Perioperative Outcomes Of Carotid Endarterectomy Research Articles

Peri-Operative Outcomes of Carotid Endarterectomy are Not Improved on Dual Antiplatelet Therapy vs. Aspirin Monotherapy: A Systematic Review and Meta-Analysis

A systematic review and meta-analysis of the peri-operative outcomes of carotid endarterectomy (CEA) on dual antiplatelet therapy (DAPT) vs. aspirin monotherapy was carried out, to determine optimal peri-operative management with these antiplatelet agents.

Perioperative outcomes of carotid endarterectomy and transfemoral and transcervical carotid artery stenting in radiation-induced carotid lesions: Presented at the Thirty-fourth Annual Meeting of the Eastern Vascular Society (Virtual), Weekly Program Series, October 7-November 18, 2020.

Objective Limited data are available to guide the choice of intervention for patients with radiation-induced carotid stenosis (RICS), either transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), or carotid endarterectomy (CEA). The purpose of the present study was to evaluate patients who had undergone these carotid artery interventions for RICS and the associated outcomes.

Perioperative outcomes of carotid endarterectomy and transfemoral and transcervical carotid artery stenting in radiation-induced carotid lesions

ObjectiveLimited data are available to guide the choice of intervention for patients with radiation-induced carotid stenosis (RICS), either transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), or carotid endarterectomy (CEA). The purpose of the present study was to evaluate patients who had undergone these carotid artery interventions for RICS and the associated outcomes. MethodsPatients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) carotid artery stenting surveillance project registry and the SVS VQI CEA modules who had undergone carotid artery intervention (TCAR, TFCAS, or CEA) for RICS were included. Those aged >90 years and those with concomitant interventions (eg, coronary bypass) were excluded. A composite of death, myocardial infarction (MI), and stroke was the primary outcome. The secondary outcomes included death, MI, stroke, cranial nerve injury (CNI), and other local and systemic complications. Multivariable logistic regression controlling for presenting symptomatic status and comorbid medical conditions was conducted for the outcome variables, except for death, which was analyzed using Cox regression modeling. ResultsA total of 1927 patients with RICS had undergone CEA (n = 1172), TCAR (n = 253), or TFCAS (n = 502). The CEA group had a higher rate of diabetes (31% vs 25% for TCAR and 25% for TFCAS; P = .01), hypertension (85% vs 82% for TCAR and 79% for TFCAS; P < .01), and peripheral vascular disease (8% vs 4% for TCAR and 4% for TFCAS; P < .01). The TCAR and TFCAS groups had higher rates of coronary artery disease (21% for CEA vs 30% for TCAR and 29% for TFCAS; P < .01). The patients who had undergone TFCAS were more likely to have had symptomatic lesions (57% for TFCAS vs 47% for CEA and 41% for TCAR; P < .01) and prior stroke (55% for TFCAS vs 47% for CEA and 40% for TCAR; P < .001). The composite outcome occurred in 3.2% of TCAR patients, 11.2% of TFCAS patients, and 11.1% of CEA patients (P < .01) with an odds ratio of 0.27 for TCAR, 0.91 for TFCAS, and 1.00 for CEA. However, no differences in the individual outcomes were noted for any procedure. TCAR exhibited the lowest odds ratio for CNI (0.15) compared with TFCAS at 0.9, both relative to CEA (P = .03). ConclusionsRICS patients treated by TCAR in the SVS VQI had the lowest risk of the composite of stroke, death, and MI and CNI. Therefore, TCAR might be the preferred treatment modality. Further comparative studies are needed to evaluate the long-term outcomes in this population and to elucidate the relationship of these procedures to the individual outcomes of stroke, MI, and death.

Results of Carotid Endarterectomy in Patients With Asymptomatic Carotid Artery Stenosis With or Without Criteria for Surgery on the Basis of the Recent European Guidelines

