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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Effect of Postoperative Stroke Timing on Perioperative Mortality After Carotid Revascularization
Kevin S Yei1, Christina L Cui1, Mokhshan Ramachandran1
1Department of Surgery, Division of Vascular Surgery, UC San Diego, San Diego, CA.
Insights
Postoperative stroke after carotid revascularization, whether in-hospital or out-of-hospital, significantly increases mortality. However, mortality rates were similar between in-hospital and out-of-hospital strokes in this study.
Area of Science:
- Vascular Surgery
- Neurology
- Health Services Research
Background:
- In-hospital stroke (IHS) is linked to poorer outcomes than out-of-hospital stroke (OHS) due to treatment delays.
- Limited research compares postoperative stroke timing after carotid revascularization.
- This study investigates IHS versus OHS impact on mortality in carotid revascularization patients.
Purpose of the Study:
- To compare the effects of in-hospital stroke (IHS) versus out-of-hospital stroke (OHS) on postoperative mortality.
- To analyze stroke timing in patients undergoing carotid artery stenting (CAS) and carotid endarterectomy (CEA).
Main Methods:
- Retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2011-2018).
- Included patients undergoing CAS or CEA.
- Analyzed outcomes based on stroke timing (no stroke, IHS, OHS) and procedure type using chi-squared tests and multivariable logistic regression.
Main Results:
- 31,304 carotid revascularizations were analyzed; 1.3% had IHS and 0.7% had OHS.
- Both IHS and OHS were associated with significantly higher perioperative mortality (OR > 19 and OR > 29, respectively).
- No significant difference in mortality was found between IHS and OHS (OR: 1.51, P=0.161).
Conclusions:
- Any postoperative stroke after carotid revascularization substantially increases 30-day mortality risk.
- Contrary to prior research, this study found similar 30-day mortality for IHS and OHS.
- Vigilant in-hospital monitoring and prompt follow-up are crucial for reducing high mortality associated with postoperative stroke in these patients.
Background:
In-hospital stroke (IHS) has been associated with worse outcomes than out-of-hospital stroke (OHS) due to delays in diagnosis and treatment. A paucity of studies exists comparing the timing of postoperative stroke after carotid revascularization. We aimed to study the effect of IHS versus OHS on postoperative mortality in carotid revascularization patients in a large-scale national database.
Methods:
This is a retrospective cohort study of patients who underwent carotid artery stenting (CAS) and carotid endarterectomy (CEA) between 2011 and 2018 in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Statistical analysis included chi-squared test and multivariable logistic regression. Patients were divided based on postoperative stroke timing (no stroke, IHS, or OHS) as well as procedure type (CEA or CAS).
Results:
A total of 31,304 carotid revascularizations were performed with 420 (1.3%) IHSs and 207 (0.7%) OHSs. On adjusted analysis, there was significantly higher perioperative mortality with both IHS [odds ratio (OR): 19.75, 95% confidence interval (CI): 13.61-28.18, P < 0.001] and OHS [OR: 29.73, 95% CI: 18.76-45.82, P < 0.001]. There was no difference in mortality after OHS versus IHS [OR: 1.51, 95% CI: 0.89-2.55, P = 0.161].
Conclusions:
Any postoperative stroke after carotid revascularization significantly increased the odds of 30-day mortality. In contrast to previous studies demonstrating worse outcomes after IHS than OHS, we observed similar 30-day mortality between the 2 stroke categories. Improved follow-up and early recognition with rescue within carotid revascularization patients compared to the general population could potentially contribute to these results. However, overall mortality remains high for any postoperative stroke following carotid revascularization, emphasizing the importance of vigilant in-hospital monitoring and follow-up even after discharging the patient.
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