secondary outcomes. Inverse variance method and random model were performed. Five studies with a total of 5,408 patients were included. Mean follow-up was 8.2years. Just 1 study addressed exclusively patients with documented coronary artery disease. Perioperative mortality did not differ between patients with or without concomitant CABG (odds ratio 1.53, 95% confidence interval 0.52 to 4.48, p=0.44). Long-term mortality did not differ between patients who received and those who did not receive concomitant CABG (odds ratio 1.79, confidence interval 0.88 to 3.65, p=0.11). Only 1 study from a multicenter registry reported data on the occurrence of postoperative stroke, which demonstrated that its incidence after adjustment was 26% in patients with concomitant CABG versus 21% in patients without concomitant CABG (p=0.003). The results suggest that in endocarditis patients, adding CABG to valve surgery does not affect perioperative or long-term mortality. Data available on the impact of concomitant CABG on neurologic outcomes are limited to a retrospective multicenter registry and suggest that concomitant CABG may be associated with higher postoperative stroke.

Timing of Postoperative Stroke and Risk of Mortality After Noncardiac Surgery: A Cohort Study.

Postoperative stroke is a devastating complication of surgery, given its association with severe long-term disability and mortality. Previous investigators have confirmed the association of stroke with postoperative mortality. However, limited data exist regarding the relationship between the timing of stroke and survival. Addressing this knowledge gap will help clinicians develop tailored perioperative strategies to reduce the incidence, severity, and mortality associated with perioperative stroke. Therefore, our objective was to determine whether the timing of postoperative stroke influenced mortality risk. We performed a retrospective cohort study of patients > 18 years who underwent noncardiac surgery and developed postoperative stroke during the first 30 days of surgery (National Surgical Quality Improvement Program Pediatrics 2010 - 2021). Our primary outcome was 30-day mortality following the occurrence of postoperative stroke. We subdivided patients into two mutually exclusive groups: early and delayed stroke. Early stroke was defined as the occurrence within 7 days following surgery, consistent with a previous study. We identified 16,750 patients who underwent noncardiac surgery and developed stroke within 30 days of surgery. Of these, 11,173 (66.7%) had an early postoperative stroke (≤ 7 days). Perioperative physiological status, operative characteristics, and preoperative comorbidities were generally comparable between patients with early and delayed postoperative stroke. Despite the comparability in these clinical characteristics, the mortality risk was 24.9% for early and 19.4% for delayed stroke. After adjusting for perioperative physiological status, operative characteristics, and preoperative comorbidities, early stroke was associated with an increased mortality risk (adjusted odds ratio: 1.39, confidence interval: 1.29 - 1.52, P-value < 0.001). In patients with an early postoperative stroke, the most common preceding complications were bleeding requiring transfusion (24.3%), followed by pneumonia (13.2%) and renal insufficiency (11.3%). Postoperative stroke tends to occur within 7 days following noncardiac surgery. Such timing of postoperative stroke carries a higher mortality risk, suggesting that targeted efforts to prevent stroke should focus on the first week following surgery to reduce the incidence and mortality associated with this complication. Our findings contribute to the growing understanding of stroke after noncardiac surgery and may help clinicians develop tailored perioperative neuroprotective strategies to prevent or improve treatment and outcomes of postoperative stroke.

Hypertriglyceridemia is associated with stroke after non-cardiac, non-neurological surgery in the older patients: A nested case-control study

Geriatric postoperative stroke is a rare but serious complication after surgery. The association between hypertriglyceridemia and postoperative stroke remains controversial, especially in older patients undergoing non-cardiac, non-neurological surgery. The study aims to address this clinical dilemma. We conducted a nested case-control study among 9601 aged patients undergoing non-cardiac non-neurological surgery from October 2015 to 2021. A total of 22 positive cases were matched for the surgical type and time, to 88 control patients by a ratio of 1:4. The effect of hypertriglyceridemia on the occurrence of postoperative stroke within 30 days after surgery was estimated using conditional logistic regression analysis by adjusting to various potential confounders. A total of 22 cases developed ischemia stroke after surgery, and compared with the non-stroke group, they had more postoperative ICU admission, longer postoperative hospitalization and higher total cost (all p < 0.05), and more patients were presenting with preoperative hypertriglyceridemia [8 (36.4%) vs. 15 (17.0%), p = 0.045]. There was a significant association between hypertriglyceridemia and postoperative stroke, with adjusted odds ratios of 6.618 (95% CI 1.286, 34.064) (p = 0.024). The above results remained robust in the sensitivity analyses. Among older patients undergoing non-cardiac and non-neurological surgery, hypertriglyceridemia was associated with significant increased risk of postoperative stroke.

