Analysis of Surgeon and Center Case Volume and Stroke or Death after Transcarotid Artery Revascularization
Nadin Elsayed1, Maryam Ali Khan1, Claire B Janssen1
1From the Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, CA (Elsayed, Khan, Janssen, Lane, Malas).
Insights
Low surgeon volume, but not hospital volume, is linked to increased stroke risk after transcarotid artery revascularization (TCAR). High-volume surgeons demonstrated better outcomes for TCAR procedures.
Area of Science:
- Vascular Surgery
- Health Services Research
- Patient Outcomes
Background:
- Hospital and surgeon volume may influence adverse events after carotid endarterectomy (CEA).
- Transcarotid artery revascularization (TCAR) outcomes related to procedural volume require investigation.
Purpose of the Study:
- To assess the association between hospital and surgeon volume and the risk of stroke or death following TCAR.
- To identify factors influencing TCAR procedure safety and efficacy.
Main Methods:
- Retrospective analysis of 22,624 TCAR cases from the Vascular Quality Initiative (2016-2021).
- Surgeon and center volumes calculated as mean number of cases (MNC) per year.
- Primary outcome: composite of in-hospital stroke or death.
Main Results:
- Low and medium hospital volumes showed no increased odds of stroke or death compared to high-volume centers.
- Low-volume surgeons had significantly higher odds of stroke and stroke with transient ischemic attack (TIA) versus high-volume surgeons.
- Medium-volume surgeons did not show increased odds of adverse events compared to high-volume surgeons.
Conclusions:
- TCAR center volume did not significantly impact patient outcomes.
- Low surgeon volume in TCAR procedures is associated with a higher risk of stroke and TIA.
- Surgeon experience, not just hospital volume, is a critical factor in TCAR safety.
Background:
It has been suggested that the annual hospital volume of cases may affect the number of adverse events after carotid endarterectomy (CEA). We aim to study the associations between hospital as well as surgeon volume and the risk of stroke or death after transcarotid artery revascularization (TCAR).
Study Design:
Retrospective review of the Vascular Quality Initiative data of patients undergoing TCAR from 2016 to 2021. Surgeon and center volume were calculated based on the mean number of cases (MNC) performed yearly by each surgeon and center. The primary outcome was a composite endpoint of in-hospital stroke or death.
Results:
A total of 22,624 cases were included. Surgeon volume was divided into 3 quantiles: low (MNC = 4), medium (MNC = 10), and high (MNC = 26). Center volume was also divided into low (MNC = 14), medium (MNC = 32), and high (MNC = 64). After adjusting for potential confounders, and when compared with high-volume centers, low and medium center volumes were not associated with any increased odds of in-hospital stroke and death, stroke, death, or stroke with transient ischemic attack (TIA). Compared with high-volume surgeons, low surgeons' volume was associated with a higher odd of stroke (odds ratio 1.5, 95% CI 1.1 to 2.04, p = 0.008), and stroke and TIA (OR 1.5, 95% CI 1.2 to 1.9, p = 0.002). However, medium surgeon volume was not associated with higher odds of stroke and death, stroke, and stroke with TIA. Neither low nor medium surgeon volume was associated with a difference in mortality compared with high surgeon volume.
Conclusions:
In this retrospective study, center volume was not associated with any differences in outcomes among patients undergoing TCAR. On the other hand, surgeons with low volume were associated with a higher risk of stroke, death, or MI and stroke or TIA when compared with high surgeon volume. There was no difference in outcomes between medium and high surgeon volume.