The objective was to retrospectively compare perioperative outcomes of carotid endarterectomy (CEA) performed for >60% asymptomatic stenosis in patients with or without preoperative clinical and imaging features suggesting the need for intervention on the basis of the 2018 European Society of Cardiology-European Society for Vascular Surgery guidelines. From January 2008 to December 2018, there were 2501 consecutive CEAs performed in a single academic institution. Data concerning these interventions were prospectively collected in a dedicated database. A retrospective analysis of the database was performed, and 1956 interventions performed in asymptomatic patients were found. Those patients were divided in two subgroups: patients not candidates for intervention on the basis of the 2018 European Society of Cardiology-European Society for Vascular Surgery guidelines (life expectancy <5 years, predominantly hyperechoic plaques on preoperative duplex ultrasound, absence of silent brain infarction at preoperative computed tomography scan; 876 interventions, group 1) and patients fulfilling the suggested indications (1080 interventions, group 2). The two groups were compared in terms of clinical, anatomic, and surgical characteristics and perioperative (<30 days) outcomes with the χ2 test. There were no differences between the two groups in terms of demographics, risk factors, and comorbidities and preoperative features, except for the cited characteristics. Intraoperative features were also similar in the two groups, with >85% of the interventions performed under clinical monitoring of the neurologic status and about 95% of polyurethane patch angioplasty closures in both groups. Shunt insertion rate was significantly higher in group 1 (19.7%) than in group 2 (16%; P = .03). Perioperative mortality was 0.3% in group 1 (three patients) and 0.3% in group 2 (three cases; P = .7). At 30 days, there were seven neurologic events in group 1 (0.8%) and eight events in group 2 (0.7%; P = .8), of which six and five were strokes, respectively. Thirty-day stroke and death rates were 1% in group 1 and 0.75% in group 2 (P = .5). There were no differences between the two groups in terms of neck hematoma requiring surgical revision, cranial nerve injuries, and perioperative myocardial infarction. Patients in group 1 more frequently experienced a perioperative atrial fibrillation (13 cases [1.4%]) than patients in group 2 (5 cases [0.4%]; P = .02). CEA performed in patients who should not undergo intervention on the basis of the recent guidelines provided excellent perioperative results, similar to those of patients inside the suggested indications. A long-term comparison is necessary.

Predictive Factors for 30-Day Stroke and Death Rate in a Contemporary Series of Carotid Endarterectomies Performed for Asymptomatic Stenosis of the Internal Carotid Artery

The objective was to retrospectively analyze the perioperative outcomes of carotid endarterectomy (CEA) performed for asymptomatic carotid stenosis in the last decade and to identify predictors of increased risk of stroke and death in a single-center experience. From January 2008 to December 2018, 2501 consecutive CEAs were performed in a single academic institution. Data concerning these interventions were prospectively collected in a dedicated database. A retrospective analysis of the database was performed, and 1956 interventions performed in asymptomatic patients were found. Univariate and multivariate (forward logistic regression) analyses were used to identify potentially significant predictors of stroke and death rate at 30 days and to calculate their weight in determining it. Thirty-day stroke and death rates were then assessed for each subgroup of different predictors. Overall, 30-day stroke and death rate was 0.9% (17 cases). On multivariate analysis, male sex, diabetes, and combined cardiac surgery and the need for selective shunting were identified as independent predictors of stroke and death at 30 days; 22.3% of patients did not have any predictor, whereas 51.3%, 23.1%, and 3.2% of the patients had one, two, or three predictors, respectively. No patient had four predictors. Thirty-day stroke and death rate for patients without any of the identified predictors was 0.2% (1 case/436 interventions), whereas the corresponding figures for patients with one, two, or three predictors were 0.7% (7 cases/1006 interventions; P = .7 in comparison with patients with no predictors), 1% (4 cases/451 interventions; P = .1 in comparison with patients with no predictors and P = .7 in comparison with patients with one predictor), and 8.5% (5 cases/63 interventions; P < .001 in comparison with patients with no predictor, one predictor, or two predictors). A subgroup of asymptomatic patients undergoing CEA with a prohibitive perioperative risk does exist, thus questioning the indication for surgery in such patients.

IP135. Perioperative Outcomes of Carotid Endarterectomy and Stenting in Octogenarians

IP135. Perioperative Outcomes of Carotid Endarterectomy and Stenting in Octogenarians

IP115. Refinements in Surgical and Anesthetic Techniques Significantly Improved the Results of Carotid Endarterectomy in Asymptomatic Patients in the Last Two Decades∗

