Elsevier

Annals of Vascular Surgery

Volume 22, Issue 4, July–August 2008, Pages 505-512
Annals of Vascular Surgery

Clinical Research
Urgent Carotid Endarterectomy Is Safe in Patients with Few Comorbid Medical Conditions

https://doi.org/10.1016/j.avsg.2007.12.019Get rights and content

Recent reports from single institutions have confirmed the efficacy of carotid endarterectomy (CEA) performed in the urgent or emergent setting, although with higher perioperative mortality and morbidity. We determined the results of urgently performed CEA in academic and community hospitals and whether patient or hospital factors affected outcome. The records of patients undergoing CEA in all nonfederal hospitals in the state of Connecticut between 1992 and 2002 were reviewed, and symptomatic patients who presented in an urgent or emergent fashion were compared to patients treated electively. Multivariable logistic regression was used to determine the effect of patient risk factors on perioperative mortality, stroke, and cardiac complications. Patients undergoing urgent CEA (n = 764, 6.3%) had higher perioperative mortality (2.0% vs. 0.3%, p < 0.0001) and stroke (2.9% vs. 1.1%, p < 0.0001) but not cardiac complications (3.0% vs. 2.2%, p = 0.14) compared to patients undergoing elective CEA (n = 11,312). Patients undergoing urgent CEA and with high rates of associated comorbidity had a higher risk of perioperative mortality (7.8% vs. 0.4, p = 0.001), stroke (10.9% vs. 0.8%, p = 0.0002), and cardiac complications (14.1% vs. 0.8%, p < 0.0001) compared to patients presenting urgently but with little comorbidity. Perioperative mortality was associated with performance of the procedure in hospitals with low bed capacity (odds ratio [OR] = 4.6, p = 0.01). Perioperative stroke was associated with renal insufficiency (OR = 5.3, p = 0.04). Perioperative cardiac complications were associated with diabetes (OR = 2.6, p = 0.03) and performance in hospitals with low bed capacity (OR = 5.0, p < 0.01). Urgent admission was associated with age ≥80 (OR = 1.2, p = 0.04), renal disease (OR = 1.8, p = 0.05), and cardiac disease (OR = 1.3, p < 0.01). Urgently performed CEA has higher perioperative mortality and stroke compared with electively performed cases. However, the subset of patients with low rates of associated comorbid medical conditions but urgently needing CEA is associated with low rates of perioperative complications. Patients with severe associated comorbid medical conditions who present urgently for CEA may form a high-risk group of patients to be considered for referral to large treatment centers or possibly alternative therapy.

Introduction

Elective carotid endarterectomy (CEA) is the established standard of care for symptomatic and asymptomatic patients with high-grade carotid artery stenosis. Multiple randomized controlled trials have proven the efficacy of CEA in long-term secondary stroke prevention with acceptably low perioperative mortality and morbidity.1, 2, 3, 4, 5 However, intervention in symptomatic patients who present urgently or emergently remains controversial. For example, the optimal timing of CEA after an ipsilateral ocular or hemispheric event is still not established. In the 1960s, poor results were obtained after urgent interventions in symptomatic patients, and this increased perioperative mortality and morbidity was attributed to the conversion of an ischemic infarct into a disabling hemorrhagic stroke.6, 7 Additional reports of increased perioperative morbidity after early CEA led to recommendations to delay surgery for 4 weeks if possible.8, 9, 10, 11, 12, 13 However, recent reports suggest the benefit of early CEA in preventing recurrent stroke in patients with good neurological recovery and absence of hemorrhage on computed tomographic scan.14, 15 Pooled analysis of the European and North American Symptomatic Carotid Endarterectomy Trial (NASCET) data has suggested a benefit for CEA in symptomatic patients randomized within 2 weeks of symptoms.16 However, optimal timing for performance of CEA in symptomatic patients is not clearly established.

In addition, there are scant data concerning the impact of patient risk factors and hospital-associated factors on outcomes after CEA performed in an urgent or emergent manner. Since several patient risk factors, such as renal insufficiency and cardiac disease, are linked to worse perioperative and long-term outcome after electively performed CEA,17, 18, 19 it is important to determine whether these factors are also associated with increased adverse outcomes after urgently performed CEA.

