US nationwide trends in carotid revascularization: hospital outcome and predictors of outcome from 1998 to 2007

Early and mid-term outcomes of carotid angioplasty and stent placement in 579 patients

BACKGROUND AND PURPOSE

Carotid angioplasty and stenting (CAS) could be considered for preventing stroke in patients with carotid artery stenosis. This study aimed to determine the incidence and the risk factors of the early and mid-term complications associated with CAS.

METHODS

This is a retrospective cohort study conducted at Shiraz University of Medical Sciences from March 2011 to March 2019. Patients at high risk and standard risk for carotid endarterectomy were included. The primary composite outcome was defined as stroke, myocardial infarction (MI), and death in the first 30 days after CAS. All-cause mortality, vascular mortality, and stroke were investigated during mid-term follow-up.

RESULTS

A total of 579 patients (618 CAS) were recruited (mean age: 71.52 years). Overall, 394 (68.40%), 211 (36.63%), 179 (31.07%), and 96 (16.72%) patients had hypertension, dyslipidemia, diabetes mellitus, or were cigarette smokers, respectively. Primary composite outcomes were observed in 2.59% of patients (1.55% stroke, 0.69% MI, and 1.72% death). Atrial fibrillation was a predictor of primary composite outcome in multivariate logistic regression (p = .048). The presence of total occlusion in the contralateral carotid artery was significantly associated with the risk of stroke in univariate logistic regression (p = .041). The patients were followed for a period ranging from 1 to 83 months. The overall survival rate for all-cause mortality was 93.48% at 1 year, 77.24% at 5 years, and 52.92% at 8 years. All-cause mortality was significantly higher among patients with symptomatic carotid stenosis (p = .014).

CONCLUSION

CAS provides acceptable short-term and mid-term outcomes in a unique population of high- and standard-surgical-risk, symptomatic and asymptomatic, octogenarian, and nonoctogenarian patients.

Female Gender Increases Risk of Stroke and Readmission after CEA and CAS

OBJECTIVES

Carotid endarterectomy (CEA) has historically demonstrated a higher rate of perioperative adverse events for female patients. However, recent evidence suggests similar outcomes for CEA between genders. In contrast, fewer studies have examined gender in carotid artery stenting (CAS). Using contemporary data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we aim to determine if gender impacts differences in postoperative complications in patients who undergo CEA or CAS.

METHODS

The ACS NSQIP database was queried from 2005-2017 using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes for retrospective review. Patients with carotid intervention (CEA or CAS) were stratified into asymptomatic vs symptomatic cohorts to determine the effect of gender on 30-day postoperative outcomes. Symptomatic patients were defined as those with perioperative transient cerebral ischemic attack or stenosis of carotid artery with cerebral infarction. Descriptive statistics were calculated. Risk-adjusted odds of 30-day postoperative outcomes were calculated using multivariate regression analysis with fixed effects for age, race, and comorbidities.

RESULTS

There were 106,568 patients with CEA or CAS (104,412 CEA and 2,156 CAS). Average age was 70.9 years old and female patients accounted for 39.9% of the population. For asymptomatic patients that underwent CEA or CAS, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.005), readmission (10%, p=0.004), bleeding complication (32%, p=0.001), and UTI (54%, p=0.001) as well as less infection (26%, p=0.001). In the symptomatic cohort, female gender was associated with significantly higher rates of CVA/stroke (32%, p=0.034), bleeding complication (203%, p=0.001), and UTI (70%, p=0.011), while female gender was associated with a lower rate of pneumonia (39%, p=0.039). Subset analysis found that, compared to male patients, female patients <75yo have an increased rate of CVA/stroke (21%, p=0.001) and readmission (15%, p<0.001), while female patients ≥75yo did not. In asymptomatic and symptomatic patients that underwent CEA, female gender was associated with significantly higher rates of CVA/stroke (13%, p=0.006 and 31%, p=0.044, respectively), but this finding was present not in patients undergoing CAS.

CONCLUSION

In patients undergoing carotid intervention, female gender was associated with significantly increased rates of postoperative CVA/stroke in the asymptomatic and symptomatic cohorts as well as readmission in the asymptomatic cohort. Female gender was associated with higher rates of CVA/stroke following CEA, but not CAS. We recommend that randomized control trials ensure adequate representation of female patients to better understand gender-based disparities in carotid intervention.