The objective of this study was to analyze the impact of surgical and anesthetic changes in the last 20 years on perioperative outcomes of carotid endarterectomy (CEA) in asymptomatic patients in a large single-center experience. From January 1996 to December 2017, there were 6636 consecutive CEAs performed. Data concerning these interventions were prospectively collected in a dedicated database. A post hoc analysis of the database was performed, and 4379 interventions performed in asymptomatic patients were found and divided in two subgroups: patients operated on between 1996 and 1999 (1321 interventions, group 1); and patients operated on between 2013 and 2017 (1179 interventions, group 2). The two groups were compared in terms of preoperative characteristics, surgery and anesthesia techniques, and perioperative results with two tests. Patients in group 2 were older than patients in group 1 and more frequently had severe cardiovascular comorbidities. There were no differences between the two groups in terms of degree of stenosis at the side operated on and status of the contralateral carotid artery. All the interventions in group 1 were performed under general anesthesia (GA) with selective shunt insertion on the basis of somatosensory evoked potential monitoring; in group 2, the corresponding figure was 14% (P < .001), whereas the remaining 1015 patients had remifentanil anesthesia with selective shunt insertion on the basis of clinical monitoring. Shunt insertion rates were 9.4% in group 1 and 13.8% in group 2 (P < .001). The frequency of primary closures fell from 39.5% in group 1 to 2.7% in group 2 (P < .001), whereas there was an increase in patch closure in group 2 (from 48% to 94%). Perioperative mortality was 0.4% in group 1 and 0.5% in group 2 (P = .7), whereas perioperative stroke rate was 1% in group 1 and 0.25% in group 2 (P = .01). Thirty-day stroke and death rates were 1.45% and 0.7%, respectively (P = .01). The corresponding values in patients with GA without patch, with GA with patch, and with clinical monitoring with patch were 1.8%, 1.3%, and 0.5%, respectively (P = 0.05). At univariate analysis, the avoidance of shunt, use of patch, and clinical monitoring significantly improved 30-day outcomes; at multivariate analysis, only the avoidance of shunt maintained its significant value (odds ratio, 4.7; 95% confidence interval, 1.7-12.8; P = .002). The introduction and wide diffusion in our experience of patch closure and remifentanil anesthesia with clinical monitoring allowed significant improvement of the perioperative results of CEA in the last two decades in asymptomatic patients.

Severe contralateral carotid stenosis or occlusion does not have an impact on risk of ipsilateral stroke after carotid endarterectomy

ObjectiveThis study evaluates the impact of severe (>70%) contralateral carotid stenosis or occlusion (SCSO) on outcomes after carotid endarterectomy (CEA). MethodsClinical data for all patients undergoing CEA at a single center were prospectively gathered and retrospectively reviewed, with the sample population stratified according to the presence of SCSO. Perioperative outcomes of CEA in the presence of SCSO were analyzed using univariate and multivariate methods. ResultsDuring a 17-year study period, 2945 CEAs were performed on 1843 patients, including 736 (25%) patients with SCSO. Patients identified with SCSO had a higher rate of positive intraoperative electroencephalographic changes (30% vs 16%; P < .0001) and use of an intraoperative shunt (40% vs 28%; P < .0001). Univariate analysis identified SCSO as a risk factor for any stroke (2.8% vs 1.5%; P = .02), death (2.2% vs 1.1%; P = .02), and any stroke/death (4.3% vs 2.4%; P < .0079) but not ipsilateral stroke (1.5% vs 1.2%; P = .38). Multivariable regression demonstrated SCSO as an independent predictor of any stroke (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.0-3.3; P = .05) and any stroke/death (OR, 1.7; 95% CI, 1.1-2.7; P = .02), without increasing risk of ipsilateral stroke (OR, 1.3; 95% CI, 0.6-2.7; P = .54). The presence of SCSO was also associated with a higher risk of late mortality (hazard ratio, 1.3; 95% CI, 1.1-1.4; P < .01). ConclusionsAlthough the presence of SCSO is a risk factor for any stroke/death with CEA, it does not increase the risk of ipsilateral stroke. These data suggest that increased attention to perioperative medical and hemodynamic management should be especially considered in this cohort of patients as the observed strokes do not occur in the territory at risk from the surgical procedure.

