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Association between perioperative stroke and 30-day mortality in carotid endarterectomy: A meta-analysis

Rajiv P Reddy¹, Tejas Karnati¹, Robyn E Massa²

¹Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Clinical Neurology and Neurosurgery

|April 16, 2019

Insights

Perioperative stroke after carotid endarterectomy (CEA) significantly increases 30-day mortality risk by nearly 40 times. This finding underscores the need for better preoperative risk assessment and neuroprotection strategies to improve patient outcomes following CEA.

Area of Science:

Vascular Surgery
Neurology
Clinical Epidemiology

Background:

Perioperative stroke is a recognized complication of carotid endarterectomy (CEA).
Previous studies indicate a higher long-term mortality risk following CEA-related strokes, but the direct impact on short-term mortality remains unclear.
The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) noted a nearly 3-fold increase in 4-year mortality after CEA-related strokes.

Purpose of the Study:

To evaluate the association between perioperative stroke and 30-day mortality in patients undergoing CEA.
To quantify the risk of 30-day mortality for patients experiencing a stroke during the perioperative period after CEA.

Main Methods:

A meta-analysis was conducted using studies from PubMed and the World Science Database.
Included were 83 randomized controlled trials and retrospective/prospective studies reporting perioperative strokes and 30-day mortality in CEA patients.
Data from 123,507 carotid endarterectomy procedures were analyzed.

Main Results:

The overall 30-day perioperative stroke rate was 2.15%, with an all-cause mortality rate of 0.93%.
Patients experiencing a perioperative stroke had a 30-day mortality rate of 17.01%, compared to 0.57% for those without a stroke.
The odds ratio for 30-day mortality associated with perioperative stroke was 39.86 (p < 0.001).

Conclusions:

Perioperative stroke following CEA is associated with a dramatically increased risk of 30-day mortality, nearly 40-fold.
These findings emphasize the critical need for improved preoperative risk stratification and the development of neuroprotective treatments for CEA patients.
Minimizing perioperative stroke is crucial for reducing short-term mortality after carotid endarterectomy.

Read full analysis

Abstract

Objectives:

Perioperative stroke is a known complication of carotid endarterectomy (CEA) for patients with symptomatic and asymptomatic carotid stenosis. The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) has shown that stroke following CEA is associated with nearly a 3-fold increase in the 4-year mortality compared to patients without such an event. However, no studies to date can establish whether the stroke was the cause of the short term mortality. Thus, our objective is to evaluate if perioperative stroke after CEA increases the risk of 30-day mortality.

Patients And Methods:

We performed a meta-analysis of the literature from PubMed and the World Science Database on studies reporting perioperative strokes and 30-day mortality in symptomatic and asymptomatic CEA patients. 3400 articles were retrieved, and abstracts were further screened using the inclusion criteria to obtain a final set of 83 randomized controlled trials and retrospective/prospective studies.

Results:

A total of 123,507 CEA procedures were included among the 83 studies. The 30-day perioperative stroke rate for all included studies was 2.15%. The 30-day all-cause mortality rate was 0.93%. In patients with perioperative strokes, the 30-day mortality rate was found to be 17.01%. Among patients without perioperative strokes, the 30-day mortality rate was much lower at 0.57%. The summary odds ratio of perioperative stroke and 30-day mortality was 39.86 (95% CI, 29.30-54.23, p < 0.001).

Conclusion:

Patients with perioperative stroke have an almost 40 times increased risk of 30-day stroke-related mortality. This study highlights the importance of developing a preoperative risk assessment and neuroprotective treatment trial for perioperative stroke.

Keywords:

Carotid endarterectomy (CEA)Carotid stenosis (CS)Meta-Analysis Mortality Outcomes Stroke

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