Effect of Perioperative Lipid Status on Clinical Outcomes after Cardiac Surgery.

Patients undergoing cardiac surgery are at increased cardiovascular risk, which includes altered lipid status. However, data on the effect of cardiac surgery and cardiopulmonary bypass (CPB) on plasma levels of key lipids are scarce. We investigated potential effects of CPB on plasma lipid levels and associations with early postoperative clinical outcomes. This is a prospective bio-bank study of patients undergoing elective cardiac surgery at our center January to December 2019. The follow-up period was 1 year after surgery. Blood sampling was performed before induction of general anesthesia, upon weaning from cardiopulmonary bypass (CPB), and on the first day after surgery. Clinical end points included the incidence of postoperative stroke, myocardial infarction, and death of any cause at 30 days after surgery as well as 1-year all-cause mortality. A total of 192 cardiac surgery patients (75% male, median age 67.0 years (interquartile range 60.0–73.0), median BMI 26.1 kg/m2 (23.7–30.4)) were included. A significant intraoperative decrease in plasma levels compared with preoperative levels (all p < 0.0001) was observed for total cholesterol (TC) (Cliff’s delta d: 0.75 (0.68–0.82; 95% CI)), LDL-Cholesterol (LDL-C) (d: 0.66 (0.57–0.73)) and HDL-Cholesterol (HDL-C) (d: 0.72 (0.64–0.79)). At 24h after surgery, the plasma levels of LDL-C (d: 0.73 (0.650.79)) and TC (d: 0.77 (0.69–0.82)) continued to decrease compared to preoperative levels, while the plasma levels of HDL-C (d: 0.46 (0.36–0.55)) and TG (d: 0.40 (0.29–0.50)) rebounded, but all remained below the preoperative levels (p < 0.001). Mortality at 30 days was 1.0% (N = 2/192), and 1-year mortality was 3.8% (N = 7/186). Postoperative myocardial infarction occurred in 3.1% of patients (N = 6/192) and postoperative stroke in 5.8% (N = 11/190). Adjusting for age, sex, BMI, and statin therapy, we noted a protective effect of postoperative occurrence of stroke for pre-to-post-operative changes in TC (adjusted odds ratio (OR) 0.29 (0.07–0.90), p = 0.047), in LDL-C (aOR 0.19 (0.03–0.88), p = 0.045), and in HDL-C (aOR 0.01 (0.00–0.78), p = 0.039). No associations were observed between lipid levels and 1-year mortality. In conclusion, cardiac surgery induces a significant sudden drop in levels of key plasma lipids. This effect was pronounced during the operation, and levels remained significantly lowered at 24 h after surgery. The intraoperative drops in LDL-C, TC, and HDL-C were associated with a protective effect against occurrence of postoperative stroke in adjusted models. We demonstrate that the changes in key plasma lipid levels during surgery are strongly correlated, which makes attributing the impact of each lipid to the clinical end points, such as postoperative stroke, a challenging task. Large-scale analyses should investigate additional clinical outcome measures.

The Performance of the Current Risk Prediction Scoring Systems in Patients Undergoing Anaortic Off-pump Coronary Artery Bypass Grafting.

BackgroundThis study aimed to evaluate the performance of the Society of Thoracic Surgeons (STS) risk model and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II for patients undergoing anaortic off-pump coronary artery bypass grafting (OPCAB).MethodsFrom January 2010 to June 2017, 1,048 patients (isolated anaortic OPCAB: 1,043, on-pump conversion:5) undergoing isolated anaortic OPCAB were enrolled. The STS risk score and EuroSCORE II were calculated with dedicated online software. Calibration of the models were performed by the risk-adjusted event ratio that was defined as observed events divided by expected events (O/E ratio) and Hosmer-Lemeshow test. The discrimination powers were evaluated by the area under the receiver operating characteristic curve (AUC).ResultsOperative mortality occurred in 10 patients (0.95%). The predicted mortality rates by the EuroSCORE II and STS risk model were 2.58 ± 4.15% and 1.72 ± 2.92%, respectively. The O/E ratio of the EuroSCORE II was 0.370 with significant overprediction of operative mortality (confidence interval [CI], 0.157–0.652; P = 0.003). The STS score also overpredicted the operative mortality (O/E ratio, 0.556) with marginal significance (CI, 0.266–1.023; P = 0.052). Permanent stroke occurred in 6 patients (0.53%). The predicted permanent stroke occurrence rate was 1.73 ± 1.48%. The O/E ratio was 0.332 with significant overprediction of permanent stroke (CI, 0.121–0.722; P = 0.011). Regarding discrimination power for the STS risk model, the operative mortality was excellent (AUC, 0.876) and permanent stroke was acceptable (AUC, 0.740). The EuroSCORE II showed good discrimination power (AUC, 0.784). There was a significant difference in discrimination power for mortality between STS and EuroSCORE II risk models (P = 0.007).ConclusionPreexisting risk predicting scoring systems, STS risk model and EuroSCORE II, overpredict the risk of mortality and stroke rate for anaortic OPCAB. These findings suggest the possibility that anaortic OPCAB can lower the operative mortality and occurrence of postoperative stroke than conventional coronary artery bypass grafting.

