A regional collaborative audit of the practice and outcome of carotid endarterectomy in the United Kingdom. Northern Regional Carotid Endarterectomy Audit Group

Carotid endarterectomy should be performed early after a cerebral ischemic event in order to be most effective

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Assessing the quality of surgical care in vascular surgery; moving from outcome towards structural and process measures

OBJECTIVES

This study presents a review of studies reporting on quality of care in vascular surgery. The aim of this study was to provide insight in quality improvement initiatives in vascular surgery.

DESIGN

Original data were collected from MEDLINE and EMBASE databases. Inclusion criteria were: description of one of the three factors of quality of care, e.g. process, outcome or structure and prospectively described. All articles identified were ascribed to a domain of quality of care.

RESULTS

57 prospective articles were included, drawn from 859 eligible reports. Structure as an indicator of quality of care was described in 19 reports, process in 7 reports and outcome in 31 reports. Most studies based on structural measures considered the introduction of a clinical pathway or a registration system. Reports based on process measures showed promising results. Outcome as clinical indicator mainly focussed on identifying risk factors for morbidity, mortality or failure of treatment.

CONCLUSIONS

Structure and process indicators are evaluated scarcely in vascular surgery. Many studies in vascular surgery have been focussed on outcomes as indicator of quality of care, but a shift towards process measures should be considered as focus of attention in the future.

RACE to protect brains

INTRODUCTION

Rapid-access carotid endarterectomy (RACE) is an evidence-based treatment for symptomatic carotid stenosis. Our vascular centre aims to provide this service within 48 h of symptoms in appropriate patients. This study audits safety and efficacy of the first year of RACE.

SUBJECTS AND METHODS

A clear trust protocol was publicised for the RACE pathway. A prospective database was established for all carotid endarterectomies (CEAs) performed. Outcomes were compared between elective (ECE) and rapid-access operations.

RESULTS

In 1 year, 96 patients received CE; 20 were performed urgently. There were no significant differences in age or gender between ECE and RACE groups. Twenty-three (30%) of ECE were for asymptomatic stenoses; no other significant differences in surgical indication were seen. Of symptomatic ECE, 43% were for completed stroke versus 55% for RACE. Median delay between diagnosis and surgery was 113 days for elective and 2 days for RACE patients. There was one death following ECE (1.3%) and one stroke after RACE (5%), all not significant. Anaesthetic method did not influence outcome. The main reasons for delaying surgery in RACE patients were optimisation of patient fitness and availability of theatre time.

CONCLUSIONS

The RACE pathway dramatically reduces delay without compromising patient safety. In the first year of service, we have treated 50% of suitable patients within 48 h. Further education of patients and colleagues should reduce delay and improve outcomes for symptomatic carotid disease.

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.

Current status of carotid endarterectomy and stenting for symptomatic carotid stenosis

There is still considerable uncertainty about the place of carotid stenting in patients with recently symptomatic carotid bifurcation stenosis. Most reviews of carotid endarterectomy versus carotid stenting concentrate on technical aspects and advances in stenting, but the techniques involved in both carotid endarterectomy and stenting are evolving. In addition to reviewing the results of the various randomised controlled trials of carotid endarterectomy versus stenting for symptomatic carotid stenosis, this review considers recent advances and current best practice for endarterectomy. Ongoing randomized trials will determine whether or not the procedural risk of stroke and death is definitely lower with endarterectomy than with stenting, but the key issue that remains to be determined reliably is how the procedural risks of stenting vary with patient characteristics - perhaps the most important question being not whether endarterectomy is better than stenting or vice versa, but for whom is one technique likely to be better than the other.

Time is brain!

Carotid endarterectomy (CEA) is a proven treatment in the prevention of stroke, but its overall effectiveness is reduced by excessive delays from symptom to surgery. Specifically, delaying surgery in symptomatic patients with 50-99% NASCET stenoses (70-99% ECST) for >12 weeks prevents only eight strokes per 1000 CEAs in the long term. This is a very depressing observation as the 2004 Sentinel Audit observed that only 50% of stroke patients in the UK will have undergone a Duplex scan by 12 weeks. Excessive delays prior to surgery not only undermine professional confidence in the role of CEA, but they effectively mean that while every patient is exposed to the risks of surgery, many may gain little in the way of long-term stroke prevention. Many of the issues debated in this review will only be resolved by a paradigm shift in political emphasis, but surgeons too have a responsibility to recognise and correct important deficiencies within their own practice.

