S. J. Aitken1,2, S. J. Aitken1,2 1Concord Repatriation General Hospital,Institute Academic Surgery (Vascular),Sydney, NEW SOUTH WALES (NSW), Australia 2University Of Sydney,Concord Clinical School,Sydney, NSW, Australia
Introduction:
Cardiac and neurological complications following carotid revascularization have been associated with an increased risk of mortality, especially in older patients. This study reports mortality and stroke following carotid revascularization in Australia, comparing outcomes up to 1 year for those with and without complications within 30days and in younger and older patients.
Methods:
Routinely collected hospital data on all patients in New South Wales (NSW), Australia, were linked to state-wide mortality records. All patients who underwent carotid revascularization (endarterectomy or stenting) between 2010-2012 were selected. Primary outcomes of mortality or stroke were measured at 30days, 90days and 1 year. Secondary outcomes were complications within 30days, length of stay and hospital readmission within 90days. Differences in outcomes between younger (aged less than 75 years old) and older (aged 75 years and older) patients were evaluated. Complications were assessed at 30days, including stroke and major adverse cardiac events (MACE). Outcomes were assessed with multivariable Cox regression and Kaplan Meier survival analysis.
Results:
3008 carotid revascularization procedures were performed between 2010 and 2013; 20% for symptomatic carotid disease (n=598). Carotid endarterectomy was the most common procedure (n=2280, 76%), with 728 patients (24%) having carotid stenting. The median age was 72 years (SD 10), with more males than females having carotid revascularization (M:F ratio 69%:31%). Mortality at 30days was 0.8% (n=26), 90days 1.4% (n=43) and 1 year 3.9% (n=112). Postoperative stroke occurred in 14 patients at 30days (0.5%), 90days 1.1% (n=32) and 1 year 1.7% (n=52). 17.3% of patients had a major complication within 30days (n=522). Median length of stay was 3 days (IQR 7). 25% of patients (n=754) had a readmission for any cause at 90days. After adjusting for age, gender and procedure type, patients aged 75 years or older were at higher mortality risk than younger patients (HR 2.7, 95%CI 2.2-3.3, P<.0001) at 1 year. After adjusting for age, gender and procedure type, older patients had a higher risk of stroke at 1 year (HR 2.4, 95%CI 1.9-2.8, P<.0001) than younger patients. Stroke risk was also associated with carotid stenting and major complications. MACE occurring within 30days predicted 1 year stroke (HR 2.1, 95%CI 1.6-2.9, P<.0001) and death (HR 2.0, 95%CI 1.5-2.7, P<.0001). Older patients had a higher incidence of MACE (IRR 1.9, 95%CI 1.4-2.6, P<.0001) and complications (IRR 1.2, 95%CI 1.1-1.4, P.007) within 30days than younger patients.
Conclusion:
Older age increased risk for all adverse outcomes including mortality, stroke, complications, increased length of stay and readmission. Postoperative complications also increased the risk of mortality and stroke at 1 year. Targeted strategies to improve perioperative care in older patients are required to reduce complications associated with postoperative mortality.