1
|
Patel RJ, Dodo-Williams TS, Sendek G, Elsayed N, Malas MB. Non-White Patients Have a Higher Risk of Stroke Following Transcarotid Artery Revascularization. J Surg Res 2024; 300:71-78. [PMID: 38796903 DOI: 10.1016/j.jss.2024.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 01/28/2024] [Accepted: 04/14/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Carotid artery revascularization has traditionally been performed by either a carotid endarterectomy or carotid artery stent. Large data analysis has suggested there are differences in perioperative outcomes with regards to race, with non-White patients (NWP) having worse outcomes of stroke, restenosis and return to the operating room (RTOR). The introduction of transcarotid artery revascularization (TCAR) has started to shift the paradigm of carotid disease treatment. However, to date, there have been no studies assessing the difference in postoperative outcomes after TCAR between racial groups. METHODS All patients from 2016 to 2021 in the Vascular Quality Initiative who underwent TCAR were included in our analysis. Patients were split into two groups based on race: individuals who identified as White and a second group that comprised all other races. Demographic and clinical variables were compared using Student's t-Test and chi-square test of independence. Logistic regression analysis was performed to determine the impact of race on perioperative outcomes of stroke, myocardial infarction (MI), death, restenosis, RTOR, and transient ischemic attack (TIA). RESULTS The cohort consisted of 22,609 patients: 20,424 (90.3%) White patients and 2185 (9.7%) NWP. After adjusting for sex, diabetes, hypertension, coronary artery disease, history of prior stroke or TIA, symptomatic status, and high-risk criteria at time of TCAR, there was a significant difference in postoperative stroke, with 63% increased risk in NWP (odds ratio = 1.63, 95% confidence interval: 1.11-2.40, P = 0.014). However, we found no significant difference in the odds of MI, death, postoperative TIA, restenosis, or RTOR when comparing NWP to White patients. CONCLUSIONS This study demonstrates that NWP have increased risk of stroke but similar outcomes of death, MI, RTOR and restenosis following TCAR. Future studies are needed to elucidate and address the underlying causes of racial disparity in carotid revascularization.
Collapse
Affiliation(s)
- Rohini J Patel
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Taiwo S Dodo-Williams
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Gabriela Sendek
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Nadin Elsayed
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California
| | - Mahmoud B Malas
- Center for Learning and Excellence in Vascular & Endovascular Research (CLEVER), Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, San Diego, California.
| |
Collapse
|
2
|
Zil-E-Ali A, Alamarie B, Paracha AW, Samaan F, Aziz F. Systematic review and meta-analysis to assess the racial disparities in the outcomes of carotid endarterectomy in the United States. J Vasc Surg 2024:S0741-5214(24)01213-8. [PMID: 38782214 DOI: 10.1016/j.jvs.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/30/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE Race-based disparities in health care have been related to a myriad of prevailing factors among minorities in the United States. This study aims to study the race-based differences in the outcomes of carotid endarterectomy (CEA). METHODS The PROSPERO database registered the review protocol (CRD42023428253). A systematic English literature review was performed using literature databases PubMed and Scopus from inception till June 2023. The review was designed on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included studies reporting mortality, stroke, or composite outcome of mortality and stroke after CEA for carotid artery disease, regardless of any degree of stenosis including both symptomatic and asymptomatic patients. The risk of bias was evaluated utilizing the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for the overall mortality was computed, and a P value of < .05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS Twelve studies were identified which included a total of 574,055 patients who underwent CEA from 1998 to 2022. Eleven of 12 studies reported 30-day mortality as an outcome for patients undergoing CEA in which 524,708 patients (92.5%) were White and 42,797 (7.5%) were non-White. The overall pooled OR indicated a statistical significance in 30-day mortality between White and non-White patients undergoing CEA (OR, 1.73; 95% confidence interval [CI], 1.37-2.18; P = .011) with substantial heterogeneity (I2 = 56.3%). Eleven of 12 studies reported stroke as an outcome for patients undergoing CEA in which 524,708 patients (92.5%) were White and 42,801 (7.5%) were non-White. The overall pooled OR indicated no statistical significance in stroke between White and non-White patients undergoing CEA (OR, 1.46; 95% CI, 1.28-1.65; P = .111) with moderate heterogeneity (I2 = 35.9%). Five of 12 studies reported composite mortality or stroke as an outcome for patients undergoing CEA. The overall pooled OR indicated no statistical significance in composite mortality or stroke between White and non-White patients undergoing CEA (OR, 1.40; 95% CI, 1.24-1.59; P = .467) with no heterogeneity (I2 = 0.0%). CONCLUSIONS Non-White patients have a relatively higher risk of mortality; however, no significant difference was observed between the racial groups in terms of stroke or a composite outcome of mortality or stroke. The odds of mortality in non-White patients have been persistent throughout recent studies.
Collapse
Affiliation(s)
- Ahsan Zil-E-Ali
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA.
| | - Billal Alamarie
- Office of Medical Education, Penn State College of Medicine, Penn State University, State College, PA
| | - Abdul Wasay Paracha
- Office of Medical Education, Penn State College of Medicine, Penn State University, State College, PA
| | - Fadi Samaan
- Office of Medical Education, Penn State College of Medicine, Penn State University, State College, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, PA
| |
Collapse
|
3
|
Bose S, McDermott KM, Keegan A, Black JH, Drudi LM, Lum YW, Zarkowsky DS, Hicks CW. Socioeconomic status fails to account for worse outcomes in non-Hispanic black patients undergoing carotid revascularization. J Vasc Surg 2023; 78:1248-1259.e1. [PMID: 37419427 PMCID: PMC10615195 DOI: 10.1016/j.jvs.2023.06.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/08/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE Previous studies have reported an association of Black race with worse carotid revascularization outcomes, but rarely include socioeconomic status as a confounding covariate. We aimed to assess the association of race and ethnicity with in-hospital and long-term outcomes following carotid revascularization before and after accounting for socioeconomic status. METHODS We identified non-Hispanic Black and non-Hispanic white patients who underwent carotid endarterectomy, transfemoral carotid stenting, or transcarotid artery revascularization between 2003 and 2022 in the Vascular Quality Initiative. Primary outcomes were in-hospital stroke/death and long-term stroke/death. Multivariable logistic regression and Cox proportional hazards models were used to assess the association of race with perioperative and long-term outcomes after adjusting for baseline characteristics using a sequential model approach without and with consideration of Area Deprivation Index (ADI), a validated composite marker of socioeconomic status. RESULTS Of 201,395 patients, 5.1% (n = 10,195) were non-Hispanic Black, and 94.9% (n = 191,200) were non-Hispanic white. Mean follow-up time was 3.4±0.01 years. A disproportionately high percentage of Black patients were living in more socioeconomically deprived neighborhoods relative to their white counterparts (67.5% vs 54.2%; P < .001). After adjusting for demographic, comorbidity, and disease characteristics, Black race was associated with greater odds of in-hospital (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.10-1.40) and long-term stroke/death (adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.23). These associations did not substantially change after additionally adjusting for ADI; Black race was persistently associated with greater odds of in-hospital (aOR, 1.23; 95% CI, 1.09-1.39) and long-term stroke/death (aHR, 1.12; 95% CI, 1.03-1.21). Patients living in the most deprived neighborhoods were at greater risk of long-term stroke/death compared with patients living in the least deprived neighborhoods (aHR, 1.19; 95% CI, 1.05-1.35). CONCLUSIONS Non-Hispanic Black race is associated with worse in-hospital and long-term outcomes following carotid revascularization despite accounting for neighborhood socioeconomic deprivation. There appears to be unrecognized gaps in care that prevent Black patients from experiencing equitable outcomes following carotid artery revascularization.
Collapse
Affiliation(s)
- Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Alana Keegan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, MD
| | - James H. Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura M. Drudi
- Division of Vascular Surgery, Department of Surgery, Centre Hospitalier de l’Université de Montréal, Montreal, Québec, Canada
| | - Ying-Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
4
|
Tran Z, Byun J, Lee HY, Boggs H, Tomihama EY, Kiang SC. Bias in artificial intelligence in vascular surgery. Semin Vasc Surg 2023; 36:430-434. [PMID: 37863616 DOI: 10.1053/j.semvascsurg.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 10/22/2023]
Abstract
Application of artificial intelligence (AI) has revolutionized the utilization of big data, especially in patient care. The potential of deep learning models to learn without a priori assumption, or without prior learning, to connect seemingly unrelated information mixes excitement alongside hesitation to fully understand AI's limitations. Bias, ranging from data collection and input to algorithm development to finally human review of algorithm output affects AI's application to clinical patient presents unique challenges that differ significantly from biases in traditional analyses. Algorithm fairness, a new field of research within AI, aims to mitigate bias by evaluating the data at the preprocessing stage, optimizing during algorithm development, and evaluating algorithm output at the postprocessing stage. As the field continues to develop, being cognizant of the inherent biases and limitations related to black box decision making, biased data sets agnostic to patient-level disparities, wide variation of present methodologies, and lack of common reporting standards will require ongoing research to provide transparency to AI and its applications.
Collapse
Affiliation(s)
- Zachary Tran
- Department of Surgery, Division of Vascular Surgery, Linda University School of Medicine, 11175 Campus Street, Suite 21123, Loma Linda, CA 92350
| | - Julianne Byun
- Department of Surgery, Division of Vascular Surgery, Linda University School of Medicine, 11175 Campus Street, Suite 21123, Loma Linda, CA 92350
| | - Ha Yeon Lee
- Department of Surgery, Division of Vascular Surgery, Linda University School of Medicine, 11175 Campus Street, Suite 21123, Loma Linda, CA 92350
| | - Hans Boggs
- Department of Surgery, Division of Vascular Surgery, Linda University School of Medicine, 11175 Campus Street, Suite 21123, Loma Linda, CA 92350
| | - Emma Y Tomihama
- Department of Surgery, Division of Vascular Surgery, Linda University School of Medicine, 11175 Campus Street, Suite 21123, Loma Linda, CA 92350
| | - Sharon C Kiang
- Department of Surgery, Division of Vascular Surgery, Linda University School of Medicine, 11175 Campus Street, Suite 21123, Loma Linda, CA 92350; Department of Surgery, Division of Vascular Surgery, VA Loma Linda Healthcare System, 11201 Benton Street, Loma Linda, CA 92357.
| |
Collapse
|
5
|
Lee MHY, Li B, Feridooni T, Li PY, Shakespeare A, Samarasinghe Y, Cuen-Ojeda C, Verma R, Kishibe T, Al-Omran M. Racial and ethnic differences in presentation severity and postoperative outcomes in vascular surgery. J Vasc Surg 2023; 77:1274-1288.e14. [PMID: 36202287 DOI: 10.1016/j.jvs.2022.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND We assessed the effect of race and ethnicity on presentation severity and postoperative outcomes in those with abdominal aortic aneurysms (AAAs), carotid artery stenosis (CAS), peripheral arterial disease (PAD), and type B aortic dissection (TBAD). METHODS MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception until December 2020. Two reviewers independently selected randomized controlled trials and observational studies reporting race and/or ethnicity and presentation severity and/or postoperative outcomes for adult patients who had undergone major vascular procedures. They independently extracted the study data and assessed the risk of bias using the Newcastle-Ottawa scale. The meta-analysis used random effects models to derive the odds ratios (ORs) and risk ratios (RRs) and their corresponding 95% confidence intervals (CIs). The primary outcome was presentation severity stratified by the proportion of patients with advanced disease, including ruptured vs nonruptured AAA, symptomatic vs asymptomatic CAS, chronic limb-threatening ischemia vs claudication, and complicated vs uncomplicated TBAD. The secondary outcomes included postoperative all-cause mortality and disease-specific outcomes. RESULTS A total of 81 studies met the inclusion criteria. Black (OR, 4.18; 95% CI, 1.31-13.26), Hispanic (OR, 2.01; 95% CI, 1.85-2.19), and Indigenous (OR, 1.97; 95% CI, 1.39-2.80) patients were more likely to present with ruptured AAAs than were White patients. Black and Hispanic patients had had higher symptomatic CAS (Black: OR, 1.20; 95% CI, 1.04-1.38; Hispanic: OR, 1.32; 95% CI, 1.20-1.45) and chronic limb-threatening ischemia (Black: OR, 1.67; 95% CI, 1.14-2.43; Hispanic: OR, 1.73; 95% CI 1.13-2.65) presentation rates. No study had evaluated the effect of race or ethnicity on complicated TBAD. All-cause mortality was higher for Black (RR, 1.23; 95% CI, 1.01-1.51), Hispanic (RR, 1.90; 95% CI, 1.57-2.31), and Indigenous (RR, 1.24; 95% CI, 1.12-1.37) patients after AAA repair. Postoperatively, Black (RR, 1.54; 95% CI, 1.19-2.00) and Hispanic (RR, 1.54; 95% CI, 1.31-1.81) patients were associated with stroke/transient ischemic attack after carotid revascularization and lower extremity amputation (RR, 1.90; 95% CI, 1.76-2.06; and RR, 1.69; 95% CI, 1.48-1.94, respectively). CONCLUSIONS Certain visible minorities were associated with higher morbidity and mortality across various vascular surgery presentations. Further research to understand the underpinnings is required.