Variation in surgical and anaesthetic technique and associations with operative risk in the European carotid surgery trial: implications for trials of ancillary techniques

OBJECTIVES

several ancillary surgical techniques, such as shunting and patching, are used in association with carotid endarterectomy. However, the balance of risks and benefits of these techniques is uncertain because of the lack of large randomised controlled trials (RCTs). To assess the potential for further trials, we studied the variation in use of these techniques by surgeon and by country in the European Carotid Surgery Trial (ECST).

METHODS

use of each ancillary technique was assessed by surgeon and by country. For each technique, the relationships between the use of the technique and baseline patient characteristics, use of other techniques, and the 30-day operative risk of stroke and death were determined.

RESULTS

there was considerable variation between surgeons in the use of ancillary operative techniques both within (p<0.001 for shunting and patching), and between countries (p<0.001 for shunting and patching). Some surgeons used techniques selectively, and so the characteristics of patients differed depending on which techniques were used. Use of each technique was also significantly associated with the use of other techniques. Multiple regression analysis, taking into account all these factors, found no statistically significant associations between operative risk and the use of shunting, patching, intra-operative EEG monitoring, or type of anaesthetic. The only surgical technique significantly associated with an increased operative risk was not using intra-operative anticoagulation (hazard ratio=2.33, 95% CI=1.4-4.2). Other factors associated with an increased risk were an operation time of less than 1 h, or greater than 1.5 h, and the surgeons' subjective assessment that the operation was difficult.

CONCLUSIONS

in the ECST, operative risk was more closely related to patient characteristics, length of surgery, and the surgeons' perception of the difficulty of the operation, than to the use of particular ancillary operative techniques. The considerable variation between surgeons, and between countries, in the use of ancillary techniques is in keeping with the lack of convincing data from RCTs, and suggests that there should be sufficient uncertainty to make large pragmatic trials possible.

Clinical and radiographic risk factors for operative stroke and death in the European carotid surgery trial

OBJECTIVES

carotid endarterectomy is associated with significant morbidity and mortality. A better understanding of the relationships between baseline characteristics and outcome may help to reduce the risks of surgery. In order to make accurate and unbiased estimates of surgical risk it is important to study cohorts of patients that were established prospectively, where independent physicians assessed outcome, and where the decision to analyse and report the results was not data-dependent. The surgical arm of the European Carotid Surgery Trial (ECST) is such a cohort.

METHODS

the 30-day outcome of carotid endarterectomy was analysed in ECST surgery patients in relation to their baseline clinical and angiographic characteristics. The severity of operative strokes was compared with that of strokes that occurred in the medical group.

RESULTS

1729 patients underwent trial surgery. There were 17 deaths (1.0%, 95% CI=0.6-1.6) and 105 non-fatal major strokes (6.1%, 95% CI=5.0-7.3) within 30 days of surgery. The risk of major stroke or death was 7.1% (95% CI=5.9-8.4). The risk of disabling or fatal stroke was 3.0% (95% CI=2.1-3.8). The ratio of disabling to non-disabling operative strokes was similar to that in the medical group. Several baseline characteristics predicted the operative risk of stroke and death in univariate analyses, but only four were independent risk factors in a multiple regression analysis: presentation with cerebral TIA vs ocular ischaemic events only (HR=2.99, 95% CI=1.33-6.69, p=0.008); female sex (HR=2.04, 95% CI=1.37--3.06, p=0.001); systolic hypertension (HR=1.01 per 10 mmHg, 95% CI=1.00-1.02, p=0.03) and peripheral vascular disease (HR=2.17, 95% CI=1.17-2.89, p=0.001).

CONCLUSIONS

the operative risk of stroke and death in the ECST was comparable with other prospective studies and trials in which patients were assessed postoperatively by both a physician and a surgeon. Case fatality and disability after operative stroke are similar to strokes that occur on medical treatment only. Several baseline patient characteristics predict surgical risk and it may be possible to use these characteristics to aid patient selection and surgical audit.