Interventions for carotid artery disease had high overall readmission rates. After adjustment for comorbidities, utilization of less invasive techniques (CAS) did not result in lower readmission rates. Further evaluation is needed to determine strategies to reduce hospital readmission rates after carotid interventions.
Objective: Interventions for carotid artery disease are typically well tolerated and involve an overnight admission. Few studies have evaluated rates of readmission in the Medicare population comparing less invasive carotid artery stenting (CAS) with traditional open carotid endarterectomy (CEA). The objective of this study was to evaluate readmission rates after CEA and CAS and identify predictors of readmission.Methods: MedPAR data (2005)(2006)(2007)(2008)(2009)) were used to select patients who underwent CEA or CAS according to International Classification of Diseases-9th Edition-Clinical Modification codes. Readmission within 30, 60, and 90 days from time of procedure was determined. Sociodemographic characteristics and Elixhauser comorbidity measures were used to adjust for confounding. Patients who received CEA and CAS were compared with 2 and multivariable logistic regression analysis.Results: A total of 235,247 carotid interventions were performed (211,118 CEA and 24,129 CAS). Readmission rates for CEA and CAS patients, respectively, were 8.84% and 11.11% at 30 days (P Ͻ .0001), 13.31% and 17.98% at 60 days (P Ͻ .0001) and 16.86% and 22.68% at 90 days (P Ͻ .0001). Less than half of patients were women (43%) and were more likely to be readmitted during 30 days after discharge (P ϭ .001). After adjustment for age, race, gender, comorbidities, and procedure, patients aged Ͼ80 years (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.20-1.30) and patients with renal failure (OR, 1.6; 95% CI, 1.56-1.73), congestive heart failure (OR, 1.6; 95% CI, 1.57-1.73), or diabetes (OR, 1.4; 95% CI, 1.27-1.52) were more likely to be readmitted. In addition, patients who underwent CAS were 1.2 times as likely to be readmitted (95% CI, 1.15-1.25) as patients who received CEA. Diagnoses at readmission were similar between groups.Conclusions: Interventions for carotid artery disease had a high overall readmission rate. After adjustment for comorbidities, use of less invasive techniques (CAS) was not associated with decreased readmission. Patients who underwent CAS were more likely to be readmitted than those who received CEA at 30, 60 and 90 days. Predictors of readmission included advanced age, congestive heart failure, renal failure, and diabetes. Further research is needed to determine strategies to reduce hospital readmission rates after carotid interventions. Contemporary Outcomes After Distal Vertebral Reconstruction
Background: Background: Complex cerebrovascular lesions require careful operative planning. We present a case of a 59 year-old male with a history of recent transient ischemic attack and right subclavian steal symptoms. Carotid duplex and CT angiography showed an aberrant left vertebral artery with critical origin stenosis, left common carotid artery (CCA) critical origin stenosis, and an occluded innominate artery extending to the right CCA bulb. This presented multiple therapeutic options including antegrade or retrograde endovascular stenting of the left CCA, with or without femoral to axillary bypass on the right to protect cerebral perfusion. We chose an alternate strategy made available by the normal left subclavian: a left subclavian to right carotid bypass, with branched grafts to the left CCA and left vertebral. No complications occurred. Follow up angiography demonstrated full-patency of the grafts and the patient has been without symptoms for greater than one year.Technical Description: Technical Description: We begin with an outline of the anatomy and the options. We then present the operation, first with a left transverse supraclavicular incision through which the phrenic nerve is preserved and the left CCA, subclavian, and vertebral arteries are circumferentially controlled. Next, through a separate incision we expose and control the right carotid vessels. We then create a retroesophageal tunnel through which we pass a ringed 6 mm graft between the two incisions. Two short 6 mm branches are then sewn into place on the left side of the graft. These are occluded with hemoclips and we proceed with the left subclavian and right carotid anastamoses. Once antegrade right carotid flow is instituted, we then perform anastomoses of the graft branches to the left CCA and vertebral arteries, without interrupting flow to the right carotid. The hemoclips are then removed to restore flow through the left CCA and vertebral arteries. Pulsatile flow is confirmed and the wounds are closed.
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