Perioperative safety analysis of carotid endarterectomy in diabetic patients

Objective: To compare perioperative outcome of carotid endarterectomy (CEA) between diabetic and non-diabetic patients and discuss the safety of CEA in diabetic patients. Methods: A total of 572 patients with carotid stenosis who underwent CEA from Juanuary 2006 to September 2014 in Peking Union Medical Colloge Hospital were collected and analyzed retrospectively. The patients were distributed into diabetes mellitus (DM) group and non-DM group according to the comorbidities. Their baseline characteristics, intraoperative index and major complications in perioperative period were analyzed and compared. Results: Of 572 cases, 184 had DM (32.2%). Diabetic patients more frequently had a history of coronary artery disease (30.4% vs 18.6%), peripheral artery disease (39.7% vs 27.3%), and hyperlipemia (50.5% vs 36.6%) than non-diabetic patients (all P<0.05). The incidence of perioperative myocardial infarction (0.5% vs 0.8%), stroke (1.6% vs 1.8%) and death (0.5% vs 0.3%) did not differ between two groups (all P>0.05). Data of follow-up was available in 89.6% of patients, with a median duration of 42 months. The incidence of myocardial infarction (4.3% vs 3.4%), stroke (1.8% vs 1.7%), death (1.1% vs 0.9%), and restenosis (2.9% vs 3.1%) did not differ between two groups (all P>0.05). Conclusion: DM does not increase the risk of perioperative complications and impair the long-term outcomes after CEA if the patients are appropriately evaluated and treated in perioperative period.

Effects of preoperative statin use on perioperative outcomes of carotid endarterectomy.

ObjectivesSeveral studies have shown the beneficial role of statins in reducing the risk of major perioperative complications and death associated with noncardiac vascular surgery, but few have focused on their effects in the event of carotid endarterectomy (CEA). This study analyzes the effects of preoperative statin use on perioperative outcomes in patients undergoing CEA.Materials and MethodsData from all consecutive patients who underwent primary CEA for symptomatic and asymptomatic carotid disease between 2002 and 2014 at a single institution were prospectively stored in a vascular surgery registry, recording risk factors, medication, and indication for surgery. Endpoints of the study were perioperative (30‐day) stroke and death.ResultsOverall, 784 patients were on statins (825 CEAs, Group I), while 494 were not (545 CEAs, Group II). There were two perioperative strokes in Group I (0.24%) and four in Group II (0.73%; p = .22), and no deaths. The only nonfatal cardiac complication occurred in Group II (0.18%, p = .39). A neurologist assessed patients at 1, 6, and 12 months after CEA, and every 2 years thereafter. Follow‐up (range: 0.1–13 years; mean, 6.3 ± 3.7 years) was obtained for 1,239 patients (1,326 CEAs). Because 165 patients (166 CEAs) crossed over from Group II to Group I during the follow‐up time, long‐term data were stratified by postoperative statin treatment rather than by preoperative statin use. The 5‐ and 10‐year restenosis/occlusion and survival rates did not differ significantly between the two groups.ConclusionsTaking statins prior to CEA did not seem to affect the risk of major perioperative ischemic events and death, most likely due to the extremely low overall incidence of perioperative complications.

Predictors of perioperative outcomes after carotid revascularization

BackgroundThe aim of our study was to compare and identify possible predictors of perioperative outcomes of carotid endarterectomy (CEA) with carotid artery stenting (CAS) using the procedure-targeted American College of Surgeons National Surgical Quality Improvement Program database. MethodsPatients who underwent CEA or CAS were identified in American College of Surgeons National Surgical Quality Improvement Program (2011-2013). Univariate and multivariable logistic regression analyses were performed to evaluate the predictors of perioperative outcomes (any stroke or death, myocardial infarction [MI], 30-d readmission and reoperation). Final models were constructed based on the lowest Akaike Information Criterion. ResultsA total of 10,169 patients underwent carotid revascularization (CEA: 9817 [96.5%] versus CAS: 352 [3.5%]). Most patients were male (61%). Patients who had CAS were younger (mean age [±standard deviation]: 69.1 [±9.7] versus 71.3 [±9.4] y, P < 0.001); however, they showed a greater prevalence of diabetes (38.4% versus 29.2%), congestive heart failure (4.8% versus 1.4%), and chronic obstructive pulmonary disease (17.3% versus 10.2%) (all P < 0.001). The risk of postoperative stroke and/or death was nearly doubled with CAS (adjusted Odds Ratio = 1.84; 95% confidence interval: 1.07-3.18, P = 0.028). The odds of reoperation were higher in nonwhite patients compared with white patients (adjusted Odds Ratio: 1.34, 95% confidence interval: 0.97-1.84, P = 0.078). Perioperative MI and readmission were mostly related to patient's age and comorbidities. ConclusionsIn a national data set representing real-world outcome, CAS is associated with higher odds of postoperative mortality and stroke in comparison to CEA. Carotid revascularization procedure type is not a predictor of postoperative MI or readmission, suggesting that these outcomes are a function of other patient factors. Nonwhite race is a predictor of reoperation.