A conservative screening algorithm to determine candidacy for robotic mitral valve surgery

ObjectivePatient selection for robotically assisted mitral valve repair remains controversial. We assessed outcomes of a conservative screening algorithm developed to select patients with degenerative mitral valve disease for robotic surgery. MethodsFrom January 2014 to January 2019, a screening algorithm that included transthoracic echocardiography and computed tomography scanning was rigorously applied by 3 surgeons to assess candidacy of 1000 consecutive patients with isolated degenerative mitral valve disease (age 58 ± 11 years, 67% male) for robotic surgery. Screening results and hospital outcomes of those selected for robotic versus sternotomy approaches were compared. ResultsWith application of the screening algorithm, 605 patients were selected for robotic surgery. Common reasons for sternotomy (n = 395) were aortoiliac atherosclerosis (n = 74/292, 25%), femoral artery diameter <7 mm (n = 60/292, 20%), mitral annular calcification (n = 83/390, 21%), aortic regurgitation (n = 100/391, 26%), and reduced left ventricular function (n = 126/391, 32%). Mitral valve repair was accomplished in 996. Compared with sternotomy, patients undergoing robotic surgery had less new-onset atrial fibrillation (n = 144/582, 25% vs n = 125/373, 34%; P = .002), fewer red blood cell transfusions (n = 61/601, 10% vs 69/395, 17%; P < .001), and shorter hospital stay (5.2 ± 2.9 days vs 5.9 ± 2.1 days; P < .001). No hospital deaths occurred, and occurrence of postoperative stroke in the robotic (n = 3/605, 0.50%) and sternotomy (n = 4/395, 1.0%; P = .3) groups was similar. ConclusionsThis conservative screening algorithm qualified 60% of patients with isolated degenerative mitral valve disease for robotic surgery. Outcomes were comparable with those obtained with sternotomy, validating this as an approach to select patients for robotic mitral valve surgery.

Cerebral monitoring during carotid endarterectomy using transcranial cerebral oximetry.

This study aimed to evaluate the outcomes of carotid endarterectomies (CEA) performed using transcranial cerebral oximetry as cerebral monitoringMETHODS: This single-center study included patients treated surgically for significant stenosis of the internal carotid artery (ICA) from January 2012 to December 2017RESULTS: Of the 654 patients, 267 were asymptomatic, and 387 were symptomatic. Eversion CEA was performed in 64.8 %, and patched conventional CEA in 35.2 % of all patients. Totally 11.4 % of all patients had a shunt inserted; all patients with the inserted shunt had the conventional pathed CEA. Severe postoperative complications occurred in 1.5 % of asymptomatic patients and 2.6 % of symptomatic patients. The stroke and death ratio in the shunted group was 2.7 %, and in the non-shunted group, 2.1 % (p = 0.7). We found no significant difference in severe postoperative complications between the shunted and non-shunted group. Further, we found the male gender (p = 0.005), coronary artery disease (p = 0.01), and ongoing smoking (p = 0.003) to be significantly associated with neurological symptoms of the ICA stenosis. We also confirmed current tobacco smoking to be significantly associated with the occurrence of postoperative stroke and death (p = 0.005)CONCLUSION: We found transcranial cerebral oximetry to be reliable in the determination of shunt insertion (Tab. 6, Ref. 26).

Which aortic clamp strategy is better to reduce postoperative stroke and death: Single center report and a meta-analysis.

