Impact of risk scoring on decision-making in symptomatic moderate carotid atherosclerosis

Dharmarajah, Brahman; Thapar, Ankur; Salem, Joseph; Lane, Tristan; Leen, Edward; Davies, Alun H.

doi:10.1002/bjs.9461

“…In addition, the inclusion of other vascular-specific risk factors correlated with poor outcomes in vascular patients, such as rest pain, diabetes, and previous amputation, may have utility in further increasing the diagnostic accuracy of the RAI. 9,[19][20][21][22][23][24][25][26][27][28]…”

Section: Discussionmentioning

confidence: 99%

Preoperative frailty Risk Analysis Index to stratify patients undergoing carotid endarterectomy

Melin

¹

,

Schmid

²

,

Lynch

³

et al. 2015

Journal of Vascular Surgery

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“…However, carotid disease provides a unique pathology with multiple treatment modalities (open surgical, endovascular, and medical) where frailty screening may actually shape management. 31 In particular, asymptomatic patients must have excellent outcomes and a reasonable life expectancy to justify a prophylactic operation. 32,33 …”

Section: Discussionmentioning

confidence: 99%

An Accumulated Deficits Model Predicts Perioperative and Long-term Adverse Events after Carotid Endarterectomy

Sridharan¹,

Chaer²,

Wu³

et al. 2018

Annals of Vascular Surgery

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Background There is increasing recognition that decreased reserve in multiple organ systems, known as accumulated deficits (AD), may better stratify perioperative risk than traditional risk indices. We hypothesized that an AD model would predict both perioperative adverse events and long-term survival after carotid endarterectomy (CEA), particularly important in asymptomatic patients. Methods Consecutive patients undergoing CEA between 1st January 2000 and 31st December 2010 were retrospectively identified. Seven of the deficit items from the Canadian Study of Health and Aging–frailty index (coronary disease, renal insufficiency, pulmonary disease, peripheral vascular disease, heart failure, hypertension, and diabetes) were tabulated for each patient. Predictors of perioperative and long-term outcomes were evaluated using regression analysis. Results About 1,782 CEAs in 1,496 patients (mean age: 71.3 ± 9.3 years, 56.3% male, 35.4% symptomatic) were included. The risk of major adverse events (stroke, death, or myocardial infarction) at 30 days for patients with ≤3 deficits was 2.53% vs. 8.81% for patients with ≥4 deficits (P < 0.001). For patients with ≥5 deficits, the risk was 15.18%. Each additional deficit increased the odds of a 30-day major adverse event and hospital stay >2 days by 1.64 (P < 0.001) and 1.15 (P < 0.001), respectively. In multivariate analysis, the presence of ≥4 deficits was more predictive of perioperative major adverse events (odds ratio [OR] = 3.62, P < 0.001) than symptomatology within 6 months (OR = 1.57, P = 0.08) or octogenarian status (OR = 2.00, P = 0.02). Kaplan-Meier analysis showed significantly decreased survival over time with accumulating deficits (P < 0.001). Patients with ≥4 deficits have a hazards ratio for death of 2.6 compared to patients with ≤3 deficits (P < 0.001). Overall survival is estimated at 79.5% (95% confidence interval [CI]: 0.77–0.82) at 5 years in patients with ≤3 deficits versus 52.4% (95% CI: 0.46–0.58) in patients with ≥4 deficits, respectively. In subgroup analysis of asymptomatic patients, 5-year survival for octogenarian male patients with ≥4 deficits was only 26.8%. For asymptomatic males aged 70–79 years with ≥4 deficits, 5-year survival was 59.9%. Conclusions An AD model is more predictive of perioperative adverse events after CEA than age or symptomatic status. This model remains predictive of long-term survival. In asymptomatic male octogenarians with 4 or more AD, 5-year survival is severely limited.

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“…However, carotid disease provides a unique pathology with multiple treatment modalities (open surgical, endovascular, and medical) where frailty screening may actually shape management. 31 In particular, asymptomatic patients must have excellent outcomes and a reasonable life expectancy to justify a prophylactic operation. 32,33 There are a number of limitations to this present study.…”

Section: Discussionmentioning

confidence: 99%

An Accumulated Deficits Model Predicts Perioperative and Long-Term Adverse Events After Carotid Endarterectomy

Sridharan

¹

,

Chaer

²

,

Wu

³

et al. 2017

Annals of Vascular Surgery

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Impact of risk scoring on decision-making in symptomatic moderate carotid atherosclerosis

Abstract: The addition of a risk score appeared to influence clinicians in their decision-making towards CEA in high-risk patients and towards best medical therapy in low-risk patients.

Cited by 7 publications

References 30 publications

Preoperative frailty Risk Analysis Index to stratify patients undergoing carotid endarterectomy

Preoperative frailty Risk Analysis Index to stratify patients undergoing carotid endarterectomy

An Accumulated Deficits Model Predicts Perioperative and Long-term Adverse Events after Carotid Endarterectomy

An Accumulated Deficits Model Predicts Perioperative and Long-Term Adverse Events After Carotid Endarterectomy

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