Preoperative symptom type influences the 30-day perioperative outcomes of carotid endarterectomy and carotid stenting in the Society for Vascular Surgery Vascular Registry

The objective of this study was to determine the effect of presenting symptom types on 30-day periprocedural outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in contemporary vascular practice. Retrospective review was undertaken of the Society for Vascular Surgery Vascular Registry database subjects who underwent CEA or CAS from 2004 to 2011. Patients were grouped by discrete 12-month preprocedural ipsilateral symptom type: stroke, transient ischemic attack (TIA), transient monocular blindness (TMB), or asymptomatic (ASX). Risk-adjusted odds ratios (ORs) were used to compare the likelihood of the 30-day outcomes of death, stroke, and myocardial infarction (MI) and the composite outcomes of death + stroke and death + stroke + MI. Symptom type significantly influences risk-adjusted 30-day outcomes for carotid intervention. Presentation with stroke predicted the poorest outcomes (death + stroke + MI composite: OR, 1.3; 95% confidence interval [CI], 0.83-2.03 vs TIA; OR, 2.56; 95% CI, 1.18-5.57 vs TMB; OR, 2.12; 95% CI, 1.46-3.08 vs ASX), followed by TIA (death + stroke + MI composite: OR, 1.97; 95% CI, 0.91-4.25 vs TMB; OR, 1.63; 95% CI, 1.14-2.33 vs ASX). For both CAS and CEA patients, presentation with stroke or TIA predicted a higher risk of periprocedural stroke than in ASX patients. Presentation with stroke predicted higher 30-day risk of death with CAS but not with CEA. MI rates were not affected by presenting symptom type. The 30-day outcomes for the TMB and ASX patient groups were equivalent in both treatment arms. Presenting symptom type significantly affects the 30-day outcomes of both CAS and CEA in contemporary vascular surgical practice. Presentation with stroke and TIA predicts higher rates of periprocedural complications, whereas TMB presentation predicts a periprocedural risk profile similar to that of ASX disease.

Perioperative Outcome of Carotid Endarterectomy According to Type and Timing of Neurologic Symptoms and Computed Tomography Findings

Carotid endarterectomy (CEA) in the early period after the onset of cerebral neurologic symptoms seems to be useful in the prevention of recurrent stroke while safety is still under debate. Asymptomatic carotid artery stenosis could be associated with silent cerebral ischemic events (CIEs) detectable on cerebral computed tomographic (CT) scans, but is not clear if (or how) silent cerebral lesions could influence the outcome of CEA. The aim of our work was to analyze the outcome of CEA according to the timing and type of neurologic symptoms and to evaluate the outcome of CEA in asymptomatic patients with silent cerebral events detected with preoperative cerebral CT scans. Consecutive patients who underwent CEA between January 2006 and December 2010 were collected in a dedicated database and divided into a symptomatic group (with CEA performed within 2weeks, 2-4weeks, and 4-24weeks after occurrence of the symptoms) and an asymptomatic group (with either positive-according to the classification of Stevens etal.-or negative preoperative cerebral CT scan) to evaluate the perioperative outcome in terms of CIEs, myocardial infarction (MI), and death. Results were compared using the chi-squared test, analysis of variance, and multivariate analysis. During the study period, 610 CEAs were performed, resulting in 16 (2.6%) CIEs (10[1.6%] strokes and 6 [1.0%] transient CIEs), 6 (1.0%) MIs, and 3 (0.5%) deaths. Symptomatic patients (n = 162; 22.6%) were independently associated with a higher incidence of stroke and MI compared with asymptomatic patients (7 [5.1%] vs. 3 [0.7%]; P < 0.002; 2 [1.4%] vs. 4[0.9%]; P < 0.02; respectively). The analysis of CEA outcome according to the timing of revascularization found no differences among groups within 2weeks (5 [7.9%]), 2-4weeks (no events), and after 4weeks (6 [7.4%]); in the same manner, the type of preoperative symptom was not associated with significant differences in outcome. Preoperative positive cerebral CT scans were present in 88 (19.6%) asymptomatic patients and were associated with a higher incidence of perioperative CIEs (7 [7.9%] vs. 2 [0.5%]; P = 0.001), transient CIEs (4 [4.5%] vs. 2[0.5%]; P = 0.004), and stroke (3 [3.0%] vs. 0 [0.0%]; P = 0.001). Although symptomatic patients have a higher risk of perioperative complications compared with asymptomatic patients, early CEA after symptom onset does not influence the results. Asymptomatic patients with positive CT scans who undergo CEA have a higher rate of neurologic complications.