Background:Stroke is severe complication of coronary artery bypass grafting (CABG) which may be associated with clamp strategy, there are 2 strategies to clamp aorta including single aortic clamp (SAC) and partial aortic clamp (PAC). It is controversial that which clamping strategy is better to reduce the postoperative stroke and death, so this study aims to investigate which is better for reducing postoperative stroke and death within 30 days.Methods:We collected 469 patients who had on-pump CABG in Fuwai Hospital during January 2014 to July 2015. The SAC group consisted of 265 patients while the PAC group included 204 patients. We compared the 2 group patient difference. At the same time, 12 studies were identified by systematic search. The odds ratio (OR) was used as effect index to compare SAC and PAC strategy by fix-effect modeling. We also tested heterogeneity and publication bias. The primary end point of study was occurrence of postoperative stroke within 30 days of operation, the second end point of study was the incidence of 30-day mortality.Results:The single center retrospective study showed that the patients in the SAC group were older than those in the PAC group (62.5 ± 8.1 vs 60.3 ± 8.0 years, P = .01). The proportions of peripheral vascular disease and hypertension of SAC were higher than PAC (71 (26.8%) versus 36 (17.6%), P = .02; 183 (69.1%) versus 115 (56.4%), P = .01, respectively). Besides, the number of vascular anastomosis was more in the SAC group (3.29 ± 0.74 versus 2.97 ± 0.974, P < .001). The linear-regression analysis suggested that the time of cardiopulmonary bypass of SAC was shorter than the PAC group (93.2 ± 22.4 vs.103.4 ± 26.8 minutes, P-regression < .001) and postoperative death within 30-days was similar (1 (0.4%) vs. 2 (1.0%), P-regression = .47). There was no stroke occurring in both the groups. And the meta-analysis suggested the postoperative stroke and death within 30-days were similar between SAC group and PAC group (OR: 0.78, 95% CI: 0.58–1.06; OR: 0.82, 95% CI: 0.61–1.10; respectively). Moreover, subgroup meta-analysis also had the same results.Conclusion:There was no significant difference between SAC and PAC clamping strategy on postoperative stroke and death within 30-days; however, SAC can reduce the usage time of cardiopulmonary bypass.

Comparison of 30-day readmission rates and risk factors between carotid artery stenting and endarterectomy

ObjectiveThe aim of this study was to analyze the rates, reasons, and risk factors of 30-day readmission, both planned and unplanned, after carotid revascularization as well as to evaluate major outcomes associated with those readmissions. MethodsUsing the Premier Healthcare database, we retrospectively identified patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) between 2009 and 2015. The primary outcome was 30-day all-cause readmission. Secondary outcomes included mortality and overall cost associated with readmissions. Univariate and multivariate analyses were used and further validated using coarsened exact matching on baseline differences between CEA and CAS patients. ResultsA total of 95,687 patients underwent carotid revascularization, 13.5% of whom underwent CAS. Crude 30-day readmission rates were 6.5% after CEA vs 6.1% after CAS (P = .10). Stroke, bleeding, pneumonia, and respiratory failure were the most common reasons for readmission after both CEA and CAS (6.7% vs 8.3%, 6.9% vs 5.3%, 3.4% vs 2.4%, and 4.4% vs 3.9%; all P > .05). Myocardial infarction and wound complications were more likely to be an indication for readmission after CEA (4.1% vs 2.5% and 4.1% vs 1.5%, respectively; P < .05). On the other hand, readmissions due to vascular or stent-related complications were more likely after CAS compared with CEA (5.8% vs 3.8%; P = .003). On multivariate analysis, CEA was found to be associated with 41% higher odds of readmission than CAS (adjusted odds ratio, 1.41; 95% confidence interval, 1.29-1.54; P < .001). Age, female gender, emergency/urgent procedures, concomitant cardiac procedures, rural hospitals, and Midwest region were significantly associated with 30-day readmission. Other risk factors included major preoperative comorbidities (diabetes, congestive heart failure, renal disease, chronic obstructive pulmonary disease, peripheral vascular disease, and history of cancer) as well as the occurrence of postoperative stroke and renal complications during the index admission and nonhome discharge. Coarsened exact matching between CEA and CAS patients also yielded higher adjusted rates of readmission after CEA (6.2% vs 4.9%; P < .001). On the other hand, patients readmitted after CAS had a longer length of hospital stay (5 days vs 4 days; P = .001), increased readmission mortality (6.2% vs 2.8%; P < .001), and higher rehospitalization costs ($8903 vs $7629; P = .01) compared with those readmitted after CEA. ConclusionsOur results show that CAS is associated with lower 30-day readmission rates compared with CEA. However, CAS readmissions are more complex and are associated with higher mortality and costs. We have also identified patients who are at high risk of readmissions, which can help focus attention on interventions that can improve the management of these patients and reduce readmission rates.

