Indications, outcomes, and provider volumes for carotid endarterectomy

Indications and Outcome of Carotid Endarterectomy (CEA): A Single Centre Experience

Background Stroke is a prevalent ailment that impacts a substantial number of individuals globally, resulting in both physical impairment and mortality. One of its major causes is carotid artery stenosis. The symptoms and degree of stenosis are key indications for carotid endarterectomy (CEA). In this study, we highlight the indications and outcomes of carotid endarterectomy in our center. Methods This is a descriptive, retrospective, observational study. Data of patients who underwent CEA at Glan Clwyd Hospital from January 2018 to January 2023 was retrieved. The study sample consisted of patients diagnosed with symptomatic carotid artery stenosis who had CEA at Glan Clwyd Hospital. The data was analyzed using statistical software SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp). Results A total of 150 patients were enrolled in the study. A majority of the patients were male, accounting for 69.3% (n = 104), and had a mean age of 71.1 ± 9.9 standard deviation. A majority of the patients were smokers (48.7%) and had additional medical conditions, including hypertension (34%), ischemic heart disease (17.3%), chronic obstructive pulmonary disease (73.3%), and diabetes (46.7%). Nevertheless, the remaining comorbidities were less common. The outcome of the CEA among the patients was cardiac event 3.3% (n = 5); transient ischemic attack (TIA) 3.3% (n = 5); stroke 0.6% (n = 1); hemorrhage 2.6% (n = 4); surgical site infection 2% (n = 3); perioperative mortality 1.3% (n = 2); and cranial nerve injury 1.3% (n = 2). However, no complications were reported in most of the patients, 85.6% (n = 128). Conclusion An endarterectomy is quite advantageous for treating symptomatic stenosis. The findings can be applied to patients who are physically suitable for surgery. The efficacy of endarterectomy is contingent upon not only the severity of carotid stenosis but also various other parameters, such as the time elapsed between the presenting event and the surgical intervention, as well as the patient's overall medical condition. However, the CEA is the gold standard in surgical management for symptomatic carotid disease.

Assessing the volume-outcome relationship of carotid artery stenting in nationwide administrative data: a challenge of patient population bias

BACKGROUND

Studies have shown an association between surgical treatment volume and improved quality metrics. This study evaluated nationwide results in carotid artery stenting (CAS) procedural readmission rates, costs, and length of stay based on hospital treatment volume.

METHODS

We used the Nationwide Readmissions Database for carotid stenosis from 2010 to 2015. Patients receiving CAS were matched based on demographics, illness severity, and relevant comorbidities. Patients were matched 1:1 between low- and high-volume centers using a non-parametric preprocessing matching program to adjust for parametric causal inferences. Nearest-neighbor propensity score matching was performed using logit distance.

RESULTS

Low- and high-volume centers admitted a mean (SD) of 4.68 (3.79) and 25.10 (16.86) patients undergoing CAS per hospital, respectively. Comorbidities were significantly different and initially could not be adequately matched. Because of significant differences in baseline patient population characteristics after attempted matching between low- and high-volume centers, we used propensity adjustment with multivariate analysis. Using this alternative approach, no significant differences were observed between low- and high-volume centers for the presence of any complication, postoperative stroke, postoperative myocardial infarction, and readmission at 30 days.

CONCLUSION

In 1:1 nearest-neighbor matching with a high number of patients, our analysis did not result in well-matched cohorts for the effect of case volume on outcomes. Comparing analytical techniques for various outcomes highlights that outcome disparities may not be related to quality differences based on hospital size, but rather variability in patient populations between low- and high-volume institutions.

Impact of Vascular Service Centralization on the Carotid Endarterectomy Pathway: A Study at the Bedfordshire, Luton, and Milton Keynes Vascular Network

Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50% internal carotid artery (ICA) stenosis supplying index hemispheric territory. The recommended period for CEA is 14 days post-index event; this period carries a heightened risk for second ischemic events. However, implementation of this stringent timeline often encounters delays stemming from multifaceted factors. The centralization of vascular services, designed to enhance patient care, introduces a paradigm shift. Centralization's efficacy in improving patient outcomes, particularly in the CEA pathway, is a subject of ongoing investigation. Our study aims to discern the impact of centralized services on the timeliness of CEA for symptomatic carotid artery stenosis, shedding light on this complex interplay of factors. Methods This retrospective study analyzed CEA data at the Bedfordshire, Luton, and Milton Keynes Vascular Network between January 2021 and June 2023. Eligible patients exhibited symptomatic carotid artery stenosis, with asymptomatic cases; those unfit for surgery or receiving best medical therapy only were excluded. Patients were categorized by their primary referral location: Hub, Spoke-1, or Spoke-2. Demographic and referral data were collected, and timelines from symptom onset to surgery were recorded. Continuous variables were expressed as means and standard deviations, and categorical variables as counts and percentages. Box plots illustrated the relationship between referral origin and surgery timing, and the Classification and Regression Tree (CART) assessed second events. Statistical significance was determined using Fisher's exact and chi-square tests, with p<0.05 indicating significance. Results A total of 148 patients underwent CEA after implementing exclusion criteria. 35.5% (n=53) of patients were referred from the Hub, while 45.6% (n=67) and 18.8% (n=28) were from Spoke-1 and Spoke-2, respectively. 40% (n=59) received CEA within the recommended timeframe, and 15.4% (n=23) experienced a second ischemic event pre-surgery. Time from TIA clinic review to referral was 5.5±8 days and 16.4±20 days from vascular referral to surgery. Patterns of delays were observed, with Spoke-2 exhibiting the most significant delays. Notably, amaurosis fugax and embolic stroke correlated with recurrent ischemic events, emphasizing the importance of timely care in CEA. Conclusion Our study underscores the significant benefits and challenges of the Hub and Spoke model in vascular surgery. The growing referral delays from Spoke sites are concerning, emphasizing the need for a multi-disciplinary team approach within Spoke sites to ensure efficient and standardized care delivery.

Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis

Importance

Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke. The clinical benefit observed in randomized clinical trials (RCTs) may not extend to real-world practice.

Objective

To examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis.

Design, Setting, and Participants

This comparative effectiveness study was conducted from August 28, 2018, to March 2, 2020, using the Corporate Data Warehouse, Suicide Data Repository, and other databases of the US Department of Veterans Affairs. Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Patients without a carotid imaging report, those with carotid stenosis of less than 50% or hemodynamically insignificant stenosis, and those with a history of stroke or transient ischemic attack in the 6 months before index imaging were excluded. A cohort of patients who received initial medical therapy and a cohort of similar patients who received CEA were constructed and followed up for 5 years. The target trial method was used to compute weighted Kaplan-Meier curves and estimate the risk of fatal and nonfatal strokes in each cohort in the pragmatic sample across 5 years of follow-up. This analysis was repeated after restricting the sample to patients who met RCT inclusion criteria. Cumulative incidence functions for fatal and nonfatal strokes were estimated, accounting for nonstroke deaths as competing risks in both the pragmatic and RCT-like samples.

Exposures

Receipt of CEA vs initial medical therapy.

Main Outcomes and Measures

Fatal and nonfatal strokes.

Results

Of the total 5221 patients, 2712 (51.9%; mean [SD] age, 73.6 [6.0] years; 2678 men [98.8%]) received CEA and 2509 (48.1%; mean [SD] age, 73.6 [6.0] years; 2479 men [98.8%]) received initial medical therapy within 1 year after the index carotid imaging. The observed rate of stroke or death (perioperative complications) within 30 days in the CEA cohort was 2.5% (95% CI, 2.0%-3.1%). The 5-year risk of fatal and nonfatal strokes was lower among patients randomized to CEA compared with patients randomized to initial medical therapy (5.6% vs 7.8%; risk difference, -2.3%; 95% CI, -4.0% to -0.3%). In an analysis that incorporated the competing risk of death, the risk difference between the 2 cohorts was lower and not statistically significant (risk difference, -0.8%; 95% CI, -2.1% to 0.5%). Among patients who met RCT inclusion criteria, the 5-year risk of fatal and nonfatal strokes was 5.5% (95% CI, 4.5%-6.5%) among patients randomized to CEA and was 7.6% (95% CI, 5.7%-9.5%) among those randomized to initial medical therapy (risk difference, -2.1%; 95% CI, -4.4% to -0.2%). Accounting for competing risks resulted in a risk difference of -0.9% (95% CI, -2.9% to 0.7%) that was not statistically significant.

Conclusions and Relevance

This study found that the absolute reduction in the risk of fatal and nonfatal strokes associated with early CEA was less than half the risk difference in trials from 20 years ago and was no longer statistically significant when the competing risk of nonstroke deaths was accounted for in the analysis. Given the nonnegligible perioperative 30-day risks and the improvements in stroke prevention, medical therapy may be an acceptable therapeutic strategy.

The Relationship Between Carotid Revascularization Procedural Volume and Perioperative Outcomes in Australia and New Zealand

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) prevent stroke in selected patients. However, each intervention carries a risk of perioperative complications including stroke or death (S/D). We aimed to determine the relationship between operator volume, hospital volume, and the perioperative risk of S/D in carotid revascularization in Australia and New Zealand. Retrospective analysis was performed on prospectively collected data extracted from the Australasian Vascular Audit between 2010 and 2017. Annual caseload volume was analyzed in quintiles (Q) using multivariate regression to assess its impact on perioperative S/D. Carotid endarterectomy procedures (n = 16 765) demonstrated higher S/D rates for lower-volume operators (2.21% for Q1-Q3 [1-17 annual cases] vs 1.76% for Q4-Q5 [18-61 annual cases]; odds ratio [OR]: 1.28; 95% CI: 1.001-1.64; P = .049). Carotid artery stenting procedures (n = 1350) also demonstrated higher S/D rates for lower-volume operators (2.63% for Q1-Q3 [1-11 annual cases] vs 0.37% for Q4-Q5 [12-31 annual cases]; OR: 6.11; 95% CI: 1.27-29.33; P = .024). No significant hospital volume-outcome effect was observed for either procedure. An inverse relationship was demonstrated between operator volume and perioperative S/D rates following CEA and CAS. Consideration of minimum operator thresholds, restructuring of services and networked referral pathways of care in Australia and New Zealand, would likely result in improved patient outcomes.

Carotid endarterectomy surgeon volumes in contemporary practice: A comparison to randomized trial inclusion criteria

BACKGROUND

Clinical decisions regarding the utility of carotid revascularization are informed by randomized controlled trial (RCT) results. However, RCTs generally require participating surgeons to meet strict inclusion criteria with respect to procedure volume. The purpose of this study was to compare annual surgeon volume for carotid endarterectomy (CEA) in contemporary practice to RCT inclusion thresholds.

METHODS

Surgeon volume thresholds were identified in 17 RCTs evaluating the efficacy of CEA (1986-present, n = 17). Contemporary annual surgeon volumes (2012-2017) were identified by aggregating data from the Medicare Provider Utilization Database and Healthcare Cost and Utilization Project Network (HCUP), and compared to RCT inclusion thresholds. Further comparisons were performed over time, and across specialties (i.e., vascular surgeon vs. other, based on board certification associated with provider NPI).

RESULTS

Minimal surgeon volume in 17 RCTs ranged from 10 to 25 CEA annually when specific case volumes were required. From 2012 to 2017, CEA incidence in Medicare beneficiaries declined from 68,608 to 56,004 and became increasingly consolidated in fewer providers (7,331 vs. 6,626). However, in 2016 only 26.2% of surgeons performing CEA in Medicare beneficiaries would have met the least stringent volume requirement (10 CEA/year). Only 6.5% of surgeons performing CEA met the most stringent RCT volume threshold (25 cases/year) during the same time period. In 2017, 819 vascular surgeons (25.5% of those certified in the specialty) performed >10 CEA in Medicare beneficiaries.

CONCLUSIONS

The majority of surgeons performing CEA do not meet the annual volume thresholds required for participation in the RCTs that have evaluated the efficacy of carotid revascularization. Given the established volume-outcome relationship in CEA, the disparity between surgeon experience in the context of RCTs versus contemporary practice is concerning. These findings have potential implications for informed decision-making, hospital privileging, and regionalization of care.

Most pediatric transplant centers are low volume, adult-focused, and in proximity to higher volume pediatric centers

BACKGROUND

Independent studies provide evidence that low volume pediatric solid organ transplant centers have inferior outcomes compared to high volume pediatric centers. The study assessed whether patients treated at low volume pediatric centers have access to higher volume pediatric centers, which offer potentially better outcomes.

METHODS

We analyzed center specific data on 467 pediatric solid organ transplant centers in the U.S using the Organ Procurement and Transplantation Network database from 2002 to 2014. The proximities of low volume pediatric centers to high volume pediatric centers were determined using Maptive, a tool based on Google Maps.

RESULTS

Most low volume pediatric transplant centers focused on transplantation of adults (84% heart, 83% liver, and 93% kidney programs). A majority of low volume pediatric centers (77% for heart, 53% for lung, 68% for liver and 90% for kidney) were within 150 miles of high volume centers. Among all children listed for transplantation, 30.7% were listed in low volume pediatric centers. Most low volume pediatric centers are adult focused and near high volume pediatric centers.

CONCLUSION

We need greater scrutiny of outcomes, particularly waitlist outcomes, of low volume pediatric solid organ transplant centers located close to high volume pediatric solid organ transplant centers.

TYPE OF STUDY AND LEVEL OF EVIDENCE

Retrospective Comparative Study, Level III.

High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis

OBJECTIVE

To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization.

BACKGROUND

Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated.

METHODS

We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model.

RESULTS

We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts).

CONCLUSIONS

We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications.

REGISTRATION

This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.

From Clinical Trial Efficacy to Real-Life Effectiveness: Why Conventional Metrics do not Work

Background

Randomised, double-blind, clinical trial methodology minimises bias in the measurement of treatment efficacy. However, most phase III trials in non-orphan diseases do not include individuals from the population to whom efficacy findings will be applied in the real world. Thus, a translation process must be used to infer effectiveness for these populations. Current conventional translation processes are not formalised and do not have a clear theoretical or practical base. There is a growing need for accurate translation, both for public health considerations and for supporting the shift towards personalised medicine.

Objective

Our objective was to assess the results of translation of efficacy data to population efficacy from two simulated clinical trials for two drugs in three populations, using conventional methods.

Methods

We simulated three populations, two drugs with different efficacies and two trials with different sampling protocols.

Results

With few exceptions, current translation methods do not result in accurate population effectiveness predictions. The reason for this failure is the non-linearity of the translation method. One of the consequences of this inaccuracy is that pharmacoeconomic and postmarketing surveillance studies based on direct use of clinical trial efficacy metrics are flawed.

Conclusion

There is a clear need to develop and validate functional and relevant translation approaches for the translation of clinical trial efficacy to the real-world setting.

Electronic supplementary material

The online version of this article (10.1007/s40801-019-0159-z) contains supplementary material, which is available to authorized users.

Relationship between patient safety indicator events and comprehensive stroke center volume status in the treatment of unruptured cerebral aneurysms

OBJECTIVE

The Agency of Healthcare Research and Quality (AHRQ) has defined Patient Safety Indicators (PSIs) for assessments in quality of inpatient care. The hypothesis of this study is that, in the treatment of unruptured cerebral aneurysms (UCAs), PSI events are less likely to occur in hospitals meeting the volume thresholds defined by The Joint Commission for Comprehensive Stroke Center (CSC) certification.

METHODS

Using the 2002–2011 National (Nationwide) Inpatient Sample, patients treated electively for a nonruptured cerebral aneurysm were selected. Patients were evaluated for PSI events (e.g., pressure ulcers, retained surgical item, perioperative hemorrhage, pulmonary embolism, sepsis) defined by AHRQ-specified ICD-9 codes. Hospitals were categorized by treatment volume into CSC or non-CSC volume status based on The Joint Commission’s annual volume thresholds of at least 20 patients with subarachnoid hemorrhage and performance of 15 or more endovascular coiling or surgical clipping procedures for aneurysms.

RESULTS

A total of 65,824 patients underwent treatment for an unruptured cerebral aneurysm. There were 4818 patients (7.3%) in whom at least 1 PSI event occurred. The overall inpatient mortality rate was 0.7%. In patients with a PSI event, this rate increased to 7% compared with 0.2% in patients without a PSI event (p < 0.0001). The overall rate of poor outcome was 3.8%. In patients with a PSI event, this rate increased to 23.3% compared with 2.3% in patients without a PSI event (p < 0.0001). There were significant differences in PSI event, poor outcome, and mortality rates between non-CSC and CSC volume-status hospitals (PSI event, 8.4% vs 7.2%; poor outcome, 5.1% vs 3.6%; and mortality, 1% vs 0.6%). In multivariate analysis, all patients treated at a non-CSC volume-status hospital were more likely to suffer a PSI event with an OR of 1.2 (1.1–1.3). In patients who underwent surgery, this relationship was more substantial, with an OR of 1.4 (1.2–1.6). The relationship was not significant in the endovascularly treated patients.

CONCLUSIONS

In the treatment of unruptured cerebral aneurysms, PSI events occur relatively frequently and are associated with significant increases in morbidity and mortality. In patients treated at institutions achieving the volume thresholds for CSC certification, the likelihood of having a PSI event, and therefore the likelihood of poor outcome and mortality, was significantly decreased. These improvements are being driven by the improved outcomes in surgical patients, whereas outcomes and mortality in patients treated endovascularly were not sensitive to the CSC volume status of the hospital and showed no significant relationship with treatment volumes.

Longitudinal survey of cranial case log entries during neurological surgery residency training

OBJECTIVE

The purpose of this study was to analyze national trends in adult cranial cases performed by neurological surgery residents as logged into the Accreditation Council for Graduate Medical Education (ACGME) system.

METHODS

The ACGME resident case logs were retrospectively reviewed for the years 2009-2017. In these reports, the national average of cases performed by graduating residents is organized by year, type of procedure, and level of resident. These logs were analyzed in order to evaluate trends in residency experience with adult cranial procedures. The reported number of cranial procedures was compared to the ACGME neurosurgical minimum requirements for each surgical category. A linear regression analysis was conducted in order to identify changes in the average number of procedures performed by residents graduating during the study period. Additionally, a 1-sample t-test was performed to compare reported case volumes to the ACGME required minimums.

RESULTS

An average of 577 total cranial procedures were performed throughout residency training for each of the 1631 residents graduating between 2009 and 2017. The total caseload for graduating residents upon completion of training increased by an average of 26.59 cases each year (r2 = 0.99). Additionally, caseloads in most major procedural subspecialty categories increased; this excludes open vascular and extracranial vascular categories, which showed, respectively, a decrease and no change. The majority of cranial procedures performed throughout residency pertained to tumor (mean 158.38 operations), trauma (mean 102.17 operations), and CSF diversion (mean 76.12 operations). Cranial procedures pertaining to the subspecialties of trauma and functional neurosurgery showed the greatest rise in total procedures, increasing at 8.23 (r2 = 0.91) and 6.44 (r2 = 0.95) procedures per graduating year, respectively.

CONCLUSIONS

Neurosurgical residents reported increasing case volumes for most cranial procedures between 2009 and 2017. This increase was observed despite work hour limitations set forth in 2003 and 2011. Of note, an inverse relationship between open vascular and endovascular procedures was observed, with a decrease in open vascular procedures and an increase in endovascular procedures performed during the study period. When compared to the ACGME required minimums, neurosurgery residents gained much more exposure to cranial procedures than was expected. Additionally, a larger caseload throughout training suggests that residents are graduating with greater competency and experience in cranial neurosurgery.

