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Published on: September 19, 2016
Procedural Risks of Carotid Intervention in 19,000 Patients
Kamran A Gaba1, Alison Halliday2, Richard Bulbulia1
1Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Insights
Carotid endarterectomy (CEA) and carotid stenting (CAS) carry higher risks for symptomatic patients. Symptomatic patients undergoing CAS had a particularly increased risk of death compared to CEA.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Services Research
Background:
- Randomized controlled trials (RCTs) established carotid endarterectomy (CEA) and carotid stenting (CAS) for stroke risk reduction.
- Historical RCTs may not reflect current clinical practice.
- Administrative datasets offer reliable estimates of procedural risks.
Purpose of the Study:
- To evaluate procedural risks associated with CEA and CAS in a contemporary, international patient cohort.
- To compare in-hospital mortality and length of stay (LOS) between CEA and CAS.
- To assess brain imaging rates as a proxy for procedural strokes.
Main Methods:
- Retrospective analysis of 18,997 patients undergoing CEA (n=16,220) or CAS (n=2,777) between 2011-2015.
- Primary outcome: in-hospital death within seven days.
- Secondary outcomes: prolonged LOS (>2 days) and brain imaging rates within 2 days.
Main Results:
- Mortality was higher in symptomatic patients for both CEA (0.2%) and CAS (3.3%).
- Symptomatic patients undergoing CAS showed a significantly higher mortality risk (3.3%) compared to CEA (0.2%).
- Prolonged LOS was more common in symptomatic patients for both CEA (57.0%) and CAS (64.3%) compared to asymptomatic patients.
Conclusions:
- Procedural risks, including death and prolonged LOS, are elevated in symptomatic patients undergoing carotid intervention.
- Symptomatic patients treated with CAS exhibited a notably higher risk of death.
- Case selection, potentially favoring sicker patients for CAS, may contribute to observed risk differences.
Background:
Randomized controlled trials (RCTs) show that carotid endarterectomy (CEA) and carotid stenting (CAS) reduce long-term stroke risk in symptomatic and asymptomatic patients with carotid artery stenosis. Historical RCTs may not represent contemporary practice and administrative datasets may estimate procedural risks more reliably. We studied procedural risks after carotid intervention in a novel, international administrative data set of 18,997 patients admitted to 28 hospitals across 7 countries.
Methods:
Symptomatic and asymptomatic patients undergoing CEA (n = 16,220) and CAS (n = 2,777) between 2011 and 2015 were studied retrospectively. The primary outcome was in-hospital death within seven days. The secondary outcome was the proportion of patients whose length of hospital stay (LOS) exceeded 2 days. We also describe the rate of computerized tomography brain imaging within 2 days of CEA and CAS (proxy for stroke) as procedural strokes were not reliably recorded.
Results:
In symptomatic patients after CEA, mortality was 0.2% [5/2,118] (95% confidence interval: 0.1-0.5), and 57.0% [628/1,101] (54.1-60.0) had prolonged LOS. In asymptomatic patients after CEA, mortality was 0.1% [21/14,102] (0.1-0.2), and 28.5% [2,864/10,039] (27.7-29.4) had prolonged LOS. In symptomatic patients after CAS, mortality was 3.3% [10/307] (1.3-5.2), and 64.3% [144/224] (58.0-70.5) had prolonged LOS. In asymptomatic patients after CAS, mortality was 0.7% [18/2,470] (0.4-1.1), and 27.5% [601/2,187] (25.6-29.4) had prolonged LOS. After CEA, 8.1% [89/1,101] (6.5-9.7) symptomatic patients and 2.1% [207/10,039] (1.8-2.3) asymptomatic patients underwent brain imaging. After CAS, 7.1% [16/224] (4.0-10.7) symptomatic patients and 3.2% [71/2,187] (2.5-4.0) asymptomatic patients underwent brain imaging.
Conclusions:
Death and LOS after CEA and CAS were higher in symptomatic than asymptomatic patients. Symptomatic patients undergoing CAS had particularly increased risk of death. This may be partly explained by case selection, with more comorbid patients preferentially undergoing CAS. While RCTs effectively compare long-term efficacy of CEA versus CAS, administrative datasets can provide reliable estimates of contemporary procedural risks.
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