title: Carotid endarterectomy in asymptomatic patients with limited life expectancy.
abstract: OBJECTIVE
  Data from randomized trials assert that asymptomatic patients undergoing carotid endarterectomy (CEA) must live 3 to 5 years to realize the benefit of surgery. We examined how commonly CEA is performed among asymptomatic patients with limited life expectancy.
  
  
  METHODS
  Within the American College of Surgeons National Quality Improvement Project we identified 8 conditions associated with limited life expectancy based on survival estimates using external sources. We then compared rates of 30-day stroke, death, and myocardial infarction after CEA between asymptomatic patients with and without life-limiting conditions.
  
  
  RESULTS
  Of 12,631 CEAs performed in asymptomatic patients, 2525 (20.0%) were in patients with life-limiting conditions or diagnoses. The most common conditions were severe chronic obstructive pulmonary disease and American Society of Anesthesiologists Class IV designation. Patients with life-limiting conditions had significantly higher rates of perioperative complications, including stroke (1.8% versus 0.9%, P<0.001), death (1.4% versus 0.3%, P<0.001), and stroke/death (2.9% versus 1.1%, P<0.001). Even after adjustment for other comorbidities, patients with life-limiting conditions were nearly 3 times more likely to experience perioperative stroke or death than those without these conditions (OR, 2.8; 95% CI, 2.1-3.8; P<0.001).
  
  
  CONCLUSIONS
  CEA is performed commonly in asymptomatic patients with life-limiting conditions. Given the high rates of postoperative stroke/death in these patients as well as their limited life expectancy, the net benefit of CEA in this population remains uncertain. Health policy research examining the role of CEA in asymptomatic patients with life-limiting conditions is necessary and may serve as a potential source for significant healthcare savings in the future.
authors.affiliation: VA Outcomes Group, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon NH 03765, USA. jessica.wallaert@hitchcock.org
authors.forename: Jessica B
authors.initials: JB
authors.lastname: Wallaert
authors.forename: Randall R
authors.initials: RR
authors.lastname: De Martino
authors.forename: Samuel R G
authors.initials: SR
authors.lastname: Finlayson
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Walsh
authors.forename: Matthew A
authors.initials: MA
authors.lastname: Corriere
authors.forename: David H
authors.initials: DH
authors.lastname: Stone
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D058070:Asymptomatic Diseases / Q000401:mortality* / Q000628:therapy*; D016893:Carotid Stenosis / Q000401:mortality / Q000601:surgery; D015331:Cohort Studies; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality*; D005260:Female; D006801:Humans; D008017:Life Expectancy / Q000639:trends*; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome