title: Practice patterns of carotid endarterectomy as performed by different surgical specialties at a single institution and the effect on perioperative stroke and cost of preoperative imaging.
abstract: BACKGROUND
  Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost.
  
  
  METHODS
  This is a retrospective analysis of prospectively collected data of 1000 consecutive CEAs performed at our institution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CTS), and vascular surgeons (VS).
  
  
  RESULTS
  VS did 474 CEAs, CTS did 404, and GS did 122. VS tended to operate more often on symptomatic patients than CTS and GS: 40% vs 23% and 31%, respectively (P < .0001). Preoperative workups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and computed tomography angiography in 27%, 35%, and 29%; and DUS and magnetic resonance angiography in 6%, 35%, and 52% for VS, CTS, and GS, respectively (P < .001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (P = .0001) and protamine was used in 0.2%, 19%, and 8% (P < .0001) for VS, CTS, and GS, respectively. VS more often used postoperative drains; however, no association was found between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (P < .0001) for VS, CTS, and GS, respectively. Bovine pericardial patches were used more often by CTS and ACUSEAL (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) patches were used more often by GS (P < .0001). The perioperative stroke/death rates were 1.3% for VS and 3.1% for CTS and GS combined (P = .055); and were 0.7% for VS and 3% for CTS and GS combined for asymptomatic patients (P < .034). Perioperative stroke rates for patients who had preoperative DUS only were 0.9% vs 3.3% for patients who had extra imaging (computed tomography angiography/magnetic resonance angiography; P = .009); and were 0.9% vs 3% for asymptomatic patients (P = .05). When applying hospital billing charges for preoperative imaging workups (cost of DUS only vs DUS and other imaging), the VS practice pattern would have saved $1180 per CEA over CTS and GS practice patterns; a total savings of $1,180,000 in this series.
  
  
  CONCLUSIONS
  CEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians who perform CEAs on cost-saving measures may be appropriate.
authors.affiliation: Department of Surgery, West Virginia University, Charleston, WVa. Electronic address: ali.aburahma@camc.org.
authors.forename: Ali F
authors.initials: AF
authors.lastname: AbuRahma
authors.affiliation: Department of Surgery, West Virginia University, Charleston, WVa.
authors.forename: Mohit
authors.initials: M
authors.lastname: Srivastava
authors.affiliation: Department of Surgery, West Virginia University, Charleston, WVa.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Hass
authors.affiliation: Department of Surgery, West Virginia University, Charleston, WVa.
authors.forename: Benny
authors.initials: B
authors.lastname: Chong
authors.affiliation: Department of Surgery, West Virginia University, Charleston, WVa.
authors.forename: Zachary
authors.initials: Z
authors.lastname: AbuRahma
authors.affiliation: CAMC Health Education and Research Institute, Charleston, WVa.
authors.forename: L Scott
authors.initials: LS
authors.lastname: Dean
authors.affiliation: Department of Surgery, West Virginia University, Charleston, WVa.
authors.forename: Patrick A
authors.initials: PA
authors.lastname: Stone
authors.affiliation: Department of Surgery, West Virginia University, Charleston, WVa.
authors.forename: Albeir Y
authors.initials: AY
authors.lastname: Mousa
mesh_terms: D006348:Cardiac Surgical Procedures / Q000191:economics / Q000639:trends; D002340:Carotid Artery Diseases / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000601:surgery*; D017046:Cost Savings; D003952:Diagnostic Imaging / Q000191:economics* / Q000639:trends*; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000191:economics / Q000639:trends*; D013502:General Surgery / Q000191:economics / Q000639:trends; D017721:Hospital Costs / Q000639:trends*; D006801:Humans; D018810:Magnetic Resonance Angiography / Q000191:economics / Q000639:trends; D010043:Outcome and Process Assessment, Health Care / Q000191:economics* / Q000639:trends*; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000639:trends*; D011237:Predictive Value of Tests; D011300:Preoperative Care; D012189:Retrospective Studies; D012307:Risk Factors; D013043:Specialties, Surgical / Q000191:economics / Q000639:trends*; D020521:Stroke / Q000175:diagnosis / Q000191:economics / Q000209:etiology* / Q000401:mortality; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000639:trends; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex / Q000191:economics / Q000639:trends; D014656:Vascular Surgical Procedures / Q000191:economics / Q000639:trends; D014903:West Virginia