Reframing the Biological Basis of Neuroprotection Using Functional Genomics: Differentially Weighted, Time-Dependent Multifactor Pathogenesis of Human Ischemic Brain Damage

Background: Neuroprotection studies are generally unable to demonstrate efficacy in humans. Our specific hypothesis is that multiple pathophysiologic pathways, of variable importance, contribute to ischemic brain damage. As a corollary to this, we discuss the broad hypothesis that a multifaceted approach will improve the probability of efficacious neuroprotection. But to properly test this hypothesis the nature and importance of the multiple contributing pathways needs elucidation. Our aim is to demonstrate, using functional genomics, in human cardiac surgery procedures associated with cerebral ischemia, that the pathogenesis of perioperative human ischemic brain damage involves the function of multiple variably weighted proteins involving several pathways. We then use these data and literature to develop a proposal for rational design of human neuroprotection protocols.

Methods: Ninety-four patients undergoing deep hypothermic circulatory arrest (DHCA) and/or aortic valve replacement surgery had brain damage biomarkers, S100β and neurofilament H (NFH), assessed at baseline, 1 and 24 h post-cardiopulmonary bypass (CPB) with analysis for association with 92 single nucleotide polymorphisms (SNPs) (selected by co-author WAK) related to important proteins involved in pathogenesis of cerebral ischemia.

Results: At the nominal significance level of 0.05, changes in S100β and in NFH at 1 and 24 h post-CPB were associated with multiple SNPs involving several prospectively determined pathophysiologic pathways, but were not individually significant after multiple comparison adjustments. Variable weights for the several evaluated SNPs are apparent on regression analysis and, notably, are dissimilar related to the two biomarkers and over time post CPB. Based on our step-wise regression model, at 1 h post-CPB, SOD2, SUMO4, and GP6 are related to relative change of NFH while TNF, CAPN10, NPPB, and SERPINE1 are related to the relative change of S100B. At 24 h post-CPB, ADRA2A, SELE, and BAX are related to the relative change of NFH while SLC4A7, HSPA1B, and FGA are related to S100B.

Conclusions: In support of the proposed hypothesis, association SNP data suggest function of specific disparate proteins, as reflected by genetic variation, may be more important than others with variation at different post-insult times after human brain ischemia. Such information may support rational design of post-insult time-sensitive multifaceted neuroprotective therapies.

Outcome of Pancreaticoduodenectomy at Low-Volume Centre in Tier-II City of India

Currently, pancreaticoduodenectomy (PD) is considered a common and feasibly performed surgery for periampullary tumours, but it is still a high-risk surgical procedure with potential morbidity and mortality rates. Previously, it was emphasised for the need of high-volume centres to perform specialised surgery such as PD. The authors have made an attempt to know the relation between low-volume centre and outcomes of PD. The study was conducted in a Tier-II city referral hospital located in Karnataka, India. A total of 37 patients with suspected periampullary neoplasms underwent surgical exploration with curative intent over a period of 4 years, i.e. from May 2012 to May 2016. Out of 37 patients, 26 underwent PD, either classic Whipple resection (n = 01) or pylorus-preserving modification (n = 25). In 11 patients, resection was not possible, where biliary and gastric drainage procedures were done. All patients were treated by standardised post-operative care protocols for pancreatic resection used at our centre. We recorded the perioperative outcome along with demographics, indications for surgery, and pre- and intra-operative factors of PD. Post-operative pancreatic fistulae were evident in 4 patients. Two patients had hepaticojejunostomy leak. One patient had chyle leak. Three patients had infection at the surgical site. One patient had post-operative pneumonia leading to mortality. None of the patients had post-op haemorrhage. The surgeon volume and surgeon experience may have minimal contributing factor in post-operative morbidity, especially if there is availability of well-equipped ICU and imaging facilities, along with well-experienced personnel like oncosurgeon, anaesthesiologist, intensivist, radiologist, and nursing staff. There is a need of a multicentre study from Tier-II city hospitals/low-volume centres and high-volume centres to come with perioperative surgical outcomes following PD.

Inferior Outcomes on the Waiting List in Low-Volume Pediatric Heart Transplant Centers

Low case volume has been associated with poor outcomes in a wide spectrum of procedures. Our objective was to study the association of low case volume and worse outcomes in pediatric heart transplant centers, taking the novel approach of including waitlist outcomes in the analysis. We studied a cohort of 6482 candidates listed in the Organ Procurement and Transplantation Network for pediatric heart transplantation between 2002 and 2014; 4665 (72%) of the candidates underwent transplantation. Candidates were divided into groups according to the average annual transplantation volume of the listing center during the study period: more than 10, six to 10, three to five, or fewer than three transplantations. We used multivariate Cox regression analysis to identify independent risk factors for waitlist and posttransplantation mortality. Of the 6482 candidates, 24% were listed in low-volume centers (fewer than three annual transplantations). Of these listed candidates in low-volume centers, only 36% received a transplant versus 89% in high-volume centers (more than 10 annual transplantations) (p < 0.001). Listing at a low-volume center was the most significant risk factor for waitlist death (hazard ratio [HR] 4.5, 95% confidence interval [CI] 3.5-5.7 in multivariate Cox regression and HR 5.6, CI 4.4-7.3 in multivariate competing risk regression) and was significant for posttransplantation death (HR 1.27, 95% CI 1.0-1.6 in multivariate Cox regression). During the study period, one-fourth of pediatric transplant candidates were listed in low-volume transplant centers. These children had a limited transplantation rate and a much greater risk of dying while on the waitlist.

Poor outcomes for children on the wait list at low-volume kidney transplant centers in the United States

BACKGROUND

Low case volume has been associated with worse survival outcomes in solid organ transplantation. Our aim was to analyze wait-list outcomes in conjunction with posttransplant outcomes.

METHODS

We studied a cohort of 11,488 candidates waitlisted in the Organ Procurement and Transplantation Network (OPTN) for pediatric kidney transplant between 2002 and 2014, including both deceased- and living-donor transplants; 8757 (76 %) candidates received a transplant. Candidates were divided into four groups according to the average volume of yearly transplants performed in the listing center over a 12-year period: more than ten, six to nine, three to five, and fewer than three. We used multivariate Cox regression analysis to identify independent risk factors for wait list and posttransplant mortality.

RESULTS

Twenty-seven percent of candidates were listed at low-volume centers in which fewer than three transplants were performed annually. These candidates had a limited transplant rate; only 49 % received a transplant versus 88 % in high-volume centers (more than ten transplants annually) (p < 0.001). Being listed at a low-volume center showed a fourfold increased risk for death while on the wait list [hazard ratio (HR) 4.0 in multivariate Cox regression and 6.1 in multivariate competing risk regression]. It was not a significant risk factor for posttransplant death in multivariate Cox regression.

CONCLUSIONS

Pediatric transplant candidates are listed at low-volume transplant centers are transplanted less frequently and have a much greater risk of dying while on the wait list. Further studies are needed to elucidate the reasons behind the significant outcome differences.

Attitudes of Canadian and U.S. Neurologists Regarding Carotid Endarterectomy for Asymptomatic Stenosis

Background:

The American Heart Association carotid endarterectomy (CE) guidelines endorse CE for asymptomatic carotid stenosis if the procedure can be performed with low morbidity. However, the Canadian Stroke Consortium has published a consensus against CE for asymptomatic stenosis. The views of practicing neurologists in the two countries on this subject are unclear.

Methods:

A survey was undertaken of 270 neurologists from either Florida or Indiana and 180 neurologists from either Ontario or Quebec.

Results:

The survey was returned by 36% of neurologists. Both Florida (65%) and Indiana neurologists (35%) were significantly more likely than Canadian neurologists (11%) to sometimes/often refer patients for surgery(p<0.001). Neurologists from Florida relied more on noninvasive methods of carotid stenosis assessment (36%) than Canadian neurologists (12%, p=0.003), who preferred angiography. Neurologists from Florida more often cited medicolegal concerns as a reason for referring patients for surgery (27%), compared to Canadian neurologists (3%, p=0.0001).

Conclusions:

Practices pertaining to carotid stenosis evaluation and management differ both regionally and by country. Canadian neurologists refer fewer asymptomatic patients for CE and rely more on angiography as a preoperative diagnostic tool. The potential of medicolegal liability is a greater force in clinical decision-making for certain U.S. neurologists, compared to their Canadian counterparts. These differences may partly explain the variations in CE utilization in the two countries.

What Should We Do with Asymptomatic Carotid Stenosis?

The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.

Temporal trends in safety of carotid endarterectomy in asymptomatic patients: systematic review

OBJECTIVE

To systematically review temporal changes in perioperative safety of carotid endarterectomy (CEA) in asymptomatic individuals in trial and registry studies.

METHODS

The MEDLINE and EMBASE databases were searched using the terms "carotid" and "endarterectomy" and "asymptomatic" from 1947 to August 23, 2014. Articles dealing with 50%-99% stenosis in asymptomatic individuals were included and low-volume studies were excluded. The primary endpoint was 30-day stroke or death and the secondary endpoint was 30-day all-cause mortality. Statistical analysis was performed using random-effects meta-regression for registry data and for trial data graphical interpretation alone was used.

RESULTS

Six trials (n = 4,431 procedures) and 47 community registries (n = 204,622 procedures) reported data between 1983 and 2013. Registry data showed a significant decrease in postoperative stroke or death incidence over the period 1991-2010, equivalent to a 6% average proportional annual reduction (95% credible interval [CrI] 4%-7%; p < 0.001). Considering postoperative all-cause mortality, registry data showed a significant 5% average proportional annual reduction (95% CrI 3%-9%; p < 0.001). Trial data showed a similar visual trend.

CONCLUSIONS

CEA is safer than ever before and high-volume registry results closely mirror the results of trials. New benchmarks for CEA are a stroke or death risk of 1.2% and a mortality risk of 0.4%. This information will prove useful for quality improvement programs, for health care funders, and for those re-examining the long-term benefits of asymptomatic revascularization in future trials.

Pediatric Liver Transplant Center Volume and the Likelihood of Transplantation

BACKGROUND

Low case volume has been associated with poorer surgical outcomes in a multitude of surgical procedures. We studied the association among low case volume, outcomes, and the likelihood of pediatric liver transplantation.

METHODS

We studied a cohort of 6628 candidates listed in the Organ Procurement and Transplantation Network for primary pediatric liver transplantation between 2002 and 2012; 4532 of the candidates went on to transplantation. Candidates were divided into groups according to the average volume of yearly transplants performed in the listing center over 10 years: >15, 10 to 15, 5 to 9, and <5. We used univariate and multivariate Cox regression analyses with bootstrapping on transplant recipient data and identified independent recipient and donor risk factors for wait-list and posttransplant mortality.

RESULTS

38.5% of the candidates were listed in low-volume centers, those in which <5 transplants were performed annually. These candidates had severely reduced likelihood of transplantation with only 41% receiving a transplant. For the remaining candidates, listed at higher volume centers, the transplant rate was 85% (P < .001). Being listed at a low-volume center was a significant risk factor in multivariate Cox regression analysis for both wait-list mortality (hazard ratio, 3.27; confidence interval, 2.53-4.23) and posttransplant mortality (hazard ratio, 2.21; confidence interval, 1.43-3.40).

CONCLUSIONS

38.5% of pediatric transplant candidates are listed in low-volume transplant centers and have lower likelihood of transplantation and poorer outcomes. If further studies substantiated these findings, we would advocate consolidating pediatric liver transplantation in higher volume centers.

Closing the Gap Between Research and Clinical Practice

Evidence-based practice and the application of research findings to practice is a major focus of attention in health care today. The quantification of variations in service delivery and the economic implications of these variations contribute to the pressure on clinicians to provide evidence-based care whenever possible. Awareness of the development of evidence-based practice (EBP), the need for EBP, factors that affect EBP, the methods used to translate research into practice, EBP quality indicators, barriers to EBP, and benefits of EBP will assist clinicians in the effective use of evidence-based information in the care of their patients.

Volume-outcome relationships in neurosurgery

For a variety of neurosurgical conditions, increasing surgeon and hospital volumes correlate with improved outcomes, such as mortality, complication rates, length of stay, hospital charges, and discharge disposition. Neurosurgeons can improve patient outcomes at the population level by changing practice and referral patterns to regionalize care for select conditions at high-volume specialty treatment centers. Individual practitioners should be aware of where they fall on the volume spectrum and understand the implications of their practice and referral habits on their patients.

Carotid Endarterectomy: A Review

Background:

Since the validation of carotid endarterectomy (CEA) as an effective means of stroke prevention, there has been renewed interest in its best indications and methods, as well as in how it compares to carotid angioplasty and stenting (CAS). This review examines these topics, as well as the investigation of carotid stenosis and the role of auditing and reporting CEAresults.

Investigation:

Brain imaging with CTor MRI should be obtained in patients considered for CEA, in order to document infarction and rule out mass lesions. Carotid investigation begins with ultrasound and, if results agree with subsequent, good-quality MRAor CTangiography, treatment can be planned and catheter angiography avoided. An equally acceptable approach is to proceed directly from ultrasound to catheter angiography, which is still the gold-standard in carotid artery assessment.

Indications:

Appropriate patients for CEA are those symptomatic with transient ischemic attacks or nondisabling stroke due to 70-99% carotid stenosis; the maximum allowable stroke and death rate being 6%. Uncertain candidates for CEA are those with 50 - 69% symptomatic stenosis, and those with asymptomatic stenosis ≥ 60% but, if selected carefully on the basis of additional risk factors (related to both the carotid plaque and certain patient characteristics), some will benefit from surgery. Asymptomatic patients will only benefit if surgery can be provided with exceptionally low major complication rates (3% or less). Inappropriate patients are those with less than 50% symptomatic or 60% asymptomatic stenosis, and those with unstable medical or neurological conditions.

Techniques:

Carotid endarterectomy can be performed with either regional or general anaesthesia and, for the latter, there are a number of monitoring techniques available to assess cerebral perfusion during carotid cross-clamping. While monitoring cannot be considered mandatory and no single monitoring technique has emerged as being clearly superior, EEG is most commonly used. “Eversion” endarterectomy is a variation in surgical technique, and there is some evidence that more widely practiced patch closure may reduce the acute risk of operative stroke and the longer-term risk of recurrent stenosis.

Carotid angioplasty and stenting:

Experience with this endovascular and less invasive procedure grows, and its technology continues to evolve. Some experienced therapists have reported excellent results in case series and a number of randomized trials are now underway comparing CAS to CEA. However, at this time it is premature to incorporate CAS into routine practice replacing CEA.

Auditing:

It has been shown that auditing of CEA indications and results with regular feed-back to the operating surgeons can significantly improve the performance of this operation. Carotid endarterectomy auditing is recommended on both local and regional levels.

Methodological considerations in observational comparative effectiveness research for implantable medical devices: an epidemiologic perspective

Medical devices play a vital role in diagnosing, treating, and preventing diseases and are an integral part of the health-care system. Many devices, including implantable medical devices, enter the market through a regulatory pathway that was not designed to assure safety and effectiveness. Several recent studies and high-profile device recalls have demonstrated the need for well-designed, valid postmarketing studies of medical devices. Medical device epidemiology is a relatively new field compared with pharmacoepidemiology, which for decades has been developed to assess the safety and effectiveness of medications. Many methodological considerations in pharmacoepidemiology apply to medical device epidemiology. Fundamental differences in mechanisms of action and use and in how exposure data are captured mean that comparative effectiveness studies of medical devices often necessitate additional and different considerations. In this paper, we discuss some of the most salient issues encountered in conducting comparative effectiveness research on implantable devices. We discuss special methodological considerations regarding the use of data sources, exposure and outcome definitions, timing of exposure, and sources of bias.

Surgical specialty and outcomes for carotid endarterectomy: evidence from the National Surgical Quality Improvement Program

BACKGROUND

Carotid endarterectomy (CEA) has been performed since the 1950s and remains one of the most common surgical procedures in the United States. The procedure is performed by cardiothoracic, general, neurologic, and vascular surgeons. This study uses data from the National Surgical Quality Improvement Program (NSQIP) to examine the outcomes after CEA when performed by general or vascular surgeons.

MATERIALS AND METHODS

Data included 34,493 CEAs from years 2005 to 2010 recorded in the NSQIP database. Primary outcomes measured were length of stay, 30-d mortality, surgical site infection, cerebrovascular accident, myocardial infarction, and blood transfusion requirement. Secondary outcomes measured were the remaining intraoperative outcomes from the NSQIP database.

RESULTS

After controlling for patient and surgical characteristics, patients treated by general surgeons did not have a significantly different LOS or 30-d mortality than those treated by vascular surgeons. Patients of general surgeons had nearly twice the risk of acquiring a surgical site infection (odds ratio [OR] = 1.94; P = 0.012), >1.5 times the risk of cerebrovascular accident (OR = 1.56; P = 0.008), and >1.8 times the risk of blood transfusion (OR = 1.85; P = 0.017) than those of vascular surgeons. Patients of general surgeons had less than half the risk of having a myocardial infarction (OR = 0.34; P = 0.031) than those of vascular surgeons.

CONCLUSIONS

Surgical specialty is associated with a wide range of postoperative outcomes after CEA. Additional research is needed to explore practice and cultural differences across surgical specialty that may lead to outcome differences.

Operative experience of surgery residents: trends and challenges

OBJECTIVE

To evaluate trends in operative experience and to determine the effect of establishing the Surgical Council on Resident Education (SCORE) operative classification system on changes in operative volume among graduating surgery residents.

DESIGN

The general surgery operative logs of graduating surgery residents from 2005 were retrospectively compared with residents who completed training in 2010 and 2011. Nonparametric statistical analyses were used (Mann-Whitney and median test) with significance set at p<0.01.

PARTICIPANTS

A total of 1022 residents completing residency in 2005 were compared with 1923 residents completing training in 2010-2011.

RESULTS

Total operations reported increased from a median of 1023 to 1238 (21%) between 2005 and 2010-2011 (p<0.001). Cases increased in most SCORE categories. The median numbers of total, basic, and complex laparoscopic operations increased by 49%, 37%, and 82%, respectively, over the 5-year interval (p<0.001). Open cavitary (thoracic + abdominal) operations decreased by 5%, whereas other major operations increased by 35% (both p<0.001). The frequency of discrete operations done at least 10 times during residency did not change. The median number of SCORE essential-common operations performed ranged from 1 to 107, whereas essential-uncommon operations ranged from 0 to 4. Twenty-three of 67 SCORE essential-common operations (34%) had a median of less than 5 and 4 had a median of 0.

CONCLUSIONS

The operative volume of graduating surgical residents has increased by 21% since 2005; however, the number of operations done 10 times or greater has not changed. Although open cavitary procedures continue to decline, there has been a large increase in endoscopy, complex laparoscopic, and other major operations. Some essential-common operations continue to be performed infrequently. These results suggest that education in the operating room must improve and alternate methods for teaching infrequently performed procedures are needed.

Unchanged safety outcomes in deep brain stimulation surgery for Parkinson disease despite a decentralization of care

OBJECT

Early work on deep brain stimulation (DBS) surgery, when procedures were mostly carried out in a small number of high-volume centers, demonstrated a relationship between surgical volume and procedural safety. However, over the past decade, DBS has become more widely available in the community rather than solely at academic medical centers. The authors examined the Nationwide Inpatient Sample (NIS) to study the safety of DBS surgery for Parkinson disease (PD) in association with this change in practice patterns.

METHODS

The NIS is a stratified sample of 20% of all patient discharges from nonfederal hospitals in the United States. The authors identified patients with a primary diagnosis of PD (332.0) and a primary procedure code for implantation/replacement of intracranial neurostimulator leads (02.93) who underwent surgery between 2002 and 2009. They analyzed outcomes using univariate and hierarchical, logistic regression analyses.

RESULTS

The total number of DBS cases remained stable from 2002 through 2009. Despite older and sicker patients undergoing DBS, procedural safety (rates of non-home discharges, complications) remained stable. Patients at low-volume hospitals were virtually indistinguishable from those at high-volume hospitals, except that patients at low-volume hospitals had slightly higher comorbidity scores (0.90 vs 0.75, p < 0.01). Complications, non-home discharges, length of hospital stay, and mortality rates did not significantly differ between low- and high-volume hospitals when accounting for hospital-related variables (caseload, teaching status, location).

CONCLUSIONS

Prior investigations have demonstrated a robust volume-outcome relationship for a variety of surgical procedures. However, the present study supports safety of DBS at smaller-volume centers. Prospective studies are required to determine whether low-volume centers and higher-volume centers have similar DBS efficacy, a critical factor in determining whether DBS is comparable between centers.

Protected stent-assisted carotid angioplasty in symptomatic high-risk NASCET-ineligible patients

BACKGROUND AND OBJECTIVES

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) excluded patients with severe medical, angiographic and neurological risk factors. The aim of this study is to determine the safety and efficacy of protected stent angioplasty in these high-risk patients.

METHODS

Sixty-eight consecutive symptomatic NASCET-ineligible patients underwent protected stent-assisted carotid angioplasty. Patients were classified according to surgical risk based on Sundt criteria, and stratified for medical therapy according to stroke risk. Twenty-one patients were classified as Sundt grade 3 (30.8%) and 36 patients as grade 4 (52.9%).

RESULTS

The procedure was technically successful in all patients, with stenosis averaging 82.1% (range 70-99%) before the procedure and 6.3% (range 0-30%) after treatment. There were no periprocedural deaths or major strokes, but two patients had minor, non-embolic stokes (2.9%). During a mean clinical follow-up of 14.4 months (range 1-30 months), no new neurological events occurred in relation to the treated vascular territory.

CONCLUSIONS

Carotid angioplasty with cerebral protection can be performed safely in high-risk patients. During the follow-up period, angioplasty was highly effective in terms of stroke prevention and arterial patency.

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: a retrospective case series

CONTEXT

Perioperative outcome of pancreaticoduodenectomy is related to work load volume and to whether the procedure is carried out in a tertiary specialized hepato-pancreatico-biliary (HPB) unit.

OBJECTIVE

To evaluate the perioperative outcome associated with pancreaticoduodenectomy in a newly established HPB unit.

PATIENTS

Analysis of 32 patients who underwent pancreaticoduodenectomy (PD) for benign and malignant indications.

DESIGN

Retrospective collection of data on preoperative, intraoperative and postoperative care of all patients undergoing PD.

RESULTS

Thirty-two patients (16 male and 16 female) with a mean age of 59.5±12.7years were analyzed. The overall morbidity rate was high at 53%. The most common complication was wound infection (n=11; 34.4%). Pancreatic and biliary leaks were seen in 5 (15.6%) and 2 (6.2%) cases, respectively, while delayed gastric emptying was recorded in 7 (21.9%). The female sex was not associated with increased morbidity. Presence of co-morbid illness, pylorus-preserving PD, intra-operative blood loss ⩾1L, and perioperative blood transfusion were not associated with significantly increased morbidity. The overall hospital mortality was 3.1% and the cumulative overall (OS) and disease free survival (DFS) at 1year were 80% and 82.3%, respectively. The cumulative overall survival for pancreatic cancer vs ampullary tumor at 1year were 52% vs 80%, respectively.

CONCLUSION

PD is associated with a low risk of operative death when performed by specialized HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate remains high, mostly due to wound infection. Further improvement by reducing postoperative infection may help curtail the high postoperative morbidity.

Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery

Background

The aim was to investigate whether a relationship existed between case volume and outcome for lower limb vascular surgical procedures.

Methods

PubMed, Embase, the Cochrane Library and Google Scholar were searched for all articles on population-based studies on the volume–outcome relationship for lower limb vascular surgery at hospital level. Outcomes were mortality and subsequent amputation after lower limb vascular surgery. The data were subjected to meta-analysis by outcome.

Results

Some 452 093 patients from ten studies were included in the systematic review and five studies were included in meta-analyses. Seven of these articles found a significant positive hospital–volume outcome relationship. The pooled effect estimate for mortality was odds ratio (OR) 0·81 (95 per cent confidence interval 0·71 to 0·91) and that for amputation was OR 0·88 (0·79 to 0·98), with better results being found after surgery at higher-volume hospitals. Significant heterogeneity was seen in the data.

Conclusion

Higher-volume hospitals were associated with reduced amputation and mortality rates after lower limb vascular surgery. These data were not as conclusive as those for other vascular surgical procedures owing to significant heterogeneity.

Risk factors associated with major cerebrovascular complications after intracranial stenting

BACKGROUND

There are limited data on the relationship between patient and site characteristics and clinical outcomes after intracranial stenting.

METHODS

We performed a multivariable analysis that correlated patient and site characteristics with the occurrence of the primary endpoint (any stroke or death within 30 days of stenting or stroke in the territory of the stented artery beyond 30 days) in 160 patients enrolled in this stenting registry. All patients presented with an ischemic stroke, TIA, or other cerebral ischemic event (e.g., vertebrobasilar insufficiency) in the territory of a suspected 50-99% stenosis of a major intracranial artery while on antithrombotic therapy.

RESULTS

Cerebral angiography confirmed that 99% (158/160) of patients had a 50-99% stenosis. In multivariable analysis, the primary endpoint was associated with posterior circulation stenosis (vs anterior circulation) (hazard ratio [HR] 3.4, 95% confidence interval [CI] 1.2-9.3, p = 0.018), stenting at low enrollment sites (< 10 patients each) (vs high enrollment site) (HR 2.8, 95% CI 1.1-7.6, p = 0.038), < or = 10 days from qualifying event to stenting (vs > or = 10 days) (HR 2.7, 95% CI 1.0-7.8, p = 0.058), and stroke as a qualifying event (vs TIA/other) (HR 3.2, 95% CI 0.9-11.2, p = 0.064). There was no significant difference in the primary endpoint based on age, gender, race, or percent stenosis (50-69% vs 70-99%).