Patients presenting in an urgent or emergent manner represent a high-risk group of patients, the treatment of whom is currently controversial. Carotid angioplasty and stenting (CAS) is an alternative method to treat carotid stenosis in patients considered to be high-risk for surgical complications; however, recent multicenter reports have demonstrated that CAS is not a perfect treatment for all high-risk patients, with different levels of risk and benefit for subgroups of patients;20, 21, 22 some high-risk groups, such as octogenarians, have been demonstrated to have improved outcomes if treated with CEA.22 Since several select series have reported increased adverse outcome after urgently performed CEA, we determined whether some groups of urgently presenting patients have acceptable risk of perioperative complications following CEA in community practice, clarifying the role of this generally low-risk procedure in higher-risk circumstances.

Section snippets

Methods

A database consisting of patient discharge records from all acute-care, nonfederal Connecticut hospitals is maintained by Chime, Inc. (www.cthosp.org; Wallingford, CT). The Connecticut Hospital Association (CHA) Chime Data Program has established and maintains a proprietary health-care information system that incorporates statewide clinical, financial, and patient demographic data dating back to 1980. Reports containing selected variables are available on a fee-for service basis. A previously

Results

There were 12,076 CEAs performed between 1992 and 2002 in the state of Connecticut and identified as being performed in an elective, urgent, or emergent fashion; 9,964 (82.5%) were performed in asymptomatic patients and 2,112 (17.5%) were performed in symptomatic patients. There were 764 (6.3%) procedures performed in an urgent or emergent fashion in patients who were symptomatic; these are the subject of this study. The demographic factors of these patients and the characteristics of the

Discussion

Patients presenting urgently with symptomatic high-grade carotid stenosis remain a clinical challenge. To our knowledge, we report the largest analysis of urgently performed CEA to date. We demonstrate that patients in the state of Connecticut who are symptomatic and present urgently for CEA have increased perioperative mortality and stroke, but not cardiac complications, compared to patients who present electively. However, increased perioperative mortality and stroke were confined to urgently

References (29)

Cited by (14)

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    Despite the greater proportion of patients being treated for symptomatic disease in Canada, perioperative and long-term stroke/death rates remain similar to the US. This demonstrates that urgent/emergency CEA can be performed safely without compromising outcomes, which is corroborated by previous literature.45,46 Regional variations in pre-operative investigations also warrant further investigation.

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    Informed consent was waived by our Institutional Review Board. Carotid interventions (CEA and CAS) performed during the same (index) hospitalization for an acute cerebral TIA or stroke were deemed urgent, as previously defined.6,14 These patients underwent CEA or CAS for ischemic symptoms during the same admission as their initial presenting acute neurologic event, that is, during the index hospitalization.

  • Early versus late carotid artery stenting for symptomatic carotid stenosis

    2015, Journal of Neuroradiology
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    Based on a pooled analysis of randomized trials assessing CEA, the timing of carotid revascularization recommended is ≤ 14 days of the last ischemic symptom, if there is no contra-indication [1,2,4,5]. However, evidence suggests the earlier the CEA is performed after symptoms, the higher the risks of mortality or stroke, which may be higher than 10% [17–20]. In spite of that, according to Naylor based on data from The Carotid Endarterectomy Trialists Collaboration, performing a carotid revascularization procedure with a 10% risk within 2 weeks could prevent approximately 150 strokes per 1000 CEA, versus only 100 strokes if the procedure is performed after 4 weeks with a 3% risk [17,18].

  • Characterization of resident surgeon participation during carotid endarterectomy and impact on perioperative outcomes

    2012, Journal of Vascular Surgery
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    For logistic models, resident surgeon participation was defined as any level trainee scrubbed during the CEA. Adjusted multivariable models were created by combining resident participation status with candidate covariates previously identified as risk factors for adverse events following CEA based on literature review, including: history of stroke,8-11 history of transient ischemic attack (TIA),8,12,13 diabetes,8,11,14,15 hypertension,16,17 coronary artery disease (defined as history of angina, myocardial infarction, or coronary revascularization),9,11,16 smoking,8 preoperative creatinine,8,14 preoperative white blood cell (WBC) count,18,19 general anesthesia (vs other),8,9,20 age (evaluated as >80 years vs other),10,12,21-23 female gender,12 American Society of Anesthesiology (ASA) physical status classification (evaluated as ≥III vs other),10,21,24 and emergent procedure status.14,23 Candidate covariates were evaluated for inclusion in adjusted models using forward selection with P < .05 as the entry criterion.

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H. A. Bazan's current address is: Department of Surgery, Section of Vascular Surgery, LSUHSC, New Orleans, LA 70118, USA.

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