Preoperative evaluation and perioperative management of patients undergoing major vascular surgery

Efficacy and Safety of Tranexamic Acid in Noncardiac Arterial Procedures: A Systematic Review and Meta-Analysis

BACKGROUND

Noncardiac arterial procedures (NCAPs) are associated with a high risk of bleeding. Tranexamic acid (TXA) is used among surgical disciplines to reduce blood loss; however, its effectiveness and safety in NCAP remain unclear. This review evaluates the efficacy and safety of TXA during NCAP.

METHODS

Systematic review and meta-analysis was performed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Literature searches in PubMed, Embase, and Cochrane databases (October 2023 and October 2024) identified studies investigating TXA in open and endovascular NCAP. Meta-analyses were conducted using Cochrane's Review Manager.

RESULTS

Five studies (n = 4304) were identified. One randomized controlled trial of TXA in noncardiac surgery (n = 9535), including a vascular cohort (14.8%; n = 699 TXA, n = 700 placebo), showed lower composite bleeding outcomes in the overall cohort receiving TXA (9.5% vs 11.7%; P < 0.001), but not in the vascular cohort (hazard ratio 0.85; 95% confidence interval [CI] 0.64-1.13). Another trial found no difference in blood loss or transfusion rates in 100 patients undergoing open abdominal aortic aneurysm surgery. Both trials reported no increased cardiovascular or thromboembolic complications (TECs) or 30-day mortality. A prospective study showed similar thrombosis-related technical failure rates in traumatic vascular injury patients (TXA 6.3% vs 3.8%, P = 0.14) and no significant differences in bleeding or hematoma (TXA 11.4% vs 4.3%, P = 0.13). In 297 carotid endarterectomy (CEA) patients, TXA significantly reduced postoperative hematoma (7.9% vs 1.3%; P = 0.01) without increasing TEC or stroke. TXA during an intraoperative hemostasis protocol during CEA (TXA n = 8) reported similar results. Meta-analysis showed no significant differences in TEC (risk ratio [RR] 1.10; 95% CI 0.71-1.70) or reoperation rates (RR 0.55; 95% CI 0.19-1.63).

CONCLUSION

TXA does not increase the risk of TEC in NCAP. However, there is currently insufficient evidence that TXA reduces bleeding complications.

Higher long-term mortality in patients with positive preoperative stress test undergoing elective carotid revascularization with carotid endarterectomy compared to transfemoral carotid artery stenting or transcarotid revascularization

OBJECTIVE

This study compared outcomes in patients with and without preoperative stress testing undergoing carotid revascularization including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid revascularization (TCAR).

METHODS

Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database who underwent elective carotid revascularization from 2016 to 2020 were included. Patients were analyzed by group based on whether they underwent cardiac stress testing within 2 years preceding revascularization without subsequent coronary intervention. Subset analysis was performed comparing outcomes between those with negative and positive results (evidence of ischemia or myocardial infarction [MI]). Outcomes of interest were postoperative MI/neurological events, 90-day readmission rates, and long-term mortality.

RESULTS

We analyzed 18,364 patients (78.8% CEA, 9.3% TF-CAS, and 11.9% TCAR). Of these, 35.8% underwent preoperative stress testing (37.4% of CEA patients, 27.5% of TF-CAS patients, and 31.9% of TCAR patients). Although comorbidities were significantly higher among patients undergoing CEA with a preoperative stress test compared with those without stress testing, the overall prevalence of comorbidities was higher among patients undergoing TF-CAS or TCAR, irrespective of preoperative stress test status. Compared with patients with a negative stress test, patients with a positive stress test undergoing any form of carotid revascularization had a significant increase in 90-day readmission rates (CEA 19.6% vs 15.8% [P = .003]; CAS 33.3% vs 18.6% [P < .001]; TCAR 25% vs 17.5% [P = .04]). No group demonstrated a difference in the incidence of in-hospital postoperative neurological events or congestive heart failure, but those undergoing CEA (but not CAS or TCAR) experienced a significant increase in-hospital postoperative MI (1.7% vs 0.6%; P < .001). In 3-year follow-up, those with a positive compared with negative stress test were more likely to undergo coronary artery bypass graft/percutaneous coronary intervention in the CEA (adjusted hazard ratio [HR], 1.87 [95% confidence interval (CI), 1.42-2.27]; P < .0001) and CAS groups (adjusted HR, 3.89 [95% CI, 1.77-8.57]; P < .01), but not the TCAR cohort. Notably, those undergoing CEA with a positive compared with negative stress test, but not CAS or TCAR, exhibited a 28% increase in mortality (adjusted HR, 1.28 [95% CI, 1.03-1.58]; P = .03) at 3 years. Conversely, those patients with a negative stress test compared with no stress test undergoing CEA experienced a 14% decrease in mortality at 3 years (adjusted HR, 0.86 [95% CI, 0.76-0.98]; P = .02); this mortality difference was not observed in similar stress test cohorts undergoing TF-CAS or TCAR.

