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The Relationship Between Carotid Revascularization Procedural Volume and Perioperative Outcomes in Australia and New
Mary Giurgius1,2, Marco Horn1, Shannon D Thomas1,2,3
1Department of Surgery, Prince of Wales Hospital, Sydney, Australia.
Insights
Higher operator volume in carotid revascularization procedures, including carotid endarterectomy (CEA) and carotid artery stenting (CAS), is linked to lower stroke or death (S/D) risks. Increased operator experience significantly improves patient outcomes in these interventions.
Area of Science:
- Vascular Surgery
- Health Services Research
- Patient Safety
Background:
- Carotid revascularization via carotid endarterectomy (CEA) and carotid artery stenting (CAS) are crucial for stroke prevention.
- Both procedures carry inherent risks of perioperative stroke or death (S/D).
- Understanding factors influencing S/D rates, such as operator and hospital volume, is vital for optimizing patient care.
Purpose of the Study:
- To investigate the association between operator volume, hospital volume, and perioperative S/D risk in CEA and CAS procedures.
- To analyze data from Australia and New Zealand to identify potential improvements in patient outcomes.
Main Methods:
- Retrospective analysis of prospectively collected data from the Australasian Vascular Audit (2010-2017).
- Multivariate regression analysis to assess the impact of annual caseload volume (quintiles) on perioperative S/D.
- Separate analyses for CEA (n=16,765) and CAS (n=1,350) procedures.
Main Results:
- Lower-volume operators for CEA had higher S/D rates (2.21% vs 1.76%, OR 1.28).
- Lower-volume operators for CAS had significantly higher S/D rates (2.63% vs 0.37%, OR 6.11).
- No significant association was found between hospital volume and S/D rates for either procedure.
Conclusions:
- A clear inverse relationship exists between operator volume and perioperative S/D rates for both CEA and CAS.
- Establishing minimum operator volume thresholds and optimizing referral pathways could enhance patient outcomes in Australia and New Zealand.
- Focusing on operator experience is critical for improving safety in carotid revascularization procedures.
Abstract:
Carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke in selected patients. However, each intervention carries a risk of perioperative complications including stroke or death (S/D). We aimed to determine the relationship between operator volume, hospital volume, and the perioperative risk of S/D in carotid revascularization in Australia and New Zealand. Retrospective analysis was performed on prospectively collected data extracted from the Australasian Vascular Audit between 2010 and 2017. Annual caseload volume was analyzed in quintiles (Q) using multivariate regression to assess its impact on perioperative S/D. Carotid endarterectomy procedures (n = 16 765) demonstrated higher S/D rates for lower-volume operators (2.21% for Q1-Q3 [1-17 annual cases] vs 1.76% for Q4-Q5 [18-61 annual cases]; odds ratio [OR]: 1.28; 95% CI: 1.001-1.64; P = .049). Carotid artery stenting procedures (n = 1350) also demonstrated higher S/D rates for lower-volume operators (2.63% for Q1-Q3 [1-11 annual cases] vs 0.37% for Q4-Q5 [12-31 annual cases]; OR: 6.11; 95% CI: 1.27-29.33; P = .024). No significant hospital volume-outcome effect was observed for either procedure. An inverse relationship was demonstrated between operator volume and perioperative S/D rates following CEA and CAS. Consideration of minimum operator thresholds, restructuring of services and networked referral pathways of care in Australia and New Zealand, would likely result in improved patient outcomes.
