title: Intraoperative Completion Studies, Local Anesthesia, and Antiplatelet Medication Are Associated With Lower Risk in Carotid Endarterectomy.
abstract: In Germany, all surgical and endovascular procedures on the carotid bifurcation must be documented in a statutory nationwide quality assurance database. We aimed to analyze the association between procedural and perioperative variables and in-hospital stroke or death rates after carotid endarterectomy.
  
  
  
  Between 2009 and 2014, overall 142 074 elective carotid endarterectomy procedures for asymptomatic or symptomatic carotid artery stenosis were documented in the database. The primary outcome of this secondary data analysis was in-hospital stroke or death. Major stroke or death, stroke, and death, each until discharge were secondary outcomes. Adjusted relative risks (RRs) were assessed by multivariable multilevel regression analyses.
  
  
  
  The primary outcome occurred in 1.8% of patients, with a rate of 1.4% in asymptomatic and 2.5% in symptomatic patients, respectively. In the multivariable analysis, lower risks of stroke or death were independently associated with local anesthesia (versus general anesthesia: RR, 0.85; 95% confidence interval [CI], 0.75-0.95), carotid endarterectomy with patch plasty compared with primary closure (RR, 0.71; 95% CI, 0.52-0.97), intraoperative completion studies by duplex ultrasound (RR, 0.74; 95% CI, 0.63-0.88) or angiography (RR, 0.80; 95% CI, 0.71-0.90), and perioperative antiplatelet medication (RR, 0.83; 95% CI, 0.71-0.97). No shunting and a short cross-clamp time were also associated with lower risks; however, these are suspected to be confounded.
  
  
  
  Local anesthesia, patch plasty compared with primary closure, intraoperative completion studies by duplex ultrasound or angiography, and perioperative antiplatelet medication were independently associated with lower in-hospital stroke or death rates after carotid endarterectomy.
authors.affiliation: From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.).
authors.forename: Christoph
authors.initials: C
authors.lastname: Knappich
authors.affiliation: From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.).
authors.forename: Andreas
authors.initials: A
authors.lastname: Kuehnl
authors.affiliation: From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.).
authors.forename: Pavlos
authors.initials: P
authors.lastname: Tsantilas
authors.affiliation: From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.).
authors.forename: Sofie
authors.initials: S
authors.lastname: Schmid
authors.affiliation: From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.).
authors.forename: Thorben
authors.initials: T
authors.lastname: Breitkreuz
authors.affiliation: From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.).
authors.forename: Michael
authors.initials: M
authors.lastname: Kallmayer
authors.affiliation: From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.).
authors.forename: Alexander
authors.initials: A
authors.lastname: Zimmermann
authors.affiliation: From the Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany (C.K., A.K., P.T., S.S., M.K., A.Z., H.-H.E.); and AQUA-Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH, Göttingen, Germany (T.B.). gefaesschirurgie@mri.tum.de.
authors.forename: Hans-Henning
authors.initials: HH
authors.lastname: Eckstein
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000772:Anesthesia, Local / Q000706:statistics & numerical data*; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery; D016894:Endarterectomy, Carotid / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D005858:Germany / Q000453:epidemiology; D017052:Hospital Mortality; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D012306:Risk; D020521:Stroke / Q000453:epidemiology*
chemical_list: D010975:Platelet Aggregation Inhibitors
keywords: anesthesia; angiography; death; endarterectomy, carotid; stroke