Trends and outcomes in Australian carotid artery revascularization surgery: 2010-2017

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce the risk of stroke in patients with severe carotid stenosis. The aim was to compare contemporary treatment trends and outcomes after CEA and CAS between states of Australia.

METHODS

A retrospective analysis was conducted on data from the Australasian Vascular Audit between 2010 and 2017. The primary endpoint was perioperative stroke or death (S/D). We also analysed stroke and death independently and revascularization rates per 100 000 population.

RESULTS

A total of 15 413 patients underwent carotid revascularization (CEA 14 070; CAS 1343). S/D rates were similar for CEA and CAS (1.9% versus 1.8%; P = 0.37; symptomatic 2.1% versus 2.3%; P = 0.12; asymptomatic 1.5% versus 1.1%; P = 0.67). Patients ≥80 years (2.7% versus 1.7%; P = 0.01), those who had shunts (2.2% versus 1.7%; P = 0.03) or surgery in teaching hospitals (2.6% versus 1.4%; P = 0.02) had higher rates of S/D after CEA. Patients whose proceduralist used a cerebral protection device had lower S/D rates after CAS for symptomatic disease (4.8% versus 2.2%; P = 0.03). There was a wide variation in practice between states, where CAS as a proportion of total carotid procedures ranged from 0% to 17%, and a wide variation in outcomes, with rates of S/D varying between 1.4-6.6% for CEA and 0-6.7% after CAS.

CONCLUSION

Outcomes after CAS are equivalent to CEA when performed by vascular surgeons, however significant variation exists for both choice of revascularization procedure and perioperative outcomes between states. Further investigation is needed to determine whether clinical care pathways should be revised to achieve consistency and quality of outcomes.

Meta-Analysis Comparing the Frequency of Carotid Artery Stenosis in Patients With Atrial Fibrillation and Vice Versa

Atrial fibrillation (AF) and carotid stenosis (CS) can coexist and this association has been reported to result in a higher risk of stroke than attributed to either condition alone. Here we aimed to summarize the data on the association of CS and AF. MEDLINE and Embase were searched to identify all published studies providing relevant data through February 27, 2020. Random-effects meta-analysis method was used to pool estimates of prevalence. Heterogeneity was assessed by mean I-squared statistic. Forty-eight studies were included, 20 reporting on the prevalence of carotid disease in a pooled population of 49,070 AF patients, and 28 on the prevalence of AF in a total of 2,288,265 patients with carotid disease. The pooled prevalence of CS in AF patients was 12.4% (95% confidence interval [CI] 8.7 to 16.0, I² 93%; n = 3,919), ranging from 4.4% to 24.3%. The pooled prevalence of carotid plaque was 48.4% (95% CI 35.2 to 61.7, I² = 99%; n = 4292). The prevalence of AF in patients with CS was 9.3% (95% CI 8.7 to 10.0, I² 99%; n = 2,286,518), ranging from 3.6% to 10.0%. This prevalence was much higher (p <0.001) in patients undergoing carotid artery stenting (12.7%, 95% CI 11.3 to 14.02, I² 38.3%) compared with those undergoing carotid endarterectomy (6.9%, 95% CI 8.3 to 10.4, I² 94.1%). There was no difference in AF prevalence between patients with CS, with and without previous cerebrovascular event (p >0.05). In conclusion, AF and CS frequently coexist, with about one in ten patients with AF having CS, and vice versa. In addition, nonstenotic carotid disease is present in about half of AF patients. These findings have important implications for AF screening in patients with CS, stroke prevention, and the opportunities to intervene on common risk factors.

Age and the risk of new ischemic lesions on diffusion weighted imaging after carotid artery stenting: A systematic review and meta-analysis

To perform a systematic review and meta-analysis to show the association between age and the risk of new ischemic lesions on diffusion-weighted magnetic resonance imaging (DWI) after carotid artery stenting in patients with carotid artery stenosis. We searched PubMed and EMBASE from their dates of inception to March 14, 2019 for eligible studies. Standardized mean difference (SMD) and pooled odds ratio (OR) with 95% confidence interval (CI) was used to evaluate the association between age and new DWI lesions. Sensitivity analysis was performed to detect the possible source of heterogeneity. Twenty-three studies enrolling 2127 patients were included. The incidence of new DWI lesions was 62% in older patients and 41% in younger patient (OR 2.44, 95%CI 1.57-3.79; p < 0.0001). The patients with new DWI lesions were older than those without (SMD 0.24, 95% CI 0.08-0.39; p = 0.003). The risk of new DWI lesions increased by 1.07 per added year (95%CI 1.04-1.11, p < 0.0001). The results remained stable in sensitivity analyses and after adjusting for publication bias. It was concluded that older age was at higher risk of new DWI lesions after stenting in patients with carotid artery stenosis.