Right brachial access is safe for branched endovascular aneurysm repair in complex aortic disease

BackgroundThe risk of perioperative cerebrovascular events in endovascular repair of thoracic and thoracoabdominal aneurysms is reported from 2% to 15%. The unavoidable use of an upper extremity access during branched endovascular aneurysm repair (b-EVAR) may play a role in embolic brain injuries. For this reason, some advocate the use of a left-sided upper access to avoid crossing the origin of supra-aortic vessels. However, the assumption that right brachial access has a higher risk for stroke during b-EVAR has not been confirmed in the literature. MethodsThis study retrospectively analyzed all consecutive patients treated by b-EVAR with right brachial access at a single institution. A through-and-through right-brachiofemoral 0.014-inch wire was used to stabilize the sheath across the arch in all cases. End point of the study was the incidence of cerebrovascular events. ResultsWe identified 61 patients (65.6% male) during a 4-year period. Mean age at the time of surgery was 70.4 years (range, 53-87 years). The most common indication for treatment was type II (32.8%), followed by type IV thoracoabdominal aortic aneurysms (23%). There were 20 urgent (32.8%) and 41 elective (67.2%) procedures. Two perioperative ischemic strokes occurred in the first postoperative day in two men (3.3%; 95% confidence interval, 0.397-11.84). No further ischemic strokes occurred perioperatively. There was no statistically significant association between the occurrence of postoperative stroke and any of the perioperative characteristics. No significant association was found between the duration of the procedure and the end point. In both patients with embolic events, the use of a left arm approach would not have been feasible due to coverage of the left subclavian artery ostium. ConclusionsThe postoperative stroke rate in b-EVAR with the use of a right brachial access in our experience was in line with the literature for treatment of thoracic and thoracoabdominal aortic aneurysms. We conclude that the right brachial access with the use of a stabilizing through-and-through wire is a safe approach during b-EVAR.

The Role of Blood Transfusion in the Development of Atrial Fibrillation after Coronary Artery Bypass Grafting.

Objectives Atrial fibrillation (AF) is the most common complication after coronary artery bypass grafting (CABG). It is associated with prolonged hospital stay and increased cost. The aim of this study is to investigate the relationship between transfusion of blood derivatives and occurrence of postoperative paroxysmal AF. Materials and Methods From June 2012 to February 2014, 446 patients undergoing CABG with cardiopulmonary bypass (CPB) were prospectively evaluated for occurrence of postoperative AF. Patients and procedural variables were recorded and were associated with the development of new-onset AF with logistic regression analysis. Results AF developed in 111 patients (24.9%). Preoperative factors associated with the development of new-onset AF included age (p < 0.05), higher EuroSCORE II (p < 0.05), carotid disease (p = 0.01), peripheral vascular disease (p = 0.02), chronic obstructive pulmonary disease (p = 0.03), renal failure (p = 0.05), and cardiac failure (p = 0.01). Intraoperative and postoperative parameters included duration of CPB (p < 0.05), number of grafts (p = 0.009), intubation time (p = 0.001), occurrence of postoperative stroke (p = 0.01), transient ischemic attack (p = 0.02), need for prolonged ventilation (p = 0.002), development of respiratory tract infection (p = 0.02), need for noninvasive ventilation (p = 0.001), reintubation (p = 0.02), development of postoperative acute kidney injury (p = 0.002), and postoperative neurocognitive dysfunction (p = 0.002). The number of red blood cell (RBC) units transfused during surgery (p = 0.7) and the total number of RBC units transfused (p = 0.2) as well as units of fresh frozen plasma (p = 0. 7) and platelets units transfused in total (p = 0.3) were not found to increase the risk of postoperative AF. Conclusion Intraoperative and postoperative blood products transfusion in patients operated for CABG is not associated with increased risk of developing postoperative AF.

The effect of atrial fibrillation on outcomes in patients undergoing carotid endarterectomy or stent placement in general practice

Atrial fibrillation is a common comorbid condition among patients undergoing carotid endarterectomy (CEA) and carotid artery stent placement (CAS); however, the outcomes of patients with atrial fibrillation undergoing CAS have not been fully examined. We sought to investigate the impact of atrial fibrillation on outcomes of CEA and CAS in general practice. We analyzed the data from the National Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2009. The primary end point was postoperative stroke, cardiac complication, postoperative mortality, and composite of these end points. Univariate and multivariate regression analyses were performed to determine, first, the association of atrial fibrillation (compared to without atrial fibrillation) and, second, the association of CEA (compared with CAS) in patients with atrial fibrillation with the occurrence of postoperative stroke, cardiac complication, or death. Covariates included in the logistic regression were the patient's gender, age, race/ethnicity, comorbid conditions, and symptom status (symptomatic vs asymptomatic status) and the hospital's characteristics. Of the total 672,074 patients who underwent CAS or CEA, 8.8% (95% confidence interval [CI], 8.7-8.9) of the procedures were performed in patients with atrial fibrillation. Atrial fibrillation was associated with an increased risk of postoperative stroke in patients undergoing CEA (n= 879 [1.7%]; P< .0001; odds ratio [OR], 1.57; 95% CI, 1.32-1.86) but not in patients undergoing CAS. The relative risk of the composite end point of postoperative stroke, cardiac complications, and mortality was increased in patients with atrial fibrillation undergoing CAS (OR, 1.43; 95% CI, 1.18-1.74) and in those undergoing CEA (OR, 3.18; 95% CI, 2.89-3.49). After adjustment for potential confounders, the odds of the composite end point of postoperative stroke, cardiac complications, and mortality (OR, 1.31; 95% CI, 1.08-1.59) in atrial fibrillation patients were significantly higher among patients who underwent CEA (compared with those who underwent CAS). An opposite relationship was seen in patients without atrial fibrillation, in whom the composite end point was significantly lower in patients undergoing CEA. Our analysis suggests that almost 10% of CAS and CEA is performed in patients with atrial fibrillation in general practice, and higher rates of adverse events are observed among these patients, particularly those undergoing CEA.