Collapse
Affiliation(s)
- Michael Ho-Yan Lee
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ben Li
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Tiam Feridooni
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Pei Ye Li
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Audrey Shakespeare
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Yasith Samarasinghe
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Cesar Cuen-Ojeda
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Raj Verma
- Royal College of Surgeons Ireland, Dublin, Ireland
| | - Teruko Kishibe
- Health Sciences Library, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
| |
Collapse
|
6
|
Paraskevas KI, Dardik A, Gloviczki P. Racial disparities in vascular care need attention without delay. J Vasc Surg 2023; 77:1289-1291. [PMID: 36948682 DOI: 10.1016/j.jvs.2022.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/16/2022] [Indexed: 03/24/2023]
Affiliation(s)
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, CT
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
7
|
Na S, Mazzaferro N, Xia W, Greenberg P, Beckerman W. Risk Factors for Surgical Site Infections After Lower Extremity Open Revascularization. Ann Vasc Surg 2023; 89:251-260. [PMID: 36404450 DOI: 10.1016/j.avsg.2022.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/01/2022] [Accepted: 09/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Surgical site infection (SSI) is a serious complication of lower extremity open revascularization and is associated with increased morbidity, increased healthcare costs, and decreased postoperative quality of life. The objective of this study was to determine factors associated with an increased risk of developing postoperative SSI in patients undergoing lower extremity revascularization. Associations between SSI and postoperative complications were also identified. METHODS Patients who underwent lower extremity open revascularization from 2014-2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). A multivariate logistic regression analysis was used to determine risk factors associated with SSIs within 30 days of the operation and postoperative complications. Odds ratios (ORs) were adjusted for demographics, preoperative comorbidities, procedure type, and intraoperative variables. RESULTS Ten thousand nine hundred ten patients who underwent lower extremity open revascularization were identified, with a mean age of 67.24 years and of whom 7,318 (67%) were male. Of the 10,910 patients, 922 (8.45%) had an SSI within 30 days of the operation. Risk factors associated with developing SSI included body mass index 25-29.9 (OR, 1.34; 95% confidence interval [CI], 1.08-1.67), body mass index ≥ 30 (OR, 2.12; 95% CI, 1.71-2.62), history of severe chronic obstructive pulmonary disease (OR, 1.47; 95% CI, 1.18-1.84), preprocedural beta-blocker use (OR, 1.25; CI 95%, 1.05-1.49), procedure time > 214 minutes (OR, 1.44; 95% CI, 1.22-1.70), and creatinine > 1.2 (OR 1.03; 95% CI, 0.87-1.21). One factor associated with a decreased risk of developing SSI was male gender (OR, 0.71; 95% CI, 0.60-0.84). Patients who developed an SSI were more likely to have adverse outcomes such as myocardial infarction/stroke, major amputation, bleeding requiring transfusion or secondary procedure, or require a reintervention in the treated segment. CONCLUSIONS There are various patient-related and operative factors that increase the likelihood of developing an SSI after lower extremity open revascularization. These findings indicate that addressing modifiable perioperative SSI risk factors may be beneficial in decreasing rates of SSI and improving postoperative outcomes.
Collapse
Affiliation(s)
- Sungshin Na
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
| | - Natale Mazzaferro
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - Weiyi Xia
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - Patricia Greenberg
- Biostatistics and Epidemiology Services Center, Rutgers School of Public Health, Rutgers University, Piscataway, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers University, Piscataway, NJ
| | - William Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| |
Collapse
|
8
|
Moehl K, Shandal V, Anetakis K, Paras S, Mina A, Crammond D, Balzer J, Thirumala PD. Predicting transient ischemic attack after carotid endarterectomy: The role of intraoperative neurophysiological monitoring. Clin Neurophysiol 2022; 141:1-8. [DOI: 10.1016/j.clinph.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 05/17/2022] [Accepted: 06/07/2022] [Indexed: 11/16/2022]
|
9
|
Mallela DP, Canner JK, Zarkowsky DS, Haut ER, Abularrage CJ, Hicks CW. Association between Race and Perioperative Outcomes after Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis in NSQIP. J Am Coll Surg 2022; 234:65-73. [PMID: 35213462 PMCID: PMC9860456 DOI: 10.1097/xcs.0000000000000016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Previous studies have documented that Black patients have worse outcomes after lower extremity revascularization procedures compared with White patients. However, the association of race on carotid endarterectomy (CEA) outcomes is not well described. The aim of this study was to compare perioperative outcomes of CEA for Black vs White patients with asymptomatic carotid artery stenosis. STUDY DESIGN All patients who underwent CEA for asymptomatic carotid stenosis in the ACS-NSQIP targeted vascular database (2011-2019) were included. Perioperative (30-day) outcomes were compared for Black vs White patients using multivariable logistic regression adjusting for age/sex, comorbidities, and disease characteristics. RESULTS Of 16,764 asymptomatic CEA patients, 95.2% (N = 15,960) were White and 4.8% (N = 804) were Black. Black patients were slightly younger (mean age 71.4 ± 0.1 vs 69.9 ± 0.3 years, P < 0.001) and more frequently had high-grade carotid artery stenosis compared to White patients (79.5% vs 74.0%, p = 0.001). Comorbidities including hypertension, diabetes, kidney disease, congestive heart failure, and coronary artery disease were all more prevalent among Black patients (p ≤ 0.01). Crude perioperative stroke (2.4% vs 1.3%, p = 0.007) and stroke/death (2.6% vs 1.4%, p = 0.003) were higher for Black patients, but myocardial infarction (1.7% vs 1.5%, p = 0.67) and death (0.4% vs 0.2%, p = 0.12) were similar. After adjusting for baseline differences between groups, the risk of perioperative stroke (odds ratio 1.66, 95% CI 1.01 to 2.73) and stroke/death (odds ratio 1.75, 95% CI 1.10 to 2.81) remained significantly higher for Black patients compared with White patients. CONCLUSIONS Black patients undergoing CEA for asymptomatic carotid artery stenosis had more severe stenosis, more comorbidities, and worse perioperative outcomes compared to White patients. Overall, our data suggest substantial differences in the treatment and outcomes of asymptomatic carotid artery stenosis based on race.
Collapse
Affiliation(s)
- Deepthi P Mallela
- From the Division of Vascular Surgery and Endovascular Therapy (Mallela, Abularrage, Hicks), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph K Canner
- the Department of Surgery, Yale University School of Medicine, New Haven, CT (Canner)
| | - Devin S Zarkowsky
- the Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO (Zarkowsky)
| | - Elliott R Haut
- the Division of Acute Care Surgery (Haut), Johns Hopkins University School of Medicine, Baltimore, MD
- the Department of Anesthesiology and Critical Care Medicine (Haut), Johns Hopkins University School of Medicine, Baltimore, MD
- the Department of Emergency Medicine (Haut), Johns Hopkins University School of Medicine, Baltimore, MD
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD (Haut)
- the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Haut)
| | - Christopher J Abularrage
- From the Division of Vascular Surgery and Endovascular Therapy (Mallela, Abularrage, Hicks), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- From the Division of Vascular Surgery and Endovascular Therapy (Mallela, Abularrage, Hicks), Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
10
|
Cardinal T, Strickland BA, Bonney PA, Lechtholz-Zey E, Mendoza J, Pangal DJ, Mack W, Giannotta S, Zada G. Disparities in the Surgical Treatment of Cerebrovascular Pathologies: A Contemporary Systematic Review. World Neurosurg 2021; 158:244-257.e1. [PMID: 34856403 DOI: 10.1016/j.wneu.2021.11.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This systematic review analyzes contemporary literature on racial/ethnic, insurance, and socioeconomic disparities within cerebrovascular surgery in the United States to determine areas for improvement. METHODS We conducted an electronic database search of literature published between January 1990 and July 2020 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for studies analyzing a racial/ethnic, insurance, or socioeconomic disparity within adult cerebrovascular surgery. RESULTS Of 2873 articles screened for eligibility by title and abstract, 970 underwent full-text independent review by 3 authors. Twenty-seven additional articles were identified through references to generate a final list of 47 included studies for analysis. Forty-six were retrospective reviews and 1 was a prospective observational cohort study, thereby comprising Levels III and IV of evidence. Studies investigated carotid artery stenting (11/47, 23%), carotid endarterectomy (22/47, 46.8%), mechanical thrombectomy (8/47, 17%), and endovascular aneurysm coiling or surgical aneurysm clipping (20/47, 42.6%). Minority and underinsured patients were less likely to receive surgical treatment. Non-White patients were more likely to experience a postoperative complication, although this significance was lost in some studies using multivariate analyses to account for complication risk factors. White and privately insured patients generally experienced shorter length of hospital stay, had lower rates of in-hospital mortality, and underwent routine discharge. Twenty-five papers (53%) reported no disparities within at least one examined metric. CONCLUSIONS This comprehensive contemporary systematic review demonstrates the existence of disparity gaps within the field of adult cerebrovascular surgery. It highlights the importance of continued investigation into sources of disparity and efforts to promote equity within the field.