Sex-Based Differences in Ten-Year Nationwide Outcomes of Carotid Revascularization

BACKGROUND

We compared the rates of stroke, death, and/or MI between men and women, stratified by symptomatic status and procedure type (carotid endarterectomy [CEA] or carotid artery stent [CAS]).

STUDY DESIGN

Using the Nationwide Inpatient Sample, crude and propensity-matched rates of the composite end point of stroke/death/MI were estimated. Multivariable logistic regression was used to calculate the odds of stroke/death/MI associated with sex.

RESULTS

Between 2005 and 2015, there were 1,242,688 carotid interventions performed (1,083,912 CEA; 158,776 CAS; 515,789 [41.5%] were female patients). Symptomatic admissions comprised 11.3% of the cohort. In-hospital stroke/death/MI rates were more prevalent in men compared with women (4.2% vs 3.9%; p < 0.01). Subgroup analysis revealed symptomatic women vs men had higher rates of stroke after CEA (7.7% vs 6.2%; p < 0.01) and CAS (9.9% vs 7.6%; p < 0.01). Asymptomatic women experienced the same rates of stroke after either CEA (0.3% vs 0.3%; p = 0.051) or CAS (0.4% vs 0.5%; p = 0.09). Propensity-matched logistic regression revealed that symptomatic males vs females had lower odds of stroke after CEA (odds ratio [OR] 0.81; 95% CI 0.72 to 0.91) and CAS (OR 0.72; 95% CI 0.57 to 0.90). Asymptomatic men and women had similar odds of stroke after both CEA (OR 0.95; 95% CI 0.79 to 1.14) and CAS (OR 0.70; 95% CI 0.43 to 1.13).

CONCLUSIONS

This is the largest cohort study to date that demonstrates asymptomatic women undergoing CEA or CAS do not have a higher risk of perioperative stroke, death, or MI. Symptomatic men experience lower rates of stroke after CEA or CAS.

De-adoption and exnovation in the use of carotid revascularization: retrospective cohort study

Objective To determine physician characteristics associated with exnovation (scaling back on use) and de-adoption (abandoning use) of carotid revascularization.Design Retrospective longitudinal cohort study.Setting Medicare claims linked to the Doximity database provider registry, 2006-13.Participants 9158 physicians who performed carotid revascularization on Medicare patients between 2006 and 2013.Main outcome measures The primary outcomes were the number of carotid revascularization procedures for each physician per year at the end of the sample period, and the percentage change in the volume of carotid revascularization procedures.Results At baseline (2006-07), 9158 physicians performed carotid revascularization. By 2012-13 the use of revascularization in this cohort had declined by 37.7%, with two thirds attributable to scaling back (exnovation) rather than dropping the procedure entirely (de-adoption). Compared with physicians with fewer than 12 years of experience, those with more than 25 years of experience decreased use by an additional 23.0% (95% confidence interval -36.7% to -9.2%). The lowest rates of decline occurred in physicians specializing in vascular or thoracic surgery, for whom the procedures accounted for a large share of revenue. Physicians with high proportions of patients aged more than 80 years or with asymptomatic carotid stenosis were less likely to reduce their use of carotid revascularization.Conclusion Surgeons with more experience and the lowest share in carotid revascularization practice reduced their use of the procedure the most. These practice factors should be considered in quality improvement efforts when the evidence base evolves away from a specific treatment.

Effect of carotid endarterectomy on brain damage markers

OBJECTIVES

Carotid endarterectomy (CEA) is a recommended treatment in the prevention of ischemic stroke. However, this procedure may cause neurological complications caused by cerebrovascular damage. While YKL-40 is a proinflammatory protein, neurofilament light polypeptide (NEFL) and brain lipid-binding protein (FABP7) are structural components of the brain. The aim of the study was to investigate YKL-40, NEFL, and FABP7 in the serum of patients undergoing CEA.

MATERIALS AND METHODS

The study included 25 participants who underwent CEA due to internal carotid artery stenosis. Blood samples were taken from each patient at three different intervals: prior to the surgery, 12 h after the surgery, and 48 h after the surgery. Serum levels of these brain damage markers were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The study showed that the serum YKL-40 level was significantly increased 48 h after CEA when compared to the level prior to surgery and also when compared to levels 12 h after surgery. There were no statistically significant differences in serum NEFL and FABP7 levels between all three recorded measurements.

CONCLUSIONS

Data from our study showed that CEA affects serum YKL-40 but not NEFL and FABP7 levels. This implicates that YKL-40 may be a valuable serum marker of brain damage after CEA. However, the observed change in serum YKL-40 level in patients after CEA does not necessarily warrant a change in recommendations concerning the use of this treatment in patients with high-grade internal carotid artery stenosis.

Impact of Clinical Trial Results on the Temporal Trends of Carotid Endarterectomy and Stenting From 2002 to 2014

Supplemental Digital Content is available in the text.

Background and Purpose—

Randomized trials provide conflicting data for the efficacy of carotid-artery stenting compared with endarterectomy. The purpose of this study was to examine the impact of conflicting clinical trial publications on the utilization rates of carotid revascularization procedures.

Methods—

We conducted a population-level time-series analysis of all individuals who underwent carotid endarterectomy and stenting in Ontario, Canada (2002–2014). The primary analysis examined temporal changes in the rates of carotid revascularization procedures after publications of major randomized trials. Secondary analyses examined changes in overall and age, sex, carotid-artery symptom, and operator specialty–specific procedure rates.

Results—

A total of 16 772 patients were studied (14 394 endarterectomy [86%]; 2378 stenting [14%]). The overall rate of carotid revascularization decreased from 6.0 procedures per 100 000 individuals ≥40 years old in April 2002 to 4.3 procedures in the first quarter of 2014 (29% decrease; P<0.001). The rate of endarterectomy decreased by 36% (P<0.001), whereas the rate of carotid-artery stenting increased by 72% (P=0.006). We observed a marked increase (P=0.01) in stenting after publication of the SAPPHIRE trial (Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy) in 2004, whereas stenting remained relatively unchanged after subsequent randomized trials published in 2006 (P=0.11) and 2010 (P=0.34). In contrast, endarterectomy decreased after trials published in 2006 (P=0.04) and 2010 (P=0.005).

Conclusions—

Although the overall rates of carotid revascularization and endarterectomy have fallen since 2002, the rate of carotid-artery stenting has risen since the publication of stenting-favorable SAPPHIRE trial. Subsequent conflicting randomized trials were associated with a decreasing rate of carotid endarterectomy.

Pathology of embolic debris in carotid artery stenting

BACKGROUND

The relationship between magnetic resonance (MR) plaque imaging and the pathology of distal embolic debris is unknown. We aimed to evaluate the relationship between the pathology of embolic debris in the embolic filter during carotid artery stenting (CAS), MR plaque imaging, and new ischemic lesions on diffusion-weighted imaging (DWI).

METHOD

We prospectively reviewed the 36 patients who underwent CAS using a filter-type embolic protection device. Pathology of debris was categorized into thrombosis, inflammatory cells, elastic fiber, and calcification. We compared the clinical parameters, MR plaque imaging, and pathological characteristics of the embolic debris retained in the filter during CAS on univariate analysis.

RESULTS

Eleven patients had and 25 patients did not have new lesion on DWI. All of DWI-high lesions were identified in affected side middle cerebral artery territory. Embolic debris was microscopically confirmed in 28 patients (78%); thrombosis in 11 (31%), inflammatory cells in 13 (36%), elastic fiber in 12 (33%), and calcification in 9 (25%). Proportion of asymptomatic carotid stenosis, intra-operative bradycardia/hypotension, and inflammatory cells of debris were significantly higher in patients with new DWI-high lesions. There was no significant relationship between the pathological characteristics and MR plaque imaging of distal embolic debris.

CONCLUSIONS

Our study showed that new DWI-high lesions might be influenced by types of debris in the filter. The need for future studies specifically examine the association of pathology of debris and findings of MR plaque imaging with new DWI-high lesions during CAS is emphasized.