Determinants of outcome after carotid endarterectomy.
BACKGROUND
The efficacy of carotid endarterectomy for selected patients has been evaluated with randomized controlled clinical trials. The generalizability of these studies to average surgical practice remains an important public health concern.


OBJECTIVE
The objective of the study was to determine the predictors of outcome after carotid endarterectomy on a regional basis.


METHODS
The study was designed as a retrospective cohort study and included all consecutive patients presented for carotid endarterectomy at the 8 University of Toronto-affiliated hospitals in the period from January 1, 1994, to December 31, 1996. The main outcome measure was 30-day postoperative stroke or death rate.


RESULTS
During the study interval, 1280 primary carotid endarterectomies were performed. The overall combined stroke and death rate was 6.3% for all patients who underwent endarterectomy (4.0% for patients who were asymptomatic). The significant predictors of poor outcome were the following: presenting symptoms (odds ratio, 1.74; 95% confidence interval [CI], 0.96, 3.12), low surgeon volume (<6 cases per year; odds ratio, 3.98; 95% CI, 1.65, 9.58), and left-sided surgery (odds ratio, 1.72; 95% CI, 1.07, 2.76).


CONCLUSIONS
These data suggest that adoption of the recommendations of the symptomatic carotid endarterectomy trials is appropriate. However, endarterectomy for asymptomatic lesions remains of uncertain benefit on a regional basis and must be individualized to the experience of the specific surgeon. The surgeon volume/outcome relationship that is identified in this study suggests a need for a minimum volume threshold for this procedure.
Kucey
D S
DS
Division of Vascular Surgery, Institute for Clinical Evaluative Sciences in Ontario, The University of Toronto, Toronto, Ontario, Canada.
Bowyer
B
B
Iron
K
K
Austin
P
P
Anderson
G
G
Tu
J V
JV
D000328:Adult; D000368:Aged; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D002561:Cerebrovascular Disorders / Q000209:etiology; D015331:Cohort Studies; D016894:Endarterectomy, Carotid / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D012307:Risk Factors