Defining the high-risk patient for carotid endarterectomy: an analysis of the prospective National Surgical Quality Improvement Program database.
BACKGROUND
Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting has been advocated in high-risk patients. The definition of such a population has been elusive, particularly because the data are largely retrospective. Our study examined results for CEA in the National Surgical Quality Improvement Program database (both Veterans Affairs and private sector).


METHODS
National Surgical Quality Improvement Program data were gathered prospectively for all patients undergoing primary isolated CEA during the interval 2000 to 2003 at 123 Veterans Affairs and 14 private sector academic medical centers. Study end points included the 30-day occurrence of any stroke, death, or cardiac event. A variety of clinical, demographic, and operative variables were assessed with multivariate models to identify risk factors associated with the composite (stroke, death, or cardiac event) end point. Adjudication of end points was by trained nurse reviewers (previously validated).


RESULTS
A total of 13,622 CEAs were performed during the study period; 95% were on male patients, and 91% of cases were conducted within the Veterans Affairs sector. The average age was 68.6 +/- 0.1 years, and 42.1% of the population had no prior neurologic event. The composite stroke, death, or cardiac event rate was 4.0%; the stroke/death rate was 3.4%. Multivariate correlates of the composite outcome were (odds ratio, P value) as follows: deciles of age (1.13, .018), insulin-requiring diabetes (1.73, <.001), oral agent-controlled diabetes (1.39, .003), decade of pack-years smoking (1.04, >.001), history of transient ischemic attack (1.41, >.001), history of stroke (1.51, >.001), creatinine >1.5 mg/dL (1.48, >.001), hypoalbuminemia (1.49, >.001), and fourth quartile of operative time (1.44, >.001). Cardiopulmonary comorbid features did not affect the composite outcome in this model. Regional anesthesia was used in 2437 (18%) cases, with a resultant relative risk reduction for stroke (17%), death (24%), cardiac event (33%), and the composite outcome (31%; odds ratio, 0.69; P = .008).


CONCLUSIONS
Carotid endarterectomy results across a spectrum of Veterans Affairs and private sector hospitals compare favorably to contemporary studies. These data will assist in selecting patients who are at an increased risk for adverse outcomes. Use of regional anesthetic significantly reduced perioperative complications in a risk-adjusted model, thus suggesting that it is the anesthetic of choice when CEA is performed in high-risk patients.
Division of Vascular and Endovascular Surgery, Masschusetts General Hospital, Boston, MA, USA. stonerm@ecu.edu
Michael C
MC
Stoner
William M
WM
Abbott
Daniel R
DR
Wong
Hong T
HT
Hua
Glenn M
GM
Lamuraglia
Chirstopher J
CJ
Kwolek
Michael T
MT
Watkins
Arvind K
AK
Agnihotri
William G
WG
Henderson
Shukri
S
Khuri
Richard P
RP
Cambria
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000765:Anesthesia, Conduction / Q000706:statistics & numerical data; D017130:Angioplasty / Q000295:instrumentation*; D002318:Cardiovascular Diseases / Q000209:etiology* / Q000401:mortality; D016893:Carotid Stenosis / Q000453:epidemiology / Q000401:mortality / Q000601:surgery*; D019992:Databases as Topic / Q000706:statistics & numerical data; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D005260:Female; D016304:Hospitals, Private / Q000706:statistics & numerical data; D006787:Hospitals, Veterans / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D011446:Prospective Studies; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology