Defining the high-risk patient for carotid endarterectomy: an analysis of the prospective National Surgical Quality Improvement Program database
Michael C Stoner1, William M Abbott, Daniel R Wong
1Division of Vascular and Endovascular Surgery, Masschusetts General Hospital, Boston, MA, USA. stonerm@ecu.edu
Insights
Carotid endarterectomy (CEA) outcomes were analyzed in a large database, identifying risk factors for adverse events. Regional anesthesia significantly reduced complications in high-risk patients undergoing CEA.
Area of Science:
- Vascular Surgery
- Neurosurgery
- Anesthesiology
Background:
- Carotid endarterectomy (CEA) is a standard treatment for carotid stenosis.
- Identifying high-risk patients for CEA remains challenging, often relying on retrospective data.
- This study analyzed CEA outcomes using a comprehensive national surgical quality database.
Purpose of the Study:
- To identify risk factors associated with adverse outcomes following CEA.
- To evaluate the impact of regional anesthesia on CEA outcomes.
- To define high-risk patient populations for CEA.
Main Methods:
- Prospective data collection from 2000-2003 across 123 VA and 14 private sector centers.
- Analysis of 13,622 primary isolated CEAs.
- Multivariate models assessed clinical, demographic, and operative variables for stroke, death, or cardiac events.
Main Results:
- The composite stroke, death, or cardiac event rate was 4.0%.
- Key risk factors included age, diabetes, smoking history, prior stroke/TIA, renal dysfunction, hypoalbuminemia, and operative time.
- Regional anesthesia was associated with a 31% reduction in the composite outcome (OR, 0.69; P = .008).
Conclusions:
- CEA outcomes in VA and private sector hospitals are comparable to contemporary studies.
- Identified risk factors can aid in selecting high-risk patients for CEA.
- Regional anesthesia is a favorable anesthetic choice for high-risk CEA patients, reducing perioperative complications.
Background:
Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting has been advocated in high-risk patients. The definition of such a population has been elusive, particularly because the data are largely retrospective. Our study examined results for CEA in the National Surgical Quality Improvement Program database (both Veterans Affairs and private sector).
Methods:
National Surgical Quality Improvement Program data were gathered prospectively for all patients undergoing primary isolated CEA during the interval 2000 to 2003 at 123 Veterans Affairs and 14 private sector academic medical centers. Study end points included the 30-day occurrence of any stroke, death, or cardiac event. A variety of clinical, demographic, and operative variables were assessed with multivariate models to identify risk factors associated with the composite (stroke, death, or cardiac event) end point. Adjudication of end points was by trained nurse reviewers (previously validated).
Results:
A total of 13,622 CEAs were performed during the study period; 95% were on male patients, and 91% of cases were conducted within the Veterans Affairs sector. The average age was 68.6 +/- 0.1 years, and 42.1% of the population had no prior neurologic event. The composite stroke, death, or cardiac event rate was 4.0%; the stroke/death rate was 3.4%. Multivariate correlates of the composite outcome were (odds ratio, P value) as follows: deciles of age (1.13, .018), insulin-requiring diabetes (1.73, <.001), oral agent-controlled diabetes (1.39, .003), decade of pack-years smoking (1.04, >.001), history of transient ischemic attack (1.41, >.001), history of stroke (1.51, >.001), creatinine >1.5 mg/dL (1.48, >.001), hypoalbuminemia (1.49, >.001), and fourth quartile of operative time (1.44, >.001). Cardiopulmonary comorbid features did not affect the composite outcome in this model. Regional anesthesia was used in 2437 (18%) cases, with a resultant relative risk reduction for stroke (17%), death (24%), cardiac event (33%), and the composite outcome (31%; odds ratio, 0.69; P = .008).
Conclusions:
Carotid endarterectomy results across a spectrum of Veterans Affairs and private sector hospitals compare favorably to contemporary studies. These data will assist in selecting patients who are at an increased risk for adverse outcomes. Use of regional anesthetic significantly reduced perioperative complications in a risk-adjusted model, thus suggesting that it is the anesthetic of choice when CEA is performed in high-risk patients.
