Variability in carotid endarterectomy practice patterns within a metropolitan area
Amit Kansara1, Daniel Miller, Rahul Damani
1Department of Neurology, Wayne State University, Henry Ford Hospital, 8-C-UHC, 4201 St Antoine, Detroit, MI 48201, USA.
Insights
Carotid endarterectomy is often performed in high-risk patients, despite a doubled complication rate. Multidisciplinary conferences may improve patient selection and safety for carotid stenosis treatment.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Neurosurgery
Background:
- Previous studies suggest carotid artery stenting or medical therapy may be better for high-risk carotid stenosis patients.
- The current practice patterns for carotid endarterectomy in high-risk individuals are not well-defined.
Purpose of the Study:
- To evaluate the proportion of high surgical risk patients undergoing carotid endarterectomy.
- To compare complication rates between conventional and high surgical risk patients undergoing carotid endarterectomy.
Main Methods:
- Retrospective audit of 335 carotid endarterectomies across 4 hospitals over 2 years.
- Comparison of in-hospital stroke, myocardial infarction, and death rates.
- Analysis of patient risk stratification and procedural outcomes.
Main Results:
- 37.9% of carotid endarterectomies were performed in high surgical risk patients.
- High surgical risk patients had a 2-fold increase in major in-hospital complications (10.2% vs 4.6%).
- The hospital with multidisciplinary carotid conferences performed fewer procedures on asymptomatic patients.
Conclusions:
- A significant number of carotid endarterectomies are performed on high-risk patients, with increased complications.
- The benefit of carotid endarterectomy in high-risk patients is questionable.
- Preintervention multidisciplinary conferences may enhance patient safety and optimize treatment selection.
Background And Purpose:
Previous clinical studies have suggested that patients with carotid stenosis with high surgical risk features may fare better with carotid artery stenting or aggressive medical therapy. The extent to which carotid endarterectomy is still being performed in this group of patients is unclear.
Methods:
A retrospective audit was performed among 4 hospitals over a 2-year period. The proportion of high surgical risk patients was compared and the in-hospital stroke, myocardial infarction, and death rates were compared among conventional and high surgical risk patients.
Results:
Three hundred thirty-five carotid endarterectomy operations were performed (63% asymptomatic) with 37.9% being high surgical risk subjects. The stroke, myocardial infarction, and death rate was 4.6% in conventional risk subjects and 10.2% in high surgical risk patients (P<0.05). The only hospital with multidisciplinary carotid conferences had the lowest proportion of carotid endarterectomy operations in asymptomatic patients.
Conclusions:
A substantial proportion of carotid endarterectomy operations are performed in patients with high surgical risk features. These patients experienced a 2-fold increase in major in-hospital complications, raising doubts about whether they benefit from carotid surgery. The use of preintervention multidisciplinary conferences may improve patient safety.