Changing Patterns in the Practice of Carotid Endarterectomy in a Large Metropolitan Area

Brott, Thomas G.; Labutta, Robert J.; Kempczinski, Richard F.

doi:10.1001/jama.1986.03370190093030

Cited by 102 publications

(21 citation statements)

References 15 publications

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“…The service volume influences the complication rate, as seen in other procedures. 19,20 The low complication rate associated with cerebral angiography may not be observed at other institutions. Therefore, the most appropriate application of these results is in high-volume settings similar to ours.…”

Section: Discussionmentioning

confidence: 99%

Role of Conventional Angiography in Evaluation of Patients With Carotid Artery Stenosis Demonstrated by Doppler Ultrasound in General Practice

Qureshi

Suri

Ali

et al. 2001

Stroke

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Background and Purpose-Previous studies have suggested that patients with carotid stenosis who are candidates for endarterectomy can be effectively identified on the basis of carotid Doppler ultrasound alone. Before widespread acceptance of this policy, the accuracy of carotid Doppler ultrasound outside selected centers and clinical trials needs to be evaluated. We performed a 12-month prospective study to evaluate the accuracy of Doppler ultrasound in identifying patients for carotid intervention in general practice settings. Methods-Each patient referred to our endovascular service for diagnostic angiography to evaluate for carotid stenosis was interviewed and examined by a neurologist. Subjects consisted of symptomatic patients with Ն50% stenosis and asymptomatic patients with Ն60% stenosis by Doppler ultrasound. Information pertaining to demographic and cerebrovascular risk factors and the results of the carotid Doppler ultrasound were recorded. The severity of stenosis on angiograms was measured with North American Symptomatic Carotid Endarterectomy Trial criteria by a blinded observer. The results of both studies were compared to determine the relative accuracy of ultrasound results. Results-Of 130 patients (mean age, 69Ϯ8.8 years) who met Doppler ultrasound criteria, 22 (17%) and 8 patients (6%)were found to have 30% to 49% or Ͻ30% stenosis by angiography, respectively. The positive predictive value of carotid Doppler ultrasound for identifying appropriate symptomatic candidates for carotid intervention (angiographic stenosis Ն50%) was 80%, with a false-positive value of 20%. The positive predictive value of carotid Doppler ultrasound for identifying appropriate asymptomatic candidates for carotid intervention (angiographic stenosis Ն60%) was 59%, with a false-positive value of 41%. Carotid endarterectomy or angioplasty and stent placement were undertaken subsequently in 60 (46%) of the patients. In 94 patients who underwent cerebral angiography alone, no complications were observed. Conclusions-The present accuracy of carotid Doppler ultrasound in general practice does not justify its use as the sole basis of selecting appropriate patients for carotid intervention. Given the relatively low rate of associated morbidity with present day techniques, additional confirmatory studies such as angiography should be performed in every patient before a decision regarding intervention is made.

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Section: Discussionmentioning

confidence: 99%

Role of Conventional Angiography in Evaluation of Patients With Carotid Artery Stenosis Demonstrated by Doppler Ultrasound in General Practice

Qureshi

Suri

Ali

et al. 2001

Stroke

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“…The overall frequencies of adverse outcomes were also higher in the 5 patients with complete ipsilateral carotid occlusions (40% T he benefit of carotid endarterectomy in comparison to medical therapy alone is highly dependent on surgical risk. 15 Postoperative complication rates higher than the 4% to 6% reported in randomized trials would eliminate the potential benefit of the operation. 69 Although several surgical series report perioperative complication rates of approximately 3%, 1 1317 A retrospective survey of all carotid endarterectomies performed at Johns Hopkins Hospital over a 10-year period found an 8.2% total rate of morbidity and mortality.…”

Section: Multicenter Review Of Preoperative Risk Factors For Carotid mentioning

confidence: 98%

Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms.