Efficacy of right axillary artery perfusion for antegrade cerebral perfusion in open total arch repair

Right axillary artery (RAxA) perfusion was introduced for selective antegrade cerebral perfusion in total aortic arch repair to prevent cerebral embolism derived from arterial cannulation. However, the strategic benefits and long-term results regarding the cannulation site remain controversial. We retrospectively compared the outcomes between propensity score-matched patients with and without using RAxA cannulation. Between 2006 and 2012, 260 consecutive patients underwent total arch repair with antegrade cerebral perfusion and moderate hypothermia at a single institution. RAxA cannulation was added in 142 patients (54.6%), and 70 propensity score-matched pairs were obtained. There were no significant differences in 30-day (2.9% [2 of 70] vs 5.7% [4 of 70]; P = .415 and in-hospital death (5.7% [4 of 70] vs 5.7% [4 of 70]; P = 1.000) between matched pairs. Although there was no significant difference in the occurrence of postoperative stroke (8.6% [6 of 70] vs 8.6% [6 of 70]; P = 1.000), the new rate of new occurrence of postoperative paraparesis was lower in patients with RAxA perfusion (0% [0 of 70] vs 4.3% [3 of 70]; P = .067). With a mean follow-up period of 1057 ± 686 days, the overall 5-year survival was 90.6% and was 89.6% for patients with RAxA perfusion. Thee difference in survival between patients with and without RAxA perfusion was not significant. RAxA perfusion is a useful option for total aortic arch repair, and the midterm outcomes were satisfactory. However, RAxA perfusion did not completely prevent stroke in patients with an atherothrombotic aorta.

Abstract 68: The Effect Of Pre-existing Atrial Fibrillation On In-hospital Outcomes In Patients Undergoing Carotid Endarterectomy Or Stent Placement In General Practice

Background: Atrial fibrillation (AF) is a relatively common comorbid condition among patients who undergo carotid endarterectomy (CEA) and carotid artery stent placement (CAS); however the outcomes of patients with AF undergoing CAS have not been fully examined. We sought to investigate the impact of AF on in-hospital outcomes of CEA and CAS in general practice. Methods: We analyzed the data from the Nationwide Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2009. The primary end point was postoperative stroke, cardiac complications, postoperative mortality, and composite of these endpoints. Multivariate regression analysis was performed to determine the 1/. the association of AF (compared to without AF); and 2/. the association of CEA (compared with CAS) with the occurrence of postoperative stroke, cardiac complication or death. Covariates included in the logistic regression were patient’s gender, age, ethnicity, comorbid conditions, symptom status (symptomatic vs asymptomatic status), and hospital characteristics. Results: Of the total 672,074 patients who underwent CAS or CEA, 8.8% of the procedures were performed in patients with AF. For patients undergoing CEA, AF was associated with an increased risk of postoperative stroke (P&lt;0.0001; OR, 1.57: 95% CI, 1.32-1.86) but not in patients undergoing CAS. The relative risk of composite endpoint of postoperative stroke, cardiac complications, and mortality was increased in patients with AF undergoing CAS (OR 1.43, 95% CI 1.18-1.74) and those undergoing CEA (OR 3.18, 95% CI 2.89-3.49). After adjustment for potential confounders, the odds of composite endpoint of postoperative stroke, cardiac complications, and mortality (OR, 1.31, 95% CI 1.08 - 1.59) were significantly higher among patients who underwent CEA (compared with those who underwent CAS). An inverse relationship was seen in patients without AF in whom the composite endpoint was significantly lower in patients undergoing CEA. Conclusion: Our analysis suggests that almost 10% of CAS and CEA are performed in patients with AF in general practice, and higher rates of adverse events are observed among these patients particularly those undergoing CEA.