Severe Contralateral Carotid Stenosis or Occlusion Does Not Impact Risk of Ipsilateral Stroke Following CEA

The impact of severe (>70%) contralateral carotid stenosis or occlusion (SCSO) on outcomes following carotid endarterectomy (CEA) is controversial. This study evaluated the effect of SCSO on outcomes following CEA. All patients undergoing carotid endarterectomy at a single institution were retrospectively stratified according to the presence of SCSO. The peri-operative outcomes of CEA in the presence of SCSO were analyzed using univariate and multivariable methods. There were 2945 CEA performed from 1/89 to 1/06, including 736 (25%) patients with SCSO. Patients identified with SCSO had a higher rate of prior contralateral CEA (44% vs 21%; P < .01), positive intra-operative EEG changes (31% vs 17%; P < .01), and use of an intra-operative shunt (40% vs 28%; P < .01). Univariate analysis identified SCSO as a risk factor for any stroke (2.8% vs 1.5%; P = .02), death (2.2% vs 1.1%; P = .03), and any stroke/death (4.3% vs 2.4%; P < .01), but not ipsilateral stroke (1.6% vs 1.2%; P = .4). Multivariable regression demonstrated SCSO as an independent predictor of any stroke (OR1.8 [95% CI: 1-3.3]; P = .05) and any stroke/death (OR1.7[95% CI: 1.1-2.7]; P = .02), without increasing risk of ipsilateral stroke (OR1.3[95% CI: 0.6-2.7]; P = .2). The presence of SCSO was also associated with a higher risk of late mortality (HR1.3 [95% CI: 1.1-1.4]; P < .01). Although the presence of SCSO is a risk factor for any stroke/death with CEA, it does not increase the risk of ipsilateral stroke. These data suggest that increased attention to peri-operative medical and hemodynamic management should be especially considered in this patient cohort as the observed strokes do not occur in the territory at risk from the surgical procedure.

The effect of surgeon's specialty and volume on the perioperative outcome of carotid endarterectomy

Several studies have demonstrated better outcomes for carotid endarterectomy (CEA) at high-volume hospitals and providers. However, only a few studies have reported on the impact of surgeons' specialty and volume on the perioperative outcome of CEA. This is a retrospective analysis of CEA during a recent 2-year period. Surgeons' specialties were classified according to their Board specialties into general surgeons (GS), cardiothoracic surgeons (CT), and vascular surgeons (VS). Surgeons' annual volume was categorized into low volume (<10 CEAs), medium volume (10 to <30 CEAs), and high volume (≥30 CEAs). The primary outcome was 30-day perioperative stroke and/or death; however, other perioperative complications were analyzed. Both univariate and multivariate analyses were done to predict the effect of specialty/volume and any other patient risk factors on stroke outcome. Nine hundred and fifty-three CEAs were performed by 24 surgeons: 122 by seven GS, 383 by 13 CT, and 448 by 4 VS. Patients' demographics/clinical characteristics were similar between specialties, except the incidence of coronary artery disease, which was higher for CT (P < .0001). The indications for CEA were symptomatic disease in 38% for VS, 31% for GS, and 23% for CT (P < .0001). The perioperative stroke and death rates were 4.1%, 2.9%, and 1.3% for GS, CT, and VS, respectively (P = .126). A subgroup analysis showed that the perioperative stroke rates for symptomatic patients were 5.3%, 2.3%, and 2.3% (P = .511) and for asymptomatic patients were 3.6%, 3%, and 0.72% (P = .099) for GS, CT, and VS, respectively. Perioperative stroke rates were significantly higher for nonvascular surgeons (GS and CT combined) vs VS in asymptomatic patients (3.2% vs 0.72%; P = .033). Perioperative stroke/death was also significantly lower for high-volume surgeons: 1.3% vs 4.1% and 4.3% for medium- and low-volume surgeons (P = .019) (1.3% vs 4.15% for high vs low/medium combined; P = .005). More CEAs were done for asymptomatic patients in the low/medium-volume surgeons (78%) vs high-volume surgeons (64%; P < .0001) with a stroke rate of 4.6% for low/medium-volume surgeons vs 0.51% for high-volume surgeons (P = .0005). A univariate logistic analysis showed that the odds ratio of having a perioperative stroke was 0.3 (95% confidence interval [CI], 0.13-0.73; P =.008) for high-volume surgeons vs low/medium-volume surgeons, 0.4 (95% CI, 0.16-1.07; P = .069) for VS vs CT/GS and 0.2 (95% CI, 0.06-0.45; P = .0004) when patching was used. A multivariate analysis showed that the odds ratio of having a perioperative stroke for CT VS was 2.1 (95% CI, 0.71-5.92; P = .183); for GS vs VS, 1.8 (95% CI, 0.49-6.90; P = .3709); for low-volume surgeons (vs high-volume) 3.4 (95% CI, 0.96-11.77; P = .0581); medium- vs high-volume surgeons 2.2 (95% CI, 0.75-6.42; P = .1509). High-volume surgeons had significantly better perioperative stroke/death rates for CEA than low/medium-volume surgeons. Perioperative stroke/death rates were also higher for nonvascular surgeons in asymptomatic patients.