Collapse
Affiliation(s)
- Tyler Cardinal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA.
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Phillip A Bonney
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Elizabeth Lechtholz-Zey
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Jesse Mendoza
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Steven Giannotta
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| |
Collapse
|
11
|
Gender, racial and ethnic disparities in index hospitalization operations for symptomatic carotid stenosis in Texas hospitals. Ann Vasc Surg 2021; 80:152-157. [PMID: 34687890 DOI: 10.1016/j.avsg.2021.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recent literature and societal recommendations support early revascularization of symptomatic carotid patients over the traditional six-week period. Nonetheless, the timing of these interventions can vary widely among populations. The goal of this study is to identify any factors influencing carotid revascularization during the index hospitalization for patients with symptomatic disease. METHODS The Texas Department of State Health Services database was queried to identify all patients > 45 years old admitted to nonfederal Texas Hospitals between 2009 to 2013 with an admission diagnosis of carotid artery stenosis and either transient ischemic attack (TIA), cerebrovascular accident (CVA), or amaurosis fugax. Diagnoses codes and demographic data were also used to adjust for clinical, social, and demographic factors (including area of residence and treatment). Descriptive statistics and multivariable logistic regression were used to identify significant factors for index admission revascularization. RESULTS A total of 29,046 symptomatic patients were identified among the 153,484 patients who had an eligible admission diagnosis. This included 16,244 (55.9%) males and 12,802 (44.1%) females. Only 4,594 (15.8%) patients were revascularized during the index hospitalization. The majority of these patients presented with amaurosis (OR 5.58; 95% CI 4.84-6.44) instead of CVAs (OR 0.48; 95% CI 0.45-0.51) or TIAs . Adjusting for hospital volume, insurance coverage, residence, and other clinical factors, rates of index admission carotid intervention remained significantly lower for women (OR 0.85; 95% CI 0.79-0.91), persons categorized as black (OR 0.60; 95% CI 0.53-0.69), and persons categorized as Hispanic (OR 0.77; 95% CI 0.70-0.86). CONCLUSIONS Gender, race and ethnicity appear to correlate with rates of carotid intervention at index hospitalization despite thorough risk adjustment for clinical, social and demographic factors. Efforts should be directed towards reducing these disparities.
Collapse
|
12
|
Cui CL, Yei KS, Janssen CB, Ramachandran M, Siracuse JJ, Malas MB. Differences in Perioperative Outcomes after Carotid Revascularization between White and Non-white Patients. Ann Vasc Surg 2021; 79:31-40. [PMID: 34687885 DOI: 10.1016/j.avsg.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/15/2021] [Accepted: 08/09/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Racial disparities in carotid endarterectomy (CEA) and carotid artery stenting (CAS) continue to persist. We aimed to provide a large-scale analysis of racial disparities in perioperative outcomes of carotid revascularization in a nationally representative cohort of patients, with sub-analyses stratifying by procedure type and symptomatic status. METHODS We studied all patients undergoing carotid revascularization between 2011 and 2018 in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Database. Univariate methods were used to compare patients' demographic and medical characteristics. Multivariable logistic regression analysis was used to compare adjusted perioperative outcomes between white patients (WP) and non-white patients (NWP). Sub-analysis was performed stratifying by method of revascularization and symptomatic status. RESULTS A total of 31,356 carotid revascularizations were performed in 26,550 (84.7%) white patients and 4,806 (15.3%) non-white patients. On adjusted analysis, NWP had increased odds of stroke (OR:1.2, 95%CI:1.1-1.5, P = 0.0496), unplanned return to the OR (OR:1.4, 95%CI:1.1-1.6, P < 0.001) and restenosis (OR:2.6, 95%CI:1.7-3.9, P < 0.001). On sub-analysis, NWP undergoing CAS had increased odds of stroke/death (OR:2.2, 95%CI:1.1-4.3, P = 0.025), stroke (OR:2.9, 95%CI:1.3-6.0, P = 0.007), and stroke/TIA (OR:2.1, 95%CI:1.0-4.2, P = 0.025). NWP undergoing CEA had increased odds of unplanned return to the OR (OR:1.4, 95%CI:1.2-1.6, P < 0.001) and restenosis (OR:2.7, 95%CI:1.7-4.0, P < 0.001). CONCLUSION NWP had higher rates of 30-day stroke, driven primarily by higher rates of perioperative stroke/death in NWP undergoing CAS. NWP undergoing CEA did not have higher rates of stroke/death after adjusted analysis, although they had higher rates of unplanned return to OR and restenosis. Upon stratification for symptomatic status, the stroke/death rate between NWP and WP was shown to be non-significant.
Collapse
Affiliation(s)
| | - Kevin S Yei
- University of California San Diego, La Jolla, CA
| | | | | | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA
| | | |
Collapse
|
13
|
Moreira CC. Developing cultural competency and maximizing its effect in vascular surgery. J Vasc Surg 2021; 74:76S-85S. [PMID: 34303463 DOI: 10.1016/j.jvs.2021.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/13/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Carla C Moreira
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, RI.
| |
Collapse
|
14
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes E Fernandes J, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of patients with asymptomatic carotid stenosis may need to be individualized: a multidisciplinary call for action. Republication of J Stroke 2021;23:202-212. INT ANGIOL 2021; 40:487-496. [PMID: 34313413 DOI: 10.23736/s0392-9590.21.04751-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient's life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Varese, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna Alma Mater Studiorum, Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
15
|
Ndrepepa G, Holdenrieder S, Cassese S, Kastrati A. Creatine kinase and bleeding in patients with acute coronary syndromes. Eur J Clin Invest 2021; 51:e13514. [PMID: 33570770 DOI: 10.1111/eci.13514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/01/2021] [Accepted: 02/08/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND The association between elevated creatine kinase (CK) and bleeding in patients with acute coronary syndrome (ACS) remains incompletely investigated. We undertook this study to assess whether there is an association between elevated CK activity and the risk for bleeding in contemporary patients with ACS. MATERIALS AND METHODS This post hoc analysis of a randomized trial included 3368 patients with ACS undergoing percutaneous coronary intervention. CK was measured serially in all patients until hospital discharge. The main outcome was 30-day incidence of major bleeding (type 3 to 5 bleeding according to the Bleeding Academic Research Consortium criteria). RESULTS Patients were categorized in groups according to the peak CK tertiles: 1st tertile (CK ≤259 U/L; n = 1127 patients), 2nd tertile (CK ≥260 to 990 U/L; n = 1119 patients), and 3rd tertile (CK ≥ 991 U/L; n = 1122 patients). Peak CK activity was higher in patients with bleeding than those without bleeding (771 [316-1845] U/L vs. 496 [190-1357] U/L; P <.001). Bleeding occurred in 26 patients (2.3%) with peak CK within 1st tertile, 39 patients (3.5%) with peak CK within 2nd tertile, and 54 patients (4.8%) with peak CK within 3rd tertile (univariable hazard ratio [HR]=1.39, 95% confidence interval [CI] 1.08 to 1.81, P =.012, per tertile increment in CK values). After adjustment, peak CK activity remained significantly associated with the 30-day bleeding (HR = 1.67 [1.16-2.41]; P =.006 per unit increment in logarithmic CK values). The C statistic of the multivariable model with CK activity was 0.807 [0.770-0.842]. CONCLUSIONS In patients with ACS, peak CK activity was independently associated with increased 30-day incidence of bleeding.
Collapse
Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Stefan Holdenrieder
- Institut für Laboratoriumsmedizin, Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| |
Collapse
|
16
|
Lal BK, Meschia JF, Brott TG, Jones M, Aronow HD, Lackey A, Howard G. Race Differences in High-Grade Carotid Artery Stenosis. Stroke 2021; 52:2053-2059. [PMID: 33940957 PMCID: PMC8154708 DOI: 10.1161/strokeaha.120.032723] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose Despite a higher incidence of stroke and a more adverse cardiovascular risk factor profile in Blacks and Hispanics compared with Whites, carotid artery revascularization is performed less frequently among these subpopulations. We assessed racial differences in high-grade (≥70% diameter-reducing) carotid stenosis. Methods Consecutive clients in a Nationwide Life Line for-Profit Service to screen for vascular disease, 2005 to 2019 were evaluated in a cross-sectional study. The prevalence of high-grade stenosis, defined by a carotid ultrasound peak systolic velocity of ≥230 cm/s, was assessed. Participants self-identified as White, Black, Hispanic, Asian, Native American, or other. Race/ethnic differences were assessed using Poisson regression. The number of individuals in the United States with high-grade stenosis was estimated by applying prevalence estimates to 2015 US Census population estimates. Results The prevalence of high-grade carotid stenosis was estimated in 6 130 481 individuals. The prevalence of high-grade stenosis was higher with increasing age in all race-sex strata. Generally, Blacks and Hispanics had a lower prevalence of high-grade stenosis compared with Whites, while Native Americans had a higher prevalence. For example, for men aged 55 to 65, the relative risk of stenosis compared with Whites was 0.40 (95% CI, 0.29–0.55) and 0.61 (95% CI, 0.46–0.81) for Blacks and Hispanics, respectively; and 1.53 (95% CI, 1.12–2.10) for Native Americans. When these prevalence estimates were applied to the Census estimates of the US population, an estimated 327 721 individuals have high-grade stenosis, of whom 7% are Black, 7% Hispanic, and 43% women. Conclusions Despite their having a more adverse cardiovascular risk profile, there was a lower prevalence of high-grade carotid artery stenosis for both the Black and Hispanic relative to the White clients. This lower prevalence of high-grade stenosis is a potential contributor to the lower use of carotid revascularization procedures in these minority populations.
Collapse
Affiliation(s)
- Brajesh K Lal
- University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
| | | | | | | | | | - Angelica Lackey
- University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
| | | |
Collapse
|
17
|
Paraskevas KI, Mikhailidis DP, Baradaran H, Davies AH, Eckstein HH, Faggioli G, Fernandes JFE, Gupta A, Jezovnik MK, Kakkos SK, Katsiki N, Kooi ME, Lanza G, Liapis CD, Loftus IM, Millon A, Nicolaides AN, Poredos P, Pini R, Ricco JB, Rundek T, Saba L, Spinelli F, Stilo F, Sultan S, Zeebregts CJ, Chaturvedi S. Management of Patients with Asymptomatic Carotid Stenosis May Need to Be Individualized: A Multidisciplinary Call for Action. J Stroke 2021; 23:202-212. [PMID: 34102755 PMCID: PMC8189852 DOI: 10.5853/jos.2020.04273] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/12/2021] [Indexed: 12/15/2022] Open
Abstract
The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g., silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient’s life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.
Collapse
Affiliation(s)
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Hediyeh Baradaran
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College & Imperial Healthcare NHS Trust, London, UK
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gianluca Faggioli
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | | | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Niki Katsiki
- First Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gaetano Lanza
- Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy
| | | | - Ian M Loftus
- St. George's Vascular Institute, St. George's University London, London, UK
| | - Antoine Millon
- Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France
| | - Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus
| | - Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia
| | - Rodolfo Pini
- Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy
| | - Francesco Spinelli
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Francesco Stilo
- Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy
| | - Sherif Sultan
- Western Vascular Institute, Department of Vascular and Endovascular Surgery, University Hospital Galway, National University of Ireland, Galway, Ireland
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Seemant Chaturvedi
- Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
18
|
Panchap L, Safavynia SA, Tangel V, White RS. Socioeconomic Disparities in Carotid Revascularization Procedures. J Cardiothorac Vasc Anesth 2020; 34:1836-1845. [PMID: 31917077 DOI: 10.1053/j.jvca.2019.11.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/17/2019] [Accepted: 11/21/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Several studies have demonstrated healthcare disparities in postoperative outcomes after carotid endarterectomy and carotid artery stenting, including increased hospital mortality, postoperative stroke, and readmission rates. The objective of the present study was to examine the intersectionality between race/ethnicity, insurance status, and postoperative outcomes in carotid procedures. DESIGN Records of adults from 2007 to 2014 were retrospectively identified, and patients with appropriate International Classification of Diseases Ninth Revision Clinical Modification codes for carotid endarterectomy or carotid artery stenting were identified. Primary outcomes were unadjusted rates and adjusted odds ratios (aORs) of postoperative in-hospital mortality, stroke, combined stroke/mortality, and cardiovascular complications. SETTING Data were sourced from the State Inpatient Databases data from California, Florida, Kentucky, Maryland, and New York during the years 2007 to 2014. PARTICIPANTS Patients undergoing carotid revascularization procedures. INTERVENTIONS The effects of race and insurance status as independent variables and as effect modifiers on postoperative outcomes. MEASUREMENTS AND MAIN RESULTS Multivariable logistic regression models were used to examine the associations between race and/or insurance status with respect to study outcomes. Race, but not payer status, was significantly associated with adverse outcomes after carotid artery procedures, with blacks, Hispanics, and other non-Caucasian races demonstrating a significantly greater risk of postoperative stroke and mortality (aOR range 1.24-1.59). This relationship persisted even when stratified by procedure type (aOR range 1.25-1.56) and symptomatology (aOR range 1.51-1.63). CONCLUSIONS These results suggest that disparities in postoperative outcomes after carotid artery procedures are associated with race but not with primary insurance status. Multiple contributing factors exist, including racial inequities in prevalence of comorbidities, health literacy, and procedure type performed.