Do Men and Women Undergoing Carotid Endarterectomy or Carotid Stent Placement in General Practice Have Different Outcomes (P06.203)

Objective: We sought to investigate the impact of gender on post-procedural outcomes of CAS and CEA in general practice at a national level. Background Data derived from Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) suggested differential comparative periprocedural benefit between CAS and CEA on basis of gender. Design/Methods: We analyzed the data from the Nationwide Inpatient Sample which is representative of all admissions from 2005-2009. The primary end point was occurrence of stroke, cardiac complications, or death during the post procedural period. Outcomes of interest were compared between men and women, undergoing CEA and CAS. Multivariate logistic regression was performed to determine the effect of gender on occurrence of post-operative stroke, cardiac complications, or death for CAS and CEA separately. Covariates included in the logistic regression were patient9s age, gender, co-morbid conditions including hypertension, diabetes mellitus, chronic lung disease, coronary artery disease etc. Results: Of the total 673,170 estimated patients, 591,543 (88%) underwent CEA and the remaining 81627 (12%) underwent CAS. There was no difference between men and women in post-operative stroke, cardiac complications, or death for women undergoing CAS for both symptomatic and asymptomatic status as well as symptomatic women undergoing CEA. Post operative strokes (0.99% vs 0.84%, p= 0.01) were higher in asymptomatic women however cardiac complications were higher for asymptomatic men (2.0% vs 1.64%, p= 0.0001) and composite end points was lower in women (2.80% vs 3.00%, p= 0.02) undergoing CEA. In multivariate analysis, gender was not a significant factor for composite end points among patients undergoing either CAS (RR, 95% CI) or CEA (RR, 95% CI) after adjusting for potential confounders. Conclusions: Our analysis suggests that postprocedural rate of events are not significantly different between men and women undergoing either CAS or CEA in general practice and should not be used to determine eligibility for either procedure. Disclosure: Dr. Khatri has nothing to disclose. Dr. Chaudhry has nothing to disclose. Dr. Watanabe has nothing to disclose. Dr. Jadhav has nothing to disclose. Dr. Hassan has nothing to disclose. Dr. Rodriguez has nothing to disclose. Dr. Suri has nothing to disclose. Dr. Qureshi has nothing to disclose.

Intraoperative Hypotension and Perioperative Ischemic Stroke after General Surgery

Postoperative stroke is a rare but major complication after surgery. The most often proposed mechanism is an embolus originating from the heart or great vessels. The role of intraoperative hypotension in the occurrence and evolution of postoperative stroke is largely unknown. A case-control study was conducted among 48,241 patients who underwent noncardiac and nonneurosurgical procedures in the period from January 2002 to June 2009. A total of 42 stroke cases (0.09%) were matched on age and type of surgery to 252 control patients. Conditional logistic regression analysis was used to estimate the effect of the duration of intraoperative hypotension (defined according to a range of blood pressure thresholds) on the occurrence of an ischemic stroke within 10 days after surgery, adjusted for potential confounding factors. After correction for potential confounders and multiple testing, the duration that the mean blood pressure was decreased more than 30% from baseline remained statistically significantly associated with the occurrence of a postoperative stroke. Intraoperative hypotension might play a role in the development of postoperative ischemic stroke. Especially for mean blood pressure values decreasing more than 30% from baseline blood pressure, an association with postoperative ischemic stroke risks was observed.

Abstract 3957: Do Men And Women Undergoing Carotid Endarterectomy Or Carotid Stent Placement In General Practice Have Different Outcomes

Background: Data derived from Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) suggested differential comparative periprocedural benefit between carotid angioplasty and stent placement (CAS) and carotid endarterectomy (CEA) on basis of gender. We sought to investigate the impact of gender on post-procedural outcomes of CAS and CEA in general practice at a national level. Methods: We analyzed the data from the Nationwide Inpatient Sample (NIS) which is representative of all admissions in the United States from 2005-2009. The primary end point was occurrence of stroke, cardiac complications, or death during the post procedural period. Outcomes of interest were compared between men and women, undergoing CEA and CAS. Multivariate logistic regression was performed to determine the effect of gender on occurrence of post-operative stroke, cardiac complications, or death for CAS and CEA separately. Covariates included in the logistic regression were patient’s age, gender, co-morbid conditions including hypertension, diabetes mellitus, chronic lung disease, coronary artery disease, congestive heart failure, and renal failure; symptom status (symptomatic versus asymptomatic status), and hospital characteristics. Results: Of the total 673,170 estimated patients, who received CEA or CAS for carotid artery disease during the study period, 591,543 (88%) underwent CEA and the remaining 81627 (12%) underwent CAS. Out of a total of 282,632 (42%) women, 250,502 (89%) women underwent CEA compared to 32130 (11%) women who underwent CAS procedures. There was no difference between men and women in post-operative stroke, cardiac complications, or death for women undergoing CAS for both symptomatic and asymptomatic status as well as symptomatic women undergoing CEA. Post operative strokes (0.99% vs 0.84%, p= 0.01) were higher in asymptomatic women however cardiac complications were higher for asymptomatic men (2.0% vs 1.64%, p= 0.0001) and composite end points was lower in women (2.80% vs 3.00%, p= 0.02) undergoing CEA. In multivariate analysis, gender was not a significant factor for composite end points among patients undergoing either CAS (RR, 95% CI) or CEA (RR, 95% CI) after adjusting for potential confounders. Conclusion: Our analysis suggests that postprocedural rate of events are not significantly different between men and women undergoing either CAS or CEA in general practice and should not be used to determine eligibility for either procedure .