Part One: For the Motion. Completion Angiography Should be Used Routinely Following Carotid Endarterectomy

Part One: For the Motion. Completion Angiography Should be Used Routinely Following Carotid Endarterectomy

Part Two: Against the Motion. Completion Angiography is Unnecessary Following Carotid Endarterectomy

Part Two: Against the Motion. Completion Angiography is Unnecessary Following Carotid Endarterectomy

The Effect of Surgeon's Specialty and Volume on Perioperative Outcome of Carotid Endarterectomy

Several studies have demonstrated better outcomes for carotid endarterectomy (CEA) at high-volume hospitals and providers. However, only a few studies have reported the effect of surgeons' specialty and volume on the perioperative outcome of CEA. This is a retrospective analysis of prospectively collected CEA data during a recent 2-year period. Surgeons' specialties were classified according to their board specialties into general surgeons (GS), cardiothoracic (CT), and vascular surgeons (VS). Surgeons' annual volume was categorized into low volume (<10 CEAs), medium volume (10 to <30 CEAs), and high volume (≥30 CEAs). The primary outcome was 30-day perioperative stroke or death, or both. Other perioperative complications were analyzed. Univariate and multivariate analyses were done to predict the effect of specialty/volume and any other patient risk factors on stroke outcome. A total of 953 CEAs were performed by 24 surgeons: 122 by 7 GS, 383 by 13 CT, and 448 by 4 VS. Patients' demographics and clinical characteristics were similar between specialties, except the incidence of coronary artery disease, which was higher for CT (P < .0001). The indications for CEA were symptomatic disease in 38% for VS, 31% for GS, and 23% for CT (P < .0001). The perioperative stroke and death rates were 4.1% for GS, 2.9% for CT, and 1.3% for VS (P = .1263). A subgroup analysis showed that the perioperative stroke rates were 5.3%, 2.3%, and 2.3% (P = .5112) for symptomatic patients and 3.6%, 3%, and 0.72% (P = .0992) for asymptomatic patients for GS, CT, and VS, respectively. Perioperative stroke rates were significantly higher for nonvascular surgeons (GS and CT combined) vs VS in asymptomatic patients (3.2% vs 0.72%, P = .0333). Perioperative stroke/death was also significantly lower for high-volume surgeons: 1.3% vs 4.1% and 4.3% for medium and low-volume surgeons (P = .0194; 1.3% vs 4.15% for high vs low/medium combined, P = .005, Fig). More CEAs were done for asymptomatic patients in the low-/medium-volume surgeons (78%) vs high-volume surgeons (64%, P < .0001), with a stroke rate of 4.6% for low-/medium-volume surgeons vs 0.51% for high-volume surgeons (P = .0005). A univariate logistic analysis showed that the odds ratio (OR) of having a perioperative stroke was 0.3 (95% confidence interval, 0.13-0.73; P = .0079) for high-volume surgeons, 0.4 (P = .0686) for VS, 0.2 (P = .0004) when patching was used, and 2.6 (P = .0521) for patients with preoperative renal insufficiency. A multivariate analysis showed that the OR of having a perioperative stroke for CT (vs VS group) was 1.8 (P = .269); for GS, 1.7 (P = .407); low-volume surgeons (vs high-volume), 3.1 (P = .073); medium-volume surgeons, 2.0 (P = .197); and for patching, 0.25 (P = .013, Table).TableMultivariate logistic analysis for perioperative stroke for specialty and volumeVariableOR95% CIPSpecialty CT vs VS1.80.64-4.98.269 GS vs VS1.70.47-6.51.407 Preoperative renal insufficiency2.40.89-6.25.083 Patching0.20.07-0.62.005Volume Low vs high3.10.90-10.76.074 Medium vs high2.00.70-5.76.197 Preoperative renal insufficiency2.50.92-6.56.073 Patching0.250.08-0.74.013 Open table in a new tab High-volume surgeons had significantly better perioperative stroke/death rates for CEA than low/medium-volume surgeons. Perioperative stroke/death rates were also higher for nonvascular surgeons, particularly in asymptomatic patients.