Collapse
Affiliation(s)
- Latha Panchap
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | | | - Virginia Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY.
| |
Collapse
|
19
|
Hicks CW, Daya NR, Black JH, Matsushita K, Selvin E. Race and sex-based disparities associated with carotid endarterectomy in the Atherosclerosis Risk in Communities (ARIC) study. Atherosclerosis 2020; 292:10-16. [PMID: 31731080 PMCID: PMC6928429 DOI: 10.1016/j.atherosclerosis.2019.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/12/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIMS The indications for carotid endarterectomy (CEA) are well established. The aim of the current study was to investigate sex and race-based disparities in the incidence of CEA after adjusting for carotid artery stenosis risk factors. METHODS We conducted a prospective cohort analysis of 14,492 black and white participants in the Atherosclerosis Risk in Communities (ARIC) study without prevalent stroke at baseline (1987-1989). We used Kaplan-Meier curves and Cox proportional hazards models adjusting for sociodemographic, cardiovascular, and disease severity risk factors to quantify the associations of sex and race with incident CEA. RESULTS CEA was performed in 330 of 14,492 ARIC participants during a median of 27 years of follow-up [incidence rate 1.00 (95% CI 0.90-1.12) per 1000 persons-years]. The crude incidence of CEA varied significantly by sex [female vs. male: HR 0.60 (95% CI 0.48-0.74)] and race [black vs. white: HR 0.65 (95% CI 0.49-0.86)]. Adjustment for sociodemographic and cardiovascular risk factors, carotid intima-media thickness, and symptomatic status attenuated the association of sex with CEA [females vs. males HR 0.96 (0.76-1.22)], but black participants had a lower risk of incident CEA after adjustment [HR 0.68 (95% CI 0.49-0.95)]. CONCLUSIONS We found significant variation in the incidence of CEA procedures based on race that was independent of traditional risk factors and carotid IMT. Whether this disparity is a reflection of differences in disease presentation or access to care deserves investigation.
Collapse
Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Natalie R Daya
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
20
|
Risk Scoring Systems to Predict Long-Term Mortality After Carotid Endarterectomy in Asymptomatic Patients: A Systematic Review. Vasc Endovascular Surg 2019; 54:247-253. [DOI: 10.1177/1538574419895378] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The present review was conducted to describe current published risk scoring systems to predict late mortality after carotid endarterectomy (CEA). The aim of the study is to identify simple, clinical, and reproducible tools to predict life expectancy in patients with asymptomatic carotid artery stenosis candidates to CEA and therefore which patients may benefit from surgery, reaching the goal of life expectancy >3 to 5 years, recommended by guidelines. Advantages, disadvantages, feasibility, simplicity, and reproducibility of each selected score were analyzed. Rigorous statistical analysis and validation of the score are essential components to produce a calibrated and usable score. Future studies should address the impact of using these tools in CEA candidates for asymptomatic disease.
Collapse
|
21
|
Brewster LM. Creatine kinase, energy reserve, and hypertension: from bench to bedside. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:292. [PMID: 30211180 PMCID: PMC6123196 DOI: 10.21037/atm.2018.07.15] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/11/2018] [Indexed: 12/17/2022]
Abstract
We hypothesized that human variation in the activity of the ATP regenerating enzyme creatine kinase (CK) activity affects hypertension and cardiovascular disease risk. CK is tightly bound close to ATP-utilizing enzymes including Ca2+-ATPase, myosin ATPase, and Na+/K+-ATPase, where it rapidly regenerates ATP from ADP, H+, and phosphocreatine. Thus, relatively high CK was thought to enhance ATP-demanding processes including resistance artery contractility and sodium retention, and reduce ADP-dependent functions. In a series of studies of our group and others, CK was linked to hypertension and bleeding risk. Plasma CK after rest, used as a surrogate measure for tissue CK, was associated with high blood pressure and failure of antihypertensive therapy in case-control and population studies. Importantly, high tissue CK preceded hypertension in animal models and in humans, and human vascular tissue CK gene expression was strongly associated with clinical blood pressure. In line with this, CK inhibition substantially reduced the contractility of human resistance arteries ex vivo. We also presented evidence that plasma CK reduced ADP-dependent platelet aggregation. In subsequent intervention studies, the oral competitive CK inhibitor beta-guanidinopropionic acid (GPA) reduced blood pressure in spontaneously hypertensive rats (SHRs), and a 1-week trial of sub-therapeutic dose GPA in healthy men was uneventful. Thus, based on theoretical concepts, evidence was gathered in laboratory, case-control, and population studies that high CK is associated with hypertension and with bleeding risk, potentially leading to a new mode of cardiovascular risk reduction with CK inhibition.
Collapse
Affiliation(s)
- Lizzy M Brewster
- Department of Cardiovascular Disease, Creatine Kinase Foundation, Amsterdam, The Netherlands
| |
Collapse
|
22
|
AbuRahma AF. Invited commentary. J Vasc Surg 2018; 68:435. [DOI: 10.1016/j.jvs.2017.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 12/06/2017] [Indexed: 10/28/2022]
|
23
|
Pothof AB, Soden PA, Deery SE, O'Donnell TFX, Wang GJ, Hughes K, de Borst GJ, Schermerhorn ML. The impact of race on outcomes after carotid endarterectomy in the United States. J Vasc Surg 2018; 68:426-435. [PMID: 29482877 PMCID: PMC6057797 DOI: 10.1016/j.jvs.2017.11.087] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 11/10/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Black patients undergoing carotid endarterectomy (CEA) in the United States are more often symptomatic at presentation and have more comorbidities compared with white patients. However, the impact of race on outcomes after CEA is largely unknown. METHODS We identified CEA patients in the Vascular Quality Initiative registry (2012-2017) and compared them by race (black vs white). All other nonwhite races (891 [1.4%]) and Hispanics (2222 [3.4%]) were excluded. We used multilevel logistic regression to account for differences in demographics and comorbidities. We assessed long-term survival using multivariable Cox regression. The primary outcome was perioperative stroke/death, with long-term survival as a secondary outcome. RESULTS We included 57,622 CEA patients; 2909 (5.0%) were black, of whom 983 (34%) were symptomatic. Of the 54,713 white patients, 16,132 (30%) were symptomatic. Black patients, compared with white patients, had a higher vascular disease burden and were less likely to be operated on in a high-volume hospital or by a high-volume surgeon. In addition, black symptomatic patients, compared with white symptomatic patients, were more often operated on <2 weeks after the index neurologic symptom (47% vs 40%; P < .001). Perioperative stroke/death was comparable between black and white patients (symptomatic, 2.8% vs 2.2% [P = .2]; asymptomatic, 1.6% vs 1.3% [P = .2]), as was unadjusted survival at 3 years (93% vs 93%; P = .7). However, after adjustment, black patients did experience better long-term survival compared with white patients (hazard ratio, 0.8; 95% confidence interval, 0.7-0.9; P = .01). On multilevel logistic regression, race was not associated with perioperative stroke/death (odds ratio, 1.0; 95% confidence interval, 0.8-1.3; P = .98). CONCLUSIONS Despite the greater prevalence of vascular risk factors in black patients and racial inequalities in surgical treatment, rates of perioperative stroke/death and unadjusted survival were similar between white and black patients. Moreover, black patients experienced better adjusted long-term survival after CEA.
