Limited Preoperative Functionality Is Associated With Worse 30-D Mortality and Heart Failure After Carotid Artery
Daniel Willie-Permor1, Munir Paul Moacdieh1, Shatha Herz Allah1
1Center for Learning and Excellence in Vascular & Endovascular Research(CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego (UCSD), La Jolla, California.
Insights
Limited preoperative functionality significantly increases 30-day mortality and congestive heart failure (CHF) risk after carotid artery stenting (CAS). However, stroke and myocardial infarction risks remain similar, suggesting tailored management for nonambulatory patients.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Health Outcomes Research
Background:
- Carotid artery stenting (CAS) is a key intervention for significant carotid artery stenosis in high-risk patients.
- Preoperative ambulatory status is a critical factor in assessing risk for carotid revascularization, yet its impact on CAS outcomes is not fully understood.
Purpose of the Study:
- To evaluate the early outcomes of CAS stratified by preoperative ambulatory status using the Vascular Quality Initiative (VQI) database.
- To determine the association between limited preoperative functionality and adverse outcomes following CAS.
Main Methods:
- Analysis of nonemergent CAS cases from 2016-2021 in the VQI database.
- Stratification of patients into full-functionality and limited-functionality (LF) groups.
- Propensity score matching and logistic regression to compare 30-day mortality and postoperative complications.
Main Results:
- Limited-functionality (LF) patients (3.54%) were older and had more comorbidities, including diabetes, hypertension, COPD, CHF, and dialysis dependence.
- After propensity matching, LF patients showed significantly higher odds of 30-day mortality (OR: 2.59) and postoperative CHF (OR: 2.03).
- No significant differences were observed in the odds of stroke, TIA, MI, or any postoperative complication between groups.
Conclusions:
- Limited preoperative functional status is a significant predictor of increased 30-day mortality and postoperative CHF after CAS.
- CAS outcomes regarding stroke, TIA, and MI were not significantly different between functional groups.
- Recommend aggressive medical management for asymptomatic carotid stenosis in nonambulatory patients and pre-procedural optimization for symptomatic individuals.
Introduction:
Carotid artery stenting is indicated in patients with significant carotid artery stenosis who are high risk for carotid endarterectomy. Patients who are nonambulatory before surgery are considered high risk for carotid revascularization. However, the effect of preoperative ambulatory status on outcomes has not been well established. We sought to use the Vascular Quality Initiative (VQI) multi-institutional database to evaluate the early outcomes of carotid artery stenting stratified by the preoperative ambulatory status.
Methods:
Patients included were nonemergent cases performed in participating VQI centers from 2016 to 2021. The study cohort was divided into two groups: full-functionality patients with full, light work, or self-care, and limited-functionality (LF) patients with assisted care or bed-bound. We used propensity scores by stratification matching on 29 demographic and preoperative clinical characteristics to obtain similar patient characteristics across the two groups. Logistic regression analysis was performed to determine 30-d mortality and postoperative complications.
Results:
We included 36,069 patients in the study, of which 1277 (3.54%) had LF. Patients in the LF group were older (mean age 74 y (SD 10.2) versus 71.9 (SD 9.4), had similar Preoperative medication exposure, similar Preoperative creatinine levels, and prior surgical intervention characteristics, but were more likely to have diabetes mellitus, hypertension, chronic obstructive pulmonary disease, prior congestive heart failure (CHF), and prior dialysis compared to full-functionality patients. After propensity stratification, both patient groups were not different across all strata on clinical and demographic characteristics. LF patients had a significantly increased odds of 30-d mortality (odds ratio (OR): 2.59, 95% confidence interval (CI): 1.77-3.78) and increased odds of post-op CHF (OR: 2.03, 95% CI: 1.09-3.77). They had similar odds of stroke (OR: 0.74, 95% CI: 0.50-1.08), transient ischemic attack (OR: 1.98, 95% CI: 0.81-4.86), myocardial infarction (OR: 1.31, 95% CI: 0.66-2.63), and any postoperative complication (OR: 1.20, 95% CI: 0.95-1.51).
Conclusions:
Limited preoperative functional status is associated with a significant increase in the odds of 30-d mortality and postoperative CHF in patients undergoing CAS. However, we found no significant differences in the odds of postoperative transient ischemic attack, stroke, and myocardial infarction. Outcomes did not differ when stratified by symptomatic status. We propose aggressive medical management for asymptomatic carotid artery stenosis in nonambulatory patients and optimization of symptomatic patients before stenting.
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