CONCLUSIONS

Our study highlights that a positive stress test in appropriately selected, asymptomatic patients undergoing elective carotid revascularization can predict select perioperative and long-term cardiovascular outcomes. However, given the high follow-up mortality associated with those undergoing CEA for elective carotid revascularization, our findings call into question whether these patients should be offered optimal medical management and/or stenting preferentially.

Prevention of Open Surgical Treatment Complications of Patients with Occlusive Lesions of the Aortoiliac Segment

INTRODUCTION

Surgical procedures on large arteries are associated with an increased likelihood of complications and a long rehabilitation period, making it extremely important to reduce the risks of such operations. The study aims to examine various aspects of preventing complications of surgical treatment, including preoperative preparation, intraoperative management, postoperative observation, and analysis of factors that determine treatment outcomes.

METHODS

The present study used clinical data from 300 patients undergoing surgical treatment of aortoiliac segment occlusion to evaluate the effectiveness of preoperative correction. The study was conducted over 3 ys, from 2018 to 2023, at the university clinic of the nonprofit joint-stock company Semey Medical University.

RESULTS

The study found that preoperative optimization, including medical correction of diabetes mellitus and chronic obstructive pulmonary disease, led to improved functional performance in patients. In the group of patients who underwent preoperative correction, intraoperative complications were recorded in only 12% of patients, while in the control group, where such correction was not performed, this figure reached 24%. A similar trend was observed concerning postoperative complications: 18% compared to 34% in the control group.

CONCLUSIONS

Multiple logistic analyses confirmed the critical role of diabetes mellitus and chronic obstructive pulmonary disease as risk factors for postoperative complications, emphasizing the need to address these conditions before surgery. The practical significance of the study is to confirm the need for preoperative drug correction to reduce the risk of intraoperative and postoperative complications and improve the outcomes of surgical treatment of aortoiliac segment occlusion.

Positive Preoperative Stress Test is Associated with Increased Risk of Postoperative Myocardial Infarction in Patients Undergoing Aortoiliac Reconstruction for Chronic Limb-Threatening Ischemia

BACKGROUND

Aortofemoral or aortoiliac bypasses (AFBs/AIBs) are considered the gold standard treatment for patients with aortoiliac occlusive disease. Myocardial infarction (MI) is a postoperative risk in AFB/AIB surgeries and preoperative stress test (PST) is frequently utilized to inform operative planning and preoperative risk discussions. The aim of this study is to assess the utility of PST in determining outcomes following AFB/AIB in patients with chronic limb-threatening ischemia (CLTI).

METHODS

This is a retrospective study from Vascular Quality Initiative database. Patients undergoing AFB/AIB for chronic limb-threatening ischemia during 2009-2023 were stratified by PST result. Primary outcomes included postoperative MI and 30-day mortality. Secondary outcomes included in-hospital death, in-hospital death/MI, postoperative respiratory complications, postoperative congestive heart failure, intensive care unit stay > 3 days, and 1-year mortality. Logistic and Cox regressions were used for multivariate analyses.

RESULTS

The study included 2 cohorts of patients: negative (N = 1,809, 81.2%) and positive PST (N = 420, 18.8%). The patients with positive PST had increased rate of postoperative MI compared to the patients with negative PST (6.7% vs. 2.9%, P < 0.001). The rate of 30-day mortality was greater for patients with positive PST but the difference was not significant (3.8% vs. 2.9%, P = 0.315). After adjusting for potential confounders, positive PST was associated with increased risk of postoperative MI (adjusted odds ratio = 1.89 [95% confidence interval: 1.04-3.43], P = 0.038). However, positive PST was not associated with 30-day mortality. Pulmonary complications, congestive heart failure, and intensive care unit stay >3 days were also not associated with PST result. The overall survival rate at 1-year was 93.3% and 92.0% for patients with negative and positive PSTs (P = 0.343), respectively. After adjusting for potential confounders, postoperative MI was associated with increased hazards of death at 1 year (adjusted hazard ratio = 3.62 [95% confidence interval: 2.21-5.92], P < 0.001).

CONCLUSION

This study emphasizes the important of appropriate preoperative planning. A positive stress test before open aortic reconstruction for aortoiliac occlusive disease is associated with increased risk of postoperative MI. Although this was neither associated with increased risk of 30-day nor 1-year mortality, the negative impact of MI on patient functionality, quality of life, and 1-year death cannot be ignored.

Computer-Assisted Protocol-Adherent Blood Lipid Evaluation in Vascular Outpatients (CAPABLE-Vascular)

Background: The lack of availability of test results in vascular surgery outpatient clinics impedes the medical management of vascular risk factors, such as dyslipidaemia and diabetes mellitus. This study sought to evaluate the feasibility of using computer-assisted processes to promote the ordering of routine investigations to promote this management. Method: After consultation with specialist clinicians, clinician-programmers developed a rule-based system to facilitate the ordering of lipid studies and HbA1c prior to vascular clinic appointments. A four-week historical control period prior to the initiation of the intervention was compared to a four-week period following the intervention. Results: There were 1165 patients in the study. In the pre-intervention period, 38.0% of patients had HbA1c and 17.9% had lipid studies in the preceding 6 months. In the post-intervention period, HbA1c and lipid studies were ordered for 100% of vascular outpatients (p < 0.001). Conclusions: The use of computer-assisted processes to facilitate the requesting of routine outpatient investigations is feasible and shows early signs of being effective. Follow-up studies examining clinical endpoints are required.

Caught Between Heart and Limbs: Navigating the Treatment of Patients With CAD and PAD in an Overwhelmed Healthcare System

Peripheral arterial disease (PAD) and coronary artery disease (CAD) are manifestations of atherosclerosis, affecting a substantial proportion of the population. Despite their interrelation, the prevalence of CAD in severe PAD varies, prompting the need to understand their complex relationship. This study retrospectively analyzes prospectively collected data from a high-volume vascular center to assess CAD prevalence, risk factors, and implications for patients undergoing vascular surgery. Among 667 arterial disease patients, 19.5% underwent coronary angiography, with CAD detected in 61.5% of cases. CAD varied across vascular beds. Decision-making around preoperative coronary angiography and revascularization remains complex, with benefits for high-risk patients still being debated. In accordance with current guidelines, the routine practice of coronary revascularization preceding vascular surgery is generally discouraged. This study underscores the need for risk stratification to identify patients who might benefit from coronary revascularization prior to vascular surgery while adhering to cost-effectiveness and avoiding unnecessary and time-consuming diagnostics in the majority of patients. Patient demographics, risk factors, and clinical presentation were analyzed alongside hospital stay, mortality, and complications. The study highlights the challenges in managing patients with concurrent CAD and PAD and calls for improved protocols for treating this high-risk group.

Most preoperative stress tests fail to comply with practice guideline indications and do not reduce cardiac events

BACKGROUND

There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines.

METHODS

We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 - Jul 1, 2022) and 6 months after (Aug 1, 2022 - Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE).

RESULTS

Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation.

CONCLUSIONS

Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making.

The Safety and Outcomes of Elective Endovascular Aneurysm Repair in the Elderly: A Systemic Review and Meta-Analysis

PURPOSE

Prevalence of abdominal aortic aneurysms (AAAs) increases with age. Previous trials confirm that elective endovascular aneurysm repair (EVAR) is an effective intervention for AAA. However, few elderly patients were recruited into randomized trials, whereas in contemporary clinical practice, elective repair is commonly performed on octogenarians. We evaluated the safety and outcome of elective EVAR in elderly patients to inform clinical practice and vascular service provision.