Collapse
Affiliation(s)
- Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Grace J Wang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Kakra Hughes
- Department of Surgery, Howard University and Hospital, Washington, D.C
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| |
Collapse
|
24
|
Soden PA, Zettervall SL, Deery SE, Hughes K, Stoner MC, Goodney PP, Vouyouka AG, Schermerhorn ML. Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention. J Vasc Surg 2018; 67:549-556.e3. [PMID: 28951156 PMCID: PMC5794625 DOI: 10.1016/j.jvs.2017.06.089] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 06/07/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although many studies have demonstrated racial disparities after major vascular surgery, few have identified the reasons for these disparities, and those that did often lacked clinical granularity. Therefore, our aim was to evaluate differences in initial vascular intervention between black and white patients. METHODS We identified black and white patients' initial carotid, abdominal aortic aneurysm (AAA), and infrainguinal peripheral artery disease (PAD) interventions in the Vascular Quality Initiative (VQI) registry from 2009 to 2014. We excluded nonblack or nonwhite patients as well as those with Hispanic ethnicity, asymptomatic PAD, or a history of prior ipsilateral interventions. We compared baseline characteristics and disease severity at time of intervention on a national and regional level. RESULTS We identified 76,372 patients (9% black), including 35,265 carotid (5% black), 17,346 AAA (5% black), and 23,761 PAD interventions (18% black). For all operations, black patients were younger, more likely female, and had more insulin-dependent diabetes, hypertension, congestive heart failure, renal dysfunction, and dialysis dependence. Black patients were less likely to be on a statin before AAA (62% vs 69%; P < .001) or PAD intervention (61% vs 67%; P < .001) and also less likely to be discharged on an antiplatelet and statin regimen after these procedures (AAA, 60% vs 64% [P = .01]; PAD, 64% vs 67% [P < .001]). Black patients presented with more severe disease, including higher proportions of symptomatic carotid disease (36% vs 31%; P < .001), symptomatic or ruptured AAA (27% vs 16%; P < .001), and chronic limb-threatening ischemia (73% vs 62%; P < .001). Black patients more often presented with concurrent iliac artery aneurysms at the time of AAA repair (elective open AAA repair, 46% vs 26% [P < .001]; elective endovascular aneurysm repair, 38% vs 23% [P < .001]). CONCLUSIONS Black patients present with more advanced disease at the time of initial major vascular operation. Efforts to control risk factors, identify and treat arterial disease in a timely fashion, and optimize medical management among black patients may provide opportunity to improve current disparities.
Collapse
Affiliation(s)
- Peter A Soden
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Kakra Hughes
- Section of Vascular Surgery, Howard University Hospital, Washington, D.C
| | - Michael C Stoner
- Section of Vascular Surgery, University of Rochester, Rochester, NY
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Ageliki G Vouyouka
- Division of Vascular Surgery, Mount Sinai Health Systems, Icahn School of Medicine, New York, NY
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| |
Collapse
|
25
|
Lichtman JH, Jones MR, Leifheit EC, Sheffet AJ, Howard G, Lal BK, Howard VJ, Wang Y, Curtis J, Brott TG. Carotid Endarterectomy and Carotid Artery Stenting in the US Medicare Population, 1999-2014. JAMA 2017; 318:1035-1046. [PMID: 28975306 PMCID: PMC5818799 DOI: 10.1001/jama.2017.12882] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Carotid endarterectomy and carotid artery stenting are the leading approaches to revascularization for carotid stenosis, yet contemporary data on trends in rates and outcomes are limited. OBJECTIVE To describe US national trends in performance and outcomes of carotid endarterectomy and stenting among Medicare beneficiaries from 1999 to 2014. DESIGN, SETTING, AND PARTICIPANTS Serial cross-sectional analysis of Medicare fee-for-service beneficiaries aged 65 years or older from 1999 to 2014 using the Medicare Inpatient and Denominator files. Spatial mixed models adjusted for age, sex, and race were fit to calculate county-specific risk-standardized revascularization rates. Mixed models were fit to assess trends in outcomes after adjustment for demographics, comorbidities, and symptomatic status. EXPOSURES Carotid endarterectomy and carotid artery stenting. MAIN OUTCOMES AND MEASURES Revascularization rates per 100 000 beneficiary-years of fee-for-service enrollment, in-hospital mortality, 30-day stroke or death, 30-day stroke, myocardial infarction, or death, 30-day all-cause mortality, and 1-year stroke. RESULTS During the study, 937 111 unique patients underwent carotid endarterectomy (mean age, 75.8 years; 43% women) and 231 077 underwent carotid artery stenting (mean age, 75.4 years; 49% women). There were 81 306 patients who underwent endarterectomy in 1999 and 36 325 in 2014; national rates per 100 000 beneficiary-years decreased from 298 in 1999-2000 to 128 in 2013-2014 (P < .001). The number of patients who underwent stenting ranged from 10 416 in 1999 to 22 865 in 2006 (an increase per 100 000 beneficiary-years from 40 in 1999-2000 to 75 in 2005-2006; P < .001); by 2014, there were 10 208 patients who underwent stenting and the rate decreased to 38 per 100 000 beneficiary-years (P < .001). Outcomes improved over time despite increases in vascular risk factors (eg, hypertension prevalence increased from 67% to 81% among patients who underwent endarterectomy and from 61% to 70% among patients who underwent stenting) and the proportion of symptomatic patients (all P < .001). There were adjusted annual decreases in 30-day ischemic stroke or death of 2.90% (95% CI, 2.63% to 3.18%) among patients who underwent endarterectomy and 1.13% (95% CI, 0.71% to 1.54%) among patients who underwent stenting; an absolute decrease from 1999 to 2014 was observed for endarterectomy (1.4%; 95% CI, 1.2% to 1.5%) but not stenting (-0.1%; 95% CI, -0.5% to 0.4%). Rates for 1-year ischemic stroke decreased after endarterectomy (absolute decrease, 3.5% [95% CI, 3.2% to 3.7%]; adjusted annual decrease, 2.17% [95% CI, 2.00% to 2.34%]) and stenting (absolute decrease, 1.6% [95% CI, 1.2% to 2.1%]; adjusted annual decrease, 1.86% [95% CI, 1.45%-2.26%]). Additional improvements were noted for in-hospital mortality, 30-day stroke, myocardial infarction, or death, and 30-day all-cause mortality as well as within demographic subgroups. CONCLUSIONS AND RELEVANCE Among fee-for-service Medicare beneficiaries, the performance of carotid endarterectomy declined from 1999 to 2014, whereas the performance of carotid artery stenting increased until 2006 and then declined from 2007 to 2014. Outcomes improved despite increases in vascular risk factors.