Perioperative outcome of carotid endarterectomy with regional anesthesia: two decades of experience from the Caribbean

Study Objective To evaluate the perioperative outcome of carotid endarterectomy (CEA) with regional anesthesia. Design Retrospective chart review of consecutive patients who underwent CEA with regional anesthesia in a 23-year period. Setting Operating rooms of a general hospital in a developing country. Measurements Demographic data, perioperative clinical data, postoperative morbidity and unplanned admissions were recorded. Main Results A total of 183 CEA procedures were performed. In 172 cases, CEA was done exclusively with deep cervical plexus block and local infiltration, while in 11 (6%) cases, there was a need for conversion to general anesthesia intraoperatively. Clamping of the internal carotid artery (ICA) for a three-minute period was the method used to monitor any development of neurological impairment. Perioperative complications included intraoperative seizures in one patient, intraoperative transient hemiparesis in three patients, postoperative transient hemiparesis in two patients, and intraoperative hemiplegia in one patient. One hundred fifty-three patients (83.6%) were discharged home within 24 hours, and 29 (15.8%) were discharged home in 48 hours. The hemiplegic patient had a hospital stay of 12 days. There was no perioperative mortality. Conclusions Regional anesthesia is a safe method for CEA in a limited-resources setting, as it facilitates intraoperative clinical assessment of the effects of ICA clamping.

Intraoperative Imaging: Does it Really Improve Perioperative Outcomes of Carotid Endarterectomy?

A variety of intraoperative imaging and assessment techniques can be used during carotid endarterectomy (CEA) to evaluate the technical results of the arterial repair. However, the necessity of utilizing these techniques routinely in every case, and the actual ability of these studies to improve the outcomes of the operation, remain areas of controversy. The most commonly used intraoperative assessment techniques include arteriography, duplex ultrasonography, and use of a hand-held continuous-wave Doppler probe. While surgeons who advocate intraoperative imaging presume that it will ultimately improve the technical "perfection" of the operation by allowing the intraoperative identification and immediate revision of occult technical defects that would likely predispose toward perioperative stroke, there is little comparative data in the literature to support this premise. Proponents of routine intraoperative assessment argue that the identification of technical imperfections will allow their immediate correction prior to a perioperative stroke resulting from thromboembolization. In addition, surgeons who use these techniques believe that the presumed reduction in rate of serious technical errors will also result in a lower rate of recurrent carotid stenosis. However, many experienced vascular surgeons who perform CEA do not routinely utilize any of these intraoperative assessment techniques, and report equally excellent results using meticulous technique alone and clinical inspection of the endarterectomy site and arterial repair. Potential issues that may arise when performing routine intraoperative assessment can include: making a determination of which type of "imperfections" actually require immediate revision of the arterial repair, and potential vascular injuries or cerebral ischemia associated with reclamping of the artery in order to perform an immediate revision. In an analysis of a large, population-based cohort study of CEAs, the authors have found no compelling evidence that routine use of these imaging techniques confers any advantage in terms of the perioperative outcomes of carotid endarterectomy. the majority of surgeons who perform carotid endarterectomy do not routinely utilize any formal intraoperative completion imaging or assessment technique during CEA, other than clinical inspection of the arterial repair. However, even among vascular surgeons, less than 50% are routinely using intraoperative imaging or assessment. The routine use of intraoperative imaging studies did not appear to significantly improve perioperative outcomes with regard to ipsilateral perioperative stroke, and stroke/death. Considering the increased time and cost of performing these procedures, routine use of intraoperative imaging and assessment techniques during CEA is of questionable value. Selective use of these imaging or assessment techniques when the surgeon has a specific concern regarding the technical outcomes of the operation appears to be a reasonable alternative.