Goldstein

McCrory

Landsman

et al. 1994

Stroke

148

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Background and Purpose Randomized clinical trials have shown that carotid endarterectomy decreases the risk of subsequent stroke in patients with high-grade carotid stenosis and ipsilateral transient ischemic attack or minor stroke. The benefit of surgery is highly dependent on surgical risk. We previously found that patients with ipsilateral hemispheric symptoms were at greater risk of carotid endarterectomy complications compared with those who were asymptomatic or had nonipsilateral symptoms. The goals of the present study were (1) to identify preoperative clinical factors that may increase the risk of complications after carotid endarterectomy in patients with ipsilateral hemispheric symptoms and (2) to develop a risk index based on this patient-level data.Methods Records from 1160 carotid endarterectomies performed at 12 academic medical centers composed the primary data set. Hospital charts for the admission during which carotid endarterectomy was performed were systematically reviewed by abstractors using a defined protocol. The present analysis was carried out on data from the subset of patients who had carotid endarterectomy for ipsilateral hemispheric symptoms. Candidate variables were identified based on univariate Fisher's exact tests or x 2 tests. A risk index was then developed using those variables with a greater than 90% probability of being associated with adverse outcomes.Results Of the 697 patients with ipsilateral symptoms, 8.5% had either stroke, myocardial infarction, or died during the postoperative period of hospitalization. Those over the age of 75 had a greater risk of myocardial infarction (6.6% versus 2.3%, P= .024) but not of stroke or death (/>> .10). The overall frequencies of adverse outcomes were also higher in the 5 patients with complete ipsilateral carotid occlusions (40%

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“…5) [32][33][34][35][36][37][38][39][40][41][42][43]. Several studies suggest that these improvements in surgical outcomes also result from training advances, improved patient selection, increased hospital procedure volumes, and improved medical management of patients [25][26][27].…”

Section: Increase In Physician Volume and Experiencementioning

confidence: 99%

The impact of regulatory approval and Medicare coverage on outcomes of carotid stenting

Gray

Verta

2013

Cathet Cardio Intervent

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Background Carotid artery stenting (CAS) was introduced in the United States nearly a decade ago as a novel treatment of severe carotid stenosis. Voluminous and high‐quality prospective data permit analysis of longitudinal trends in CAS outcomes. Methods Outcomes from all prospective trials with the Food and Drug Administration (FDA) oversight from 2000–2011 were reviewed, as were the subset of studies using a single CAS system. All studies shared common inclusion/exclusion criteria, endpoints, independent assessment/adjudication of neurological events, and were conducted in accordance with FDA regulations. Death and stroke (DS) rates from FDA‐approved studies in high‐surgical‐risk patients were assessed. Results Between 2000 and 2011, two distinct periods with clustered and differentiated outcomes in CAS IDE trials were observed, separated by FDA approval and Centers for Medicare and Medicaid Services (CMS) coverage in 2004–2005. The mean 30‐day DS rate in the first wave (2000–2004) of CAS trials was 5.3% (95% CI: 4.6–6.2%), and fell significantly to 2.6% (95% CI: 1.9–3.7%; P = 0.0001) in the second wave (2006–2011). This decline occurred during a simultaneous, independent 24‐fold increase in monitored CAS activity. This decline in DS rates was observed in symptomatic and asymptomatic patients, alike independent of device tested. Conclusions Declines in periprocedural DS rates in CAS appear linked to regulatory and coverage approvals leading to increased operator experience along with continued regulatory oversight, and provide insight into the introduction of other novel therapies. © 2013 Wiley Periodicals, Inc.

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Changing Patterns in the Practice of Carotid Endarterectomy in a Large Metropolitan Area

Cited by 102 publications

References 15 publications

Role of Conventional Angiography in Evaluation of Patients With Carotid Artery Stenosis Demonstrated by Doppler Ultrasound in General Practice

Role of Conventional Angiography in Evaluation of Patients With Carotid Artery Stenosis Demonstrated by Doppler Ultrasound in General Practice

Multicenter review of preoperative risk factors for carotid endarterectomy in patients with ipsilateral symptoms.

The impact of regulatory approval and Medicare coverage on outcomes of carotid stenting

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