Optimal selection of asymptomatic patients for carotid endarterectomy based on predicted 5-year survival
Jessica B Wallaert1, Jack L Cronenwett, Daniel J Bertges
1VA Outcomes Group, Dartmouth Hitchcock Medical Center, Lebanon, NH 03765, USA. jessica.wallaert@hitchcock.org
Insights
Carotid endarterectomy (CEA) for asymptomatic stenosis offers good 5-year survival for most patients. However, high-risk individuals may not live long enough to benefit from this stroke prevention surgery.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Neurosurgery
Background:
- Carotid endarterectomy (CEA) is a surgical procedure to prevent stroke in patients with internal carotid artery (ICA) stenosis.
- Long-term survival is crucial for patients undergoing CEA, particularly those who are asymptomatic.
Purpose of the Study:
- To examine factors associated with 5-year survival following CEA in patients with asymptomatic ICA stenosis.
- To identify risk factors for mortality and develop a predictive risk score for 5-year survival post-CEA.
Main Methods:
- Analysis of prospectively collected data from 4114 isolated CEAs for asymptomatic stenosis (2003-2011).
- Survival determined using the Social Security Death Index.
- Cox proportional hazard models used to identify mortality risk factors and calculate a risk score.
Main Results:
- Overall 5-year survival after CEA was 82%.
- Factors associated with worse survival included older age, diabetes, smoking, heart failure, COPD, poor renal function, lack of statin use, and contralateral ICA stenosis.
- Risk stratification identified low (96%), medium (80%), and high (51%) 5-year survival rates.
Conclusions:
- The majority of asymptomatic patients selected for CEA achieved 5-year survival, indicating appropriate patient selection in the study region.
- High-risk patients, especially those with multiple major risk factors, may not survive long enough to benefit from prophylactic CEA.
- Predicting survival is essential for informed decision-making in high-risk patients considered for CEA.
Objective:
Although carotid endarterectomy (CEA) is performed to prevent stroke, long-term survival is essential to ensure benefit, especially in asymptomatic patients. We examined factors associated with 5-year survival following CEA in patients with asymptomatic internal carotid artery (ICA) stenosis.
Methods:
Prospectively collected data from 4114 isolated CEAs performed for asymptomatic stenosis across 24 centers in the Vascular Study Group of New England between 2003 and 2011 were used for this analysis. Late survival was determined with the Social Security Death Index. Cox proportional hazard models were used to identify risk factors for mortality within the first 5 years after CEA and to calculate a risk score for predicting 5-year survival.
Results:
Overall 3- and 5-year survival after CEA in asymptomatic patients were 90% (95% CI 89%-91%) and 82% (95% CI 81%-84%), respectively. By multivariate analysis, increasing age, diabetes, smoking history, congestive heart failure, chronic obstructive pulmonary disease, poor renal function (estimated glomerular filtration rate <60 or dialysis dependence), absence of statin use, and worse contralateral ICA stenosis were all associated with worse survival. Patients classified as low (27%), medium (68%), and high risk (5%) based on number of risk factors had 5-year survival rates of 96%, 80%, and 51%, respectively (P < .001).
Conclusions:
More than four out of five asymptomatic patients selected for CEA in the Vascular Study Group of New England achieved 5-year survival, demonstrating that, overall, surgeons in our region selected appropriate patients for carotid revascularization. However, there were patients selected for surgery with high risk profiles, and our models suggest that the highest risk patients (such as those with multiple major risk factors including age ≥ 80, insulin-dependent diabetes, dialysis dependence, and severe contralateral ICA stenosis) are unlikely to survive long enough to realize a benefit of prophylactic CEA for asymptomatic stenosis. Predicting survival is important for decision making in these patients.
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