Collapse
Affiliation(s)
- Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, Connecticut
| | - Michael R. Jones
- Cardiology Division, Baptist Health Lexington, Lexington, Kentucky
| | - Erica C. Leifheit
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Alice J. Sheffet
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama, Birmingham
| | - Brajesh K. Lal
- Department of Vascular Surgery, School of Medicine, University of Maryland, Baltimore
| | - Virginia J. Howard
- Department of Epidemiology, School of Public Health, University of Alabama, Birmingham
| | - Yun Wang
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Yale University, New Haven, Connecticut
| | - Jeptha Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, Yale University, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | |
Collapse
|
26
|
Garcia RM, Yoon S, Cage T, Potts MB, Lawton MT. Ethnicity, Race, and Postoperative Stroke Risk Among 53,593 Patients with Asymptomatic Carotid Stenosis Undergoing Revascularization. World Neurosurg 2017; 108:246-253. [PMID: 28890012 DOI: 10.1016/j.wneu.2017.08.184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 08/29/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The incidence of postoperative stroke after carotid endarterectomy is an uncommon event, and differences by racial and ethnic subgroups are not described fully in the literature. OBJECTIVE To investigate the impact of race and ethnicity on postoperative stroke risk among patients with asymptomatic carotid stenosis undergoing carotid endarterectomy. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was searched for patients between the dates 2008 and 2015 to identify patients undergoing carotid endarterectomy with no history of stroke. Four racial and ethnic subgroups were included: non-Hispanic white, Hispanic white, non-Hispanic back, and non-Hispanic Asian. In addition to a descriptive statistical analysis, univariate and multivariate regression models were created to adjust for cardiovascular and perioperative risk factors and corrected for multiple comparisons. RESULTS Among the 53,593 patients identified meeting the inclusion criteria, 788 (1.45%) patients experienced a stroke within 30 days. The non-Hispanic white group compared with the minority subgroups had a lower risk of postoperative stroke (1.43% vs. 1.67%, P = 0.18). The greatest difference was between the non-Hispanic white and Hispanic white groups, but this was not significant on multivariable analysis (odds ratio 1.40, 95% confidence interval 0.97-2.02, P = 0.08) after adjustment for risk stroke factors. The strongest predictors of postoperative stroke were perioperative blood transfusion, dependent functional status, and longer operative time. CONCLUSIONS There was no difference between the racial and ethnic groups and the proportion of postoperative stroke among patients undergoing revascularization for asymptomatic carotid stenosis.
Collapse
Affiliation(s)
- Roxanna M Garcia
- Department of Neurosurgery, Northwestern University, Chicago, Illinois, USA.
| | - Seungwon Yoon
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tene Cage
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Matthew B Potts
- Department of Neurosurgery, Northwestern University, Chicago, Illinois, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, University of California, San Francisco, California, USA
| |
Collapse
|
27
|
Lieber BA, Henry JK, Agarwal N, Day JD, Morris TW, Stephens ML, Abla AA. Impact of Surgical Specialty on Outcomes Following Carotid Endarterectomy. Neurosurgery 2016; 80:217-225. [DOI: 10.1093/neuros/nyw027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/22/2016] [Indexed: 11/13/2022] Open
|
28
|
Race as a predictor of delay from diagnosis to endarterectomy in clinically significant carotid stenosis. J Vasc Surg 2015; 62:49-56. [PMID: 25776188 DOI: 10.1016/j.jvs.2015.01.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/27/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Prompt carotid endarterectomy (CEA) in clinically significant carotid stenosis is important in the prevention of neurologic sequelae. The greatest benefit from surgery is obtained by prompt revascularization on diagnosis. It has been demonstrated that black patients both receive CEA less frequently than white patients do and experience worse postoperative outcomes. We sought to test our hypothesis that black race is an independent risk factor for a prolonged time from sonographic diagnosis of carotid stenosis warranting surgery to the day of operation (TDO). METHODS From 1998 to 2013 at a single institution, 166 CEA patients were retrospectively reviewed using Synthetic Derivative, a de-identified electronic medical record. Factors potentially affecting TDO, including demographics, preoperative cardiac stress testing, degree of stenosis, smoking status, and comorbidities, were noted. Multivariate analysis was performed on variables that trended with prolonged TDO on univariate analysis (P < .10) to determine independent (P < .05) predictors of TDO. Subgroup analyses were further performed on the symptomatic and asymptomatic stenosis cohorts. RESULTS There were 32 black patients and 134 white patients studied; the mean TDO was 78 ± 17 days vs 33 ± 3 days, respectively (P < .001). In addition to the need for preoperative cardiac stress testing, black race was the only variable that demonstrated a trend with (P < .10) or was an independent risk factor for (P < .05) prolonged TDO among all patients (B = 42 days; P < .001) and within the symptomatic (B = 35 days; P = .08) and asymptomatic (B = 35 days; P = .003) cohorts. On Kaplan-Meier analysis, black patients in each stratum of symptomatology (all, symptomatic, and asymptomatic patients) experienced prolonged TDO (log-rank, P < .03 for all three groups). CONCLUSIONS Black race is a risk factor for a temporal delay in CEA for carotid stenosis. Awareness of this disparity may help surgeons avoid undesirable delays in operation for their black patients.
Collapse
|
29
|
Creatine kinase inhibits ADP-induced platelet aggregation. Sci Rep 2014; 4:6551. [PMID: 25298190 PMCID: PMC4190537 DOI: 10.1038/srep06551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 08/11/2014] [Indexed: 02/08/2023] Open
Abstract
Bleeding risk with antiplatelet therapy is an increasing clinical challenge. However, the inter-individual variation in this risk is poorly understood. We assessed whether the level of plasma creatine kinase, the enzyme that utilizes ADP and phosphocreatine to rapidly regenerate ATP, may modulate bleeding risk through a dose-dependent inhibition of ADP-induced platelet activation. Exogenous creatine kinase (500 to 4000 IU/L, phosphocreatine 5 mM) added to human plasma induced a dose-dependent reduction to complete inhibition of ADP-induced platelet aggregation. Accordingly, endogenous plasma creatine kinase, studied in 9 healthy men (mean age 27.9 y, SE 3.3; creatine kinase 115 to 859 IU/L, median 358), was associated with reduced ADP-induced platelet aggregation (Spearman's rank correlation coefficient, -0.6; p < 0.05). After exercise, at an endogenous creatine kinase level of 4664, ADP-induced platelet aggregation was undetectable, normalizing after rest, with a concomitant reduction of creatine kinase to normal values. Thus, creatine kinase reduces ADP-induced platelet activation. This may promote bleeding, in particular when patients use platelet P2Y12 ADP receptor inhibitors.
Collapse
|
30
|
Ju MH, Kibbe MR. Regarding "Race as a predictor of morbidity, mortality, and neurologic events after carotid endarterectomy". J Vasc Surg 2013; 58:1444. [PMID: 24160317 DOI: 10.1016/j.jvs.2013.06.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 06/18/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Mila H Ju
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | |
Collapse
|