Predictors of prolonged length of stay after elective carotid revascularization
Hanaa D Aridi1, Brandon Leon1, Michael P Murphy1
1Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, IN.
Insights
Prolonged length of stay (pLOS) after carotid revascularization affects nearly 23% of patients, driven mainly by complications. Identifying pLOS predictors can improve patient outcomes and quality of care.
Area of Science:
- Vascular Surgery
- Health Services Research
- Quality Improvement
Background:
- Postoperative day-one discharge is a key quality indicator for carotid revascularization.
- Predicting prolonged length of stay (pLOS) is crucial for optimizing patient care and resource allocation.
Purpose of the Study:
- To identify predictors of prolonged length of stay (pLOS), defined as >1 day, after elective carotid revascularization procedures.
- To analyze factors contributing to pLOS across carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS).
Main Methods:
- Analysis of 118,625 elective carotid revascularization cases from the Vascular Quality Initiative (2016-2022).
- Multivariable logistic regression was employed to identify significant predictors of pLOS for each procedure type.
Main Results:
- Nearly 23.2% of patients experienced pLOS, with major adverse events being the primary driver.
- Predictors of pLOS included patient demographics, comorbidities, presentation, and procedural factors like day of surgery and physician volume.
- pLOS was significantly associated with increased 1-year mortality across all three procedures (CEA, TCAR, TFCAS).
Conclusions:
- Prolonged length of stay (>1 day) is a notable outcome after carotid revascularization.
- Procedure-related complications are the main contributors to pLOS.
- Identifying at-risk patients enables targeted quality improvement strategies to enhance short- and long-term outcomes.
Objective:
Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization.
Methods:
Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure.
Results:
A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05).
Conclusions:
A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.
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