B. J. Nejim1, I. Arhuidese1, C. Hicks1, T. Obeid1, S. Wang1, J. Canner1, M. Malas1 1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA
Introduction: The aim of our study is to compare the postoperative outcomes of Carotid Endarterectomy (CEA) with Carotid Artery Stenting (CAS) using the Procedure-targeted American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.
Methods: Patients who underwent CEA or CAS were identified in ACS-NSQIP for the years 2011 – 2013. Mean difference estimates and chi-square tests were used as appropriate. Univariate and multivariate logistic regression analysis were performed to evaluate the predictors of post-operative outcomes (any stroke or death and myocardial infarction (MI)) adjusting for age, gender, comorbidities, symptomatology, degree of stenosis and emergency surgical status.
Results: Of the 10,169 patients who underwent carotid revascularization, 9,817 (96.5%) underwent CEA while 352 (3.5%) underwent CAS during the study period. Sixty one percent of the cohort were males. Patients who underwent CEA were older than those undergoing CAS [mean age (SD): 71.3 (9.4) vs. 69.1 (9.7) years, p <0.001]. However, patients who underwent CAS had a greater prevalence of diabetes (38.4% vs. 29.2%, p<0.001), hypertension (88.1% vs. 84.9%, p=0.104), congestive heart failure (4.8% vs. 1.4%, p<0.001) and COPD (17.3% vs. 10.2%, p<0.001). The risk of post-operative stroke/death was 92% higher with CAS (Adjusted odds ratio: 1.92; 95% Confidence Interval: 1.04-3.52), receiving blood transfusion 72 hours prior to surgery was associated with 5-fold increase of mortality odds (aOR: 5.47; 95%CI: 1.79-16.73), other significant predictors of stroke/death were symptomatic status (aOR: 1.60 ,95%CI:1.19-2.16) and emergency surgery status (aOR: 2.35 ,95%CI: 1.31-4.23). No significant association was found between the type of procedure and odds of unplanned reoperation (aOR: 0.60; 95%CI: 0.22-1.63). Thirty-day post-op myocardial infarction was mostly related to patient’s age and being on hypertension medication whereas the type of procedure was found not to be significantly associated with post-op MI (aOR: 0.84; 95%CI: 0.26-2.67). Although readmission odds was higher for CAS, this association was not significant (aOR: 1.23; 95%CI: 0.82-1.85)
Conclusion: Carotid stenting is associated with higher odds of both post-operative mortality and stroke. The adverse impact of pre-procedural blood transfusion on outcomes is a call for caution and deserves further elucidation. Carotid procedure type is not a predictor of post-op MI or readmission, suggesting that these outcomes are a function of other patient factors. Further studies are warranted to evaluate the ability of the administrative dataset models to predict postoperative outcomes following carotid revascularization.
