title: The need for treatment of hemodynamic instability following carotid endarterectomy is associated with increased perioperative and 1-year morbidity and mortality.
abstract: OBJECTIVE
  The objective of this study was to evaluate the outcomes of patients after carotid endarterectomy (CEA) who developed postoperative hypertension or hypotension requiring the administration of intravenous vasoactive medication (IVMED).
  
  
  METHODS
  We examined consecutive, primary elective CEA performed by 128 surgeons within the Vascular Study Group of New England (VSGNE) database (2003-2010) and compared outcomes of patients who required postoperative IVMED to treat hyper- or hypotension with those who did not. Outcomes included perioperative death, stroke, myocardial infarction (MI), congestive heart failure (CHF), hospital length of stay, and 1-year stroke or death. Propensity score matching was performed to facilitate risk-adjusted comparisons. Multivariable regression models were used to compare the association between IVMED and outcomes in unmatched and matched samples. Factors associated with use of IVMED in postoperative hypertension and hypotension were evaluated, and predictive performance of multivariable models was examined using receiver operating characteristic (ROC) curves.
  
  
  RESULTS
  Of 7677 elective CEAs identified, 23% received IVMED for treatment of either postoperative hypertension (11%) or hypotension (12%). Preoperative neurological symptomatic status (20%) was similar across cohorts. In the crude sample, the use of IVMED to treat postoperative hypertension was associated with increased 30-day mortality (0.7% vs 0.1%; P < .001), stroke (1.9% vs 1%; P = .018), MI (2.4% vs 0.5%; P < .001), and CHF (1.9% vs 0.5%; P < .001). The use of IVMED to treat postoperative hypotension was also associated with increased perioperative mortality (0.8% vs 0.1%; P < .001), stroke (3.2% vs 1.0%; P < .001), MI (2.7% vs 0.5%; P < .001), and CHF (1.7% vs 0.5%; P < .001), as well as 1-year death (5.1% vs 2.9%; P < .001) or stroke (4.2% vs 2.1%; P < .001). Hospital length of stay was significantly longer among patients who needed IVMED for postoperative hypertension (2.8 ± 4.7 days vs 1.7 ± 5.5 days; P < .001) and hypotension (2.8 ± 5.9 days vs 1.7 ± 5.5 days; P < .001). In multivariable analysis, IVMED for postoperative hypertension was associated with increased MI, stroke, or death (odds ratio, 2.6; 95% confidence interval [CI], 1.6-4.1; P < .001). Similarly, IVMED for postoperative hypotension was associated with increased MI, stroke, or death (odds ratio, 3.2; 95% CI, 2.1-5.0; P < .001), as well as increased 1-year stroke or death (hazard ratio, 1.6; 95% CI, 1.2-2.2; P = .003). Smoking, coronary artery disease, and clopidogrel (ROC, 0.59) were associated with postoperative hypertension requiring IVMED, whereas conventional endarterectomy and general anesthesia were associated with postoperative hypotension requiring IVMED (ROC, 0.58). The unitization of IVMED varied between 11% and 38% across VSGNE, and center effect did not affect outcomes.
  
  
  CONCLUSIONS
  Postoperative hypertension requiring IVMED after CEA is associated with increased perioperative mortality, stroke, and cardiac complications, whereas significant postoperative hypotension is associated with increased perioperative mortality, cardiac, or stroke complications, as well as increased 1-year death or stroke following CEA. The utilization of IVMED varied across centers and, as such, further investigation into this practice needs to occur in order to improve outcomes of these at-risk patients.
authors.affiliation: Division of Vascular and Endovascular Surgery, Louisiana State University Health Sciences Center, Shreveport, La. Electronic address: ttan1@lsuhsc.edu.
authors.forename: Tze-Woei
authors.initials: TW
authors.lastname: Tan
authors.affiliation: Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Mass.
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Eslami
authors.affiliation: Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Mass.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kalish
authors.affiliation: Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Mass.
authors.forename: Robert T
authors.initials: RT
authors.lastname: Eberhardt
authors.affiliation: Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Mass.
authors.forename: Gheorghe
authors.initials: G
authors.lastname: Doros
authors.affiliation: Section of Vascular Surgery, Darthmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Section of Vascular Surgery, Darthmouth-Hitchcock Medical Center, Lebanon, NH.
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
authors.affiliation: Section of Vascular and Endovascular Surgery, Boston University Medical Center, Boston, Mass.
authors.forename: Alik
authors.initials: A
authors.lastname: Farber
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D002340:Carotid Artery Diseases / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D016009:Chi-Square Distribution; D017558:Elective Surgical Procedures; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D007022:Hypotension / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009511:New England; D016017:Odds Ratio; D057216:Propensity Score; D012372:ROC Curve; D012042:Registries; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*
chemical_list: D000959:Antihypertensive Agents; D014662:Vasoconstrictor Agents