CONCLUSIONS

Major cerebrovascular complications after intracranial stenting may be associated with posterior circulation stenosis, low volume sites, stenting soon after a qualifying event, and stroke as the qualifying event. These factors will need to be monitored in future trials of intracranial stenting.

Model for the reconfiguration of specialized vascular services

Background

This article built on previous work to develop an algorithm for elective abdominal aortic aneurysm (AAA) repair and carotid endarterectomy (CEA), with the aim of improving patient survival by regionalization of services. Vascular procedures were used as an example of specialized surgical services.

Methods

A model was generated based on a national data set that incorporated the statistical demonstration of procedural safety, hospital annual surgical case volume, and travel distance and time. Elective AAA repair was used to construct a hub-and-spoke model that was tested against CEA. The impact of the model was quantified in terms of mortality rates, and travel distance and time.

Results

Only 48 vascular hubs were required to provide adequate coverage in England, with the majority of patients travelling for less than 1 h to access inpatient vascular surgery. The model predicted a reduction in the number of deaths from elective surgery for AAA (P &lt; 0·001) and CEA (P = 0·016).

Conclusion

Adoption of this strategic model may lead to improved outcome after AAA and CEA. It could be used as a model for the regionalization of specialized surgery. The model does not take into account the complexity of providing a comprehensive vascular service in every locality.

Multidetector-row computed tomography in evaluation of atherosclerotic carotid plaques complicated with intraplaque hemorrhage

Our aim was to determine the sensitivity and specificity of multidetector-row computed tomography (CT) in detecting atherosclerotic carotid plaques complicated with intraplaque hemorrhage. We examined carotid plaques from 31 patients operated for carotid artery stenosis. Results of preoperative multidetector-row CT analysis of carotid plaques were compared with results of histological analysis of the same plaque areas. Carotid endarterectomy was performed within 1 week of multidetector-row CT. American Heart Association classification of atherosclerotic plaques was applied for histological classification. Median tissue density of carotid plaques complicated with intraplaque hemorrhage was 22 Hounsfield units (HU). Median tissue density of noncalcified segments of uncomplicated plaques was 59 HU (p=0.0062). The highest tissue density observed for complicated plaques was 31 HU. Multidetector-row CT detected plaques complicated with hemorrhage with sensitivity of 100% and specificity of 64.7%, with tissue density of 31 HU as a threshold value. Multidetector-row CT showed a high level of sensitivity and a moderate level of specificity in detecting atherosclerotic carotid plaques complicated with hemorrhage.

Patients Requiring Dialysis are not at Risk of Greater Complication after Carotid Endarterectomy

Stroke is a leading cause of disability and the third leading cause of death. Landmark studies have demonstrated that carotid endarterectomy (CEA) reduced the risk of stroke among selected patients with carotid stenosis. Renal insufficiency is a known risk factor for stroke and appears to be an independent risk factor for poor outcome after CEA. Studies have reported high morbidity and mortality after CEA in patients on dialysis. However, our experience has been that patients undergoing dialysis have no greater risk for a poor outcome. This study was a retrospective review of our CEA patients to ascertain our morbidity and mortality results in dialysis patients versus patients not on dialysis. An institutional retrospective chart review of CEAs from January 1999 to December 2007 was conducted. Patients on dialysis at the time of CEA were identified. Their charts were reviewed for complications 30 days after surgery. This was compared with our total experience with CEAs from January 1999 to December 2007. Of the 28 patients undergoing CEA while dialysis dependent, none had complications in the 30-day postoperative period. This compares favorably with the cohort of all CEAs by the same surgeons. In that group, 13 complications were identified (13 of 1,141). Patients undergoing dialysis are at no greater risk for complications when undergoing carotid endarterectomy than the general population.

The impact of surgical specialty on outcomes for carotid endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is one of the most frequently performed surgical procedures in the United States. Traditionally, this procedure has been performed by surgeons in at least four specialties. The purpose of this study was to examine the effect of surgeon specialty on the long-term outcomes of CEA among patients receiving the procedure in Pennsylvania.

MATERIALS AND METHODS

Data included 17,635 patient admissions for CEA performed between 1995 and 1997, and patient readmission data for the 5-y follow-up period ending in 2002. Five-y outcomes for these patients were compared between vascular, cardiothoracic, general, and neurosurgeons. The primary outcome measures were mortality, stroke, combined stroke and mortality, transient ischemic attack (TIA), and re-occlusion of the ipsilateral artery. Secondary outcomes measured were length of stay and total charges.

RESULTS

Using general surgeon as the reference group, and controlling for age, race, severity, and admission type, we found no significant difference across surgical specialties in overall mortality at 5 y post-CEA. Patients treated by vascular surgeons were found to have significantly fewer (P=0.012) strokes and significantly lower re-occlusion rate (P=0.021) at 5 y compared with patients of general surgeons. Patients treated by vascular surgeons also had significantly shorter hospital stay (P<0.0001) but significantly higher charges (P<0.0001) relative to general surgeons.

CONCLUSIONS

These results suggest that there are significant differences in outcomes following carotid endarterectomy according to surgeon training. Additional research is needed to explore differences across specialties that may be driving outcomes and to explore the role of surgeon volume at the profession level and cross-volume effects on CEA outcomes.

The Relationship between Hospital Case Volume and Outcome from Carotid Endartectomy in England from 2000 to 2005

OBJECTIVES

To assess the outcome of carotid endarterectomy in England with respect to the hospital case-volume.

METHODS

Data were from English Hospital Episode Statistics (2000-2005). Admissions were classified as elective or emergency. Risk-adjusted data were analysed through modelling of death rate, complication rate and length of admission with regard to the year of procedure and annual hospital volume of surgery. Hospitals with elevated death rates were identified and the evidence quantified that they had outlying mortality rates.

RESULTS

There were 280,081 diagnoses of extra-cranial atherosclerotic arterial disease in which 18,248 CEA were performed. The mean mortality rates were 1.04% for elective and 3.16% for emergency CEA. A volume-related improvement in mortality (p=0.047) was seen for elective CEA. Length of stay decreased as annual volume increased for elective and emergency CEA (p<0.001). 20% of the operations were performed in 67.1% of the hospitals, each of which performed fewer than 10 CEA per annum. A number of hospitals had elevated death rates.

CONCLUSIONS

Volume-related improvements in outcome were demonstrated for elective CEA. Minimum volume-criteria of 35 CEA per annum should be established in England. Hospitals performing low annual volumes of surgery should consider arrangements to network services.