Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis

Abstract

BACKGROUND Carotid endarterectomy (CEA) and carotid artery stenting (CAS) represent options to treat many patients with carotid stenosis. Although randomized trial data are plentiful, estimated rates of morbidity and mortality for both CEA and CAS have varied substantially. OBJECTIVE To evaluate rates of adverse outcomes after CAS and CEA in a large national database. METHODS We analyzed 84 191 adult patients undergoing elective, nonemergent CAS (n = 81 361) or CEA (n = 2830), from 2011 to 2018, in the American College of Surgeons’ National Surgical Quality Improvement Program database. Odds of adverse outcomes (30-d rates of stroke, myocardial infarction (MI), cardiac arrest, prolonged length of stay (LOS), readmission, reoperation, and mortality) were evaluated in propensity-matched (n = 2821) cohorts through logistic regression. RESULTS In the propensity-matched cohorts, CAS had increased odds of periprocedural stroke (odds ratio [OR] 1.97, 95% CI 1.32-2.95) and decreased odds of cardiac arrest (OR 0.33, 95% CI 0.13-0.84) and 30-d reoperation (OR 0.59, 95% CI 0.44-0.80) compared to CEA. Relative odds of MI, prolonged LOS, discharge to destination other than home, 30-d readmission, or 30-d mortality were statistically similar. In the unmatched patient population, rates of adverse outcomes with CEA were constant over time; however, for CAS, rates of stroke increased over time. In both the matched and unmatched patient cohorts, patients 70 yr and older had lower rates of post-procedural stroke with CEA, but not with CAS, compared to younger patients. CONCLUSION In a propensity-matched analysis of a large, prospectively collected, national, surgical database, CAS was associated with increased odds of periprocedural stroke, which increased over time. Rates of MI and death were not significantly different between the 2 procedures.

Unplanned readmission after carotid stenting versus endarterectomy: analysis of the United States Nationwide Readmissions Database

“…We therefore analyzed the reasons and risks for readmission after each of these two procedures at three distinguishable clinical stages: preoperative characteristics at baseline, postoperative adverse events and outcomes, and diagnoses underlying the subsequent readmission. When examining baseline characteristics, we found a significantly higher risk ratio for readmission in octogenarian and older patients, male patients, patients on Medicaid, and patients with higher APR-DRG mortality, APR-DRG severity of illness, and Elixhauser Comorbidity Index scores, largely in agreement with previous smaller studies17 18 24 25 as well as studies restricted to Medicare beneficiaries 15 16. Our data would therefore suggest that for prevention of readmission, targeting octogenarian and older patients, those with higher comorbidities, and patients on Medicaid might be a worthwhile strategy, although evidence for preadmission intervention in surgical patients remains sparse 26…”

“…It is interesting that CAS, a less invasive procedure, is associated with a higher unadjusted readmission rate in both symptomatic and asymptomatic patients. However, this higher readmission rate may reflect inherent selection bias as patients undergoing CAS often have higher comorbidities 24. Accordingly, both multivariate analysis and propensity matching largely nullified differences in readmission rates between CAS and CEA in symptomatic patients in our data, although higher rates and risk ratios of readmission after CAS persisted in asymptomatic patients.…”

Outcomes Following Carotid Endarterectomy and Carotid Artery Stenting in Patients with Carotid Artery Stenosis: A Retrospective Study from a Single Center in South Korea

“…According to the American Heart Association, the combined risk of stroke and death from CEA should not exceed 3% for asymptomatic patients and 6% for symptomatic patients. The overall periprocedural risk of carotid revascularization should be less than 3% or 6% for asymptomatic and symptomatic carotid stenosis, respectively, according to the European guidelines for choosing CAS or CEA [ 23 ]. Our study results were consistent with the recommendations of these guidelines.…”

“…CAS was selected in cases of stenosis distant from the carotid bifurcation ( Figure 5A ), long segment ( Figure 5B ), and contralateral intracerebral artery (ICA) occlusion or severe stenosis ( Figure 5C ). Patients who are regarded as too high-risk for surgery, or who have surgically inaccessible lesions, have been offered CAS [ 3 , 23 , 40 ]. In asymptomatic patients, CAS is preferred because it is less invasive and does not require general anesthesia.…”

Ultrasound-guided intermediate cervical plexus block for postoperative analgesia in patients undergoing carotid endarterectomy under general anesthesia: a case-control study

“…[1] Although carotid artery stenting is an alternative, there are studies indicating that the rate of periprocedural stroke is higher. [2] Therefore, it has not completely replaced endarterectomy. According to current guidelines, symptomatic internal carotid artery stenosis greater than 50% and asymptomatic internal carotid artery stenosis greater than 60% are stated as indications for CEA.…”