METHODS

A systematic review and meta-analysis of studies reporting risk of complications and death in patients undergoing elective EVAR was performed (PROSPERO CRD: 42022308423). Observational studies and interventional arms of randomized trials were included if the outcome rates or raw data were provided. Primary outcome was 30-day mortality. Secondary outcomes were longer-term mortality, 30-day major adverse events, and aneurysm-related mortality. Primary and secondary outcomes were compared between octogenarians and non-octogenarians. Exclusion criteria were emergency procedures, non-infrarenal aneurysms, and lack of octogenarian data.

RESULTS

A total of 41 studies were eligible from 10 099 citations, including 10 national and 5 international registries, 26 retrospective studies, and our own prospective cohort. The analysis included 208 997 non-octogenarians (mean age=70.19 [SD=0.62]) and 106 188 octogenarians (mean age=83.75 [SD=0.35]). The 30-day mortality post-elective EVAR was higher in octogenarians (1.08% in non-octogenarians, 2.31% in octogenarians, odds ratio [OR]=2.27 [2.08-2.47], p<0.0001). Linear regression demonstrated a 0.83% increase in 30-day mortality for every 10-year age increase above 60 years old. Mortality for octogenarians increased significantly during follow-up: 11.35% (OR=1.87 [1.65-2.13], p<0.001), 22.80% (OR=1.89 [1.52-2.35], p<0.001), 32.00% (OR=1.98 [1.66-2.37], p<0.001), 47.53%, and 51.08% (OR=2.40 [1.90-3.03], p<0.001) at 1-through-5-year follow-up, respectively. The 30-day major adverse events after elective EVAR were higher in octogenarians (OR=1.75-2.83, p<0.001).

CONCLUSIONS

Octogenarians experience higher but acceptable peri-operative morbidity and mortality compared with younger patients. However, 3-year to 5-year survival is very low among octogenarians. Our findings challenge the notion of routine intervention in elderly patients and support very careful selection for elective EVAR. Many octogenarians with peri-threshold (<6 cm) AAAs may derive no benefit from EVAR due to limited 3-year to 5-year overall survival and low risk of aneurysm rupture with conservative management. An adjusted threshold for intervention in octogenarians may be warranted.

CLINICAL IMPACT

Octogenarians with infra-renal AAA are increasingly managed with elective EVAR. Previous studies have demonstrated that EVAR is safer than open repair for octogenarians, with lower peri-operative mortality and major adverse events. However, randomised trials, on which much of contemporary evidence is based, recruited a relatively younger population of participants. This systematic review and meta-analysis provides a contemporary synthesis of the literature comparing outcomes in octogenarians to younger patients. The results of this analysis, together with low rupture rates amongst octogenarians in existing literature, question the benefit of routine elective intervention for peri-threshold aneurysms and an adjusted threshold for intervention in octogenarians may be warranted.

Preoperative Echocardiographic Assessment in Elective Surgery Patients: A Cross-Sectional Study From Duhok, Iraqi Kurdistan

Background and aim Echocardiography plays a pivotal role in the preoperative risk assessment of patients undergoing various surgical procedures. Therefore, we conducted this study to detect various cardiac abnormalities through a preoperative echocardiographic study for cases undergoing elective surgeries in Duhok, Iraqi Kurdistan. Methods This cross-sectional study assessed echocardiographic findings in preoperative patients at Azadi Teaching Hospital, Duhok, Kurdistan Region of Iraq, from 2023 to 2024. The study encompasses 468 adult patients. We gathered clinicodemographic characteristics, indications of referral to a preoperative echo study, and the echocardiographic findings, particularly regional wall motion abnormalities, valvular heart diseases, and heart failure (systolic or diastolic/left ventricular hypertrophy). Results In a cohort of 468 patients, 205 (43.80%) were aged 35-54 years, and 269 (57.48%) were female. Most patients (366; 78.21%) resided in Duhok. Nearly only half of the cases 219 (46.79%) had clear preoperative echostudy indications. A total of 289 (61.74%) had no remarkable echocardiographic findings. Diastolic heart failure was most prevalent at 65 (13.89%). Older cases had more prevalent echo findings in terms of valve dysfunctions and heart failure. Notable associations were found between echocardiographic abnormalities and surgical types, particularly higher regional wall motion abnormalities in genito-urinary system operations (4; 8.16%) and valvular heart disease in orthopedic surgeries (13; 15.85%). Conclusions Echocardiographic abnormalities were remarkably observed in patients aged 65 and older. Many cases had no clear indications for preoperative echo study and hence unremarkable echo findings. More scrutiny is indicated during referral, and focusing on older adults' preoperative cardiac screening is recommended.