Age differential between outcomes of carotid angioplasty and stent placement and carotid endarterectomy in general practice

Data derived from prospective randomized clinical trials suggest differential comparative benefit between carotid angioplasty and stent (CAS) placement and carotid endarterectomy (CEA) in various age strata. We sought to investigate the impact of age on outcomes of CAS and CEA in general practice. We analyzed the data from the Nationwide Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2008. The primary end point was occurrence of stroke, cardiac complications, or death during the postprocedural period. Outcomes of interest were compared between patients aged ≥70 years and <70 years, undergoing CEA and CAS. Multivariate logistic regression was performed to determine the effect of age on occurrence of postoperative stroke, cardiac complications, or death. Covariates included in the logistic regression were patient's age, gender, comorbid conditions, including hypertension, diabetes mellitus (DM), chronic lung disease, coronary artery disease (CAD), congestive heart failure (CHF), and renal failure; symptom status (symptomatic vs asymptomatic status), and hospital characteristics. Of the total 495,331 estimated patients who received treatment for CAD during the study period, 88% underwent CEA and the remaining 12% underwent CAS. Of the total procedures, 41% of the procedures were performed in patients aged <70 years compared to the remaining 59% that were performed among patients aged ≥70 years. For patients undergoing CAS, age ≥70 years was an important predictor of postoperative stroke (P = .0025; odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.5) and cardiac complications postprocedure (P = .045; OR, 1.3; 95% CI, 1.0-1.6). For patients undergoing CEA, age ≥70 years was associated with higher cardiac complications (P < .001; OR, 1.5; 95% CI, 1.3-1.7) and higher postoperative mortality risk (P = .0008; OR, 1.4; 95% CI, 1.1-1.8) compared to patients aged <70 years. The increased risk of composite end point (postoperative stroke/cardiac complications/mortality) among patients aged ≥70 years was a significant factor for patients undergoing either CAS or CEA (OR of 1.3 for both procedures). Our analysis suggests that most CAS and CEAs are performed in patients aged ≥70 years in general practice, and higher rates of postoperative complications are observed among these patients regardless of procedure choice.

Off-pump vs. on-pump coronary artery bypass surgery: an updated meta-analysis and meta-regression of randomized trials

The benefits of off-pump coronary artery bypass (OPCAB) continue to be debated, in part due to the fact that pooled effects fail to consider differences in trial and patient characteristics. We sought to analyse the contemporary evidence for OPCAB vs. conventional coronary artery bypass (CCAB), incorporating recent larger trials, and adjusting for differences in trials using a technique known as meta-regression. We systematically reviewed MEDLINE, EMBASE, and the Cochrane database for published and unpublished randomized trials of OPCAB vs. CCAB in which 30-day or in-hospital clinical outcomes were reported. The outcomes of interest were: all-cause mortality, stroke, and myocardial infarction. In addition to measuring the pooled treatment effects using a random effects meta-analysis model, we measured the effect of selected trial-level factors on the effects observed using the meta-regression technique. Fifty-nine trials were included, encompassing 8961 patients with a mean age of 63.4 and 16% females. There was a significant 30% reduction in the occurrence of post-operative stroke with OPCAB [risk ratio (RR) 0.70, 95% CI: 0.49-0.99]. There was no significant difference in mortality (RR: 0.90, 95% CI: 0.63-1.30) or myocardial infarction (pooled RR: 0.89, 95% CI: 0.69-1.13). In the meta-regression analysis, the effect of OPCAB on all of the clinical outcomes was similar regardless of mean age, proportion of females in the trial, number of grafts per patient, and trial publication date. Our meta-analysis incorporating recent trials suggests that there appears to be a beneficial effect of OPCAB on stroke. Moreover, our meta-regression does not support the hypothesis that differences in study populations are responsible for the observed outcomes, although pooled individual patient-data would be better suited to confirm these findings.