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Carotid endarterectomy in a metropolitan community: comparison of results from three institutions
Insights
Carotid endarterectomies (CEA) performed by supervised residents showed results comparable to experienced surgeons. This study analyzed CEA outcomes across different hospital settings, finding similar morbidity despite varying patient characteristics and operative times.
Area of Science:
- Vascular Surgery
- Surgical Education
- Health Services Research
Background:
- Carotid endarterectomy (CEA) is a crucial procedure for stroke prevention.
- Assessing the impact of surgical training and hospital setting on CEA outcomes is vital for patient care.
- Variations in patient populations and surgical supervision may influence procedural results.
Purpose of the Study:
- To compare the outcomes of carotid endarterectomies (CEA) performed by experienced vascular surgeons in university hospitals (UH) and private community hospitals (PCH) versus senior general surgery residents (GSR) supervised by vascular surgeons in a Veterans Administration (VA) hospital.
- To analyze differences in patient characteristics, operative times, and postoperative complications across these distinct surgical settings.
- To evaluate the overall morbidity and safety of CEA performed by well-supervised residents compared to fully trained surgeons.
Main Methods:
- A retrospective analysis of 300 hospitalizations for carotid endarterectomies (CEA).
- Patients were divided into three groups: 100 in UH (experienced surgeons), 100 in PCH (experienced surgeons), and 100 in VA (supervised residents).
- Data collected included patient demographics, comorbidities, operative details, and postoperative outcomes such as hypertension, hematomas, and cranial nerve injury.
Main Results:
- VA patients, operated on by supervised residents, were younger with more complex conditions (peripheral vascular disease, smoking, contralateral occlusions, ulcerated lesions).
- Residents experienced longer operating room and ischemia times but postoperative hypertension and neck hematomas were less frequent in the PCH group.
- Despite longer hospitalizations for VA patients, overall morbidity was not increased, and cranial nerve injury symptoms were often temporary across all groups.
Conclusions:
- Carotid endarterectomies (CEA) performed by well-supervised residents yield results comparable to those performed by fully trained vascular surgeons.
- Hospital setting and surgeon experience do not significantly alter important CEA outcomes when residents are adequately supervised.
- These findings support the integration of supervised resident training in vascular surgery within diverse hospital environments without compromising patient safety or procedural efficacy.
Abstract:
The hospitalizations of 300 patients who had carotid endarterectomies (CEA) in three different kinds of hospital were analyzed. 100 patients had CEA performed by experienced vascular surgeons in a university hospital (UH), 100 patients had CEA performed by experienced vascular surgeons in private community hospitals (PCH), and 100 patients had CEA performed by senior general surgery residents (GSR) assisted by experienced vascular surgeons in a university-affiliated Veterans Administration hospital (VA). Analysis of patient characteristics revealed that, compared with the other groups, VA patients were (1) younger (62 +/- 7 years; p less than 0.001); (2) had a higher frequency of peripheral vascular operations (51%; p less than 0.01; (3) were more often cigarette smokers (84%; p less than 0.001); and (4) had more contralateral carotid occlusions (19%) and ulcerated lesions (73%) (p less than 0.01). GSR had longer operating room times and cerebral ischemia times during shunt insertion and removal (6 +/- 2.8 minutes) and during the CEA (30 +/- 27 minutes) (p less than 0.001). Postoperative hypertension and neck hematomas were less common in PCH patients (p less than 0.001) than in the other groups. Although their duration of hospitalization (17 +/- 12 days) was longer, the VA patients experienced no increased morbidity. There was a high rate of cranial nerve injury in all groups (27%, 15%, 17%) but symptoms were not often permanent (9%, 6%, 6%). Our data indicate that results of vascular operations performed by well-supervised residents are comparable in all important respects to those performed by fully trained surgeons.