2023 Update on Vascular Anesthesia

The authors thank the editors for this opportunity to review the recent literature on vascular surgery and anesthesia and provide this clinical update. The last in a series of updates on this topic was published in 2019.1 This review explores evolving discussions and current trends related to vascular surgery and anesthesia that have been published since then. The focus is on the major points discussed in the recent literature in the following areas: carotid artery surgery, infrarenal aortic surgery, peripheral vascular surgery, and the preoperative evaluation of vascular surgical patients.

Prognostic value of extended cardiac risk assessment before elective open abdominal aortic surgery

BACKGROUND

Major vascular surgery is associated with a high perioperative risk and significant mortality. Despite advances in risk stratification, monitoring, and management of perioperative complications, cardiac complications are still common. Stress echocardiography is well established in coronary artery disease diagnostics; however, its prognostic value before high-risk aortic surgery is unknown. This prospective, single-center study compared the outcome of patients undergoing extended cardiac risk assessment before open abdominal aortic surgery with the outcome of patients who had received standard preoperative assessment.

METHODS

The study included patients undergoing elective open abdominal aortic surgery. Patients who underwent standard preoperative assessment before the start of a dedicated protocol were compared with patients who had extended cardiac risk assessment, including dobutamine stress echocardiography, as part of a stepwise interdisciplinary cardiovascular team approach. The combined primary endpoint was cardiovascular death, myocardial infarction, emergency coronary revascularization, and life-threatening arrhythmia within 30 days. The secondary endpoint was acute renal failure and severe bleeding.

RESULTS

In total, 77 patients (mean age 68.1 ± 8.1 years, 70% male) were included: 39 underwent standard and 38 underwent cardiac risk assessment. The combined primary endpoint was reached significantly more often in patients before than after implementation of the extended cardiac stratification procedure (15% vs. 0%, p = 0.025). The combined secondary endpoint did not differ between the groups.

CONCLUSIONS

Patients with extended cardiac risk assessment undergoing elective open abdominal aortic surgery had better 30-day outcomes than did those who had standard preoperative assessment.

Incidental Cardiovascular Abnormalities in the Abdominal Aortic Aneurysm (AAA) Surveillance Population During the AAA Get Fit Trial: A Case Series and Review of the Literature

Background The prevalence of cardiovascular disease and incidence of major adverse cardiovascular events (MACEs) is very high among the abdominal aortic aneurysm (AAA) surveillance population. Formal assessments of and interventions to reduce cardiovascular risk are not a routine part of the surveillance programme at present. However, its potential importance is highlighted by incidental findings during the AAA Get Fit Trial, a randomised controlled trial which included baseline cardiopulmonary exercise testing (CPET). We speculate that CPET can act as an opportunistic screening programme to identify cardiovascular disease in AAA surveillance patients. Methods The AAA Get Fit Trial was a prospective, randomised controlled trial at a tertiary vascular centre, Manchester University NHS Foundation Trust, conducted between November 2017 and August 2019. Patients underwent CPET at baseline, 8, 16, 24 and 36 weeks as well as clinical history and examination and blood tests. We report on incidental cardiovascular abnormalities diagnosed during the trial. Results Of the 59 participants in the trial, four (6.8%) were identified to have abnormal findings suggestive of unstable cardiovascular disease. On subsequent further investigation, two patients were diagnosed and treated for severe coronary artery disease after abnormal ECG findings were noted during CPET. One patient was diagnosed with unstable angina after obtaining a detailed history on baseline assessment which was treated medically before going on to have a successful elective AAA repair. Conclusions There is a high incidence of MACEs among this high-risk population both pre and perioperatively. Identifying and treating cardiovascular disease among the AAA surveillance population must be a focus of the future AAA screening programme.

Increased Preoperative Stress Test Utilization is Not Associated With Reduced Adverse Cardiac Events in Current US Surgical Practice

OBJECTIVE

To measure the frequency of preoperative stress testing and its association with perioperative cardiac events.

BACKGROUND

There is persistent variation in preoperative stress testing across the United States. It remains unclear whether more testing is associated with reduced perioperative cardiac events.

