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Editor's Choice - Safety of Shunting Strategies During Carotid Endarterectomy: A Vascular Quality Initiative Data
Xavier Hommery-Boucher1, William Fortin2, Nathalie Beaudoin1
1Centre hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
Insights
Carotid endarterectomy (CEA) shunt usage did not significantly impact in-hospital stroke or death rates. These findings hold true even for patients with contralateral carotid occlusion or recent stroke.
Area of Science:
- Vascular Surgery
- Clinical Outcomes Research
- Surgical Technique Evaluation
Background:
- Carotid endarterectomy (CEA) is a crucial procedure for stroke prevention.
- Shunt usage during CEA is a debated topic, with varying surgeon preferences.
- Specific patient populations, such as those with contralateral carotid occlusion (CCO) or recent stroke, may have different risk profiles.
Purpose of the Study:
- To evaluate the impact of different carotid endarterectomy (CEA) shunt strategies on in-hospital outcomes.
- To specifically assess outcomes in patients undergoing CEA with contralateral carotid occlusion (CCO) or recent stroke.
- To compare outcomes across surgeons categorized by their shunt usage rates: non-shunters, selective shunters, and routine shunters.
Main Methods:
- Analysis of data from the Vascular Quality Initiative database (2012-2020).
- Inclusion of 113,202 patients undergoing CEA, excluding specific cases (e.g., re-interventions, concomitant procedures).
- Surgeons categorized into non-shunters (<5% shunt use), selective shunters (5-95%), and routine shunters (>95%).
- Primary outcomes: in-hospital stroke, death, and stroke and death rate (SDR) analyzed in symptomatic and asymptomatic cohorts.
Main Results:
- No statistically significant differences in in-hospital stroke, death, or SDR were observed among the three shunt usage groups in both symptomatic and asymptomatic cohorts.
- Multivariable analysis confirmed no significant differences in primary outcomes across shunting strategies.
- Subgroup analysis revealed no significant differences in SDR for patients with CCO or recent stroke.
Conclusions:
- The choice of shunting strategy (non-shunter, selective, or routine) does not significantly affect in-hospital stroke and death rates after CEA.
- These findings apply to the general CEA population as well as specific high-risk subgroups, including those with CCO or recent stroke.
Objective:
This study aimed to evaluate in hospital outcomes after carotid endarterectomy (CEA) according to shunt usage, particularly in patients with contralateral carotid occlusion (CCO) or recent stroke. Data from CEAs registered in the Vascular Quality Initiative database between 2012 and 2020 were analysed, excluding surgeons with < 10 CEAs registered in the database, concomitant procedures, re-interventions, and incomplete data.
Methods:
Based on their rate of shunt use, participating surgeons were divided in three groups: non-shunters (< 5%), selective shunters (5 - 95%), and routine shunters (> 95%). Primary outcomes of in hospital stroke, death, and stroke and death rate (SDR) were analysed in symptomatic and asymptomatic patients.
Results:
A total of 113 202 patients met the study criteria, of whom 31 147 were symptomatic and 82 055 were asymptomatic. Of the 1 645 surgeons included, 12.1% were non-shunters, 63.6% were selective shunters, and 24.3% were routine shunters, with 10 557, 71 160, and 31 579 procedures in each group, respectively. In the univariable analysis, in hospital stroke (2.0% vs. 1.9% vs. 1.6%; p = .17), death (0.5% vs. 0.4% vs. 0.4%; p = .71), and SDR (2.2% vs. 2.1% vs. 1.8%; p = .23) were not statistically significantly different among the three groups in the symptomatic cohort. The asymptomatic cohort also did not show a statistically significant difference for in hospital stroke (0.9% vs. 1.0% vs. 0.9%; p = .55), death (0.2% vs. 0.2% vs. 0.2%; p = .64), and SDR (1.0% vs. 1.1% vs. 1.0%; p = .43). The multivariable model did not show a statistically significant difference for the primary outcomes between the three shunting cohorts. On subgroup analysis, the SDRs were not statistically significantly different for patients with CCO (3.3% vs. 2.5% vs. 2.4%; p = .64) and those presenting with a recent stroke (2.9% vs. 3.4% vs. 3.1%; p = .60).
Conclusion:
No statistically significant differences were found between three shunting strategies for in hospital SDR, including in patients with CCO or recent stroke.
