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Practice Patterns of Carotid Endarterectomy as Performed by Different Surgical Specialties and the Impact on Perioperative Stroke and Cost
Ali F. AbuRahma, MD, Mohit Srivastava, MD, Benny Y. Chong, MD, Zachary AbuRahma, MS, Stephen M. Hass, MD, L. Scott Dean, PhD, MBA, Patrick A. Stone, MD, Albeir Y. Mousa, MD.
R C Byrd Health Science Center of West Virginia University, Charleston, WV, USA.
OBJECTIVES:
Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their impact on perioperative stroke and cost.
METHODS:
This is a retrospective analysis of prospectively collected data of 1,000 consecutive CEAs performed at our institution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CT), and vascular surgeons (VS).
RESULTS:
474 CEAs were done by VS, 404 by CT, and 122 by GS. VS tended to operate more often on symptomatic patients than CT and GS: 40% versus 23% and 31%, respectively (p<0.0001). Preoperative work-ups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and CTA in 27%, 35%, and 29%; DUS and MRA in 6%, 35%, and 52% for VS, CT, and GS, respectively (p<0.001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (p=0.0001) and protamine was used in 0.2%, 19%, and 8% (p<0.0001) for VS, CT, and GS, respectively. Postoperative drains were used more often by VS; however there was no association between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (p<0.0001) for VS, CT, and GS. Bovine pericardial patches were used more often by CT and ACUSEAL (Gore) patches were used more often by VS (p<0.0001). The perioperative stroke/death rates were 1.27% for VS and 3.04% for CT and GS combined (p=0.055); and for asymptomatic patients, 0.7% for VS and 3.02 for CT and GS combined (p<0.034). Perioperative stroke rates for patients who had preoperative DUS only were 0.88%, versus 3.29% for patients who had extra imaging (CTA/MRA) (p=0.009); and for asymptomatic patients, it was 0.94% versus 3.01% (p=0.05). When applying hospital billing charges for preoperative imaging work-ups (cost of DUS only versus DUS and other imaging), the VS practice pattern would have saved $1180 per CEA over CT and GS practice patterns; a total savings of $1,180,000 in this series.
CONCLUSIONS:
CEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians, who perform CEAs, on cost-saving measures may be appropriate.
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