METHODS

We used the Vizient Clinical Data Base to study patients who underwent 1 of 8 elective major surgical procedures (general, vascular, or oncologic) from 2015 to 2019. We grouped centers into quintiles by frequency of stress test use. We computed a modified revised cardiac risk index (mRCRI) score for included patients. Outcomes included in-hospital major adverse cardiac events (MACEs), myocardial infarction (MI), and cost, which we compared across quintiles of stress test use.

RESULTS

We identified 185,612 patients from 133 centers. The mean age was 61.7 (±14.2) years, 47.5% were female, and 79.4% were White. Stress testing was performed in 9.2% of patients undergoing surgery, and varied from 1.7% at lowest quintile centers, to 22.5% at highest quintile centers, despite similar mRCRI comorbidity scores (mRCRI>1: 15.0% vs 15.8%; P =0.068). In-hospital MACE was less frequent among lowest versus highest quintile centers (8.2% vs 9.4%; P <0.001) despite a 13-fold difference in stress test use. Event rates were similar for MI (0.5% vs 0.5%; P =0.737). Mean added cost for stress testing per 1000 patients who underwent surgery was $26,996 at lowest quintile centers versus $357,300 at highest quintile centers.

CONCLUSIONS

There is substantial variation in preoperative stress testing across the United States despite similar patient risk profiles. Increased testing was not associated with reduced perioperative MACE or MI. These data suggest that more selective stress testing may be an opportunity for cost savings through a reduction of unnecessary tests.

Complications of exercise and pharmacologic stress echocardiography

Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).

Postoperative Disability and One-Year Outcomes for Patients Suffering a Stroke after Carotid Endarterectomy

OBJECTIVES

Although post-carotid endarterectomy (CEA) strokes are rare, they can be devastating. The degree of disability that patients develop after such events and its effects on long-term outcomes are unclear. Our goal was to assess the extent of postoperative disability in patients suffering strokes after CEA and evaluate its association with long-term outcomes.

METHODS

The Vascular Quality Initiative CEA registry (2016-2020) was queried for CEAs performed for asymptomatic or symptomatic indications in patients with preoperative modified Rankin Scale (mRS) scores of 0-1. The mRS grades stroke-related disability as 0 (none), 1 (not significant), 2-3 (moderate), 4-5 (severe), and 6 (dead). Patients suffering postoperative strokes with recorded mRS scores were included. Postoperative stroke-related disability based on mRS and its association with long-term outcomes were analyzed.

RESULTS

Among 149,285 patients undergoing CEA, there were 1,178 patients without preoperative disability who had postoperative strokes and reported mRS scores. Mean age was 71 ± 9.2 years and 59.6% of patients were male. Regarding ipsilateral cortical symptoms within six months preoperatively, 83.5% of patients were asymptomatic, 7.3% had transient ischemic attacks, and 9.2% had strokes. Postoperative stroke-related disability was classified as mRS 0 (11.6%), 1 (19.5%), 2-3 (29.4%), 4-5 (31.5%), and 6 (8%). One-year survival stratified by postoperative stroke-related disability was 91.4% for mRS 0, 95.6% for mRS 1, 92.1% for mRS 2-3, and 81.5% for mRS 4-5 (P<.001). Multivariable analysis demonstrated that while severe postoperative disability was associated with increased death at one year (HR 2.97, 95% CI 1.5-5.89, P=.002), moderate postoperative disability had no such association (HR .95, 95% CI .45-2, P=.88). One-year freedom from subsequent ipsilateral neurological events or death stratified by postoperative stroke-related disability was 87.8% for mRS 0, 93.3% for mRS 1, 88.5% for mRS 2-3, and 77.9% for mRS 4-5 (P<.001). Severe postoperative disability was independently associated with increased ipsilateral neurological events or death at one year (HR 2.34, 95% CI 1.25-4.38, P=.01). However, moderate postoperative disability exhibited no such association (HR .92, 95% CI .46-1.82, P=.8).

CONCLUSIONS

The majority of patients without preoperative disability who suffered strokes after CEA developed significant disability. Severe stroke-related disability was associated with higher one-year mortality and subsequent neurological events. These data can improve informed consent for CEA and guide prognostication after postoperative strokes.